Over 300,000 patients experience in-hospital cardiac arrest in the United States each year, resulting in substantial morbidity, mortality, and loss of disability-adjusted life years. Although survival following in-hospital cardiac arrest improved over the past two decades, outcomes remain poor and many initial survivors of in-hospital cardiac arrest are discharged with substantial disability. Across the United States, risk-standardized survival following in-hospital cardiac arrest varies significantly, reflecting potential for process improvement. Improving processes of care and outcomes following in-hospital cardiac arrest is a priority of national organizations such as the Joint Commission, the American Hospital Association, and other professional bodies. Nevertheless, best approaches to improving in-hospital cardiac arrest care have not been well defined. Performance of regular, multidisciplinary in-situ cardiac arrest simulations has been identified as a trait common to best performing hospitals with respect to in-hospital cardiac arrest outcomes. Yet, no clear approach to establishing an in-situ cardiac arrest program has been established. In this How I Do It installment, we describe the creation of a robust and sustainable in-situ cardiac program including securing sponsorship and assembling a multidisciplinary team, acquiring and maintaining equipment and resources, execution of realistic simulations, and facilitating structured debriefings and continuous quality improvement. Our framework and ready-to-use tools will enable hospitals to implement sustainable in-situ IHCA simulation programs and drive measurable improvements in care and outcomes.

Interstitial Lung Disease (ILD) is a term encompassing a wide array of pulmonary conditions characterized by inflammation and fibrosis of the pulmonary parenchyma. Pulmonary hypertension (PH) is frequently encountered in patients with fibrotic ILDs and poses unique difficulties for both diagnosis and management. Patients with ILD associated pulmonary hypertension (ILD-PH) are complex, often ailing and presenting with multiple comorbidities whose individual contributions to the underlying PH can be challenging to disentangle. Evidence supporting treatment with PH-specific medications in ILD-PH is limited. This edition of "How I Do It" presents a longitudinal case-based discussion of ILD-PH to address these challenges, highlight pearls and pitfalls in the diagnostic workup of these patients, and provide a framework for the practical evidence-based approach to accurate diagnosis and management of these challenging patients.

Fibrinolysis and complicated parapneumonic effusion/empyema have a longstanding relationship. Many of the first major breakthroughs in the discovery of plasminogen and its activators were made using Streptococcus species isolated from a patient with empyema. Fatefully, the first clinical use of plasminogen activators to treat human disease involved administering the identified Streptococcal plasminogen activator, streptokinase, intrapleurally to treat parapneumonic effusion and empyema. Refinement of fibrinolytic therapy over the last decades has led to the common practice of adjunctive intrapleural fibrinolytic therapy using a combination of recombinant human tissue plasminogen activator and deoxyribonuclease 1. However, current intrapleural fibrinolytic therapy for is inefficient resulting in an average hospital stay of 14 days. Further, many patients demonstrating residual pleural effusion after therapy, some of whom ultimately require surgery. This leads to billions of dollars of healthcare expenditure annually in the United States. This Special Feature aims to provide a historical overview of intrapleural fibrinolysis, review the current clinical fibrinolytic therapy practices for treatment of complicated parapneumonic effusion/empyema, and highlight knowledge gaps in our understanding of the pathobiology of resistance to intrapleural fibrinolytic therapy. While non-fibrinolytic modalities such as pleural irrigation and surgery are referenced for context, they are not the focus of this review and will not be discussed in depth. Improved knowledge of the mechanisms underlying aberrant fibrinolysis in the pleural space has the potential to improve prognostication, guide precision therapeutics, and enhance the care of CPE/E patients, leading to better individual outcomes and reduced healthcare expenditure.

Uptake of evidence-based practices (EBPs) in pulmonary and critical care medicine is frequently incomplete. To address these gaps implementation scientists seek to understand the clinical and societal contexts in which innovations and EBP are introduced. They also design and evaluate complex interventions to facilitate the adoption of an EBP in those contexts. We propose that well-established methods for analyzing hierarchical, observational data can complement and strengthen this process by identifying sources of practice variability. This manuscript reviews the dominant framework used to understand the clinical context of implementation programs, describes how measuring practice variability could help streamline this approach, and tests an assumption of the proposed combined methodology using observational data from a national study of mechanically ventilated patients conducted by The Prevention and Early Treatment of Acute Lung Injury (PETAL) Network. We discuss how the combined approach can be used to 1) focus the search for determinants of practice, 2) quantify the impact of evidence generation and evaluate the success of implementation projects, and 3) facilitate comparisons between implementation strategies when multiple approaches are trialed simultaneously.

Digital health technologies (DHT) such as mobile health technologies, wearables, telehealth and telemonitoring are increasingly used in healthcare. This is particularly true for respiratory conditions such as asthma, cystic fibrosis, tuberculosis, interstitial lung disease and COPD as DHTs can support diagnosis, self-management, and ongoing care. However, respiratory conditions change across an individual's lifespan in both their presentation and management priorities for the clinician and patient. This creates new challenges and opportunities for using DHT. Adopting an 'all-of-life' approach is key when considering DHT use within each life stage and across the lifespan.

Sepsis-induced cardiomyopathy (SICM) is a heterogeneous cardiovascular dysfunction associated with sepsis and septic shock. While traditionally defined by reversible left ventricular (LV) systolic dysfunction, recent evidence has revealed a broader spectrum, including LV diastolic dysfunction, hyperdynamic LV systolic states, and right ventricular (RV) injury, occurring independently or in combination. Despite their prognostic significance, these phenotypes remain underrecognized and understudied.

Obstructive sleep apnea (OSA) is a common, chronic sleep disorder affecting up to 49% of men and 23% of women, yet it remains highly underdiagnosed. Sex-specific prevalence and OSA phenotype suggests that affected women are comparatively more likely to experience certain symptoms, such as insomnia and mood disturbances, and less likely to have loud snoring and observed apneas. Sex differences in symptom presentation may contribute to OSA underdiagnosis in women, as traditional diagnostic criteria and clinical assessments often prioritize symptoms more common in men. This review highlights reproductive aging as an overlooked risk factor for OSA, independent of aging, and describes resultant barriers and inequities in OSA screening.

In April 2023, the American Thoracic Society (ATS) published the Official ATS Statement: Race and Ethnicity in Pulmonary Function Test (PFT) Interpretation recommending the adoption of race-neutral reference equations for PFT interpretation. However, lack of a clear roadmap to implement this recommendation effectively remains a challenge. This paper outlines how our large, safety-net hospital systematically transitioned from race-specific to race-neutral reference equations. Our approach, guided by the Kotter Change Model, can serve as a framework for other institutions.

Long COVID or a post-COVID condition, defined as the persistence of symptoms at least 3 months after acute COVID-19 infection, is a novel condition in which a definitive diagnostic marker and treatment have yet to be found. This condition, which has been estimated to impact > 65 million individuals worldwide, manifests with multisystem involvement, most commonly presenting with fatigue, brain fog, dyspnea, cough, or a combination thereof. The burden of these symptoms can range from mild to severe, with many patients reporting an inability to return to usual activities. Herein, we present several hypothetical but clinically representative case reports to allow discussion around how we approach the diagnosis of respiratory symptoms of long COVID in those with and without chronic lung disease.

Small airways are recognized as the main site of disease progression and airflow limitation in patients with chronic obstructive pulmonary disease (COPD). Whereas conventional lung function testing, e.g. spirometry, is non-specific to small airway disease (SAD), the advent and wider availability of techniques sensitive to SAD, such as oscillometry, has improved our understanding of the clinical importance of small airway dysfunction. Despite this progress, a gap between the recent advances in knowledge of SAD to its implementation in daily clinical practice remains. We aimed to answer key questions that would allow practitioners (e.g. family doctors, internists, pulmonologists) to introduce oscillometry in their clinical practice.

Clinicians who care for patients with chronic respiratory failure are faced with complex medical decisions when initiating and managing home mechanical ventilation. The technological advances and complexities of home mechanical ventilators (HMVs) have outpaced the education and resources provided to clinicians who manage this unique patient population. Many clinicians are familiar with 1 brand and depend on medical equipment suppliers when prescribing and managing home ventilators. A recent national safety recall in the United States of one of the most commonly used HMVs has led to an increase in burden and challenges facing clinicians caring for patients with chronic respiratory failure. The recall has forced clinicians to address knowledge gaps in evolving home mechanical ventilation technology. Evidence supporting the use of advanced and proprietary algorithms is limited, and understanding how to initiate or transition between devices to achieve success using such modes requires education, awareness, and expertise on the risks and benefits of tailoring therapy appropriately. This review focuses on providing practical, real-world guidance to transitioning autotitrating algorithms between HMVs to optimize patient therapy.

Lung cancer remains the number 1 cause of cancer death in men and women in the United States and much of the world. This CHEST organization guideline examines the literature on primary treatment of patients with stage I and II non-small cell lung cancer (NSCLC) to provide evidence-based recommendations.

Successful procedural training is a universal concern for pulmonary and critical care medicine (PCCM) program directors. Bootcamps may provide a unique and often first opportunity for intense, immersive procedural learning without exposing patients to harm. New trainees must otherwise learn on the job while acclimating to unfamiliar environments and responsibilities. Our goal was to create a structured regional educational event conducted early in fellowship; we aspired to optimize familiarity with procedures and equipment, allay stress among trainees, and create a collaborative learning environment through sharing of simulation equipment and faculty among programs. This article outlines the design, implementation, and lessons learned from this 1-day, multidisciplinary PCCM and critical care medicine procedural bootcamp in the southwest region of the United States. The bootcamp program was designed as learner centered, with educational and experiential goals and feasibility in mind, using a flipped classroom model and testing to maximize time for psychomotor skills building. A multidisciplinary approach enriched the learning environment, modeled team-based procedural care, and fostered interprofessional collaboration. Assessments measured pre-knowledge and post-knowledge acquisition as well as gauged learner performance using checklists and small group interaction. Evaluation of feedback from learners, faculty, and participating programs allowed for yearly iterative improvements. We share these lessons learned as a model for other scalable and impactful medical education initiatives.

Lung cancer screening (LCS) has evolved over the past decade with research advances and clinical experience helping to define target populations for screening, to improve lung nodule detection and management, and to identify structural components of programs that improve the quality of screening delivery. The 2015 American College of Chest Physicians and American Thoracic Society Policy Statement, "Components Necessary for High-Quality Lung Cancer Screening," identified 9 essential components for high-quality LCS. Ten years later, optimizing the balance between the benefits and harms of LCS and ensuring equitable screening among all population groups remain fundamental objectives. In this 2025 update, we aimed to summarize new knowledge and highlight critical components that are needed for providing high-quality LCS. A multidisciplinary group of LCS experts was assembled to review evidence from the past 10 years. The original components were reviewed and updated to develop 8 refined components that should be considered essential structural elements of screening programs. Each component recommended by the authors is supported by an evidence update. Applying this framework will allow screening programs across the country to ensure implementation of high-quality, net-benefit LCS.

Current indications for long-term oxygen therapy (LTOT) primarily are based on thresholds of arterial oxygen saturation (SaO2) or PaO2 that ignore fundamental mechanisms of adaptation and intolerance to hypoxia. In individuals exposed to chronic hypoxic conditions, the accumulation of hypoxia-inducible factors (HIFs) in the cell nucleus upregulates target genes that favor tolerance to hypoxia. Adaptations include hyperventilation, systemic vascular bed development, increased erythropoiesis, and cellular metabolic adjustments. Excessive responses to hypoxia also may develop, leading to pulmonary vasculature remodeling and other end-organ dysfunctions. Biomarkers of hypoxia may complement the measurement of SaO2 or PaO2 in personalizing oxygen prescription before end-organ dysfunction becomes clinically apparent.

Pulmonary arteriovenous malformations (PAVMs) require therapeutic embolization and careful surveillance to prevent serious complications, including stroke, brain abscess, and hemoptysis. Although initial treatment guidelines are well established, posttreatment surveillance practices remain heterogeneous, with no standardized approach for monitoring treated lesions or detecting PAVM persistence. This variability in follow-up care may affect patient outcomes, particularly in high-risk populations such as those with hereditary hemorrhagic telangiectasia (HHT).

Establishing the cause of a pleural effusion can be challenging. Analysis of pleural fluid (PF) is a powerful tool to determine the cause of a pleural effusion. Surprisingly, despite the diagnostic power of PF analysis (PFA), it is often underused. This review provides a practical framework to maximize the diagnostic potential of the PFA. We describe the role of a PFA in establishing the cause of a pleural effusion. We also discuss challenges and limitations of PFA.

Pulmonary embolism (PE) is one of the leading causes of pregnancy-related deaths in high-income countries. Maternal mortality from PE has been attributed to delayed recognition and investigations. The diagnosis of PE may be challenging, as its early signs and symptoms may overlap with physiological changes of pregnancy. As such, promptly ruling out suspected PE using diagnostic testing is of paramount importance. This narrative review provides a contemporary overview of risk assessment tools, diagnostic modalities, counseling needs, and existing best practice guidance for the diagnosis of PE in pregnancy.

Right heart catheterization is the gold standard for the diagnosis of pulmonary hypertension. There are variations in practice and several pitfalls introducing errors in diagnosis that can significantly affect treatment. Errors in assessing the correct pulmonary artery wedge pressure can significantly affect accurate classification of patients with pulmonary hypertension and lead to potentially deleterious treatment decisions. This review focuses on best practices in right heart catheterization performance, emphasizing practical and pathophysiological principles to obtain the most accurate result, as well as advanced applications in pulmonary hypertension.

From screening to treatment, the continuum of lung cancer reflects unequal access and delivery, with more vulnerable patients less able to receive high-quality care. Despite great advances in lung cancer care (eg, screening and nodule programs to identify early-stage disease and immune-mediated and targeted therapies for advanced-stage disease), disparities persist both in the United States and globally. In this narrative review, the spectrum of disparities that influence lung cancer care on a national scale, including race, ethnicity, age, socioeconomic status, geographic location, and insurance access, are explored. The review focuses on how disparities impact screening efforts and lung cancer treatments. Where data are available, trends on a global scale are addressed. Potential solutions are offered to address recognized disparities, primarily by identifying pertinent social determinants of health and launching multipronged interventions to improve the care of all patients with lung cancer.