PulmPEEPs Podcast Por PulmPEEPs arte de portada

PulmPEEPs

PulmPEEPs

De: PulmPEEPs
Escúchala gratis

Pulmonary and Critical Care content for learners and practitioners of all levelsPulm PEEPs Enfermedades Físicas Higiene y Vida Saludable
Episodios
  • 119. Guideline Series: Pulmonary Embolism

    119. Guideline Series: Pulmonary Embolism
    Mar 24 2026
    We are unbelievably excited this week to be reviewing the hot-off-the-presses 2026 Multi-Society (AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN) Pulmonary Embolism Guidelines with lead author Dr. Mark A. Creager. We will talk about key updates in these guidelines compared to prior practice, including the new risk classification model, and provide an overview from diagnosis to follow-up. Given the clinical importance and prevalence of pulmonary embolism, these guidelines are certainly going to shape practice going forward, so this episode is a can’t miss! Watch the full video of this episode with graphics and helpful teaching visuals on our YouTube channel: https://www.youtube.com/@pulmpeeps Meet Our Guest Dr. Mark Creager is a Professor of Medicine at Dartmouth Hitchcock Medical Center where he specializes in Cardiovascular Medicine with an emphasis on venous thromboembolic disease. He served as the lead author of the 2026 Pulmonary Embolism Guidelines. Article and Reference Creager MA, Barnes GD, Giri J, Mukherjee D, Jones WS, Burnett AE, Carman T, Casanegra AI, Castellucci LA, Clark SM, Cushman M, de Wit K, Eaves JM, Fang MC, Goldberg JB, Henkin S, Johnston-Cox H, Kadavath S, Kadian-Dodov D, Keeling WB, Klein AJP, Li J, McDaniel MC, Moores LK, Piazza G, Prenger KS, Pugliese SC, Ranade M, Rosovsky RP, Russo F, Secemsky EA, Sista AK, Tefera L, Weinberg I, Westafer LM, Young MN. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2026 Feb 19:S0735-1097(25)10161-7. doi: 10.1016/j.jacc.2025.11.005. Epub ahead of print. PMID: 41712898. Key Learning Points Why these guidelines matter: This is the first joint AHA/ACC clinical practice guideline specifically on acute PE, bringing together a truly multidisciplinary writing committee (cardiology, pulmonology, hematology, emergency medicine, interventional radiology, surgery, and others). Prior guidelines existed from individual societies, but nothing this comprehensive had been updated in roughly five to six years. New PE clinical categories (A through E): One of the most impactful changes is replacing the old “massive/submassive” and “low/intermediate/high risk” labels with five categories that form a severity continuum. Category A is subclinical (incidental PE found on imaging in asymptomatic patients). Category B covers symptomatic but low-severity patients. Category C is where much of the clinical complexity lives — symptomatic, hemodynamically stable patients subdivided into C1, C2, and C3 based on RV function and biomarkers. Category D represents incipient cardiopulmonary failure (transient hypotension, normotensive shock with end-organ dysfunction). Category E is frank cardiopulmonary failure, with E2 being the sickest — refractory or recurrent cardiac arrest. Respiratory modifiers (hypoxia requiring supplemental oxygen) layer onto C, D, and E. Diagnostic approach: Clinical evaluation comes first — history, exam, and validated decision tools (Wells score, revised Geneva, PERC). If clinical probability is low and D-dimer is normal, imaging can be safely avoided. If either is concerning, imaging is warranted. CTPA remains the preferred imaging modality due to superior sensitivity, specificity, wide availability, and ability to assess clot burden and alternative diagnoses. VQ scanning is still appropriate when CTPA is contraindicated, and VQ SPECT offers better reproducibility and specificity than traditional planar VQ if available. Echocardiography is not a diagnostic test for PE but is important for risk stratification — RV size, TAPSE, and tissue Doppler measures all contribute prognostic information. Anticoagulation updates: Anticoagulation remains the cornerstone of treatment. For patients potentially needing advanced therapies (C3, D, E), parenteral anticoagulation is started first. A notable recommendation: low molecular weight heparin is generally preferred over unfractionated heparin, based on evidence showing more effective VTE risk reduction, more predictable pharmacokinetics, no need for routine monitoring, lower rates of heparin-induced thrombocytopenia, and no increase in major bleeding. The committee acknowledged this may create discomfort for clinicians accustomed to unfractionated heparin’s easy reversibility, but the difficulty of achieving and maintaining therapeutic levels with UFH was a significant concern. Advanced therapies: Catheter-based thrombolysis, mechanical thrombectomy, systemic thrombolysis, and surgical embolectomy all received mostly class 2B recommendations (“can consider”) for C3 and D categories, reflecting that current evidence shows improvement in short-term surrogate measures (RV/LV ratio, hemodynamics) but lacks definitive hard outcome data on mortality. For category E1 ...
    Más Menos
    Menos de 1 minuto
  • 118. Pulm PEEPs Pearls: Methacholine Challenge

    118. Pulm PEEPs Pearls: Methacholine Challenge
    Feb 24 2026
    Furf and Monty are back with another Pulm PEEPs Pearls episode. The topic of today’s discussion is an often discussed, but often misunderstood, test; the methacholine challenge. They’ll review when to utilize this test, how it should be performed, and the appropriate interpretation. Contributors This episode was prepared with research by Pulm PEEPs Associate Editor George Doumat. Dustin Latimer, another Pulm PEEPs Associate Editor, assisted with audio and video editing. Key Learning Points What the Test Measures Methacholine challenge is a direct bronchial provocation test of airway hyperresponsiveness (AHR), a core physiologic feature of asthma.Anyone will bronchoconstrict at high enough concentrations — the test looks for an abnormal threshold.The key endpoint is the PC20: the methacholine concentration causing a 20% fall in FEV1. Abnormal in adults: PC20 ≤ 8–16 mg/mL Test Performance Meta-analyses: pooled sensitivity ~60%, specificity ~90%.Real-world cohorts: sensitivity 55–62%, specificity 56–100% (varies by population, protocol, and threshold used).Not a standalone yes/no test — best used as part of a broader diagnostic pathway. Where It Fits in the Asthma Workup The test belongs in a stepwise approach: Step 1: Spirometry + bronchodilator responseStep 2: Add FeNO and/or peak flow variability (if available)Step 3: If the picture is still unclear → methacholine challenge It is most useful for symptomatic patients with normal spirometry and no bronchodilator reversibility. Given its cost, mild risk, and discomfort, it should not be a first-line test — most asthma diagnoses do not require it. Technique and Medication Prep Technique ERS guidelines favor tidal breathing over deep inspiratory maneuvers.Deep breaths can be bronchoprotective and blunt the response, reducing sensitivity — especially in mild or well-controlled asthma. Medication Washout (to Avoid False Negatives) Medication ClassWashout PeriodShort-acting beta-agonists (SABA)≥ 6 hoursLong-acting beta-agonists (LABA)~24 hoursUltra-long-acting beta-agonists~48 hoursShort-acting anticholinergics (e.g., ipratropium)~12 hoursLong-acting muscarinic antagonists (LAMA, e.g., tiotropium)7 days Inhaled corticosteroids, leukotriene blockers, and antihistamines do not significantly affect the test acutely — continue these. Withdrawing ICS also carries its own risk for asthma patients.Practical tip: Spell out exactly what to hold and when — for both the patient and the PFT lab — at the time the test is ordered. Interpreting Results Negative Test (PC20 > 16 mg/mL) Very high negative predictive value in symptomatic adults.Makes current asthma quite unlikely (assuming proper test conduct).This is the test’s greatest strength: it is an excellent rule-out test. Positive Test (PC20 ≤ 8–16 mg/mL) More nuanced — airway hyperresponsiveness is not unique to asthma.Can be positive in: chronic cough, allergic rhinitis, COPD, and even some healthy asymptomatic individuals.A positive result raises probability but must be interpreted alongside the clinical story, variable respiratory symptoms, peak flow variability, FeNO, and ICS response. Safety and Risks Overall, the test is quite safe; significant adverse effects are rare.Temporary breathing discomfort is expected (bronchoconstriction is being induced).Severe bronchospasm is possible: A trained clinician should be available; SABA inhaler/nebulizer must be immediately on hand; a physician should be reachable in the facility. Contraindications / cautions: Avoid if FEV1 < 70% predicted or < 1–1.5 L (baseline obstruction greatly increases risk).Avoid within 3 months of an acute cardiac event (rare risk of cardiac events with unstable cardiac disease). Five Pearls — Quick Recap What it tests: Methacholine challenge is a direct test of AHR with high specificity but variable sensitivity — it belongs inside a diagnostic pathway, not as a standalone asthma test.When to use it: Most useful for symptomatic patients with normal spirometry and no bronchodilator response, after FeNO and peak flow variability have been considered.Technique and meds matter: Use tidal breathing protocol; respect washout intervals — especially the 7-day LAMA washout and 24–48 hour LABA window — to avoid false negatives.Safety: Generally safe, but can induce significant bronchoconstriction. Have a SABA available and avoid the test in patients with FEV1 < 70% predicted.Interpretation: A negative test (PC20 > 16 mg/mL) strongly argues against current asthma. A positive test raises probability but is not specific — interpret alongside the full clinical picture. References and Further Reading Coates AL, Wanger J, Cockcroft DW, Culver BH; Bronchoprovocation Testing Task Force: Kai-Håkon Carlsen; Diamant Z, Gauvreau G, Hall GL, Hallstrand TS, Horvath I, de Jongh FHC, Joos G, Kaminsky DA, Laube BL, Leuppi JD, Sterk PJ. ERS technical standard on bronchial challenge testing: general considerations and ...
    Más Menos
    18 m
  • 117. Pulm PEEPs Pearls: Spontaneous Breathing Trials

    117. Pulm PEEPs Pearls: Spontaneous Breathing Trials
    Feb 10 2026
    This week’s Pulm PEEPs Pearls episode is all about spontaneous breathing trials (SBTs). SBTs are a standard part of the daily practice in the intensive care unit, but the exact methods vary across ICUs and institutions. Listen in to hear about the most common methods of SBTs, the physiology of each method, and what the evidence says. Contributors This episode was prepared with research by Pulm PEEPs Associate Editor George Doumat. Dustin Latimer, another Pulm PEEPs Associate Editor, assisted with audio and video editing. Key Learning Points What an SBT is really testing An SBT is a stress test for post-extubation work of breathing, not just a ventilator check.The goal is to balance sensitivity and specificity: Too hard → unnecessary failures and delayed extubationToo easy → false positives and higher risk of reintubation Common SBT modalities and how they compare T-piece No inspiratory support and no PEEPHighest work of breathingMost “physiologic” but often too strict Pressure support (PS) + PEEP (e.g., 5/5 or 8/5) Offsets ETT resistance and provides modest assistanceEasier to pass than T-piece CPAP (0/5) No inspiratory help, but provides PEEP to counter ETT resistanceSits between PS and T-piece in difficulty Evidence favors pressure-supported SBTs for most patients Large meta-analysis (~6,000 patients, >40 RCTs): Pressure-supported SBTs increase successful extubation (~7% absolute benefit)No increase in reintubation rates Trials (e.g., FAST trial): Patients pass SBTs earlierLeads to earlier extubation and fewer ventilator-associated risks Bottom line: A 30-minute PS 5/5 SBT is evidence-based and appropriate for most stable ICU patients When a T-piece still makes sense T-piece SBTs are useful when: Cost of reintubation is high Difficult airwayPrior failed extubation Pretest probability of success is low Prolonged or difficult weaningTracheostomy vs extubation decisions Need to mimic physiology without positive pressure In LV dysfunction or pulmonary edema even small amounts PEEP may significantly improve physiology Some centers use a hybrid approach: PS SBT → short confirmatory T-piece before extubation CPAP as a middle ground Rationale: Allows full patient effort while compensating for ETT resistance Evidence: Fewer and smaller trialsPossible modest improvement in extubation successNo clear mortality or LOS benefit Reasonable option based on patient physiology, institutional protocols, and clinician comfort No single “perfect” SBT mode Across PS, T-piece, CPAP, and newer methods (e.g., high-flow via ETT) there are no consistent differences in mortality or length of stayWhat matters most: Daily protocolized screeningThoughtful bedside clinical judgmentMatching SBT difficulty to patient-specific risk Institutional variation is normal—and acceptable Examples: PS 10/5 in postoperative surgical ICU patientsPS 5/0 as an intermediate difficulty option Key question clinicians should ask: What does passing or failing this specific SBT tell me about this patient’s likelihood of post-extubation success? Take-home pearls SBTs are stress tests of post-extubation physiology.PS 5/5 for 30 minutes is a strong default for most ICU patients.T-piece trials are valuable when false positives are costly or physiology demands it.CPAP is reasonable but supported by less robust data.Consistency, daily screening, and judgment matter more than the exact mode. References and Further Reading Burns KEA, Khan J, Phoophiboon V, Trivedi V, Gomez-Builes JC, Giammarioli B, Lewis K, Chaudhuri D, Desai K, Friedrich JO. Spontaneous Breathing Trial Techniques for Extubating Adults and Children Who Are Critically Ill: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2024 Feb 5;7(2):e2356794. doi: 10.1001/jamanetworkopen.2023.56794. PMID: 38393729; PMCID: PMC10891471.Burns KEA, Sadeghirad B, Ghadimi M, Khan J, Phoophiboon V, Trivedi V, Gomez Builes C, Giammarioli B, Lewis K, Chaudhuri D, Desai K, Friedrich JO. Comparative effectiveness of alternative spontaneous breathing trial techniques: a systematic review and network meta-analysis of randomized trials. Crit Care. 2024 Jun 8;28(1):194. doi: 10.1186/s13054-024-04958-4. PMID: 38849936; PMCID: PMC11162018.Subirà C, Hernández G, Vázquez A, Rodríguez-García R, González-Castro A, García C, Rubio O, Ventura L, López A, de la Torre MC, Keough E, Arauzo V, Hermosa C, Sánchez C, Tizón A, Tenza E, Laborda C, Cabañes S, Lacueva V, Del Mar Fernández M, Arnau A, Fernández R. Effect of Pressure Support vs T-Piece Ventilation Strategies During Spontaneous Breathing Trials on Successful Extubation Among Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial. JAMA. 2019 Jun 11;321(22):2175-2182. doi: 10.1001/jama.2019.7234. Erratum in: JAMA. 2019 Aug 20;322(7):696. doi: 10.1001/jama.2019.11119. PMID: 31184740; PMCID: PMC6563557.Burns KEA, Wong J, Rizvi L, Lafreniere-Roula M, Thorpe K, Devlin JW, Cook DJ, Seely A, Dodek PM, Tanios M, Piraino...
    Más Menos
    Menos de 1 minuto
Todavía no hay opiniones