Simulation-Based Medical Education (SBME) is a learning tool for healthcare providers and medical teams. Despite widespread use across health systems and teaching hospitals, instructional guidelines and standardized approaches for its implementation are lacking. Furthermore, the diversity of techniques, methods, and curricula introduces variability in simulation program design. Many programs remain isolated within individual clinical units or departments and seldom integrate multidisciplinary teams, which limits opportunities for collaboration or system-level learning. We describe our critical care SBME program, ICU UNITED, at Seattle Children's Hospital and how it fits within the simulation landscape while addressing many SBME shortcomings. ICU UNITED is an innovative, cross-unit simulation program that integrates in situ sessions through a shared resource model across the pediatric, cardiac, and neonatal intensive care units. We present an instructional framework for longitudinal program organization and individual session design, emphasizing clear scenario objectives, learner participation, and measures of participant satisfaction to support program sustainability. This framework provides a pragmatic model for programs seeking to grow, develop, or expand an interdisciplinary simulation program capable of assessing and addressing system-level challenges.

Recurrent venous thromboembolism (rVTE) occurring during therapeutic anticoagulation represents a clinically challenging and high-risk condition.

Non-cystic fibrosis bronchiectasis (NCFB) is a heterogeneous chronic airway disease increasingly recognized worldwide and associated with a substantial burden of extra-pulmonary manifestations. Osteoporosis has emerged as a highly prevalent yet underappreciated comorbidity. Unlike cystic fibrosis, where bone health guidelines exist, no screening or management recommendations are available for NCFB despite overlapping risk factors, including chronic inflammation, malnutrition, hypoxia, medication exposure, and physical inactivity.

Dysregulated calcium and vitamin D metabolism poses unique challenges for clinicians caring for patients with sarcoidosis. These patients often require supplementation to support their metabolic bone health, yet such interventions may theoretically increase the risk of hypercalcemia and hypercalciuria, along with their associated complications. This article presents four clinical vignettes that illustrate common dilemmas encountered in managing these patients.

Low-dose computed tomography (LDCT) has been established in the past decade as an important and effective tool for lung cancer screening (LCS) in high-risk individuals, with large trials demonstrating significant lung cancer mortality reduction. Beyond pulmonary nodules, LDCT frequently detects a range of smoking-related additional findings, including emphysema, coronary artery calcium, interstitial lung abnormalities (ILA), osteoporosis, and sarcopenia. Accordingly, here we review current evidence on the prevalence, prognostic value, and clinical implications of such smoking-related findings in LCS, with a focus on the findings themselves, their relevance in COPD patients, emerging technologies and future directions for integration into screening protocols.

Management of critically ill patients with pulmonary hypertension (PH) presents significant clinical challenges. Regardless of the underlying etiology or chronicity of PH, superimposed acute illness can precipitate decompensated right ventricular failure (RVF) and death. Hospitalization, particularly in the intensive care unit (ICU), is associated with high mortality, with RVF serving as the direct or indirect cause in most cases. In this article we will focus on the management of acute decompensated RVF in patients with known pulmonary arterial hypertension (PAH). ICU management of the PAH patient with RVF centers on the recognition and treatment of potentially reversible precipitants for decompensation and supportive strategies to optimize right ventricular (RV) function. Key goals include maintaining adequate oxygenation and tissue perfusion, correcting electrolyte and other metabolic abnormalities, optimizing fluid balance and RV preload, enhancing RV contractility, and reducing RV afterload. Continuous monitoring of cardiac function is essential, as is identifying and treating potential complications, such as arrhythmias or acute kidney injury (AKI). When RVF persists despite maximal medical therapy, extracorporeal life support may be considered as a bridge to recovery or transplantation. In patients with advanced disease multidisciplinary discussions aligned with patient and family preferences should guide the goals of care. Integration of palliative care specialists to manage symptoms and support caregivers remains a critical component of comprehensive ICU management for patients with PAH.

Pulmonary hypertension (PH) represents a pathophysiologically diverse and clinically intricate spectrum of disorders characterized by elevated pulmonary arterial pressures and progressive right ventricular dysfunction. The management of PH has evolved considerably over recent decades; these developments underscore the dynamic nature of the field and the necessity for continual reappraisal of diagnostic and therapeutic frameworks. The European Society of Cardiology and Respiratory Society (ESC/ERS) and the World Symposium on Pulmonary Hypertension (WSPH) were pivotal in addressing key PH topics, including hemodynamic definitions, disease classification, risk stratification and evolving therapeutic agents, and generating consensus-driven recommendations that shape global clinical practice.

This article addresses the challenges of shared decision-making (SDM) when a patient's request conflicts with accepted medical practice, using the case of Maria, a 72-year-old patient receiving dialysis. Maria, admitted to the ICU, insists on continuing hemodialysis sessions despite symptomatic hypotension and wants to take the herbal supplement Jin Gui Shen Qi Tang (JGSQT). We argue that understanding-the mutual effort by patient and clinician to comprehend each other's reasons, goals, and values-is a foundational element of SDM, superseding the goal of reaching agreement about the preferred intervention. For the JGSQT request, a physician should approach with curiosity and epistemic humility, acknowledging the limits of medical knowledge on alternative treatments. Given the supplement's low risk and Maria's perceived benefit, allowing its use promotes a shared process. Conversely, the request to continue dialysis during symptomatic hypotension poses a significant threat of medical harm, justifying the physician in asserting professional values to stop the session. In both instances, the physician must approach the situation with curiosity and seek truly to understand the patient's perspective and also must explain thoroughly the rationale for a decision to Maria, ensuring that she understands the risks and the basis for the decision while looking for acceptable compromises. Ultimately, although SDM may not always result in a shared final decision, the shared process of mutual understanding ensures a patient-centered approach that respects patient autonomy while acknowledging the ethical limits of autonomous patient requests.

Right heart thrombus (RHT) in the setting of pulmonary embolism (PE) is a uniquely high-risk event. RHT management has not been rigorously studied in clinical trials and is not part of risk stratification schemas for PE. However, it is a major risk factor for clinical deterioration and mortality. There are no guidelines for RHT management, and most practice is based on case series and anecdote. Historically, RHT has been managed with surgical embolectomy or systemic thrombolysis; however, there is now increasing experience with catheter-based mechanical thrombectomy. Furthermore, a subset of patients with RHT can be treated with anticoagulation monotherapy. In this article, the authors use existing evidence for diagnostic tools and outcomes data to provide a practical framework for approaching RHT in the setting of PE.

Transbronchial cryobiopsy has expanded beyond its established role in interstitial lung disease, driven by release of single-use cryoprobes, most notably the 1.1 mm cryoprobe. As use of transbronchial cryobiopsy accelerates across non-interstitial lung disease diagnostic contexts, practice variability has outpaced evidence generation and formal guidance.

The integration of molecular and anatomic imaging-particularly via modalities such as PET/CT scan, PET/MRI scan, and emerging total-body PET scan-has significantly advanced the detection, characterization, and personalized treatment of both oncological and nononcological pulmonary diseases.

Access to polysomnography, the recommended standard for the diagnosis of obstructive sleep apnea (OSA) in children, is limited in many jurisdictions. Many children undergo treatment for OSA without confirmatory testing, are denied treatment in the absence of testing, or have a delay in treatment of other sleep disorders until OSA can be ruled out.

Pulmonary aspergilloma are characterized by a fungal ball that forms in a preexisting lung cavity. Although many patients remain asymptomatic, others may develop progressive symptoms including cough, hemoptysis, weight loss, fever, and, in severe cases, death. Management is often complex and highly patient-centered, ranging from routine surveillance in stable patients to invasive procedural or surgical approaches in those with more severe disease. Systemic antifungal therapy is generally not indicated for stable, asymptomatic simple aspergilloma but may be considered in select scenarios such as symptomatic or progressive disease in nonsurgical candidates, periprocedural/perioperative settings, or when overlapping chronic pulmonary aspergillosis phenotypes (eg, chronic cavitary pulmonary aspergillosis) are suspected. However, despite the significant morbidity and mortality associated with pulmonary mycetoma, there is a paucity in our understanding of their natural course, optimal treatment modalities and duration, appropriate follow-up plan, and prognostication. Consequently, clinical decision-making is frequently based on clinician experience or institutional protocols. In this article, we provide a comprehensive review of pulmonary aspergilloma and its management, with the goal of presenting a practical and evidence-based framework to support clinicians in the evaluation and treatment of this chronic fungal disease.

Methamphetamine is a potent CNS stimulant that is highly addictive. Although methamphetamine use historically has been localized to the Western United States Census region, its reach has been growing, and methamphetamine use now is expanding throughout the United States and the world. Methamphetamine is now considered a definite cause of pulmonary arterial hypertension (PAH). Despite being one of the fastest growing causes of PAH, recommendations to guide the care of patients with methamphetamine-associated PAH have not been published. This review focuses on the care of patients with methamphetamine-associated PAH. It provides a practical approach to care that incorporates pharmacologic therapy in conjunction with harm reduction strategies as well as support from ancillary services such as addiction medicine and social work.

To provide an expert consensus framework for standardizing lung ultrasound training for neonatologists.

As awareness of sleep's role in health grows, consumer sleep technologies (CSTs) have gained wide use among both researchers and the public. These devices offer continuous, noninvasive sleep tracking in real-world environments. However, understanding their accuracy compared with that of polysomnography (PSG), the gold standard in sleep measurement, remains limited, particularly in free-living settings and clinical populations. Assessing CST performance and usability in these contexts is essential for guiding future adoption.

The historic National Lung Screening Trial (NLST) reported lung cancer-specific and all-cause mortality reductions associated with low-dose CT (LDCT) imaging, and nearly all relevant authoritative organizations established guidelines and policies supporting implementation and insurance coverage for individuals who meet eligibility criteria. The immediate challenge became translating results into community settings. Early translation showed substantial challenges to delivery of quality lung cancer screening (LCS). The Kentucky LEADS (Lung Cancer Education Awareness Detection Survivorship) Collaborative developed a comprehensive system to evaluate and support LCS delivery in community contexts with an emphasis on supporting rural and low-resource settings. The QUILS System 1.0 (Quality Implementation of Lung Cancer Screening) featured 4 key components: (1) the QUILS Index 1.0, a quantitatively driven evaluation system assessing quality across 6 essential LCS implementation domains; (2) the QUILS Audit and Feedback Process 1.0, a strategy for providing feedback and guidance to bridge the QUILS Index and the QUILS Resource Portal; (3) the QUILS Resource Portal 1.0, online tools and trainings that are directly tied to components within the QUILS Index 1.0; and (4) the QUILS Technical Assistance and Coaching 1.0, providing additional problem-solving and support upon request. The 6 essential domains included: (1) Screening Eligibility; (2) Radiology Operations; (3) Team Operations; (4) Prevention Efforts; (5) Patient Education; and (6) Community Outreach. To collect initial feedback and evaluate the QUILS System 1.0, the investigative team planned and conducted a rigorous evaluation of this initial framework across 10 sites in Kentucky over an 18-month period.

Patients with neuromuscular disease and other thoracic restrictive disorders are at increased risk of hypoxia during high-altitude travel due to an ineffective hypoxic ventilatory response. Efforts to identify clinical parameters that successfully predict the need for hypoxic challenge testing, a tool used to assess the risk of hypobaric hypoxia, and its outcomes in this population have been inconsistent and limited mainly to small, retrospective studies. Consequently, recommendations regarding the evaluation and management of these patients prior to high-altitude travel have been uncertain and differ across medical societies. We provide a clinical management algorithm for this patient population that draws on the available data.

There is no consensus for identifying ideal candidates for extracorporeal membrane oxygenation (ECMO), a life-sustaining technology that can supply oxygenated blood to a patient whose heart and/or lungs are not properly functioning. Without clear and standardized guidelines, the decision about who to cannulate often falls upon 1 or several clinicians who weigh the procedure's risks and benefits. Limited data, and therefore substantial clinical judgment, guides ECMO candidacy determination, rendering the process particularly susceptible to heuristic-based decision-making and cognitive biases resulting from mental shortcuts. This can lead to candidates being inappropriately accepted or declined for ECMO and suboptimal allocation of a limited resource. This article presents a hypothetical case based on real clinical scenarios highlighting the impact that cognitive biases may play in ECMO candidacy and discussing their potential harms. We argue that ECMO candidacy determination is especially vulnerable to cognitive biases and offer several ways to mitigate their influence on candidacy selection. Our aim was to stimulate the recognition and mitigation of cognitive bias in ECMO deliberations as 1 step toward the standardization of ECMO candidacy determinations, with the goal of achieving more equitable and effective care for patients who would most benefit from this technology.

Multiple clinical and inflammatory risk factors for asthma attacks have been identified, including attack history, comorbidities, blood eosinophil count (BEC), and exhaled nitric oxide (Feno). However, the impact of sex on their prognostic value is unclear.