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BACKGROUND AND AIM: The optimal mode of delivering topical anesthesia during flexible bronchoscopy remains unknown. Herein, we compare the efficacy and safety of nebulized lignocaine, lignocaine oropharyngeal spray, or their combination. METHODS: Consecutive subjects were randomized 1:1:1 to receive nebulized lignocaine (2.5 mL of 4% solution, group A), oropharyngeal spray (10 actuations of 10% lignocaine, group B), or nebulization (2.5 mL, 4% lignocaine) and two actuations of 10% lignocaine spray (group C)...

BACKGROUND: Lymphangioleiomyomatosis (LAM), a destructive lung disease that primarily affects women, is caused by loss-of-function mutations in TSC1 or TSC2, leading to hyperactivation of mechanistic/mammalian Target of Rapamycin 1 (mTORC1). Rapamycin (sirolimus) treatment suppresses mTORC1, but also induces autophagy, which promotes the survival of TSC2-deficient cells. Based on the hypothesis that simultaneous inhibition of mTORC1 and autophagy would limit the availability of critical nutrients and inhibit LAM cells, we conducted a Phase I clinical trial of sirolimus and hydroxychloroquine for LAM...

STUDY OBJECTIVES: Positive airway pressure (PAP) and upper airway stimulation (UAS) are approved obstructive sleep apnea (OSA) treatment options.. Although the effect of PAP on improvement in blood pressure (BP) and daytime sleepiness (defined by Epworth Sleepiness Scale, ESS) has been established, the impact of UAS on BP remains unclear. We hypothesize that PAP and UAS will confer improvements in BP and daytime sleepiness. METHODS: Clinic-based BP and ESS were compared between 517 OSA (apnea hypopnea index (AHI), 15-65) patients with body mass index <35 kg/m2 initiating PAP therapy (2010-2014) at Cleveland Clinic and 320 patients with UAS implantation (2015-2017) via an international registry with 2-6 month follow-up...

Most physician leaders assume their administrative role based on past achievements but with very little leadership training. In this article, leaders of the Association of Pulmonary, Critical Care and Sleep Division Directors describe two leadership skills that are often required to effectively lead in a clinical division at an academic or community hospital setting: leading change and negotiation strategy. We adopted our discussion from the business sector and refined the approaches through our own experiences to help division leaders in leading a successful team, whether as a division chief, residency or fellowship program director, or a clinical service director...

No abstract text is available yet for this article.

BACKGROUND: Shared decision-making is an essential element of low-dose computed tomography (LDCT) screening for lung cancer. Understanding patient-level outcomes from the National Lung Screening Trial (NLST) is critical to effectively communicate risks and benefits of screening to patients. METHODS: We performed a secondary analysis of data collected in the NLST. We determined outcomes of each individual LDCT performed in the NLST (downstream evaluation, complications, lung cancer diagnoses), and compared outcomes at the test-level to outcomes calculated at the patient-level for those randomized to LDCT screening...

BACKGROUND: Multiple studies have identified COPD subtypes using visual or quantitative evaluation of CT images. However, there has been no systematic assessment of a combined visual and quantitative CT classification. We integrated visually defined patterns of emphysema with quantitative imaging features and spirometry data to produce a set of ten non-overlapping CT subtypes, and we assessed differences between subtypes in demographic features, physiology, longitudinal disease progression, and mortality...

No abstract text is available yet for this article.

BACKGROUND: The anatomical location of small airways, the distribution of airway cartilage and their correlation with ageing have not been well elucidated. OBJECTIVE: To explore the morphological characteristics of small airways in vivo, and how airway structural changes correlate with age using endobronchial optical coherence tomography (EB-OCT). METHODS: We recruited 112 subjects with peripheral pulmonary nodules. Participants underwent computed tomography, spirometry, and EB-OCT measurements...

Neutrophil extracellular traps (NETs) are extrusions of intracellular DNA and attached granular material which enable bacterial killing. NETs are increasingly recognised for their role in the pathogenesis of respiratory disease. NETs are composed of a complex mix of intracellular derived material which neutrophils organise within the cytoplasm then expel in a non-directed manner in the vicinity of invading organisms. Combined, these trap and destroy multiple genera of microbes including bacteria, fungi, viruses and protozoans, limiting infection especially where phagocytosis is not possible...

This article reviews four key clinician strategies to improve the care of adult patients receiving supplemental oxygen in the outpatient setting in the United States. The current barriers to adequate oxygen services are substantial and complex and include decreased reimbursement to Durable Medical Equipment (DME) companies, a substantially lower number of available DME suppliers, difficult communication with DME suppliers, rigid patient testing, prescription, and documentation requirements, and unclear patient benefit and adherence...

No abstract text is available yet for this article.

BACKGROUND: Pulmonary arterial hypertension (PAH) is a chronic disease that ultimately progresses to right-sided heart failure (HF) and death. Close monitoring of pulmonary artery pressure (PAP) and right ventricular (RV) function allows clinicians to appropriately guide therapy. However, the burden of commonly used methods to assess RV hemodynamics, such as right heart catheterization, precludes frequent monitoring. The CardioMEMS™ HF System is an ambulatory implantable hemodynamic monitor, previously only used in NYHA Class III HF patients...

Since the first description of mechanical ventilation, our understanding of the positive and negative effects of this form of life support has continued to evolve. In order to maintain "normal" aeration of the lungs and "normal" blood gas measurements, patients often require much higher airway pressures and tidal volumes than would be expected in a healthy, spontaneously breathing adult. In the early days of mechanical ventilation the goal was to normalize the blood gas, but over the last several decades, we have developed a much better appreciation for the deleterious effects of mechanical ventilation...

Chronic inflammatory diseases of the lung are often life-threating and are a leading cause of morbidity in our communities. MicroRNA (miR) are now recognized to play critical roles in a wide-range of cellular functions including the regulation immunological processes, which are often dysregulated in chronic respiratory diseases. These small non-coding RNA molecules regulate networks of genes by inhibiting translation by targeting one or multiple messenger RNA transcripts. In this review we highlight discoveries that identify important roles for miRs in the regulation of specific pathogenic features of a range of diseases...

Point of care ultrasonography (POCUS) is a key skill for the critical care clinician and is gaining widespread acceptance by clinicians in all areas of medicine. In addition to mastery of image acquisition, image interpretation, and clinical application, the intensivist needs to be adept with billing for their scanning activity. This article will summarize the requirements for documentation and image storage that must be met in order to obtain reimbursement for POCUS services.

The direct acting oral anticoagulants (DOACs) have been increasingly utilized over vitamin K antagonists (VKA) in recent years because they do not require monitoring and have an immediate anti-coagulation effect. In general, DOACs have shown a better safety profile and non-inferiority for venous thromboembolism (VTE) prophylaxis and treatment, and stroke prevention in patients with atrial fibrillation, when compared to VKA agents in the non-ICU population. Whether this holds true in patients who are critically ill remains unknown...

BACKGROUND: The efficacy of azathioprine (AZA) and mycophenolate mofetil (MMF) for interstitial lung disease (ILD) has been described, but mainly in connective tissue disease-associated ILD (CTD-ILD). The objective of this study was to evaluate the effect of AZA and MMF on lung function and prednisone dose in myositis-related ILD (M-ILD). METHODS: Retrospective study of M-ILD patients seen at Johns Hopkins and treated with AZA or MMF and no other steroid sparing agents were included...

BACKGROUND: Oronasal mask is frequently used to treat OSA. In contrast to nasal CPAP, the effectiveness of oronasal CPAP varies for unknown mechanisms. We hypothesized that oral breathing and pressure transmission through the mouth compromises oronasal CPAP efficacy. METHODS: Thirteen OSA patients, well adapted to oronasal CPAP, were monitored by full polysomnography, pharyngeal pressure catheter and nasoendoscope. Patients slept with low doses of midazolam using an oronasal mask with sealed nasal and oral compartments...

BACKGROUND: Pulmonary embolism (PE) is one of the leading causes of death in hospitalized patients. Treatment patterns and patient demographics for PE are changing; therefore, we sought to evaluate national trends in admission rate, discharge disposition, and length of stay (LOS) in patients hospitalized with PE. METHODS: The National Inpatient Sample database was used to collect data for hospitalizations of patients ≥20 years old with primary diagnosis of PE between 1/2000 and 9/2015...