While beta-blockers are effective at reducing mortality in certain cardiovascular diseases (CVD), their effectiveness in patients with chronic obstructive pulmonary disease (COPD) and CVD is uncertain, particularly with the concurrent use of long-acting β2-agonist bronchodilators (LABA).

Safe and long-lasting separation from invasive mechanical ventilation (MV) is a critical aspect of care provision in the intensive care unit (ICU), yet it remains a complex and heterogeneously applied process. Current weaning strategies often rely on fragmented assessments, personal judgment, and poorly integrated decision milestones that individually and collectively may contribute to delayed attempts, weaning and extubation failure. In this How I Do It article, we propose a comprehensive framework based on seven hallmarks, organized into three sequential and interrelated phases (3S framework): screening, separating, and securing. The screening phase includes sedation management, the facilitation phase (maintaining limb and respiratory muscles strength and functionality, as well as cardiac function) and the transition phase (which involves switching from controlled to partial support mode and the stepwise reduction of ventilatory support). The separating phase includes the assessment of readiness for spontaneous breathing trial (SBT), SBT conduct, and extubation risk assessment and decision-making. The securing phase focuses on post-extubation management and includes strategies to prevent respiratory failure. Rather than focusing on isolated physiological parameters or scores, this framework highlights the dynamic, staged, and integrative nature of the weaning process. By structuring current evidence around these hallmarks, we aim to provide both a patient-centered approach to ventilator liberation and a conceptual foundation for future research, protocol development, and clinical decision-making.

A 68-year-old man presented to our thoracic surgery department for evaluation of a left upper-lobe pulmonary nodule detected on chest CT scan. The oncologic history extended over 7 years. In December 2014, the patient was diagnosed with colorectal adenocarcinoma (ileocecal junction) by colonoscopy, and he underwent a laparoscopic right hemicolectomy and lymph node dissection. Postoperative pathological examination revealed a grade II-III adenocarcinoma of the ileocecal region (ulcerative type), infiltrating into the muscularis. Surgical margins were free of tumor. No metastasis was identified in the examined lymph nodes, including paracolic (19), paracolic (7), intermediate mesenteric (23), and central vascular (2) lymph nodes, corresponding to a pathologic stage of pT2N0M0. The patient recovered well and was placed on regular follow-up.

A 70-year-old man with transfusion-dependent myelodysplastic syndrome was treated with luspatercept. Nine months into treatment and 2 months after dose increase, he developed new hypoxemia with a room air resting oxygen saturation of 88%. He was admitted, requiring up to 90% Fio2 by high-flow nasal cannula to maintain saturations ≥ 92%. CT scan demonstrated stable mild probable usual interstitial pneumonia, without ground-glass, pulmonary embolism, or arteriovenous malformation. Agitated saline contrast-enhanced echocardiogram was late positive, consistent with intrapulmonary shunt. Macroaggregated albumin (MAA) shunt scintigraphy demonstrated a shunt of 7.5%. Extensive investigations ruled out congenital portosystemic shunt and hepatopulmonary syndrome. We diagnosed hypoxemia from intrapulmonary vascular dilatation (IPVD), with luspatercept as a possible cause. Oxygen requirements improved, and supplemental oxygen was discontinued by 7 weeks after cessation. Repeat MAA 10 weeks after cessation confirmed shunt resolution (3.6% shunt). This case of reversible IPVD attributable to luspatercept highlights important monitoring implications in treated patients.

Granulomatosis with polyangiitis (GPA) and eosinophilic granulomatosis with polyangiitis (EGPA) are recognized subtypes of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Their clinical boundaries, however, may be more dynamic than assumed. We describe 2 patients illustrating sequential phenotype transitions with prominent respiratory involvement. The first patient was initially diagnosed with GPA, presenting with neuropathy, purpura, epistaxis, renal disease, and myeloperoxidase (MPO)-ANCA positivity. Six years later, she developed asthma, marked eosinophilia, and eosinophilic myocarditis, consistent with evolution toward EGPA despite stable ANCA serology. The second patient was first classified as EGPA based on eosinophilic asthma, chronic rhinosinusitis with nasal polyps, and MPO-ANCA with borderline proteinase 3 (PR3)-ANCA. After SARS-CoV-2 infection, he developed GPA-like disease with strongly positive PR3-ANCA and destructive airway involvement, including tracheobronchomalacia requiring tracheostomy and stenting. These cases highlight that recognizing this dynamic nature is essential for the timely reassessment of disease classification, prognosis, and therapeutic approach in AAV.

A 53-year-old Black woman was referred to the pulmonary clinic for progressively worsening exertional dyspnea over the past 3 years and a chronic nonproductive cough. She had a history of childhood asthma, with 2 prior hospitalizations, as well as an unspecified nasal surgery 20 years ago. She was diagnosed with bronchiectasis 10 years ago by her primary care physician and was compliant with airway clearance techniques, including nebulized hypertonic (7%) saline and albuterol-ipratropium and a positive expiratory pressure handheld device. Review of systems was positive for fatigue, seasonal allergies, occasional heartburn, and occasional stiffness of the small joints of the hands. She had a family history of asthma in her cousin and sarcoidosis in her father; her mother had a significant smoking history and was deceased from complications of lung cancer. She had no history of occupational exposures, no pets, and no significant travel history.

A 33-year-old male farmer residing in the Kendujhar district (central part) of Odisha state, India, with a 3-year history of type 2 diabetes mellitus that was not well-controlled, presented with a 4-month history of recurrent fever, dyspnea, left-sided pleuritic chest pain, loss of appetite, and significant loss of weight. Despite multiple hospital admissions and several courses of antibiotics during this period, he showed no sustained clinical improvement, with only brief asymptomatic intervals followed by symptom recurrence.

A 19-year-old woman presented with low back pain and dyspnea that had begun approximately 3 months earlier, with low back pain progressively worsening since onset. The patient has no significant medical history or recurrent respiratory conditions. She was residing in a rural village located in Ağrı Province in the Eastern Anatolia Region, Turkey, inhabited by approximately 30 families. Sheep and cattle breeding were the main agricultural activities in this village. She had spent her entire life in the same area without any domestic or international travel.