As outcomes have improved across the hematologic malignancy population, candidacy for ICU admission has increased. This complex population may develop a variety of complications related to their treatment or underlying disease that can result in critical illness necessitating ICU support. This review highlights common causes of critical illness associated with hematologic malignancies, including the following: (1) neutropenic sepsis; (2) hyperleukocytosis and leukostasis across patients with acute myeloid leukemia; (3) complications of acute promyelocytic leukemia; (4) tumor lysis syndrome; and (5) critical care complications that can arise following hematopoietic stem cell transplantation.

Cystic fibrosis (CF) is characterized by chronic airway infection and progressive respiratory decline. Historically, a narrow spectrum of bacterial pathogens was believed to comprise the bulk of respiratory infections in CF, with Haemophilus influenzae and Staphylococcus aureus dominating childhood infections, and Pseudomonas aeruginosa or, less commonly, a member of the Burkholderia cepacia complex becoming the dominant infecting organism in adulthood. Today, the landscape is changing for airway infection in CF. The prevalence of "less typical" gram-negative bacterial infections are rising due to a number of factors: the CF population is aging; new therapies are being introduced; antibiotic usage is increasing; diagnostic tests are evolving; and taxonomic changes are being made as new bacterial species are being discovered. Less is known about the clinical relevance and evidence for treatment strategies for many of the other lower prevalence organisms that are encountered in CF. The aim of this article was to discuss the current evidence and recommended strategies for treating airway infection in CF, focusing on bacterial infections.

The effect of nonobstructive chronic bronchitis (CB) on mortality is unclear.

Predictive analytic models leveraging machine learning methods increasingly have become vital to health care organizations hoping to improve clinical outcomes and the efficiency of care delivery for all patients. Unfortunately, predictive models could harm populations that have experienced interpersonal, institutional, and structural biases. Models learn from historically collected data that could be biased. In addition, bias impacts a model's development, application, and interpretation. We present a strategy to evaluate for and mitigate biases in machine learning models that potentially could create harm. We recommend analyzing for disparities between less and more socially advantaged populations across model performance metrics (eg, accuracy, positive predictive value), patient outcomes, and resource allocation and then identify root causes of the disparities (eg, biased data, interpretation) and brainstorm solutions to address the disparities. This strategy follows the lifecycle of machine learning models in health care, namely, identifying the clinical problem, model design, data collection, model training, model validation, model deployment, and monitoring after deployment. To illustrate this approach, we use a hypothetical case of a health system developing and deploying a machine learning model to predict the risk of mortality in 6 months for patients admitted to the hospital to target a hospital's delivery of palliative care services to those with the highest mortality risk. The core ethical concepts of equity and transparency guide our proposed framework to help ensure the safe and effective use of predictive algorithms in health care to help everyone achieve their best possible health.

Although maintaining some amount of positive end-expiratory pressure (PEEP) seems essential, selecting and titrating a specific level for patients with ARDS remains challenging despite extensive research on the subject. Although an "open lung" approach to ventilation is popular and has some degree of biological plausibility, it is not without risk. Furthermore, there is no clear evidence-based guidance regarding initial PEEP settings or how to titrate them early in the course of the illness. Many busy clinicians use a "one-size-fits-all" approach based on local medical culture, but an individualized approach has the potential to offer significant benefit. Here we present a pragmatic approach based on simple measurements available on all ventilators, focused on achieving balance between the potential risks and benefits of PEEP. Acknowledging "best PEEP" as an impossible goal, we aim for a straightforward method to achieve "better PEEP."

Direct oral anticoagulants (DOACs) are increasingly used in clinical practice and have become essential in the management of atrial fibrillation and VTE. The enthusiasm for DOACs has fueled the off-label application of these agents in cardiopulmonary disease, and their use has often outpaced the evidence supporting their application. This article reviews the evidence and current off-label use of DOACs in various cardiopulmonary disease states.

Basic critical care echocardiography emphasizes two-dimensional (2D) findings, such as ventricular function, inferior vena cava size, and pericardial assessment, while generally excluding quantitative findings and Doppler-based techniques. Although this approach offers advantages, including efficiency and expedited training, it complicates attempts to understand the hemodynamic importance of any 2D abnormalities detected. Stroke volume (SV), as the summative event of the cardiac cycle, is the most pragmatic available indicator through which a clinician can rapidly determine, no matter the 2D findings, whether aberrant cardiac physiology is contributing to the state of shock. An estimate of SV allows 2D findings to be placed into better context in terms of both hemodynamic significance and acuity. This article describes the technique of SV determination, reviews common confounding factors and pitfalls, and suggests a systematic approach for using SV measurements to help integrate important 2D findings into the clinical context.

A cardiopulmonary exercise test (CPET) is ideally suited to quantify exercise tolerance and evaluate the pathophysiological mechanism(s) of dyspnea and exercise limitation in people with chronic respiratory disease. Although there are several statements on CPET and many outstanding resources detailing the cardiorespiratory and perceptual responses to exercise, limited information is available to support the health care provider in conducting a practical CPET evaluation. This article provides the health care provider with practical and timely information on how to use CPET data to understand dyspnea and exercise intolerance in people with chronic respiratory diseases. Information on CPET protocol, as well as how to evaluate maximal patient effort, peak rate of oxygen consumption, ventilatory demand, pulmonary gas exchange, ventilatory reserve, operating lung volumes, and exertional dyspnea, is presented. Two case examples are also described to highlight how these parameters are evaluated to provide a clinical interpretation of CPET data.

Pulmonary embolism (PE) is the most common filling defect seen on CT scan pulmonary angiography. Pulmonary artery (PA) tumors can mimic PE on imaging and clinical presentation. One classic feature of tumors is failure to improve on anticoagulation. PA tumors, particularly malignant ones, have radically different treatments and usually have a grim prognosis. Thus, it is essential that PA tumors, when suspected, receive an expedited confirmatory diagnosis followed by multidisciplinary treatment at an expert center. In this review, we present clinical, imaging, and histopathologic features of benign and malignant PA tumors, emphasizing differentiating features from PE. We also describe available diagnostic and treatment methods for PA tumors.

Organizing pneumonia (OP), characterized histopathologically by patchy filling of alveoli and bronchioles by loose plugs of connective tissue, may be seen in a variety of conditions. These include but are not limited to after an infection, drug reactions, radiation therapy, and collagen vascular diseases. When a specific cause is responsible for this entity, it is referred to as "secondary OP." When an extensive search fails to reveal a cause, it is referred to as "cryptogenic OP" (previously called "bronchiolitis obliterans with OP"), which is a clinical, radiologic, and pathologic entity classified as an interstitial lung disease. The clinical presentation of OP often mimics that of other disorders, such as infection and cancer, which can result in a delay in diagnosis and inappropriate management of the underlying disease. The radiographic presentation of OP is polymorphous but often has subpleural consolidations with air bronchograms or solitary or multiple nodules, which can wax and wane. Diagnosis of OP sometimes requires histopathologic confirmation and exclusion of other possible causes. Treatment usually requires a prolonged steroid course, and disease relapse is common. The aim of this article is to summarize the clinical, radiographic, and histologic presentations of this disease and to provide a practical diagnostic algorithmic approach incorporating clinical history and characteristic imaging patterns.

Lung cancer screening is slowly but steadily entering the realm of preventive health maintenance. Standardization of reporting of positive findings identified on screening low-dose CT (LDCT) scans, specifically lung nodules, is a key element of high-quality lung cancer screening. The American College of Radiology developed the Lung CT Screening Reporting and Data System (Lung-RADS) system for this purpose. In addition to detailed categorization of lung nodules, Lung-RADS identifies category S for other incidental findings identified on screening LDCT scans. In contrast to the highly structured reporting for nodules, category S findings are reported at the discretion of individual readers, with the potential for high variability of reporting. Incidental findings on lung cancer screening studies are common, may trigger unwarranted evaluation with potential harm and cost, and may precipitate patient distress. In response to these concerns, our multidisciplinary lung cancer screening program developed a structured system for standardized reporting of category S findings based on recommendations of the American College of Radiology and relevant specialty societies.

Patients with non-small cell lung cancer (NSCLC) and preexisting interstitial lung disease (ILD) are often excluded from clinical trials of immune checkpoint inhibitors (ICIs), leaving a gap in knowledge.

Initial waves of the COVID-19 pandemic have largely spared children. With the advent of vaccination in many older age groups and the spread of the highly contagious Delta variant, however, children now represent a growing percentage of COVID-19 cases. PICU capacity is far less than that of adult ICUs. Adult ICUs may need to support pediatric care, much as PICUs provided adult care earlier in the pandemic. Critically ill children selected for care in adult settings should be at least 12 years of age and ideally have conditions common in children and adults alike (eg, community-acquired sepsis, trauma). Children with complex, pediatric-specific disorders are best served in PICUs and are not recommended for transfer. The goal of such transfers is to maintain critical capacity for those children in greatest need of the PICU's unique abilities, therefore preserving systems of care for all children.

Hematologic conditions (malignant or benign) may progress to acute critical illness requiring prompt recognition and intensive management. This review outlines diagnostic considerations and approaches to management for intensivists of common benign hematologic emergencies, including the following: thrombotic thrombocytopenic purpura, atypical hemolytic uremic syndrome, disseminated intravascular coagulopathy, catastrophic antiphospholipid antibody syndrome, hemophagocytic lymphohistiocytosis, acute chest syndrome associated with sickle cell disease, and hyperhemolysis syndrome.

Several countries mandate informed or shared decision-making for low-dose CT (LDCT) lung cancer screening, but knowledge is limited about the type of information and presentation techniques used to support decision-making in practice. This review aimed to characterize the content, format, mode, and presentation methods of decision support tools (DSTs) for LDCT lung cancer screening. DSTs reported within peer-reviewed articles (January 2000-April 2021) were identified systematically from PubMed, PsycInfo, EMBASE, and CINAHL Plus. Inclusion criteria revolved around the development or evaluation of a resource or tool intended to support individual or shared decision-making for LDCT lung cancer screening. The data-charting and extraction framework was based on the International Patient Decision Aids Standards instrument and Template for Intervention Description and Reporting. Extracted data were organized within two categories: (1) study characteristics and context, format, and mode of DST use and (2) DST content and presentation methods. This review identified 22 DSTs in paper, video, or electronic formats across 26 articles. Most DSTs (n = 13) focused on knowledge exchange, whereas seven used interactive techniques to support values clarification (eg, Likert scales) and nine DSTs guided deliberation (eg, suggested discussion topics). The DSTs addressed similar topics, but the detail, quantification of probability, and presentation methods varied considerably. None described all the potential screening harms and results. The heterogeneity in DST design may affect the quality of decision-making, particularly for participants with lower literacy and numeracy. Evidence-based consensus guidelines for DST content and presentation methods should be developed collaboratively with screening-eligible adults.

Pleural disease is a common presentation and spans a heterogeneous population across broad disease entities; a common feature is the requirement for interventional procedures. Despite the frequency of such procedures, there is little consensus on rates of complications and risk factors associated with such complications. This narrative review was based on a structured search of the literature. Searches were limited to 2010 onward, in recognition of the transformation in procedural complications following the mainstream use of thoracic ultrasound. Procedures of interest were limited to thoracocentesis, intercostal drains, indwelling pleural catheters (IPCs), and local anesthetic thoracoscopy. A total of 4,308 studies were screened, and 48 studies were identified for inclusion. Iatrogenic pneumothorax remains the most common complication following thoracocentesis (3.3%; 95% CI, 3.2-3.4), although pneumothorax requiring intervention was rare (0.3%; 95% CI, 0.2-0.4) when the procedure was ultrasound guided. Drain blockage and displacement were the most common complications following intercostal drain insertion (6.3% and 6.8%, respectively). IPC-related infections can be a significant problem (5.8%; 95% CI, 5.1-6.7). However, most cases can be managed without removal of the IPC. Local anesthetic thoracoscopy has an overall mortality of 0.1% (95% CI, 0.03-0.3). Data on safety and complication rates in procedural interventions are limited by methodologic problems, and novel methods to study this topic should be considered. Although complications remain rare events, once encountered, they have the potential to rapidly escalate. It is of paramount importance for operators to prepare and have in place plans for such events to ensure high quality and, above all, safe care.

Central sleep apnea (CSA) frequently coexists with heart failure and atrial fibrillation and contributes to cardiovascular disease progression and mortality. A transvenous phrenic nerve stimulation (TPNS) system has been approved for the first time by the Food and Drug Administration for the treatment of CSA. This system, remedē System (Zoll Medical, Inc.), is implanted during a minimally invasive outpatient procedure and has shown a favorable safety and efficacy profile. Currently, patient access to this therapy remains limited by the small number of specialized centers in the United States and the absence of a standard coverage process by insurers. Although a period of evaluation by insurers is expected for new therapies in their early stages, the impact on patients is particularly severe given the already limited treatment options for CSA. Implantation and management of this novel therapy require the establishment of a specialized multidisciplinary program as part of a sleep medicine practice and support from health care systems and hospitals. Several centers in the United States have been successful in building sustainable TPNS programs offering this novel therapy to their patients by navigating the current reimbursement environment. In this article, we review the background and efficacy data of TPNS and briefly address relevant aspects of the clinical activities involved in a TPNS program. The article presents the status of coverage and reimbursement for this novel therapy. We also discuss the current approach to obtaining reimbursement from third-party payors during this transitional period of evaluation by Medicare and other insurers.

Building an efficient facility for advanced bronchoscopic procedures involves many considerations. This review places particular emphasis on anesthesiology services, based on experience at a tertiary/quaternary care referral academic medical center. Topics include equipment requirements, applicable clinical standards, and multidisciplinary collaboration. Patient flow arrangements for both outpatients and inpatients, from preoperative care to discharge/disposition, are highlighted. The importance of effective business planning, personnel training, leadership, communication, team building, quality of care, and patient safety are also discussed.

Improved treatments for cystic fibrosis (CF)-related lung disease have resulted in increased longevity, but also increased prevalence and severity of extrapulmonary manifestations of CF, treatment-related complications, age-related conditions, and psychosocial effects of longstanding chronic disease. Likewise, the recognition of mild CF phenotypes has changed the landscape of CF disease. This review outlines our current understanding of the common extrapulmonary complications of CF, as well as the changing landscape and future directions of the extrapulmonary complications experienced by patients with CF.

COPD is a progressive debilitating disease with diminished quality of life after hospital admissions. Because of the nature of the disease, it is important to address patients' goals of care, preferably prior to the development of refractory COPD. Advance Care Planning (ACP) is an all-encompassing term that involves discussing goals with patients. Various review articles on ACP and COPD focus on the definition of ACP, identification of barriers to addressing ACP, and the use of interventions to incorporate ACP in practice. There is evidence that ACP improves quality of communication, reduces admissions, and increases quality of life, but often the focus of that research has been on patients with cancer. Many of the articles have suggestions for how to apply ACP to chronic lung disease; however, without further research and definitive guidance, obtaining funding for programs dedicated to ACP may be difficult. There are currently no guidelines for addressing ACP in patients with COPD. Research addresses the reason that advance care planning is important, yet there are barriers that patients, families, and health care providers encounter that prevent meaningful discussions. Research has also found that the use of multidisciplinary teams improves care and quality of life; however, research should be dedicated to the investigation of the effects of advance care planning initiatives on outcomes in patients with COPD, particularly in the reduction of hospital admissions and improvement of quality of life. This review seeks to educate providers about end-stage COPD and advance care planning, the evidence that shows the importance of advance care planning, and the current and future state of research.