Auto-PEEP What is Auto-PEEP? • Progressive air trapping & dynamic hyperinflation → ↑Palv at end expiration • Auto-PEEP = intrinsic PEEP When does Auto-PEEP happen? • Auto-PEEP happens when there is incomplete exhalation before the next inspiration • Commonly due to expiratory airway resistance (e.g. asthma), or high VE How do we detect Auto-PEEP? • Suspect when flow on ventilator does not go back to O before next breath • An expiratory hold maneuver on the ventilator allows us to quantify auto-PEEP Why do we care about auto-PEEP? • Auto-PEEP → ↑ intrathoracic pressure → barotrauma and decreased venous return → hypotension. Also, increased effort to trigger a breath How do we fix auto-PEEP? • Decrease airway resistance (e.g. bronchodilators) • Increase expiratory time (Tflow rate = decrease I:E ratio, decrease RR) • Decrease overall minute ventilation • In acute scenario (e.g. hypotension) disconnect patient from ventilator By @PulmPEEPs #AutoPEEP #PEEP #pulmonary #diagnosis #management #criticalcare #MechanicalVentilation

Titrating PEEP in ARDS Key Principles: 1) The ideal PEEP optimizes alveolar recruitment and reduces atelectrauma, while minimizing over-distension and barotrauma 2) Variables to monitor with PEEP titrations are: • Plateau pressure (Pplat) • Driving pressure (ΔP = Pplat - PEEP) • Oxygenation • Blood pressure 3) No one method has proven to be the superior option for titrating PEEP 4) Optimal PEEP is dynamic, and should be re-assessed frequently 5) High-PEEP recruitment maneuvers are harmful and should be avoided Optimize PEEP with one of these methods: • Driving Pressure and Incremental / Decremental PEEP trial • Esophageal Manometry • Pressure - Volume Loop • Stress Index By @PulmPEEPs #PEEP #ARDS #titration #management #criticalcare #pulmonary

Reverse Halo Sign Defined as a central ground class opacity surrounded by a ring of dense consolidation Differential Diagnosis: • Infection: Mucormycosis, Aspergillosis, Tuberculosis, Pneumocystis jiroveci • Autoimmune: Granulomatosis with polyangiitis • Vasculature: Pulmonary infarction secondary to PE • Malignancy: Primary pulmonary neoplasms, metastatic disease • Other: Cryptogenic organizing pneumonia, Sarcoidosis, Radiation pneumonitis By @PulmPEEPs #Reverse #Halo #Sign #differential #diagnosis #pulmonary #radiology

Asthma Chronic lung disease characterized by airway inflammation, airway and variable expiratory air flow obstruction There are 2 main critieria that are used to identify obstruction: • FEV1 / FVC of 0.70 or lower • FEV1 / FVC below the lower limit of normal (LLN) Severity is determined by reduction in FEV1%: • > 70% - mild • 50-69% - moderate • <50% - severe Reversibility on spirometry: • Increase of FEV1 or FVC of 12% or more, or • Increase of 200 mL or greater in FEV or FVC By @PulmPEEPs #Asthma #diagnosis #pulmonary

Pneumonia on Lung POCUS Large subpleural consolidation with static air bronchograms. Dr. Stephen Alerhand @SAlerhand #Pneumonia #Lung #POCUS #Ultrasound #Air #Bronchograms #Clinical #Pulmonary

Hyperacute Hypoxemia - Workup and Management Differential Diagnosis: Aspiration, Flash Pulmonary Edema, Mucous Plugging, Bronchospasm, Pulmonary Embolism, Pneumothorax, Alveolar Hemorrhage (DAH), Anaphylaxis Targeted Exam: Mental Status, Volume Exam (JVP, edema), Lung Exam, POCUS (B-lines, lung sliding) Diagnostics: STAT Labs (BMP, CBC, coags, BNP, Troponin), ABG, STAT CXR, CTA Chest, Echocardiogram, Bronchoscopy Therapeutics: Airway, Circulatory Support, O2 Escalation, Tailored Therapy • Aspiration/PNA: antibiotics • Flash Edema: Lasix + BP control • Bronchospasm: Solu-Medrol, • stacked nebs • PE: anticoagulation • Anaphylaxis: 1M Epi, ± Solu-Medrol. Benadryl. PPI Oxygen Therapy: • Low Flow • Reservoir • High Flow • NIPPV Sophia Hayes MD @Sophia_Hayes_MD #Hyperacute #Hypoxemia #Hypoxia #Workup #diagnosis #Management #treatment #criticalcare

Lung re-expansion of pneumothorax after pigtail thoracostomy on Lung POCUS Dr. Stephen Alerhand @SAlerhand #Lung #reexpansion #pneumothorax #POCUS #ultrasound #clinical #pulmonary

High-Res Chest CT Patterns - Differential Diagnosis Framework Reticular: • Septal Thickening: Lymphangitic Carcinoma, Interstitial Edema, Alveolar Proteinosis, Lymphoma, Sarcoidosis, Silicosis • Honeycombing - See Low Attenuation Nodular: • Random: Metastases, Miliary Infection (TB, Fungal) • Perilymphatic: Sarcoidosis, Silicosis, Lymphangitic Carcinoma, Coal Pneumoconiosis • Centrilobular: Hypersensitivity Pneumonitis, Respiratory Bronchiolitis, Bronchopneumonia High Attenuation: • Acute Ground Glass: Edema, Hemorrhage, Pneumonia, Acute Hypersensitivity, Acute Eos PNA • Chronic Ground Glass: Hypersensitivity Pneumonia, COP, Chronic Eos PNA, Fibrosis, BAC • Crazy Paving: Alveolar Proteinosis, Sarcoidosis, NSIP, COP, Infection, Neoplasm (BAC), Hemorrhage, Edema • Consolidation: Pus, Blood, Water, Tumor Low Attenuation: • Emphysema: Smoking, Alpha-1-Antitripsyn Def • Cysts: Congenital, Langerhans Histiocytosis, Lymphocytic Int PNA, Lymphangioleiomyomatosis • Honeycombing: Idiopathic Pulmonary Fibrosis, RA, Scleroderma, End-Stage Hypersensitivity, End-Stage Sarcoidosis • Bronchiectasis: Prior Infection, Aspiration, Cystic Fibrosis, ABPA, Immune Deficiency Sophia Hayes MD @Sophia_Hayes_MD #High #Resolution #HiRes #HighRes #Chest #CT #Patterns #Differential #Diagnosis #pulmonary #radiology

Mucopurulent findings on Bronchoscopy Dr. Altair Costa Jr @altair.doc #Mucopurulent #purulence #Bronchoscopy #clinical #video #pulmonary #bronchoscopy

Endobronchial Carcinoid Tumor on Bronchoscopy Dr. Altair Costa Jr @altair.doc #Endobronchial #Carcinoid #Tumor #Bronchoscopy #clinical #video #pulmonary