Chest
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The lung function laboratory frequently provides relevant information to the practice of pulmonology. Clinical interpretation of pulmonary function and exercise tests, however, has been complicated more recently by temporal changes in demographic characteristics (higher life expectancy), anthropometric attributes (increased obesity prevalence), and the surge of polypharmacy in a sedentary population with multiple chronic degenerative diseases. ⋯ Following a Bayesian perspective, we suggest interpretative algorithms that consider the pretest probability of abnormalities as indicated by additional clinical information. We, therefore, adopt a pragmatic approach to help the practicing pulmonologist to apply the information provided by the lung function laboratory to the care of individual patients.
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Pulmonary hypertension (PH) due to interstitial lung disease (ILD; PH-ILD) can complicate a multitude of ILDs, including idiopathic pulmonary fibrosis, chronic hypersensitivity pneumonitis, and nonspecific interstitial pneumonia. Development of PH-ILD is associated with increased need for supplemental oxygen, reduced mobility, and decreased survival. A high index of suspicion is required to make the diagnosis, given the substantial overlap in symptoms with those of ILD without PH. ⋯ Right-sided heart catheterization remains the gold standard for confirming a diagnosis of PH-ILD. Although there is little debate about the use of supplemental oxygen and diuretic therapy in the treatment of PH-ILD, treatment with pulmonary vasodilator therapy remains controversial. Although several studies have been terminated prematurely for harm, the recently completed INCREASE trial of inhaled treprostinil appears to validate the concept of treating PH-ILD with pulmonary vasodilators and, we hope, will serve as a foundation from which future studies can be developed.
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Smoking is associated with one of five deaths in the United States. Multimodality tobacco treatment increases rates of successful cessation by at least 20%. The coronavirus disease 2019 pandemic has put a halt to many inpatient and outpatient medical visits that have been deemed nonessential, including tobacco treatment. ⋯ A military health facility on Fort Eustis in Virginia runs a successful tobacco treatment program and adapted it to pandemic times. This article describes the process and lessons learned from this initiative. The model is applicable and scalable to government and civilian health centers as health care adapts to a new normal.
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Review
Teaching Clinical Reasoning and Critical Thinking: From Cognitive Theory to Practical Application.
Teaching clinical reasoning is challenging, particularly in the time-pressured and complicated environment of the ICU. Clinical reasoning is a complex process in which one identifies and prioritizes pertinent clinical data to develop a hypothesis and a plan to confirm or refute that hypothesis. Clinical reasoning is related to and dependent on critical thinking skills, which are defined as one's capacity to engage in higher cognitive skills such as analysis, synthesis, and self-reflection. ⋯ In addition, the article describes how internal and external factors in the clinical environment can affect students' and trainees' clinical reasoning abilities, as well as their capacity to understand and incorporate strategies for effective critical thinking into their practice. Utilizing applicable cognitive psychological theory, the relevant literature on teaching clinical reasoning is reviewed, and specific strategies to effectively teach clinical reasoning and critical thinking in the ICU and other clinical settings are provided. Definitions, operational descriptions, and justifications for a variety of teaching interventions are discussed, including the "one-minute preceptor" model, the use of concept or mechanism maps, and cognitive de-biasing strategies.
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The outbreak of vaping-related acute lung injury in the United States, named EVALI (e-cigarette or vaping product use associated acute lung injury), has reignited concerns about the health effects of vaping. Initial case reports of vaping-related lung injury date back to 2012, but the ongoing outbreak of EVALI began in the summer of 2019 and has been implicated in 2,807 cases and 68 deaths as of this writing. Review of the scientific literature revealed 216 patient cases that spanned 41 reports of parenchymal lung injury attributed to vaping. ⋯ A high index of suspicion combined with a good history are the keys to an accurate diagnosis. Treatment is supportive; the mortality rate is low, and most patients recover. Corticosteroids have been used with apparent success in patients with severe disease, but more rigorous studies are needed to clarify their role in the treatment of vaping-related lung injury.