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 (SpO2) and tissue (StO2) oxygenation is routinely performed in clinical practice. Arterial Blood Gas (ABG) analysis, though considered as the gold standard for SpO2 estimation, requires arterial puncture, trained personnel and laboratory back up. Currently, there is a lack of universally accepted and widely used method for StO2 measurement. Available non-invasive 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.

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 patients.

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 EBP 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.

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 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.

In April 2023, the American Thoracic Society (ATS) published an official ATS statement entitled, "Race and Ethnicity in Pulmonary Function Test (PFT) Interpretation," recommending the adoption of race-neutral reference equations for PFT 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.

Small airways are recognized as the main site of disease progression and airflow limitation in patients with COPD. Whereas conventional lung function testing, for example spirometry, is nonspecific to small airways 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 airways dysfunction. Despite this progress, a gap between the recent advances in knowledge of SAD and its implementation in daily clinical practice remains. We aimed to answer key questions that would allow practitioners (eg, family doctors, internists, pulmonologists) to introduce oscillometry into 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 1 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.

Lung cancer remains the number 1 cause of cancer death in men and women in the United States and much of the world. This CHEST organization guideline examines the literature on primary treatment of patients with stage I and II non-small cell lung cancer (NSCLC) to provide evidence-based recommendations.

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, improve lung nodule detection and management, and 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 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).