Adjunctive strategies are an important part of the management of ARDS. However, their application in clinical practice remains inconsistent.

Ultrasound studies to detect DVT are traditionally performed and interpreted by sonographers and radiologists, respectively, but the growth of point-of-care ultrasound is putting this powerful tool in the hands of front-line physicians. Literature from ambulatory patients in the ED suggests this tool performs well in the hands of nonconventional users, and it is now being commonly deployed to aid in the management of critically ill patients. This article presents an approach for incorporating these tools into bedside practice, including illustrative figures and narrated video presentations to demonstrate the techniques described.

Idiopathic pulmonary fibrosis (IPF) is a disease with a male predominance. Prior data suggest that male sex is associated with disease progression and survival. The basis for this sex difference is unknown.

In early 2018, the Centers for Medicare & Medicaid Services released the Medical Review of Evaluation and Management (E/M) Documentation, which allows supervising teaching physicians to rely on a medical student's documentation to support billing for E/M services. This change has potential to enhance education, clinical documentation quality, and the satisfaction of students, postgraduate trainees, and teaching physicians. However, its practical adoption presents many challenges that must be navigated successfully to realize these important goals in compliance with federal and local requirements, while avoiding unintended downstream problems. Implementation requires careful planning, policy creation, education, and monitoring, all with collaboration between institutional leaders, compliance and information technology professionals, educators, and learners. In this paper, we review the 2018 Centers for Medicare & Medicaid Services rule change, address common questions and potential impacts, outline practical workflows to meet the supervision requirement, and discuss steps for successful implementation.

Providing guideline-concordant management of pulmonary nodules can present challenges when a patient's anxiety about cancer or fear of invasive procedures colors judgment. The way in which providers discuss and make decisions about how to evaluate a pulmonary nodule can affect patient satisfaction, distress, and adherence to evaluation. This article discusses the complexity of tailoring patient-provider communication, decision-making, and implementation of guidelines for pulmonary nodule evaluation to the individual patient, emphasizing the importance of how information is conveyed and the value of listening to and addressing patients' concerns. We summarize the relevant guideline recommendations and literature, and provide two case scenarios to illustrate a patient-centered approach to discussing and managing pulmonary nodules from our perspectives as a pulmonologist and thoracic surgeon.

Portable monitoring is a convenient means for diagnosing sleep apnea. However, data on whether one night of monitoring is sufficiently precise for the diagnosis of sleep apnea are limited.

Pulmonary capillary stress failure is potentially involved in exercise-induced hypoxemia (ie, a significant fall in hemoglobin oxygen saturation [Spo2]) during sea level exercise in endurance-trained athletes. It is unknown whether there are specific properties of pulmonary vascular function in athletes exhibiting oxygen desaturation.

Transbronchial lung biopsies are commonly performed for a variety of indications. Although generally well tolerated, complications such as bleeding do occur. Description of bleeding severity is crucial both clinically and in research trials; to date, there is no validated scale that is widely accepted for this purpose. Can a simple, reproducible tool for categorizing the severity of bleeding after transbronchial biopsy be created?

Drowning is still a major cause of accidental death worldwide. In 1997, Szpilman proposed a classification of drowning that has become the reference. As considerable efforts have been made to improve prevention and care, it seemed appropriate to reassess the prognosis and clinical presentation of drowning patients more than 20 years after this first publication. The aim of this study is to provide a reappraisal of patients who need advanced health care and a precise description of their respective neurologic, respiratory, and hemodynamic profiles.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare lung disease associated with proliferation of neuroendocrine cells in the lung and multifocal neuroendocrine tumorlets/tumors. Although usually considered an indolent condition, DIPNECH causes chronic, progressive cough and dyspnea which can adversely impact quality of life. There is very limited information on the treatment of this condition. The objective of this study was to assess changes in symptoms and pulmonary function tests (PFTs) in response to somatostatin analog (SSA) treatment.

Signs of both motor and sensory nervous lesions have previously been shown in the upper airway of patients with OSA and habitual snorers. Snoring per se may damage all upper airway neurons over time, thereby causing progression to manifest sleep apnea. To test this hypothesis, nonsnoring subjects, untreated snorers, and CPAP-treated patients underwent repeated sensory testing of the soft palate in a prospective long-term study.

Idiopathic inflammatory myopathies are autoimmune processes that are characterized by skeletal muscle inflammation. The lung is the most commonly involved extramuscular organ, and, when present, pulmonary disease drives morbidity and mortality. A subset of patients can present with rapidly progressive hypoxemic respiratory failure due to myositis-related interstitial lung disease. Confirmatory autoantibody testing requires sending samples to a reference laboratory; thus, diagnosis of rapidly progressive myositis-associated interstitial lung disease relies on a high index of suspicion and careful history and physical examination. Although the cornerstone of therapy for these patients remains multimodality immunosuppression, emerging data support a role for advanced therapies (including extracorporeal membrane oxygenation and lung transplantation) in appropriately selected patients. It is hoped that greater awareness of the clinical features of this syndrome will allow for appropriate diagnosis and treatment of these potentially treatable patients, as well as raise awareness of the need for multicenter collaboration to prospectively study how to manage this complex disease.

There is increasing evidence that COPD is a disease of accelerated lung aging, with the accumulation of senescent cells that lose their ability to repair and secrete multiple inflammatory proteins known as the senescence-associated secretory phenotype (SASP), which mimic the profile of inflammatory mediators secreted in COPD. This review discusses novel drugs (senotherapies) that target cellular senescence and which may be a promising therapeutic approach to prevent currently unaddressed disease progression and mortality in COPD. A major pathway leading to senescence is via the activation of phosphoinositide-3-kinase/mammalian target of rapamycin signaling. Existing drugs, such as rapamycin and metformin, target this pathway. Mitochondrial oxidative stress is a key driving mechanism for this pathway, and mitochondria-targeted antioxidants are promising. A key finding in COPD is loss of antiaging molecules such as sirtuin-1 and sirtuin-6, which are reduced by phosphoinositide-3-kinase/mammalian target of rapamycin signaling through microRNA-34a. Sirtuin activators are in development, and inhibiting microRNA-34a restores sirtuin expression experimentally in COPD cells. Senolytic therapies induce apoptosis and removal of senescent cells and reduce the senescence-associated secretory phenotype response in animal models of aging and in pilot clinical studies of other age-related diseases. A combination of senolytics and senostatics (drugs that inhibit cellular senescence) may be a valuable new approach to COPD, especially if started early in the disease process. Furthermore, COPD is associated with several comorbidities that share the same aging pathways which may be spread by extracellular vesicles, and thus a single treatment for all these diseases is feasible in the future to extend health span.

Guidelines for clinical documentation of evaluation and management face-to-face services were developed > 20 years ago. Recently, the Centers for Medicare & Medicaid Services (CMS) have addressed office and other outpatient services and the corresponding reimbursement, intending to reduce the amount of required documentation and to alleviate clerical burden. A CMS final rule for 2021 will eliminate the history and physical examination as criteria for level of service, allow time or medical decision-making to be used as coding criteria, and will recognize a code for prolonged service. The net effect of these changes may be some decrease in documentation burden, a change in the composition of clinical notes, and greater recognition by CMS of primary care and those who see highly complex patients requiring prolonged services.

Lung cancer screening, despite its proven mortality benefit, remains vastly underutilized. Previous studies examined knowledge, attitudes, and beliefs to better understand the reasons underlying the low screening rates. These investigations may have limited generalizability because of traditional participant recruitment strategies and examining only subpopulations eligible for screening. The current study used crowdsourcing to recruit a broader population to assess these factors in a potentially more general population.

A 49-year-old man was sent by his primary care physician to the rheumatology clinic with complaints of several months of bilateral lower extremity swelling. The swelling migrated from both ankles up to his knees. Presenting symptoms consisted of bilateral knee pain as well as bilateral wrist and hand pain with swelling. Pulmonary symptoms consisted of a nagging productive cough of several months. He also complained of significant weight loss: 50 pounds over 12 months. He was a never smoker. The examination was notable for bilateral knee effusions. Radiographs of his wrists, hands, and knee were obtained, along with a chest radiograph. He was then referred to a pulmonologist for further workup.

A 72-year-old man presented to our ED less than 24 hours following the acute onset of nausea, vomiting, and diarrhea. Within 12 hours of symptom onset, he noted bilateral lower extremity pain and swelling. His pain was associated with a new violaceous irregular rash on the anterior aspect of both feet and legs. There was no history of inciting trauma or recent wounds. In addition, there was no history of consumption of raw or undercooked food (including seafood) or recent change in food source. There was accompanying fever and chills for the same duration and painful swelling of his left thumb. His comorbidities included stage IIIb classical Hodgkin lymphoma diagnosed 4 months prior. His last dose of doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy was 4 days before presentation. He had previously failed anti-CD30 monoclonal therapy resulting from attributed pancolitis.