Pulmonary arteriovenous malformations (PAVMs) require therapeutic embolization and careful surveillance to prevent serious complications including stroke, brain abscess, and hemoptysis. While initial treatment guidelines are well established, post-treatment surveillance practices remain heterogeneous, with no standardized approach for monitoring treated lesions or detecting PAVM persistence. This variability in follow-up care may impact patient outcomes, particularly in high-risk populations such as those with Hereditary Hemorrhagic Telangiectasia (HHT).

Establishing the cause of a pleural effusion can be challenging. Analysis of pleural fluid is a powerful tool to determine the etiology of a pleural effusion. Surprisingly, despite the diagnostic power pleural fluid analysis (PFA), it is often underused. The purpose of this review is to provide a practical framework to maximize the diagnostic potential of the PFA. In this manuscript we will describe the role of a PFA in establishing the cause of a pleural effusion. We will also discuss challenges and limitations of PFA.

Challenges facing health care professionals (HCPs) in selecting an inhaled medication-delivery system for patients with chronic obstructive pulmonary disease (COPD) include: 1. numerous maintenance medications and combinations; 2. at least 22 different handheld inhaler devices; 3. management recommendations focusing mainly on classes of medications; 4. lack of knowledge about available medications/combinations, delivery systems, and guidelines/expert recommendations for treating patients with COPD; 5. in some countries, contracts between health insurance and pharmaceutical companies limit which medications-devices are covered. In this article we address three considerations for HCPs related to treating patients with COPD: selecting an inhaled delivery system; assessing whether the inhaled medication-device has provided symptomatic benefit; and providing educational materials for patients on how to use their prescribed medication-device correctly. Four patient cases are presented to illustrate these clinical aspects. The main patient factors for selecting an inhaled delivery system include cognitive function, manual dexterity, and inhalation ability. Continuity of the type of handheld inhaler can be beneficial if the patient is using it correctly. To assess the efficacy of the inhaled medication-device at follow-up, HCPs can ask the patient, "Does your current treatment help your breathing?" If the response is Yes, it is appropriate to continue the therapy and to also review inhaler technique; if the response is No, then the next step is to assess the patient's inhaler technique as well as adherence. If the patient demonstrates and/or describes good technique, is adherent, and does not report subjective benefit, it is reasonable to change the medication and/or device.

Pulmonary embolism (PE) is one of the leading causes of pregnancy-related deaths in high-income countries. Maternal mortality from PE has been attributed to delayed recognition and investigations. The diagnosis of PE may be challenging, as its early signs and symptoms may overlap with physiologic changes of pregnancy. As such, promptly ruling out suspected PE using diagnostic testing is of paramount importance. In this narrative review, we provide a contemporary overview of risk assessment tools, diagnostic modalities, counseling needs, and existing best practice guidance for the diagnosis of PE in pregnancy.

Right heart catheterization (RHC) is the gold standard for the diagnosis of pulmonary hypertension (PH). There are variations in practice and several pitfalls introducing errors in diagnosis that can significantly impact treatment. Errors in assessing the correct pulmonary artery wedge pressure (PAWP) can significantly affect accurate classification of patients with pulmonary hypertension, and lead to potentially deleterious treatment decisions. This review focuses on best practices in RHC performance, emphasizing practical and pathophysiologic principles to obtain the most accurate result, as well as advanced applications in PH.

From screening to treatment, the continuum of lung cancer reflects unequal access and delivery, with more vulnerable patients less able to receive high-quality care. Despite great advances in lung cancer care (eg, screening and nodule programs to identify early-stage disease and immune-mediated and targeted therapies for advanced-stage disease), disparities persist both in the United States and globally. In this narrative review, the spectrum of disparities that influence lung cancer care on a national scale, including race, ethnicity, age, socioeconomic status, geographic location, and insurance access, are explored. The review focuses on how disparities impact screening efforts and lung cancer treatments. Where data are available, trends on a global scale are addressed. Potential solutions are offered to address recognized disparities, primarily by identifying pertinent social determinants of health and launching multipronged interventions to improve the care of all patients with lung cancer.

Lung transplantation (LTx) remains the ultimate treatment for many patients with advanced lung disease. Although the age cutoffs for LTx have been debated due to variable outcomes, the number of LTx procedures performed on patients aged ≥ 65 years has significantly increased in recent decades, reflecting the realities of an aging demographic. This trend underscores the unique management challenges faced by this cohort and highlights the importance of addressing evidence gaps in their perioperative and postoperative care.

Coronary artery calcification (CAC) can be a significant incidental finding on low-dose computed tomography (CT) scans performed for lung cancer screening (LCS). CAC presence and grade hold important diagnostic, and preventive value, particularly in patients without previously recognized coronary artery disease. This scoping review describes the prevalence of CAC as an incidental finding on LCS CT scans across prior studies and identifies directions for future research.

Improved childhood management strategies have decreased the early life morbidity and mortality of severe developmental lung disorders, such that an increasing number of individuals ultimately transition care to adult pulmonologists for management. Alternatively, individuals with milder malformations may present in adulthood or may have an increased risk for the development of more common adult pulmonary comorbidities (eg, COPD, pulmonary hypertension). As such, there is a critical need for adult pulmonologists to understand how developmental lung disorders may impact respiratory morbidity over the lifespan.

High-flow nasal cannula (HFNC) is a first-line therapy for patients with acute respiratory failure. Despite increased HFNC utilization over recent years-accelerated in part by the COVID-19 pandemic-high-quality evidence to guide HFNC discontinuation is lacking. Decisions about when and how quickly to reduce flow rate, Fio2, or both simultaneously are frequently left to clinicians' discretion without clear guidance on an optimal approach. Failure to de-escalate HFNC support when clinically appropriate has many potential consequences, such as prolongation of ICU/hospital length of stay, increased health care costs, and reduced availability of limited hospital resources. With the goal of improving care efficiency and resource utilization among hospitalized patients with acute respiratory failure, we propose a standardized approach for HFNC discontinuation focused on "liberation" (similar to spontaneous breathing trials for patients undergoing mechanical ventilation), using a stepwise approach guided by physiology.

Millions of people around the world survive critical illness each year only to realize that they and their loved ones are grappling with a new "normal" after hospital discharge for which their medical team may not have adequately prepared them. Up to one-half of all ICU survivors suffer from new or worsening impairments in physical, cognitive, and psychological domains of health that are often not realized until they attempt to re-enter their previous lives. These devastating long-term sequelae of critical illness, collectively described as post-intensive care syndrome (PICS), can carry enormous consequences for an ICU survivor's ability to care for their family, return to work, and regain their previous quality of life for months to years after their inciting illness. Despite mounting research on PICS and survivorship, a knowledge gap exists whereby ICU team members may not always be aware of PICS and may not counsel their patients on the challenges awaiting them after discharge. Understanding how best to communicate these challenges to patients and families is crucial in preparing for survivorship beyond the ICU. In this review, we summarize PICS and possible recovery trajectories of ICU survivors. We then discuss communication strategies, emphasizing the role of empathy. Finally, we provide a suggested framework to handle these crucial conversations. We aim to equip clinicians with the knowledge and framework to care for a patient who has survived critical illness but now faces the possibility of struggles inadequately addressed by our health care system.

Alpha-1-antitrypsin (A1AT) deficiency is a common hereditary disorder associated with increased risk of developing chronic obstructive pulmonary disease (COPD). Many individuals with severe A1AT deficiency go undiagnosed, or are diagnosed late, and fail to benefit from disease-specific counseling and modifying care. Since the 2012 Canadian Thoracic Society (CTS) A1AT deficiency clinical practice guideline, new approaches to optimal diagnosis using modern genetic testing and studies of A1AT augmentation therapy have been published. We performed a systematic review and meta-analysis, which along with expert clinical input, informed recommendations. We conditionally recommend testing for A1AT deficiency in all individuals with COPD at the time of diagnosis, individuals with adult-onset asthma with persistent airway obstruction, and individuals with unexplained bronchiectasis. We suggest genetic testing with DNA sequencing of SERPINA1 gene as the initial test for individuals with high clinical suspicion for A1AT deficiency, and initial measurement of serum A1AT levels in individuals with moderate clinical suspicion of A1AT deficiency, followed by genetic testing with DNA sequencing of SERPINA1 gene if A1AT level is <23 μmol/L (<1.2 g/L). Following identification of an abnormal gene for A1AT in individuals, whether heterozygote or homozygote, we suggest first-degree relatives be provided genetic counseling and offered testing for A1AT deficiency. The panel conditionally recommends A1AT augmentation therapy to patients who do not smoke or who formerly smoked with COPD (forced expiratory volume in 1 s [FEV1] < 80% predicted; associated with emphysema), with documented deficiency genotypes and severely reduced A1AT level (< 11 μmol/L or < 0.57 g/L) in addition to receiving optimal pharmacological and nonpharmacological therapies for COPD.

Education and psychosocial support are essential components of pulmonary rehabilitation (PR). However, the delivery of education often follows a one-size-fits-all approach, with individual factors that influence learning rarely considered. Moreover, education-related outcomes are frequently overlooked in PR assessments, and their inconsistent use has limited our understanding of education's impact on people with chronic respiratory diseases. There is a clear need for practical guidance to identify key learning determinants and to define targeted education outcomes, ultimately optmizing PR and establishing quality standards.

Accurate assessment of a patient's volume status is crucial in many conditions, informing decisions on fluid prescribing, vasoactive agents, and decongestive therapies. Determining a patient's volume status is challenging because of limitations in examination and investigations and the complexities of fluid homeostasis in disease states. Point-of-care ultrasound (POCUS) is useful in assessing hemodynamic parameters related to volume status, fluid responsiveness, and fluid tolerance. It requires understanding several physiologic concepts to interpret and integrate POCUS findings accurately into volume-related clinical decision-making.

The prevalence of chronic respiratory diseases is increasing globally. There is evidence that those with spirometric impairment and no signs of obstruction (termed preserved ratio impaired spirometry [PRISm]) have an increased risk of morbidity and mortality compared with those with normal lung function. Several gaps remain in characterizing PRISm.

The small airways comprise generations 8 to 23 of the bronchial tree, consist of airways with an internal diameter < 2 mm, and are classically difficult to assess and treat in persistent asthma. Small airways dysfunction (SAD) is integral to the asthma management paradigm because it is associated with poorer symptom control and greater levels of type 2 inflammation, and it has been proposed as a potentially treatable asthma trait. Although identification of SAD based on oscillometry has been found to be clinically useful in managing asthma, very few physicians, including specialists, use this technique as part of standard or adjunct evaluation of lung function to diagnose asthma, grade severity of airway obstruction, ascertain disease control or the risk for future exacerbations, or to make management decisions. To rectify the unrecognized value of oscillometry in the asthma community, a consortium of authors who are investigators with knowledge and experience of oscillometry wished to address the most important clinical questions raised by our colleagues who are considering using this technique, including its clinical utility. In this article, we discuss integral concepts, including applicability of oscillometry as a predictive tool for asthma exacerbations and disease control, adequacy of spirometry and oscillometry in assessing SAD, potential limitations of oscillometry, and treatment options for SAD.

When an understanding of pathogenesis exists, skin lesions that have the appearance of blood in the skin can provide insight into the mechanisms leading to a systemic process that results in cutaneous manifestations. Of the vascular disturbances of the skin that occur in patients who are critically ill, some result from a nonhemorrhagic process, whereas others represent bleeding into the skin. The lesions of livedo, petechiae, purpura, and ecchymoses can be approached from such a perspective. In their most characteristic forms, they develop because of problems with platelets, blood vessels, and hypocoagulability. The tactile component of palpability in their clinical evaluation can denote that inflammation is part of the process. The goal of this review is to provide a conceptual approach not only to the diagnosis of vascular disturbances of the skin, but also to the pathophysiologic processes occurring that might offer clues to the underlying disease process.

Pulmonary vascular disease (PVD), and in particular, pulmonary hypertension (PH), is a highly specialized area of medicine comprising complex diagnostics, classification systems, risk assessment tools, and therapeutics, the correct application of which has been shown to impact patient outcomes. The PVD scientific and patient community recognizes the importance of standardization of care patterns and thus has implemented a clinical accreditation process for PH care centers across the United States. However, a similar standardization system is lacking in PVD subspecialty provider training. Non-Accreditation Council for Graduate Medical Education PVD advanced fellowships exist nationally, but do not provide a unified approach to trainee education. Therefore, first, a survey of all Pulmonary Hypertension Association-accredited center directors across the United States was performed to gauge interest in a standardized educational initiative in the field of PVD. Second, the National Consortium on Pulmonary Vascular Disease Fellowship Training was founded to establish a common curriculum and set of training requirements across PVD programs in the United States. A particular emphasis was placed on the training requirements for provider competency in PH because (1) reliable access to patients with PH could be supported by all consortium institutions and (2) the consortium members believed that national PH training curricula lacked standardization and detail. This article provides the results of the national survey, a guideline summary of the fellowship curriculum and training requirements, and a discussion of the impact of the consortium on PVD training and on the PVD subspecialty as a potential emerging formal discipline in internal medicine.

Coccidioidomycosis, caused by the dimorphic fungi Coccidioides immitis and Coccidioides posadasii, is recognized as an increasing threat both nationally and worldwide. This is in large part secondary to the expanding range of Coccidioides species and increased international travel to endemic regions. Most individuals exposed to airborne Coccidioides organisms do not need medical attention, but approximately 30% will demonstrate primary pulmonary coccidioidomycosis with signs and symptoms that mimic community-acquired pneumonia or other respiratory illnesses. Further, 5% of those with a diagnosis of pulmonary coccidioidomycosis will demonstrate serious and even life-threatening manifestations, including extrapulmonary or disseminated coccidioidomycosis. Of those who demonstrate pulmonary coccidioidomycosis, past evidence suggests that approximately 5% to 15% will experience long-term pulmonary sequelae in the form of nodules, abscesses, or cavitary lesions. These lesions may not be easily distinguished from malignancy or other infections, such as TB, and they add a substantial burden to both patients and the health care system. Despite the long-term consequences of cavitary coccidioidomycosis in some individuals, the current literature review and practice guidelines demonstrate a paucity of clear management strategies to treat these patients. In this report, we focus on cavitary lesions in coccidioidomycosis with the goal of presenting a description of the evaluation and management of their various forms, manifestations, and complications. These recommendations are derived from a multidisciplinary group of experts.

Annual lung cancer screening using low-dose CT (LDCT) imaging effectively reduces mortality from lung cancer and is recommended for people who are at high risk of developing the disease. The utilization of lung cancer screening, however, has remained low. Due to significantly higher cigarette smoking rates, patients with behavioral health disorders (those living with mental illness and/or substance use disorders) are more likely to be diagnosed with and die of lung cancer; at the same time, they are less likely to undergo cancer screenings. There is an urgent need for targeted efforts to improve access to lung cancer screening among this population disproportionately affected by the disease. In this commentary, we propose integrating lung cancer screening facilitation into services provided by behavioral health professionals who are uniquely positioned to reach these patients and deliver interventions to increase uptake of cancer screenings. We suggest several measures that could improve lung health outcomes of patients with behavioral health disorders: (1) training behavioral health professionals in lung cancer screening eligibility assessment; (2) providing patients with educational materials; (3) integrating shared decision-making counseling for lung cancer screening into behavioral health care settings; (4) providing the practical support needed to access screening; and (5) establishing effective partnerships with community organizations. Regardless of the level of engagement, possibly ranging from brief training to the implementation of comprehensive programs, any involvement will benefit patients. This integrated approach will contribute to reducing lung cancer mortality among patients with behavioral health disorders who have long experienced systemic health inequities.