In April 2023, the American Thoracic Society (ATS) published the Official ATS Statement: Race and Ethnicity in Pulmonary Function Test (PFT) Interpretation recommending the adoption of race-neutral reference equations for PFT interpretation. However, lack of a clear roadmap to implement this recommendation effectively remains a challenge. This paper 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.

Small airways are recognized as the main site of disease progression and airflow limitation in patients with chronic obstructive pulmonary disease (COPD). Whereas conventional lung function testing, e.g. spirometry, is non-specific to small airway disease (SAD), the advent and wider availability of techniques sensitive to SAD, such as oscillometry, has improved our understanding of the clinical importance of small airway dysfunction. Despite this progress, a gap between the recent advances in knowledge of SAD to its implementation in daily clinical practice remains. We aimed to answer key questions that would allow practitioners (e.g. family doctors, internists, pulmonologists) to introduce oscillometry in their clinical practice.

Clinicians who care for patients with chronic respiratory failure are faced with complex medical decisions when initiating and managing home mechanical ventilation. The technological advances and complexities of home mechanical ventilators (HMVs) have outpaced the education and resources provided to clinicians who manage this unique patient population. Many clinicians are familiar with 1 brand and depend on medical equipment suppliers when prescribing and managing home ventilators. A recent national safety recall in the United States of one of the most commonly used HMVs has led to an increase in burden and challenges facing clinicians caring for patients with chronic respiratory failure. The recall has forced clinicians to address knowledge gaps in evolving home mechanical ventilation technology. Evidence supporting the use of advanced and proprietary algorithms is limited, and understanding how to initiate or transition between devices to achieve success using such modes requires education, awareness, and expertise on the risks and benefits of tailoring therapy appropriately. This review focuses on providing practical, real-world guidance to transitioning autotitrating algorithms between HMVs to optimize patient therapy.

Successful procedural training is a universal concern for pulmonary and critical care medicine (PCCM) program directors. Bootcamps may provide a unique and often first opportunity for intense, immersive procedural learning without exposing patients to harm. New trainees must otherwise learn on the job while acclimating to unfamiliar environments and responsibilities. Our goal was to create a structured regional educational event conducted early in fellowship; we aspired to optimize familiarity with procedures and equipment, allay stress among trainees, and create a collaborative learning environment through sharing of simulation equipment and faculty among programs. This article outlines the design, implementation, and lessons learned from this 1-day, multidisciplinary PCCM and critical care medicine procedural bootcamp in the southwest region of the United States. The bootcamp program was designed as learner centered, with educational and experiential goals and feasibility in mind, using a flipped classroom model and testing to maximize time for psychomotor skills building. A multidisciplinary approach enriched the learning environment, modeled team-based procedural care, and fostered interprofessional collaboration. Assessments measured pre-knowledge and post-knowledge acquisition as well as gauged learner performance using checklists and small group interaction. Evaluation of feedback from learners, faculty, and participating programs allowed for yearly iterative improvements. We share these lessons learned as a model for other scalable and impactful medical education initiatives.

Lung cancer screening (LCS) has evolved over the past decade with research advances and clinical experience helping to define target populations for screening, to improve lung nodule detection and management, and to identify structural components of programs that improve the quality of screening delivery. The 2015 American College of Chest Physicians and American Thoracic Society Policy Statement, "Components Necessary for High-Quality Lung Cancer Screening," identified 9 essential components for high-quality LCS. Ten years later, optimizing the balance between the benefits and harms of LCS and ensuring equitable screening among all population groups remain fundamental objectives. In this 2025 update, we aimed to summarize new knowledge and highlight critical components that are needed for providing high-quality LCS. A multidisciplinary group of LCS experts was assembled to review evidence from the past 10 years. The original components were reviewed and updated to develop 8 refined components that should be considered essential structural elements of screening programs. Each component recommended by the authors is supported by an evidence update. Applying this framework will allow screening programs across the country to ensure implementation of high-quality, net-benefit LCS.

Current indications for long-term oxygen therapy (LTOT) primarily are based on thresholds of arterial oxygen saturation (SaO2) or PaO2 that ignore fundamental mechanisms of adaptation and intolerance to hypoxia. In individuals exposed to chronic hypoxic conditions, the accumulation of hypoxia-inducible factors (HIFs) in the cell nucleus upregulates target genes that favor tolerance to hypoxia. Adaptations include hyperventilation, systemic vascular bed development, increased erythropoiesis, and cellular metabolic adjustments. Excessive responses to hypoxia also may develop, leading to pulmonary vasculature remodeling and other end-organ dysfunctions. Biomarkers of hypoxia may complement the measurement of SaO2 or PaO2 in personalizing oxygen prescription before end-organ dysfunction becomes clinically apparent.

Pulmonary arteriovenous malformations (PAVMs) require therapeutic embolization and careful surveillance to prevent serious complications, including stroke, brain abscess, and hemoptysis. Although initial treatment guidelines are well established, posttreatment surveillance practices remain heterogeneous, with no standardized approach for monitoring treated lesions or detecting PAVM persistence. This variability in follow-up care may affect patient outcomes, particularly in high-risk populations such as those with hereditary hemorrhagic telangiectasia (HHT).

Establishing the cause of a pleural effusion can be challenging. Analysis of pleural fluid (PF) is a powerful tool to determine the cause of a pleural effusion. Surprisingly, despite the diagnostic power of PF analysis (PFA), it is often underused. This review provides a practical framework to maximize the diagnostic potential of the PFA. We describe the role of a PFA in establishing the cause of a pleural effusion. We also discuss challenges and limitations of PFA.

Pulmonary embolism (PE) is one of the leading causes of pregnancy-related deaths in high-income countries. Maternal mortality from PE has been attributed to delayed recognition and investigations. The diagnosis of PE may be challenging, as its early signs and symptoms may overlap with physiological changes of pregnancy. As such, promptly ruling out suspected PE using diagnostic testing is of paramount importance. This narrative review provides a contemporary overview of risk assessment tools, diagnostic modalities, counseling needs, and existing best practice guidance for the diagnosis of PE in pregnancy.

Right heart catheterization is the gold standard for the diagnosis of pulmonary hypertension. There are variations in practice and several pitfalls introducing errors in diagnosis that can significantly affect treatment. Errors in assessing the correct pulmonary artery wedge pressure can significantly affect accurate classification of patients with pulmonary hypertension and lead to potentially deleterious treatment decisions. This review focuses on best practices in right heart catheterization performance, emphasizing practical and pathophysiological principles to obtain the most accurate result, as well as advanced applications in pulmonary hypertension.

From screening to treatment, the continuum of lung cancer reflects unequal access and delivery, with more vulnerable patients less able to receive high-quality care. Despite great advances in lung cancer care (eg, screening and nodule programs to identify early-stage disease and immune-mediated and targeted therapies for advanced-stage disease), disparities persist both in the United States and globally. In this narrative review, the spectrum of disparities that influence lung cancer care on a national scale, including race, ethnicity, age, socioeconomic status, geographic location, and insurance access, are explored. The review focuses on how disparities impact screening efforts and lung cancer treatments. Where data are available, trends on a global scale are addressed. Potential solutions are offered to address recognized disparities, primarily by identifying pertinent social determinants of health and launching multipronged interventions to improve the care of all patients with lung cancer.

Lung transplantation (LTx) remains the ultimate treatment for many patients with advanced lung disease. Although the age cutoffs for LTx have been debated due to variable outcomes, the number of LTx procedures performed on patients aged ≥ 65 years has significantly increased in recent decades, reflecting the realities of an aging demographic. This trend underscores the unique management challenges faced by this cohort and highlights the importance of addressing evidence gaps in their perioperative and postoperative care.

Lung cancer is the leading cause of global cancer mortality. It is also the third most common cancer in the United Kingdom and the most prevalent worldwide. Pulmonary nodules can indicate early-stage lung cancer, but adherence to guidelines for radiologic surveillance is suboptimal, which affects early detection and treatment. Although interventions have been developed to improve follow-up, it remains unclear which approaches are most effective.

Early detection and treatment of COPD are becoming important for improving the prognosis of individuals who have a history of heavy tobacco use. Despite the higher risk of COPD among individuals participating in lung cancer screening, many of these patients continue to show rates of underdiagnosis of lung cancer.

Improved childhood management strategies have decreased the early life morbidity and mortality of severe developmental lung disorders, such that an increasing number of individuals ultimately transition care to adult pulmonologists for management. Alternatively, individuals with milder malformations may present in adulthood or may have an increased risk for the development of more common adult pulmonary comorbidities (eg, COPD, pulmonary hypertension). As such, there is a critical need for adult pulmonologists to understand how developmental lung disorders may impact respiratory morbidity over the lifespan.

High-flow nasal cannula (HFNC) is a first-line therapy for patients with acute respiratory failure. Despite increased HFNC utilization over recent years-accelerated in part by the COVID-19 pandemic-high-quality evidence to guide HFNC discontinuation is lacking. Decisions about when and how quickly to reduce flow rate, Fio2, or both simultaneously are frequently left to clinicians' discretion without clear guidance on an optimal approach. Failure to de-escalate HFNC support when clinically appropriate has many potential consequences, such as prolongation of ICU/hospital length of stay, increased health care costs, and reduced availability of limited hospital resources. With the goal of improving care efficiency and resource utilization among hospitalized patients with acute respiratory failure, we propose a standardized approach for HFNC discontinuation focused on "liberation" (similar to spontaneous breathing trials for patients undergoing mechanical ventilation), using a stepwise approach guided by physiology.

Millions of people around the world survive critical illness each year only to realize that they and their loved ones are grappling with a new "normal" after hospital discharge for which their medical team may not have adequately prepared them. Up to one-half of all ICU survivors suffer from new or worsening impairments in physical, cognitive, and psychological domains of health that are often not realized until they attempt to re-enter their previous lives. These devastating long-term sequelae of critical illness, collectively described as post-intensive care syndrome (PICS), can carry enormous consequences for an ICU survivor's ability to care for their family, return to work, and regain their previous quality of life for months to years after their inciting illness. Despite mounting research on PICS and survivorship, a knowledge gap exists whereby ICU team members may not always be aware of PICS and may not counsel their patients on the challenges awaiting them after discharge. Understanding how best to communicate these challenges to patients and families is crucial in preparing for survivorship beyond the ICU. In this review, we summarize PICS and possible recovery trajectories of ICU survivors. We then discuss communication strategies, emphasizing the role of empathy. Finally, we provide a suggested framework to handle these crucial conversations. We aim to equip clinicians with the knowledge and framework to care for a patient who has survived critical illness but now faces the possibility of struggles inadequately addressed by our health care system.

Alpha-1-antitrypsin (A1AT) deficiency is a common hereditary disorder associated with increased risk of developing chronic obstructive pulmonary disease (COPD). Many individuals with severe A1AT deficiency go undiagnosed, or are diagnosed late, and fail to benefit from disease-specific counseling and modifying care. Since the 2012 Canadian Thoracic Society (CTS) A1AT deficiency clinical practice guideline, new approaches to optimal diagnosis using modern genetic testing and studies of A1AT augmentation therapy have been published. We performed a systematic review and meta-analysis, which along with expert clinical input, informed recommendations. We conditionally recommend testing for A1AT deficiency in all individuals with COPD at the time of diagnosis, individuals with adult-onset asthma with persistent airway obstruction, and individuals with unexplained bronchiectasis. We suggest genetic testing with DNA sequencing of SERPINA1 gene as the initial test for individuals with high clinical suspicion for A1AT deficiency, and initial measurement of serum A1AT levels in individuals with moderate clinical suspicion of A1AT deficiency, followed by genetic testing with DNA sequencing of SERPINA1 gene if A1AT level is <23 μmol/L (<1.2 g/L). Following identification of an abnormal gene for A1AT in individuals, whether heterozygote or homozygote, we suggest first-degree relatives be provided genetic counseling and offered testing for A1AT deficiency. The panel conditionally recommends A1AT augmentation therapy to patients who do not smoke or who formerly smoked with COPD (forced expiratory volume in 1 s [FEV1] < 80% predicted; associated with emphysema), with documented deficiency genotypes and severely reduced A1AT level (< 11 μmol/L or < 0.57 g/L) in addition to receiving optimal pharmacological and nonpharmacological therapies for COPD.

Education and psychosocial support are essential components of pulmonary rehabilitation (PR). However, the delivery of education often follows a one-size-fits-all approach, with individual factors that influence learning rarely considered. Moreover, education-related outcomes are frequently overlooked in PR assessments, and their inconsistent use has limited our understanding of education's impact on people with chronic respiratory diseases. There is a clear need for practical guidance to identify key learning determinants and to define targeted education outcomes, ultimately optmizing PR and establishing quality standards.