PulmPEEPs

In this episode, we’re concluding our review of the Global Initiative for Asthma (GINA) guidelines on asthma today with a cased based episode on special considerations in asthma care. We’ve covered asthma diagnosis and phenotyping, the approach to therapy inhaler and oral medical therapy, and biologic therapy. On today’s episode we’re talking about complex cases that are at the edges of the guidelines, or may be in future guidelines. To help us with this exciting topic we’re joined by an expert in the field. Enjoy!  Meet Our Guest Dr. Meredith McCormack is a Professor of Medicine at Johns Hopkins, where she leads multiple NIH funded endeavors at understanding lung health and disease. She is the Division Director for Pulmonary and Critical Care Medicine, while also directing the Asthma Precision Medicine Center of Excellence, and the BREATHE Center, which focuses on understanding the effects of the environment on lung health and disease through research and community engagement.  She is an internationally recognized expert in asthma management and is a dedicated member of the faculty who is committed to the trainees. Meet Our Co-Hosts Rupali Sood  grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education. Tom Di Vitantonio  is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward. Key Learning Points Episode themesBuilt on GINA 2024: final capstone focusing on evolving topics + case-based application.Three focal areas: (1) obesity/metabolic health (GLP-1s, metformin), (2) dual biologics vs switching, (3) de-escalating inhalers while on biologics.Emphasis throughout on personalized care, shared decision-making, and multidisciplinary collaboration.Obesity & metabolic health in asthmaObesity affects mechanics, inflammation, and treatment response; tackling metabolic dysfunction can improve asthma control.GLP-1 receptor agonists may provide additive benefit beyond weight loss for some patients (early clinical signals; trials ongoing).Metformin is being studied as a potential adjunct targeting metabolic-inflammatory pathways.Practical approach: screen/counsel on weight, activity, and metabolic disease; partner with primary care/endocrine/sleep clinics; consider GLP-1/other agents when indicated for comorbidities, with potential asthma “bonus.”Biologics: switching vs dual therapyConsider switching/adding when control is not achieved or sustained on a biologic despite adherence.Upstream vs downstream targets:Upstream: anti-TSLP (e.g., tezepelumab) may help when multiple pathways/biomarkers (e.g., high IgE + eos) suggest broader blockade.Downstream: IL-5/IL-4/13/IgE agents selected to match phenotype/endotypes.Comorbidities can drive choice:Nasal polyps or upper airway syndromes: there are biologic options that improve upper airway symptoms in addition to asthmaAtopic dermatitis: agents with dual indications can be life-changing.Logistics matter: injection burden/needle phobia and dosing cadence (e.g., every 2 vs 4–8 weeks) can determine real-world success.De-escalating inhalers on biologicsDon’t step down immediately. Ask patients to maintain their full regimen for ~3 months after starting a biologic to gauge true benefit.Set expectations early and share a step-down plan to prevent unsupervised discontinuation.Typical order (individualize):Remove non-essential add-ons first (e.g., antihistamines, leukotriene modifiers).Reduce ICS dose gradually (high → medium → low).Keep ICS/LABA combination among the last therapies to taperTargets while stepping down: “normal” lung function when feasible, minimal/no day or night symptoms, full activity, no exacerbations.When patients don’t respond to biologicsRe-check the fundamentals:Adherence/technique for inhalers and biologic.Biomarkers behaving as expected (e.g., eosinophils falling on anti-IL-5).Revisit the diagnosis and contributors/mimics (e.g., vocal cord dysfunction, upper-airway disease). Consider moving upstream (e.g., to TSLP) if a downstream agent underperforms.Communication & practical pearlsUse visual aids to verify what patients actually take and how (e.g., Asthma & Allergy Network inhaler pictogram).Needle issues are common; home vs clinic administration and family support can make or break adherence.Biologics are transformative for the right patient—consider them early in steroid-dependent or poorly controlled severe asthma.Think longitudinally: plan for monitoring, comorbidity management, and timely adjustments. 

We’re back with our 4th episode in our collaborative series with BMJ Thorax. This week’s episode covers four articles related to bronchiectasis and covers a range of topics in this domain including novel therapeutics, registry data to understand risk, and health related quality of life. Our mission at Pulm PEEPs is to disseminate and promote pulmonary and critical care education, and we highly value the importance of peer reviewed journals in this endeavor. Each month in BMJ Thorax, a journal club is published looking at high yield and impactful publications in pulmonary medicine. We will be putting out quarterly episodes in association with Thorax to discuss a journal club publication and synthesize four valuable papers. Meet Our Guests Chris Turnbull is an Associate Editor for Education at Thorax. He is an Honorary Researcher and Respiratory Medicine Consultant at Oxford University Hospitals. In addition to his role as Associate Editor for Education at BMJ Thorax, he is also a prominent researcher in sleep-related breathing disorders. Dr. George Doumat completed his medical school at the American University of Beirut and now is an internal medicine resident at UT south western in his second year of training. Prior to starting residency he was a research fellow at MGH studying chronic lung disease. Journal Club Papers Journal club paper from BMJ Thorax Phase 3 Trial of the DPP-1 Inhibitor Brensocatib in Bronchiectasis Cathepsin C (dipeptidyl peptidase 1) inhibition in adults with bronchiectasis: AIRLEAF, a phase II randomised, double-blind, placebo-controlled, dose-finding study Five-Year Outcomes among U.S. Bronchiectasis and NTM Research Registry Patients Anxiety, depression, physical disease parameters and health-related quality of life in the BronchUK national bronchiectasis cohort To submit a journal club article of your own to Thorax, you can contact Chris directly – christopher.turnbull@ouh.nhs.uk To engage with Thorax, please use the social media channels (Twitter – @ThoraxBMJ; Facebook – Thorax.BMJ) and subscribe on your preferred platform, to get the latest episodes directly on your device each month. Key Learning Points Four recent papers (2 RCTs, 2 large cohorts) chosen to show both new therapeutics and real-world comorbidities/outcomes, pushing toward precision medicine. 1) ASPEN trial – brensocatib (DPP-1 inhibitor) Design: Phase 3, ~1,700 pts, 35 countries, 52 weeks; stratified randomization by region. Results: ↓ annualized exacerbation rate (~1.0 vs 1.3/yr; RR≈0.8), longer time to first exacerbation, ~10% absolute ↑ in “exacerbation-free” patients at 1 year, QoL improved, modest FEV1 decline difference (~40 mL/yr). Take: First targeted therapy with consistent benefit; effect on lung function small but directionally supportive. Gaps: Need long-term durability, adolescent data, and comparisons/positioning in pts with asthma/COPD overlap. 2) AIRLEAF (BI 1291583) – reversible cathepsin C inhibitor Design: Phase 2, 4 arms (3 doses + placebo), model-based dose–response analysis to optimize dose selection. Results: Overall dose–response signal; individual low-dose arms trended to fewer exacerbations but not statistically significant; skin events more common at higher doses. Take: Promising class targeting neutrophil pathway, but needs Phase 3 before clinical use. 3) U.S. Bronchiectasis & NTM Registry – 5-year outcomes Cohort: >2,600 CT-confirmed; ~59% with baseline NTM identified. Results: 5-yr mortality ~12%; no mortality difference with vs without NTM; predictors = lower baseline FEV1, older age, male sex, prior hospitalization. FEV1 decline ~38 mL/yr. Baseline NTM group had fewer exacerbations (counterintuitive). Interpretation cautions: Likely mix of colonization vs active disease; referral/management effects in specialized centers; registry strengths (size, real-world, longitudinal) vs pitfalls (confounding, data quality, causality). 4) Bronch-UK cohort – anxiety & depression Cohort: 1,340 adults; HADS screening. Prevalence: Anxiety ~33%, depression ~20%; many undiagnosed (≈26%/16%). Impact: Worse QoL, more severe disease; depression ~1.8× higher hospitalization risk and shorter time to severe exacerbation. Caveat: Association ≠ causation; sicker patients may have more mental health burden. Practical takeaways for clinic Consider brensocatib for appropriate non-CF bronchiectasis patients once accessible; frame benefits around fewer exacerbations and QoL, not big lung function gains. Do not introduce cathepsin C inhibitors outside trials yet; discuss as pipeline only. Risk stratify using FEV1, age, sex, and prior hospitalizations; expect ~40 mL/yr average FEV1 decline. Screen mental health routinely (HADS, PHQ-9, GAD-7). Build multidisciplinary pathways; consider brief CBT-style supports embedded in bronchiectasis clinics, with targeted referrals. Registry data ≠ RCTs: Use for counseling and service design, but avoid causal claims. Research/implementation gaps highlighted Long-term safety/efficacy and subgroup effects for brensocatib (adolescents, asthma/COPD overlap). Phase 3 confirmation for cathepsin C inhibition and dose selection. Granular NTM phenotyping (colonization vs disease) to reconcile paradoxical exacerbation signals. Scalable mental-health interventions integrated into respiratory clinics; trials to test impact on exacerbations/hospitalizations. Pro tip from the episode When appraising trials, check the CONSORT diagram for generalizability and look for stratification methods in multinational RCTs; in phase 2 programs, expect model-based dose–response designs that trade breadth for power.

Dr. Vishwajit Hegde, a second-year Pulmonary and Critical Care fellow, shares a captivating case of a 26-year-old with chronic cough and pulmonary nodules. Dr. Sahil Pandya, an Associate Professor and program director, dives into diagnostic strategies, emphasizing a Bayesian approach to avoid premature conclusions. They discuss interpreting intricate imaging patterns and the decision-making process for bronchoscopic tissue sampling. The big reveal? A diagnosis of miliary lung adenocarcinoma leading to a targeted therapy breakthrough. Insights into KU's fellowship culture shine as both guests emphasize mentorship and trainee education.

Dive into the complexities of Immune Checkpoint Inhibitor Pneumonitis, a growing concern in oncology due to increased immunotherapy usage. Discover essential diagnostic strategies, including how to identify respiratory symptoms in patients on immunotherapy. Learn about the varying CT findings and the importance of ruling out infections. The hosts break down treatment protocols for different severity levels and explore alternative options when steroids aren't enough. This engaging discussion sheds light on emerging therapies and the need for teamwork in managing these cases.

Join Jim Devanney, a physiatrist transitioning to a role at the University Health Network, and Kalilah Pais, a third-year internal medicine resident passionate about critical care. They dive into the often-overlooked issue of ICU Acquired Weakness, detailing its clinical presentation and potential causes. A compelling case study reveals the significant challenges faced by a sepsis patient experiencing muscle weakness. The duo emphasizes the importance of systematic diagnosis and early intervention strategies to improve recovery in critical care settings.

Chris Kapp, an interventional pulmonologist at Northwestern, shares invaluable insights on managing pleural effusions. He discusses the importance of thoracentesis and pleural fluid analysis, emphasizing accurate diagnosis with the LIGHTS criteria. Kapp clarifies the distinctions between transudative and exudative effusions and explains the role of pleural pH and cell counts in clinical assessment. He also delves into diagnostic challenges like eosinophilic effusions and the significance of adenosine deaminase in identifying tuberculosis pleuritis.

In this fascinating discussion, Matt Freedman, a pulmonary fellow at UVA, presents the complex case of an immunocompromised patient suffering from respiratory failure. Joining him are fellow doctors John Popovich, who discusses diagnostic strategies, and Tim Scialla, who offers insights on bronchoscopy and shock assessment. They delve into challenges of diagnosing ARDS in immunosuppressed patients, weighing the risks of steroids against potential infections, and the intricacies of shock evaluation using POCUS. Their expert commentary reveals the nuances of critical care management.

Today is our third episode in our collaborative series with BMJ Thorax. Our mission at Pulm PEEPs is to disseminate and promote pulmonary and critical care education, and we highly value the importance of peer reviewed journals in this endeavor. Each month in BMJ Thorax, a journal club is published looking at high yield and impactful publications in pulmonary medicine. We will be putting out quarterly episodes in association with Thorax to discuss a journal club publication and synthesize four valuable papers. This week’s episode covers four articles related to obstructive sleep apnea therapies, and the use of non-invasive ventilation and high flow nasal cannula for intubation and COPD exacerbations. Meet Our Guests Chris Turnbull is an Associate Editor for Education at Thorax. He is an Honorary Researcher and Respiratory Medicine Consultant at Oxford University Hospitals. In addition to his role as Associate Editor for Education at BMJ Thorax, he is also a prominent researcher in sleep-related breathing disorders. Natalie McLeod is  a resident in respiratory medicine and is currently doing a clinical fellowship in sleep and ventilation at Oxford University Hospitals. Journal Club Papers Journal club article from Thorax Effect of CPAP therapy on blood pressure in patients with obstructive sleep apnoea: a worldwide individual patient data meta-analysis Hypoglossal nerve stimulation for obstructive sleep apnea in adults: An updated systematic review and meta-analysis Noninvasive Ventilation for Preoxygenation during Emergency Intubation Nasal high flow or noninvasive ventilation? navigating hypercapnic COPD exacerbation treatment: A randomized noninferiority clinical trial To submit a journal club article of your own to Thorax, you can contact Chris directly – christopher.turnbull@ouh.nhs.uk To engage with Thorax, please use the social media channels (Twitter – @ThoraxBMJ; Facebook – Thorax.BMJ) and subscribe on your preferred platform, to get the latest episodes directly on your device each month.

Dive into the NAVIGATOR trial as experts discuss tezepelumab, a game-changing monoclonal antibody for treating non-allergic asthma. Learn about the trial's design, significant outcomes, and the challenges of asthma exacerbation management. The conversation shifts to the importance of phenotyping patients to tailor treatments based on their unique inflammatory pathways. Discover the drug’s safety profile and the mild adverse effects reported, primarily among those on placebo. It’s a fascinating look at improving asthma therapies!

We are podcasting today directly from ATS 2025 in San Francisco! Every year, in collaboration with the ATS Critical Care Assembly, we highlight some of the scientific symposium programming from the conference. Today, Furf and Monty sit down with the three chairs of the scientific symposium entitled: Mechanical Ventilation of the Future: New Foundations For Ventilator Strategies. Meet Our Guests Juliana Ferreira is an Associate Professor at the University of Sao Paulo, Brazil where she is also co-director of the pulmonary and critical care fellowship program. She is an MD, PhD, and a physician scientist with specific interests in mechanical ventilation and medical education. Finally, she serves ATS as the ATS MECOR Latin America Director. Bhakti Patel is an Assistant Professor Medicine at the University of Chicago. She is a dedicated researcher and educator. Her research focuses on non-invasive ventilator support. Akram Khan is an Associate Professor of Medicine at Oregon Health and Science University. Akram is a pulmonary, critical care, and sleep provider with specific clinical interests in critical illness, pulmonary vascular disease and sleep apnea. Additionally, he is an accomplished translational science researcher.