Interstitial lung diseases (ILDs) are a heterogeneous group of entities characterized by similar clinical, pathologic, and radiologic features. High-resolution CT scan is the first-line imaging modality; however, the use of ionizing radiation in patients requiring several follow-ups, the limitation in distinguishing active inflammation from fibrosis, as well as its poor tissular characterization properties have opened a scenario in which MRI may have a role in patients with ILD. The high prevalence of lung cancer in ILD and the frequently unrecognized ILD-related pulmonary hypertension (PH) have raised interest in the potential application of MRI in these patients.

Follow-up of incidental lung nodules in real-world clinical practice is often inconsistent and suboptimal. Improving these follow-up processes presents a complex challenge, particularly for institutions without existing infrastructure. Although advanced tools such as natural language processing and artificial intelligence hold promise, many successful programs have relied on low-cost, manual approaches tailored to local workflows and resource availability. This article outlines a practical, experience-based framework for enhancing incidental lung nodule follow-up across diverse health care settings-including those with limited resources-by proposing scalable, feasible strategies that help bridge the gap between evidence-based guidelines and routine clinical practice.

The 2009 Family Smoking Prevention and Tobacco Control Act granted the US Food and Drug Administration regulatory authority over tobacco products, extended to include electronic cigarettes (ECs) in 2016. Regulatory science informs potential market restrictions based on the population health standard. The CHEST Tobacco and Vaping Workgroup is charged with prioritizing tobacco-related advocacy. To identify critical gaps in the science guiding EC regulation, wean exploration of existing evidence to develop future research recommendations.

The standard of care for management of asthma attacks has remained unchanged for 70 years, relying on a symptom-based, severity-stratified approach. Severe asthma attacks are defined by a worsening of asthma requiring oral corticosteroid (OCS) treatment for unresolved symptoms for at least 48 hours, decreased lung function, or both. The 1-size-fits-all strategy with OCS treatment overlooks the biological mechanisms driving attacks and may lead to suboptimal outcomes. Importantly, OCS-related toxicities lead to significant morbidity, and cumulative OCS use has been associated with increased mortality. Antibiotics, often used indiscriminately, also increase adverse events and antimicrobial resistance.

The clade 2.3.4.4b highly pathogenic avian influenza (HPAI) virus H5N1 is the etiologic agent for an ongoing panzootic with a rapidly increasing number of human infections. Although morbidity and mortality in humans with this clade seems to be limited to date, previous HPAI H5N1 viruses have been associated with mortality rates of approximately 50% in humans. Not all cases of clade 2.3.4.4b influenza A(H5N1) HPAI in humans have been associated with known exposure to infected animals. Therefore, clinicians must be aware of the changing viral ecology, human risk factors, and clinical presentations associated with H5N1 viruses to facilitate early case recognition and management of clade 2.3.4.4b A(H5N1) HPAI infection in humans.

Pulmonary alveolar proteinosis (PAP) is a rare diffuse lung syndrome characterized by impaired surfactant clearance and alveolar filling, most commonly the result of autoimmune neutralization of granulocyte-macrophage colony-stimulating factor (GM-CSF) by autoantibodies. Whole lung lavage (WLL) remains the cornerstone of treatment, yet procedural practices vary widely across institutions. This report presents a reproducible, evidence-aligned protocol for WLL developed across 2 high-volume centers, detailing perioperative management, technical execution, and follow-up. We describe our approach to patient selection, contraindication screening, anesthesia and airway strategy, and the stepwise lavage process using warmed saline instillation and drainage under general anesthesia with single-lung ventilation. Lavage is performed in 2 staged sessions, guided by effluent clarity and clinical tolerance. Intraoperative challenges such as hypoxemia, fluid spillover, or poor return are anticipated and addressed using structured response algorithms. Postprocedural care includes diuresis, lung re-expansion measures, and early mobilization, with discharge typically within 24 to 48 hours for elective outpatients. Most patients experience rapid improvement in symptoms, gas exchange, and functional capacity; however, recurrence is common, with one-third of patients requiring repeat lavage within 2 to 3 years. Inhaled GM-CSF therapy now is considered after WLL in all eligible patients, especially those with incomplete response or high relapse risk, prolonging remission and reducing the need for subsequent procedures. Our experience supports a combined strategy of lavage, adjunctive therapy, and longitudinal surveillance to achieve sustained disease control. By emphasizing multidisciplinary coordination, individualized risk assessment, and protocolized execution, this framework aims to enhance safety, reproducibility, and long-term monitoring to reduce recurrence and improve outcomes in PAP.

Measurement of blood oxygen saturation (Spo2) and tissue oxygenation (Sto2) is routinely performed in clinical practice. Arterial blood gas analysis, although considered the gold standard for Spo2 estimation, requires arterial puncture, trained personnel, and laboratory backup. Currently, there is a lack of universally accepted and widely used methods for Sto2 measurement. Available noninvasive methods for Spo2 and Sto2 estimation have several limitations. Many technologies are under development to address this unmet clinical need.

Asthma, the most prevalent respiratory condition in pregnancy, affects up to 12% of pregnant women globally and is associated with adverse perinatal outcomes when poorly controlled. Modern asthma management emphasizes achieving clinical remission through personalized, trait-based approaches targeting modifiable risk factors. Insights into the mechanisms of airway inflammation have led to biomarker-directed therapy and the emergence of biologic agents for severe asthma. An evidence review was conducted to evaluate the applicability of these contemporary principles within the context of pregnancy.

Severe asthma affects 5% to 10% of patients with asthma but constitutes close to one-half of the medical costs related to asthma due to higher morbidity and health care utilization. Biologic agents have become a standard of care in those unresponsive to standard treatments yet the choice of biologic agent is complex due to the varying mechanisms of action, efficacies, and lack of head-to-head comparisons. Therefore, clinicians need further clinical guidance to optimize their use.

Over 300,000 patients experience in-hospital cardiac arrest in the United States each year, resulting in substantial morbidity, mortality, and loss of disability-adjusted life years. Although survival after in-hospital cardiac arrest has improved over the past 2 decades, outcomes remain poor and many initial survivors of in-hospital cardiac arrest are discharged with substantial disability. Across the United States, risk-standardized survival after in-hospital cardiac arrest varies significantly, reflecting potential for process improvement. Improving processes of care and outcomes after in-hospital cardiac arrest is a priority of national organizations such as the Joint Commission, the American Hospital Association, and other professional bodies. Nevertheless, best approaches to improving in-hospital cardiac arrest care have not been well defined. Performance of regular multidisciplinary in situ cardiac arrest simulations has been identified as a trait common to best performing hospitals with respect to in-hospital cardiac arrest outcomes. However, no clear approach to establishing an in situ cardiac arrest program has been established. In this How I Do It installment, we describe the creation of a robust and sustainable in situ cardiac program including securing sponsorship and assembling a multidisciplinary team, acquiring and maintaining equipment and resources, execution of realistic simulations, and facilitating structured debriefings and continuous quality improvement. Our framework and ready-to-use tools will enable hospitals to implement sustainable in situ in-hospital cardiac arrest simulation programs and drive measurable improvements in care and outcomes.

Interstitial lung disease (ILD) is a term encompassing a wide array of pulmonary conditions characterized by inflammation and fibrosis of the pulmonary parenchyma. Pulmonary hypertension (PH) is frequently encountered in patients with fibrotic ILDs and poses unique difficulties for both diagnosis and management. Patients with ILD-associated pulmonary hypertension (ILD-PH) are complex, often ailing and presenting with multiple comorbidities whose individual contributions to the underlying PH can be challenging to disentangle. Evidence supporting treatment with PH-specific medications in ILD-PH is limited. This edition of "How I Do It" presents a longitudinal case-based discussion of ILD-PH to address these challenges, highlight pearls and pitfalls in the diagnostic workup of these patients, and provide a framework for the practical evidence-based approach to accurate diagnosis and management of these challenging cases.

Fibrinolysis and complicated parapneumonic effusion/empyema have a longstanding relationship. Many of the first major breakthroughs in the discovery of plasminogen and its activators were made using Streptococcus species isolated from a patient with empyema. Fatefully, the first clinical use of plasminogen activators to treat human disease involved administering the identified streptococcal plasminogen activator, streptokinase, intrapleurally to treat parapneumonic effusion and empyema. Refinement of fibrinolytic therapy has led to the common practice of adjunctive intrapleural fibrinolytic therapy, using a combination of recombinant human tissue plasminogen activator and deoxyribonuclease-1. However, current intrapleural fibrinolytic therapy is inefficient, resulting in an average hospital stay of 14 days. Further, many patients demonstrate residual pleural effusion after therapy, some of whom ultimately require surgery. This leads to billions of dollars of health care expenditure annually in the United States. This review aims to provide a historical overview of intrapleural fibrinolysis, review the current clinical fibrinolytic therapy practices for treatment of complicated parapneumonic effusion/empyema, and highlight knowledge gaps in our understanding of the pathobiology of resistance to intrapleural fibrinolytic therapy. Although nonfibrinolytic modalities such as pleural irrigation and surgery are referenced for context, they are not the focus of this review and are not discussed in depth. Improved knowledge of the mechanisms underlying aberrant fibrinolysis in the pleural space has the potential to improve prognostication, guide precision therapeutics, and enhance the care of patients with complicated parapneumonic effusion/empyema, leading to better individual outcomes and reduced health care expenditure.

Uptake of evidence-based practices (EBPs) in pulmonary and critical care medicine is frequently incomplete. To address these gaps, implementation scientists seek to understand the clinical and societal contexts in which innovations and EBPs are introduced. They also design and evaluate complex interventions to facilitate the adoption of an EBP in those contexts. We propose that well-established methods for analyzing hierarchical, observational data can complement and strengthen this process by identifying sources of practice variability. This paper reviews the dominant framework used to understand the clinical context of implementation programs, describes how measuring practice variability could help streamline this approach, and tests an assumption of the proposed combined methodology using observational data from a national study of patients on mechanical ventilation conducted by the Prevention and Early Treatment of Acute Lung Injury Network. We discuss how the combined approach can be used (1) to focus the search for determinants of practice, (2) to quantify the impact of evidence generation and evaluate the success of implementation projects, and (3) to facilitate comparisons between implementation strategies when multiple approaches are trialed simultaneously.

Digital health technologies (DHTs), such as mobile health technologies, wearables, telehealth, and telemonitoring, are used increasingly in health care. This is particularly true for respiratory conditions such as asthma, cystic fibrosis, TB, interstitial lung disease, and COPD because DHTs can support diagnosis, self-management, and ongoing care. However, respiratory conditions change across an individual's lifespan in both their presentation and management priorities for the clinician and patient. This creates new challenges and opportunities for using DHTs. Adopting an all-of-life approach is key when considering DHT use within each life stage and across the lifespan.

Sepsis-induced cardiomyopathy (SICM) is a heterogeneous cardiovascular dysfunction associated with sepsis and septic shock. Although traditionally defined by reversible left ventricular (LV) systolic dysfunction, recent evidence has revealed a broader spectrum, including LV diastolic dysfunction, hyperdynamic LV systolic states, and right ventricular (RV) injury, occurring independently or in combination. Despite their prognostic significance, these phenotypes remain underrecognized and understudied.

High doses of a maintenance inhaled corticosteroids (ICSs) in asthma may achieve only modest additional clinical benefit beyond low-to-medium doses and are associated with an increased risk of adverse systemic effects. The ICS dose-response relationship when administered as maintenance combination ICS/long-acting beta2-agonist (LABA) therapy is uncertain.

OSA is a common, chronic sleep disorder affecting up to 49% of men and 23% of women, yet it remains highly underdiagnosed. Sex-specific prevalence and OSA phenotype suggests that affected women, here referring to adult females, are comparatively more likely to experience certain symptoms, such as insomnia and mood disturbances, and less likely to have loud snoring and observed apneas. Sex differences in symptom presentation may contribute to OSA underdiagnosis in women because traditional diagnostic criteria and clinical assessments often prioritize symptoms more common in men. This review highlights reproductive aging as an overlooked risk factor for OSA, independent of aging, and describes resultant barriers and inequities in OSA screening.

Despite research identifying clear sex-specific differences in the risk profile for heart failure with preserved ejection fraction (HFpEF), these risk factors are typically not reported in "participant characteristics" of heart failure research. This leads to an incomplete understanding of how and why female individuals are heavily predisposed to developing HFpEF.

In April 2023, the American Thoracic Society (ATS) published an official ATS statement entitled "Race and Ethnicity in Pulmonary Function Test Interpretation" recommending the adoption of race-neutral reference equations for pulmonary function test results interpretation. However, lack of a clear roadmap to implement this recommendation effectively remains a challenge. This article outlines how our large safety net hospital systematically transitioned from race-specific to race-neutral reference equations. Our approach, guided by the Kotter change model, can serve as a framework for other institutions.

Long COVID or a post-COVID condition, defined as the persistence of symptoms at least 3 months after acute COVID-19 infection, is a novel condition in which a definitive diagnostic marker and treatment have yet to be found. This condition, which has been estimated to impact > 65 million individuals worldwide, manifests with multisystem involvement, most commonly presenting with fatigue, brain fog, dyspnea, cough, or a combination thereof. The burden of these symptoms can range from mild to severe, with many patients reporting an inability to return to usual activities. Herein, we present several hypothetical but clinically representative case reports to allow discussion around how we approach the diagnosis of respiratory symptoms of long COVID in those with and without chronic lung disease.