Septic shock is defined by the need for vasopressor agents to correct hypotension and lactic acidosis resulting from infection, with 30%-40% case fatality rates. The care of patients with worsening septic shock involves multiple treatment decisions involving vasopressor choices and adjunctive treatments. In this edition of "How I Do It", we provide a case-based discussion of common clinical decisions regarding choice of first-line vasopressor, BP targets, route of vasopressor delivery, use of secondary vasopressors, and adjunctive medications. We also consider diagnostic approaches, treatment, and monitoring strategies for the patient with worsening shock, as well as approaches to difficult weaning of vasopressors.

Lung cancer remains the leading cause of cancer-related mortality in the United States. The National Lung Screening Trial (NLST) demonstrated a 20% reduction in lung cancer mortality resulting from lung cancer screening (LCS) with an additive reduction from smoking abstinence. However, successful smoking cessation within LCS is variable.

Pulmonary hypertension (PH) complicates the course of many patients with fibrotic interstitial lung disease (ILD). Inhaled treprostinil (iTre) has been shown to improve functional ability and to delay clinical worsening in patients with PH resulting from ILD.

Functional capacity, as measured by the 6-min walk test (6MWT), is often reduced in fibrotic interstitial lung disease (ILD). This study evaluated longitudinal changes and the prognostic significance of 6MWT parameters, and explored change in oxygenation status as a physiological criterion to define disease progression in patients with fibrotic ILD.

Critically ill patients sometimes remember periods of neuromuscular blockade.

Reduced daily life physical activity (DLPA) in pulmonary arterial hypertension (PAH) contributes to a poor quality of life.

A 35-year-old man presented to the ED with a 7-day history of fever, asthenia, and cough. He had previously received a 3-day course of amoxicillin and clavulanic acid (1 g tid po) and then ceftriaxone (1 g IM once per day) prescribed by his general practitioner with no substantial benefit. He was an active smoker (11.2 pack/y), without known allergy-related syndromes and any important reports in his medical history.

A 63-year-old Japanese woman with no medical history presented as an outside hospital transfer for further management of acute hypoxemic respiratory failure. Per her family, the patient had developed a rash and intermittent shortness of breath 2 months prior to hospital presentation. The rash was described as an erythematous maculopapular rash located on her proximal arms, chest, and upper eyelids. She saw her primary care physician, who prescribed a course of oral and topical corticosteroids. Despite these symptoms, the patient had an excellent functional status and exercised several times per week without muscle weakness. Two months following the initial presentation, the patient progressively became lethargic, prompting her son to bring her to the hospital for admission and evaluation. While in the hospital, the patient had progressive shortness of breath and developed worsening hypoxemic respiratory failure. Despite broad-spectrum antibiotics, her hypoxemia worsened, requiring intubation. She was subsequently started on 80 mg of IV methylprednisolone three times daily and transferred to our institution for further management. The patient arrived from the outside hospital receiving deep sedation and paralysis. Despite maximal ventilator settings, the patient remained hypoxemic and developed shock requiring multiple vasopressors.

A previously healthy 57-year-old man presented to the ED with altered mental status and severe shortness of breath. He was found to be in acute hypercapnic respiratory failure and required admission to the ICU. He reported the following: a 4-month history of progressive shortness of breath; left-sided chest pain; cough productive of brown, foul-smelling sputum; and weight loss. He had an extensive smoking history but had quit 1 year prior. The patient was born in Ethiopia but had been living in the United States for the last 20 years. His last visit to Ethiopia was in 2009, and he denied any other recent travel or exposure to TB. There was no history to suggest immune compromise. He had not seen a physician in many years and never established medical care in the United States.

A 65-year-old woman was referred for a second opinion regarding a 7-month history of a persistent, progressive, nonproductive cough. Her cough occurred several times a minute, causing a significant impact on her daily activities. She denied fever, chills, weight loss, chest pain, wheezing, symptoms of gastroesophageal reflux, or postnasal drip. She was a never smoker with no history of asthma, allergies, sinus disease, or dermatitis. She had never taken an angiotensin-converting enzyme inhibitor. Her medical history included rheumatoid arthritis, for which she was treated with methotrexate for 3 years. She denied any occupational or environmental exposures. She was previously treated with a short-acting β-agonist, inhaled corticosteroid/long-acting β-agonist, montelukast, nasal steroids, a proton pump inhibitor, gabapentin, and azithromycin without relief. She also received codeine, which provided mild relief.

A 43-year-old woman with a medical history of hypothyroidism, psoriasis, and tobacco abuse (30-pack year history) who had quit smoking several months prior to presentation presented with pleuritic chest pain. She also noted a 2-year history of progressive numbness and weakness in her bilateral upper and lower extremities that now prevented her from completing her activities of daily living. She had worsening exertional dyspnea and a subjective 50-lb weight loss over the past year.

A 45-year-old man sought treatment at the ED during the third wave of the COVID-19 pandemic with a month-long history of fatigue, cough, myalgia, and hand stiffness. He did not report dyspnea. He had no past medical history and previously was fit and active, working as a farmer. He was a lifelong nonsmoker and had no family history of lung disease.