Balanced crystalloid solutions may improve clinical outcomes compared with saline for some critically ill adults, but it is unclear whether differences in composition between balanced crystalloid solutions affect outcomes.

A 40-year-old man with chronic myeloid leukemia presented to the hospital with recurrent dyspnea and hypoxemic respiratory failure. He presented from his outpatient transplant infectious diseases appointment with dyspnea, cough, worsening hypoxemia, acute kidney injury, and somnolence after discharge from the hospital 2 weeks prior with a similar presentation. During the previous hospital stay, he underwent bronchoscopy and alveolar lavage with negative infectious workup. He was prescribed caspofungin, amphotericin, and continued posaconazole for prior probable invasive fungal infection (elevated blood BD-glucan and pulmonary nodules). Antibiotics included previous meropenem for esophageal nocardiosis, cefepime and azithromycin during admission, and now ceftriaxone for nocardiosis in the outpatient setting for convenience of home infusion. He was prescribed diuretics for presumed volume overload. Despite home diuretics, antimicrobials, and supplemental oxygen, he re-presented with worsening symptoms.

Pulmonary arterial hypertension (PAH) frequently is associated with an imbalance in antiproliferative bone morphogenic protein-2 receptor signaling and proproliferative type-II activin receptor signaling, favoring the latter. Sotatercept is an activin ligand trap that reduces the dominant detrimental activin signaling and provides clinical benefit. We report a patient with heritable PAH in whom sotatercept had neither positive nor negative effects; we relate that fact to his PAH being caused by a previously unreported variant of unknown significance (c.1276T>C, p.[Cys426Arg]) in the GDF2 gene. GDF2 encodes bone morphogenic protein type-9, the presence of which is required for proper functioning of the pulmonary microvasculature. Low levels of functionally active bone morphogenic protein type-9 contribute to PAH. As we enter an era of precision medicine for patients with PAH with increasingly costly therapies, genetic screening may direct appropriate therapy and limit the use of expensive but likely ineffective therapies.

Pediatric pulmonary hypertension (PH) is a severe incurable disease with a poor prognosis. In pediatric PH, trial design is hampered by the absence of age-appropriate trial end points. This study evaluated physical activity (PA) measured by hip-anchored accelerometry as a potential trial end point in pediatric PH.

Patient-reported outcomes should be considered alongside clinical assessments to guide therapy for COPD.

Millions of people around the world survive critical illness each year only to realize that they and their loved ones are grappling with a new "normal" after hospital discharge for which their medical team may not have adequately prepared them. Up to one-half of all ICU survivors suffer from new or worsening impairments in physical, cognitive, and psychological domains of health that are often not realized until they attempt to re-enter their previous lives. These devastating long-term sequelae of critical illness, collectively described as post-intensive care syndrome (PICS), can carry enormous consequences for an ICU survivor's ability to care for their family, return to work, and regain their previous quality of life for months to years after their inciting illness. Despite mounting research on PICS and survivorship, a knowledge gap exists whereby ICU team members may not always be aware of PICS and may not counsel their patients on the challenges awaiting them after discharge. Understanding how best to communicate these challenges to patients and families is crucial in preparing for survivorship beyond the ICU. In this review, we summarize PICS and possible recovery trajectories of ICU survivors. We then discuss communication strategies, emphasizing the role of empathy. Finally, we provide a suggested framework to handle these crucial conversations. We aim to equip clinicians with the knowledge and framework to care for a patient who has survived critical illness but now faces the possibility of struggles inadequately addressed by our health care system.

There is limited knowledge about long-term mortality, care pathways, and health-related quality of life (HrQoL) among patients in the ICU receiving prolonged mechanical ventilation (PMV).

Quoting patients in electronic medical record (EMR) notes is controversial. Quotations may be used to promote accuracy in documentation. However, they also may be used to cast skepticism on patient speech. Little is known about how quotations are used in EMR notes documenting goals-of-care (GOC) conversations.

Although small airway disease (SAD) has been recognized as a major contributor to obstructive respiratory diseases, the association between occupational endotoxin exposure and SAD, as characterized by CT scans, requires further investigation.

Airway management is a critical component of the care of patients experiencing cardiac arrest, but data from randomized trials on the use of video vs direct laryngoscopy for intubation in the setting of cardiac arrest are limited. Current American Heart Association guidelines recommend placement of an endotracheal tube either during CPR or shortly after return of spontaneous circulation, but do not provide guidance around intubation methods, including the choice of laryngoscope.

Accurate assessment of a patient's volume status is crucial in many conditions, informing decisions on fluid prescribing, vasoactive agents, and decongestive therapies. Determining a patient's volume status is challenging because of limitations in examination and investigations and the complexities of fluid homeostasis in disease states. Point-of-care ultrasound (POCUS) is useful in assessing hemodynamic parameters related to volume status, fluid responsiveness, and fluid tolerance. It requires understanding several physiologic concepts to interpret and integrate POCUS findings accurately into volume-related clinical decision-making.

Adaptation of the right ventricle is a key determinant of outcomes in pulmonary arterial hypertension (PAH). Despite a compelling rationale to develop targeted therapies for the right ventricle in PAH, no such treatments exist. H2-receptor antagonism is a potential myocardial-focused paradigm in heart failure.

Up to two-thirds of patients with severe uncontrolled asthma (SUA) who received biologic therapy do not have a complete response.

The small airways comprise generations 8 to 23 of the bronchial tree, consist of airways with an internal diameter < 2 mm, and are classically difficult to assess and treat in persistent asthma. Small airways dysfunction (SAD) is integral to the asthma management paradigm because it is associated with poorer symptom control and greater levels of type 2 inflammation, and it has been proposed as a potentially treatable asthma trait. Although identification of SAD based on oscillometry has been found to be clinically useful in managing asthma, very few physicians, including specialists, use this technique as part of standard or adjunct evaluation of lung function to diagnose asthma, grade severity of airway obstruction, ascertain disease control or the risk for future exacerbations, or to make management decisions. To rectify the unrecognized value of oscillometry in the asthma community, a consortium of authors who are investigators with knowledge and experience of oscillometry wished to address the most important clinical questions raised by our colleagues who are considering using this technique, including its clinical utility. In this article, we discuss integral concepts, including applicability of oscillometry as a predictive tool for asthma exacerbations and disease control, adequacy of spirometry and oscillometry in assessing SAD, potential limitations of oscillometry, and treatment options for SAD.

A large number of symptomatic individuals with central sleep apnea (CSA) in clinical practice have an indication for adaptive servoventilation (ASV) therapy.

Annual lung cancer screening using low-dose CT (LDCT) imaging effectively reduces mortality from lung cancer and is recommended for people who are at high risk of developing the disease. The utilization of lung cancer screening, however, has remained low. Due to significantly higher cigarette smoking rates, patients with behavioral health disorders (those living with mental illness and/or substance use disorders) are more likely to be diagnosed with and die of lung cancer; at the same time, they are less likely to undergo cancer screenings. There is an urgent need for targeted efforts to improve access to lung cancer screening among this population disproportionately affected by the disease. In this commentary, we propose integrating lung cancer screening facilitation into services provided by behavioral health professionals who are uniquely positioned to reach these patients and deliver interventions to increase uptake of cancer screenings. We suggest several measures that could improve lung health outcomes of patients with behavioral health disorders: (1) training behavioral health professionals in lung cancer screening eligibility assessment; (2) providing patients with educational materials; (3) integrating shared decision-making counseling for lung cancer screening into behavioral health care settings; (4) providing the practical support needed to access screening; and (5) establishing effective partnerships with community organizations. Regardless of the level of engagement, possibly ranging from brief training to the implementation of comprehensive programs, any involvement will benefit patients. This integrated approach will contribute to reducing lung cancer mortality among patients with behavioral health disorders who have long experienced systemic health inequities.

Asthma is a common, multifaceted respiratory disease with a major impact on quality of life. Despite increased insights into mechanisms underlying various asthma phenotypes and endotypes and the availability of targeted biologic treatment options, the disease remains uncontrolled in a substantial proportion of patients with risk of exacerbations, requiring systemic corticosteroids, and with progressive disease. Current international guidelines advocate for a personalized management approach to patients with uncontrolled severe asthma. The European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) asthma expert panel was convened to discuss strategies to optimize asthma care and to prevent systemic corticosteroid overuse and disease progression. In this meeting report, we summarize current concepts and recommendations and provide a rationale to implement personalized asthma management at earlier stages of the disease. The ultimate goal is to move away from the current one-size-fits-most concept, which focuses on a symptom-driven treatment strategy, and shift toward a phenotype- and endotype-targeted approach aimed at curbing the disease course by improving clinical outcomes and preserving health-related quality of life. Herein, we provide a consensus view on asthma care that advocates a holistic approach and highlight some unmet needs to be addressed in future clinical trials and population studies.

A 36-year-old man with severe Crohn disease complicated by urethral strictures and enterocutaneous and enterovesicular fistulas presented for several weeks of poor appetite, weight loss, failure to thrive, and newly worsening altered mentation. Further history revealed he chronically did not urinate through his urethra, but rather "leaked" through multiple enterocutaneous fistulas in his abdomen and perineum. Medications included ustekinumab (anti-IL12/IL23 monoclonal antibody) for Crohn disease, methadone, and hydrocodone. He had had multiple surgeries because of fistulas related to his Crohn disease, which included subtotal colectomy with ileostomy creation, proctectomy, and ischiorectal flap creation. He drank 10-15 ounces of liquor per week, smoked 10 cigarettes daily, and smoked marijuana weekly.