Patients with pulmonary subsolid nodules (SSNs) of ≤ 2 cm in diameter and a consolidation to tumor ratio (CTR) of ≤ 0.25 have good postoperative prognoses, but their management remains controversial.

Up to two-thirds of patients with severe uncontrolled asthma (SUA) who received biologic therapy do not have a complete response.

High-flow nasal cannula (HFNC) has emerged as a promising intervention for postextubation oxygen therapy, with the potential to reduce the need for reintubation. However, it remains unclear whether using a higher flow setting provides better outcomes than the commonly used flow rate of 30 to 50 L/min.

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.

A large number of symptomatic individuals with central sleep apnea (CSA) in clinical practice have an indication for adaptive servoventilation (ASV) therapy.

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.

Continuing data on racial bias in pulse oximeters and artificial intelligence have sparked calls for health systems to drive innovation against racial bias in health care device and artificial intelligence markets by incorporating equity concerns explicitly into purchasing decisions.

The management of incidental pulmonary nodules is guided by recommendations set forth by the Fleischner Society. Although most pulmonary nodules are benign, timely and evidence-based follow-up can reduce morbidity and mortality. There are known socioeconomic disparities for engagement with recommended cancer screenings; however, it is unclear whether disparities exist for follow-up of incidentally detected pulmonary lesions.

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.

The screening strategy for interstitial lung disease (ILD) in patients with rheumatoid arthritis is currently debated. Although high-resolution CT (HRCT) imaging is the gold standard for diagnosing ILD, its systematic use as a screening tool is not yet recommended. The role of lung ultrasound (LUS) in assessing ILD has been previously explored.

Low-dose morphine may be prescribed to reduce chronic breathlessness in COPD. Subjective findings suggest morphine may influence breathlessness through sleep-related mechanisms. However, concerns exist regarding opioid safety in COPD. The effects of morphine during sleep in COPD have not been objectively investigated. This study aimed to objectively determine the effects of low-dose morphine on sleep in COPD.

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.

Asthma is a common, multifaceted respiratory disease with a major impact on quality of life. Despite increased insights into mechanisms underlying various asthma phenotypes and endotypes and the availability of targeted biologic treatment options, the disease remains uncontrolled in a substantial proportion of patients with risk of exacerbations, requiring systemic corticosteroids, and with progressive disease. Current international guidelines advocate for a personalized management approach to patients with uncontrolled severe asthma. The European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) asthma expert panel was convened to discuss strategies to optimize asthma care and to prevent systemic corticosteroid overuse and disease progression. In this meeting report, we summarize current concepts and recommendations and provide a rationale to implement personalized asthma management at earlier stages of the disease. The ultimate goal is to move away from the current one-size-fits-most concept, which focuses on a symptom-driven treatment strategy, and shift toward a phenotype- and endotype-targeted approach aimed at curbing the disease course by improving clinical outcomes and preserving health-related quality of life. Herein, we provide a consensus view on asthma care that advocates a holistic approach and highlight some unmet needs to be addressed in future clinical trials and population studies.

A 68-year-old woman presented with worsening dyspnea. She had presented to her local community hospital 10 days earlier with similar symptoms. She was diagnosed with a right-sided pleural effusion, which was attributed to pneumonia and treated with antibiotics. She underwent two thoracenteses within a week, with relief of dyspnea after each procedure. Two days after hospital discharge, she developed recurrence of dyspnea and presented to our hospital. She denied any cough, fever, chills, or night sweats. She denied leg swelling, orthopnea, or paroxysmal nocturnal dyspnea. She did not have any recent surgeries or trauma. She had a medical history notable for Hodgkin lymphoma treated with radiation 40 years ago, renal cancer treated with nephrectomy, COPD on chronic 2 L oxygen nasal cannula, and pulmonary embolism on chronic anticoagulation. She also had a chronic left-sided chest port, which had been placed for a long-standing history of difficult IV access.

An 80-year-old man with no history of substance addiction presented with complaints of cough and breathlessness for 4 months. His cough was nonproductive, waxing and waning in nature with high symptom load during daytime, but not associated with chest pain or wheezing. He gives no history of nasal or sinus symptoms, aspiration, or reflux symptoms. Breathlessness was nonparoxysmal, independent of cough and progressing from modified medical research council Grade-I to Grade II. It was not accompanied by wheezing or stridor. He denied specific triggers and seasonal, diurnal, or postural variation of symptoms. His medical history was largely unremarkable, apart from hypertension diagnosed 2 decades earlier. Despite 6 months of treatment with dual antihypertensive medications, his BP remained uncontrolled. He did not receive angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for the treatment of hypertension as per his old medical records. He denies history of atopy, occupational or environmental dust exposure. He refused history of fever, significant loss of weight or appetite. He had been treated for asthma with a combination of a long-acting beta-2 agonist and an inhaled corticosteroid inhaler, which provided no relief.

A 36-year-old man with severe Crohn disease complicated by urethral strictures and enterocutaneous and enterovesicular fistulas presented for several weeks of poor appetite, weight loss, failure to thrive, and newly worsening altered mentation. Further history revealed he chronically did not urinate through his urethra, but rather "leaked" through multiple enterocutaneous fistulas in his abdomen and perineum. Medications included ustekinumab (anti-IL12/IL23 monoclonal antibody) for Crohn disease, methadone, and hydrocodone. He had had multiple surgeries because of fistulas related to his Crohn disease, which included subtotal colectomy with ileostomy creation, proctectomy, and ischiorectal flap creation. He drank 10-15 ounces of liquor per week, smoked 10 cigarettes daily, and smoked marijuana weekly.

Zanubrutinib is an orally administered second-generation covalent inhibitor of Bruton tyrosine kinase that was recently approved by the US Food and Drug Administration for the treatment of chronic lymphocytic leukemia and small lymphocytic leukemia. It has been associated with significant major and minor bleeding events, including intracranial and GI hemorrhage and hematuria, with or without concurrent antiplatelet or anticoagulation therapy. We report a case of a 65-year-old man with relapsing chronic lymphocytic leukemia. He presented to us with repeated episodes of worsening dyspnea secondary to hemorrhagic pleural effusion 2 months after the initiation of zanubrutinib with concomitant apixaban use. On discontinuation of zanubrutinib after the second episode, he remained asymptomatic on further follow-up examination. Previously only described with the first-generation Bruton tyrosine kinase inhibitor, our case focuses attention on a rare adverse event and a first reported incidence, to our knowledge, of recurrent hemorrhagic pleural effusion associated with zanubrutinib in a patient with relapsing chronic lymphocytic leukemia.

Traditional approaches for learning anatomy for curvilinear endobronchial ultrasound (EBUS) require learners to mentally visualize structures relative to the position of the bronchoscope. Virtual reality (VR) can show anatomy from the perspective of bronchoscopic tools.