PulmPEEPs

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PulmPEEPs episodes

July 01, 2025103. Fellows’ Case Files: University of Virginia
Today, we’re virtually visiting the University of Virginia for another Fellows’ Case Files. This is a fantastic case that covers ARDS, the infectious work up of an immunosuppressed patient, and the evaluation of undifferentiated shock. Please let us know what you think of the episode and always feel free to reach out with interesting cases!

Meet Our Guests
John Popovich completed his residency training and chief year at UVA and has stayed on there for his pulmonary and critical care fellowship.
Tim Scialla is an associate professor of medicine at UVA. He completed his residency and fellowship at Johns Hopkins Hospital where he was also an ACS. His clinical and research focuses are advanced airways disease. He is also the program director of the PCCM fellowship.
Matt Freedman completed his residency training at Virginia Commonwealth University and is currently a second year fellow at University of Virginia.

Case Presentation
Patient: 52-year-old male with psoriasis, HIV/AIDS (CD4 count: 71), presenting with progressive shortness of breath, fever, non-productive cough, and weight loss.
Vital signs: Febrile (103°F), tachycardic (HR 110), hypoxemic on 6L O₂ (SpO₂ 90–92%).
Exam: Diffuse crackles, ill-appearing.
Imaging: CXR and CT showed bilateral upper lobe infiltrates, ground-glass opacities, septal thickening, and peripheral cystic changes.

Infographics
POCUS algorithms for investigating shock
Shock physiology:

Key Learning Points
Diagnostic Reasoning in Immunocompromised Hosts
Framework: Anchor the differential based on type of immunosuppression.
HIV/AIDS → T-cell dysfunction, affecting susceptibility to PCP, TB, CMV, fungi (e.g. histo/blasto), and common CAP organisms.
PCP considerations:
PCP can occur despite prophylaxis (e.g. Bactrim), especially if adherence or resistance issues exist.
Classic symptoms in AIDS: acute, febrile, hypoxemic respiratory failure.
Use of Serum Markers and Imaging
LDH: Elevated in PCP, but non-specific. High negative predictive value when normal.
1,3-β-D-glucan: Elevated in PCP and other fungal infections. Very sensitive for PCP (up to 95%).
Imaging: Ground-glass opacities with cystic changes support PCP diagnosis.
Role of Bronchoscopy and Diagnostic Yield
BAL studies to obtain:
DFA for PCP (rapid, high specificity, lower sensitivity)
PCR for PCP (higher sensitivity, slower turnaround)
Cultures: bacterial, fungal, mycobacterial
Cytology, galactomannan, histo/blasto urine antigens
Bronch Risk-Benefit:
Can change management in 40–60% of cases.
Complication rate: ~10–15%, most often hypoxemia.
Heuristic for pre-bronch ABG on non-rebreather:
PaO₂ >150 → likely safe
100–150 → ~25% risk of intubation
<100 → high risk of decompensation
Steroids in PCP and Severe CAP
Steroids indicated in PCP with significant hypoxemia (PaO₂ <70 mmHg).
With new CAP guidelines (Cape Cod trial), steroids may also be considered in severe bacterial CAP.
Shock Evaluation in ICU
Framework: Simplify into likely causes — distributive most common, but rule out cardiogenic, obstructive, hypovolemic.
Physical exam + POCUS essential early.
POCUS: cardiac views, IVC, lung US, abdominal free fluid.
Low EF doesn’t exclude distributive shock.
PA catheter (Swan) utility:
Useful when physiology unclear or when tracking response to therapy is critical.
Swan data in this patient: low CVP and wedge, high SVR → distributive shock, not cardiogenic despite low EF.
27 min
June 17, 2025102. Journal Club with BMJ Thorax – Sleep and Non-Invasive Ventilation
Today is our third episode in our collaborative series with BMJ Thorax. Our mission at Pulm PEEPs is to disseminate and promote pulmonary and critical care education, and we highly value the importance of peer reviewed journals in this endeavor. Each month in BMJ Thorax, a journal club is published looking at high yield and impactful publications in pulmonary medicine. We will be putting out quarterly episodes in association with Thorax to discuss a journal club publication and synthesize four valuable papers. This week’s episode covers four articles related to obstructive sleep apnea therapies, and the use of non-invasive ventilation and high flow nasal cannula for intubation and COPD exacerbations.
Meet Our Guests
Chris Turnbull is an Associate Editor for Education at Thorax. He is an Honorary Researcher and Respiratory Medicine Consultant at Oxford University Hospitals. In addition to his role as Associate Editor for Education at BMJ Thorax, he is also a prominent researcher in sleep-related breathing disorders.
Natalie McLeod is a resident in respiratory medicine and is currently doing a clinical fellowship in sleep and ventilation at Oxford University Hospitals.
Journal Club Papers
Journal club article from Thorax
Effect of CPAP therapy on blood pressure in patients with obstructive sleep apnoea: a worldwide individual patient data meta-analysis
Hypoglossal nerve stimulation for obstructive sleep apnea in adults: An updated systematic review and meta-analysis
Noninvasive Ventilation for Preoxygenation during Emergency Intubation
Nasal high flow or noninvasive ventilation? navigating hypercapnic COPD exacerbation treatment: A randomized noninferiority clinical trial
To submit a journal club article of your own to Thorax, you can contact Chris directly – [email protected]
To engage with Thorax, please use the social media channels (Twitter – @ThoraxBMJ; Facebook – Thorax.BMJ) and subscribe on your preferred platform, to get the latest episodes directly on your device each month.
23 min
June 03, 2025101. RFJC – NAVIGATOR
We’re back with another Rapid Fire Journal Club. Luke Hedrick and Dave Furfaro discuss the NAVIGATOR trial published in NEJM in 2021 evaluating tezepelumab for adults with asthma.
Article and Reference
We are talking today about the NAVIGATOR trial evaluating the use of tezepelumab in adults with asthma.
Menzies-Gow A, Corren J, Bourdin A, Chupp G, Israel E, Wechsler ME, Brightling CE, Griffiths JM, Hellqvist Å, Bowen K, Kaur P, Almqvist G, Ponnarambil S, Colice G. Tezepelumab in Adults and Adolescents with Severe, Uncontrolled Asthma. N Engl J Med. 2021 May 13;384(19):1800-1809. doi: 10.1056/NEJMoa2034975. PMID: 33979488.
https://www.nejm.org/doi/full/10.1056/NEJMoa2034975
Key Learning Points
Background & Rationale
Asthma biologics already exist, targeting IgE and type 2 cytokines (IL-4, IL-5, IL-13), but there’s an unmet need for patients with non-allergic or non-eosinophilic phenotypes.
Tezepelumab is a monoclonal antibody targeting TSLP (thymic stromal lymphopoietin), an upstream mediator of both T2 and non-T2 inflammation, offering a potentially broader therapeutic effect.
10 min
May 18, 2025 100. ATS 2025 Critical Care Assembly: The Future of Mechanical Ventilation
We are podcasting today directly from ATS 2025 in San Francisco! Every year, in collaboration with the ATS Critical Care Assembly, we highlight some of the scientific symposium programming from the conference. Today, Furf and Monty sit down with the three chairs of the scientific symposium entitled: Mechanical Ventilation of the Future: New Foundations For Ventilator Strategies.

Meet Our Guests
Juliana Ferreira is an Associate Professor at the University of Sao Paulo, Brazil where she is also co-director of the pulmonary and critical care fellowship program. She is an MD, PhD, and a physician scientist with specific interests in mechanical ventilation and medical education. Finally, she serves ATS as the ATS MECOR Latin America Director.
Bhakti Patel is an Assistant Professor Medicine at the University of Chicago. She is a dedicated researcher and educator. Her research focuses on non-invasive ventilator support.
Akram Khan is an Associate Professor of Medicine at Oregon Health and Science University. Akram is a pulmonary, critical care, and sleep provider with specific clinical interests in critical illness, pulmonary vascular disease and sleep apnea. Additionally, he is an accomplished translational science researcher.
11 min
May 06, 202599. Fellows’ Case Files: Rutgers – Robert Wood Johnson Medical School
We’re back with another edition of Fellows’ Case Files! Today, we’re virtually visiting Rutgers University, Robert Wood Johnson Medical School to work through a fascinating pulmonary case. Enjoy, and let us know your thoughts.
Meet Our Guests
Khalil El Gharib completed his residency training at Northwell at Staten Island University Hospital Program and is currently a first year fellow at Rutgers Robert Wood Johnson Medical School.
Sabiha Hussain completed her residency training at Robert Wood Johnson Medical School and her fellowship training at Columbia Presbyterian Medical Center in New York. She is currently a Professor of Medicine and the fellowship Program Director.
Case Presentation
Patient: 28-year-old male with Asperger’s syndrome and IgA nephropathy.
Symptoms: 3-month history of progressive dry cough and dyspnea on exertion; later developed mild hemoptysis.
Notable exposure: Questionable black mold in the patient’s apartment.
Initial Workup and Diagnostic Reasoning
Vital signs: Hypoxemia (SpO₂ 91% on room air).
Exam: Inspiratory crackles.
ABG findings: Elevated A–a gradient (~50), indicating a gas exchange problem.
Chest X-ray: Bilateral, patchy infiltrates without specific lobar preference.
Initial management: Discharged with empiric antibiotics for presumed multifocal pneumonia.
Re-Presentation and Further Testing
Symptoms worsened; now with blood-tinged sputum.
Chest CT: Showed diffuse ground-glass opacities (GGOs) without fibrosis, consolidation, or lymphadenopathy.
Imaging and Pathology
Pathology images a courtesy to Dr Isago Jerrett, pathology resident at RWJMS
Key Learning Points
Diagnostic Framework for Hypersensitivity Pneumonitis (HP)
New classification: Based on fibrotic vs. non-fibrotic phenotype (not acute/chronic).
CT features of HP:
GGOs with lobular air trapping.
“Three-density sign” (normal lung, low-density air-trapping, and ground-glass opacities).
BAL: Typically shows lymphocytic predominance in chronic HP, neutrophilic in early stages.
Serum IgG testing: Helps identify antigen exposure but doesn’t confirm disease alone.
Lung biopsy (VATS): Revealed poorly formed granulomas and airway-centered inflammation—consistent with HP.
Differential Diagnosis of Granulomatous Disease
Infectious: TB, fungal (must rule out with stains/cultures).
Non-infectious: Sarcoidosis, HP, granulomatosis with polyangiitis.
Key pathology clues for HP: Loosely formed granulomas, airway inflammation, giant cells.
Management and Outcome
Primary treatment: Antigen avoidance (patient moved out of mold-exposed apartment).
Adjunct therapy: Oral prednisone with a slow taper.
Outcome: Symptomatic and radiographic improvement over six months.
Teaching Pearls
Always take a detailed environmental and occupational exposure history.
Hypoxemia with an elevated A–a gradient in a young adult should trigger concern for interstitial/parenchymal lung disease.
CT and history are often enough to diagnose HP—biopsy is reserved for uncertain cases.
Remember evolving terminology: think fibrotic vs. non-fibrotic HP, not acute/chronic.
40 min
April 22, 202598. Guidelines Series: GINA Guidelines - Biologics for Treatment of Asthma
Today, we continue our review of the Global Initiative for Asthma (GINA) guidelines on asthma. We’ve covered asthma diagnosis and phenotyping, and the initial approach to therapy. On today’s episode we’re talking about biologic therapies for asthma and will cover everything from when to consider starting them, which to choose, and what to monitor for after a patient is started. To help us with this exciting topic we’re joined by an expert in the field. We again have a great infographic prepared along with the episode, and a boards-style question for your review.

Meet Our Guest
Megan Conroy is an Assistant Professor of Medicine at The Ohio State University, and is also the associate program director for curriculum and quality in the Pulmonary and Critical Care Medicine Fellowship. Megan’s clinical area of expertise involves asthma and biologic therapies and she was recently recognized for her work in this area as the 2024 CHEST Airway Disorders Network Rising Star Award.
Meet Our Co-Hosts
Rupali Sood grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.
Tom Di Vitantonio is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.

Key Learning Points
Core Themes and Clinical Relevance
Biologic therapies represent a paradigm shift in managing severe asthma, especially those with type 2 inflammation.Understanding how to select and monitor biologics is crucial for pulmonary fellows and practicing clinicians.Key Concepts and DefinitionDifficult-to-control asthma ≠ severe asthma:
~20% of asthma patients have difficult-to-control asthma.
Only ~5% have severe asthma after optimizing inhaler use, addressing comorbidities, and ensuring adherence.
Type 2 inflammation: Driven by eosinophils, IgE, IL-4, IL-5, IL-13, and TSLP. Markers include:
Elevated eosinophils (≥150/µL)
High IgE
High fractional exhaled nitric oxide (FeNO)
Choosing the Right BiologicClinical phenotype + biomarkers + comorbidities are used together.Example considerations:
Nasal polyps, EoE, atopic dermatitis → Dupilumab
Strong allergic sensitization → Omalizumab
T2-low or mixed features → Tezepelumab
Consider patient lifestyle, needle aversion, travel, and insurance in decision-making.
Monitoring and Follow-Up
Reassess at 3 and 6 months:
Look for ≥50% reduction in exacerbations or steroid use
Check spirometry, asthma control, and side effects
Special considerations:
Dupilumab → monitor eosinophils (risk of HES)
Omalizumab → ensure access to epinephrine auto-injector
Special PopulationsPregnancy:
Limited data, but omalizumab has most evidence supporting safety.
Expert consensus supports continuing or initiating biologics if benefits outweigh risks.
T2-low asthma:
Only Tezepelumab is indicated.
Clinical Pearls
Always reassess inhaler technique and adherence before escalating to biologics.Shared decision-making is vital when choosing therapies.Biologics take time—avoid early discontinuation without a full trial (4–6 months).New biologics are on the horizon (e.g., ultra-long-acting anti-IL-5 agents).Infographic
Boards Style Question

References:
Mauer Y, Taliercio RM. Managing adult asthma: The 2019 GINA guidelines. Cleve Clin J Med. 2020 Aug 31;87(9):569-575. doi: 10.3949/ccjm.87a.19136. PMID: 32868307.
Viswanathan RK, Busse WW. Biologic Therapy and Asthma. Semin Respir Crit Care Med. 2018 Feb;39(1):100-114. doi: 10.1055/s-0037-1606218. Epub 2018 Feb 10. PMID: 29427990.
Brusselle GG, Koppelman GH. Biologic Therapies for Severe Asthma. N Engl J Med. 2022 Jan 13;386(2):157-171. doi: 10.1056/NEJMra2032506. PMID: 35020986.
27 min
April 08, 202597. Rapid Fire Journal Club – MIST 2
In this episode, we add another article to our Rapid Fire Journal Club. Luke Hedrick and Dave Furfaro discuss the MIST 2 trial published in NEJM in 2011 evaluating enzymatic therapy for complex parapneumonic effusions and empyemas.

Article and Reference
We are talking today about the MIST 2 trial evaluating the use of intrapleural tPa and DNase for intrapleural infections.
Rahman NM, Maskell NA, West A, Teoh R, Arnold A, Mackinlay C, Peckham D, Davies CW, Ali N, Kinnear W, Bentley A, Kahan BC, Wrightson JM, Davies HE, Hooper CE, Lee YC, Hedley EL, Crosthwaite N, Choo L, Helm EJ, Gleeson FV, Nunn AJ, Davies RJ. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011 Aug 11;365(6):518-26. doi: 10.1056/NEJMoa1012740. PMID: 21830966.
Key Learning Points
Background:
Infections in the pleural space are common and morbid, often requiring surgical intervention. Unfortunately, antibiotics and chest tube drainage often fail. The MIST1 trial (NEJM, 2005) of intrapleural streptokinase showed no benefit. MIST2 studied intrapleural tPA and DNase to ease drainage by breaking down septations and thinning pleural fluid.
Study Design (design, primary outcome, participants, etc)
Design:
Double-blind, double-dummy, 2×2 factorial RCT at 11 UK hospitals from 12/2005 to 11/2008
By double dummy, we mean that there was a sham placebo for each of the study drugs
Primary Outcome
Change in the percent of the hemithorax taken up by effusion on CXR at day 7 compared to day 1
Key secondary outcomes:
Referral for surgery
Hospital LOS
All cause 3 month and 12 month mortality
AEs
Participants
Inclusion:
Clinical evidence of infection (assessed by recruiting MD; EG, fever, CRP, WBC) and
Pleural fluid with any of:
Grossly purulent
Positive pleural fluid culture or gram stain
pH < 7.2
Exclusion: aiming to exclude patients with increased bleeding risk or who can’t re-expand the lung after drainage
Age < 18
Previous intrapleural fibrinolytics, DNase, or both for empyema
Allergy to tPA or DNase
Coincidental stroke (hemorrhage risk)
Major hemorrhage or trauma
Major surgery in the last 5 days
Previous pneumonectomy on the infected side
Pregnancy, lactation
Expected survival < 3 months from something other than what caused the pleural problem
Summary: Middle-aged, mostly male patients with complicated pleural effusion or empyema occupying 1/3 to 2/5 hemithorax with mostly small-bore CDs for mostly community-acquired infections
Small-bore here meant < 15 Fr
Intervention/Limitations
N = 210 (193 analyzed) randomized approximately 1:1 to one of the following 4 arms:
tPA/Dnase (10mg and 5mg)
tPA and placebo
DNase and placebo
Double placebo
Medications were given BID for 3 days with clamping of the CD for 1 hour after each dose (to keep the drug in the pleural space)
Outcomes/Safety
Power: with N = 210 (actual analysis = 193), 80% power to detect 1 in 5 more patients with a 50% reduction in pleural opacity on CXR
We’ll discuss the outcomes of tPA/DNase in combination because there was a highly significant interaction between the two (P = 0.002) for the primary outcome
Efficacy:
Primary (pleural effusion size reduction): -29.5% hemithorax vs baseline and -7.9% effusion size vs placebo (P = 0.005)
Neither drug worked on their own
Secondary:
Referral for surgery: 4% vs 16% (OR 0.17, P = 0.03)
Hospital LOS (excluding 391d outlier in placebo group): mean 11.8 vs 17 days (P = 0.006)
Mortality: no difference
Safety:
No difference in AE between groups
6 serious events across all groups, mostly related to bleeding (intra-pleural, GI, hemoptysis); other AE were made up of pain with drug administration, transient AMS, rash
Takeaway
Combination intrapleural enzyme therapy (IET) with tPA and DNase improves drainage of infected pleural fluid, and reduces need for surgery and hospital LOS
Infographic
16 min
March 04, 202596. Guidelines Series: GINA Guidelines – Asthma Treatment and Management
We’re back with our second episode in our guideline initiative, and continuing our review of the Global Initiative for Asthma (GINA) guidelines on asthma. In our first episode of this series, we talked about making the diagnosis of asthma, the importance of appropriate phenotyping, and doing an initial assessment of asthma severity. Today, we’re discussing the initial management of asthma and discussing but pharmacologic and non-pharmacologic treatments. We have a great infographic prepared along with the episode, and a boards-style question for your review.
Meet Our Co-Hosts
Rupali Sood grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.
Tom Di Vitantonio is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.
Key Learning Points
Introduction to Asthma Guidelines
The podcast continues a guideline series on asthma, focusing on the Global Initiative for Asthma (GINA) 2024 guidelines.
Emphasizes practical applications for clinicians managing asthma in different settings.
Importance of Evidence-Based Asthma Management
Asthma treatment must be systematic and personalized, considering recent clinical evidence.
Previous reliance on short-acting beta agonists (SABAs) as rescue inhalers has shifted towards inhaled corticosteroid (ICS)-containing therapies.
Over-reliance on SABAs is linked to increased exacerbations, airway inflammation, and poor long-term outcomes.
Stepwise Approach to Asthma Management (GINA 2024)
The Track 1 approach (preferred) centers around ICS-formoterol as both maintenance and reliever therapy (MART).
Track 2 (alternative approach) includes daily ICS or ICS-LABA with a separate SABA as a reliever.
Stepwise Therapy
Step 1-2 (Mild asthma): Low-dose ICS-formoterol as needed for symptom relief.
Step 3 (Moderate asthma): Low-dose maintenance ICS-formoterol (MART therapy).
Step 4 (Persistent symptoms): Medium-dose ICS-formoterol (MART) with additional inhaler adjustments.
Step 5 (Severe asthma): Consider biologic therapies, phenotyping, and additional controllers.
MART Therapy as a Game-Changer
Maintenance and Reliever Therapy (MART):
Uses a single inhaler for both daily maintenance and symptom relief.
Reduces overuse of SABAs.
Provides real-time up-titration of ICS during exacerbations.
Leads to better adherence and control.
Supporting Evidence from Trials:
SIGMA 1 & 2, Novel Start, Practical (2018-2019): Showed ICS-formoterol reduces exacerbations and steroid exposure compared to SABAs.
MANDALA (2022): Showed ICS-SABA improves outcomes over SABA alone, though not a true MART study.
Practical Considerations in Asthma Management
Patient adherence is critical—educate on proper inhaler use and symptom monitoring.
Insurance and cost barriers may require prescribing alternative inhalers.
Review and adjust treatment regularly using the “Assess, Adjust, Review” framework.
Avoid high-dose ICS without exploring additional controller therapies like LAMAs, leukotriene receptor antagonists (Montelukast), and azithromycin.
Non-Pharmacologic Interventions
Smoking cessation (including vaping/marijuana).
Weight management and physical activity.
Avoiding triggers (allergens, occupational exposures, pollution).
Air purifiers and HEPA filters.
Vaccinations (flu, COVID-19) to prevent viral exacerbations.
Managing comorbidities (GERD, sleep apnea, anxiety/depression).
Case Discussion & Real-World Application
Patient with recurrent asthma symptoms post-viral illness.
Started on low-dose ICS-formoterol as needed.
Symptoms persisted, leading to maintenance ICS-formoterol (MART therapy).
Regular follow-up to monitor and adjust therapy.
Looking Ahead
Next episode will focus on biologic therapies for severe asthma.
Emphasis on ongoing education, practical application, and patient-centered care.
Infographic

Boards Style Question

References
Mauer Y, Taliercio RM. Managing adult asthma: The 2019 GINA guidelines. Cleve Clin J Med. 2020 Aug 31;87(9):569-575. doi: 10.3949/ccjm.87a.19136. PMID: 32868307.
Matera MG, Rinaldi B, Annibale R, De Novellis V, Cazzola M. The pharmacological management of asthma in adults: 2023 update. Expert Opin Pharmacother. 2024 Mar;25(4):383-393. doi: 10.1080/14656566.2024.2332627. Epub 2024 Mar 20. PMID: 38497368.
Arismendi E, Ribo P, García A, Torrego A, Bobolea I, Casas-Saucedo R, Palomino R, Picado C, Muñoz-Cano R, Valero A. Asthma Control According to GINA 2023: Does Changing the Criteria Improve Asthma Control? J Clin Med. 2024 Nov 6;13(22):6646. doi: 10.3390/jcm13226646. PMID: 39597790; PMCID: PMC11594371.
http://ginasthma.org/2023-gina-main-report/
https://www.uptodate.com/contents/an-overview-of-asthma-management-in-children-and-adults
https://onlinelibrary.wiley.com/doi/full/10.1111%2Fresp.14782
Dubin S, Patak P, Jung D. Update on Asthma Management Guidelines. Mo Med. 2024 Sep-Oct;121(5):364-367. PMID: 39421468; PMCID: PMC11482852.
39 min
February 25, 202595. Clinical Pearl: Prone Positioning with Elevated Intracranial Pressure
Today we have a mini-episode / clinical pearl. We previously discussed the PROSEVA trial and the evidence for prone positioning in ARDS. In that trial, patients with elevated intracranial pressure (ICP) were excluded. We are joined now by Dr. Jon Rosenberg, a neuro intensivist, to discuss his how prone positioning can still be employed for patients with neurologic injuries and elevated ICP.

Meet Our Guest
Dr. Jon Rosenberg is an assistant professor of neurology and neurosurgery at Westchester Medical Center, New York Medical College. He’s also the associate program director of the Neurocritical Care Fellowship at Westchester Medical Center and a frequent contributor to the Neurocritical Care Society podcast.

Key Learning Points
Elevated Intracranial Pressure (ICP) and Proning: A Common Misconception
Elevated ICP is often considered a contraindication to proning, but this is more of a relative caution rather than an absolute contraindication.
Many neuro ICUs have successfully proned patients with elevated ICP, particularly since the COVID-19 pandemic, when critical care units had to manage both respiratory failure and neurological conditions simultaneously.
Patient Selection for Proning with Elevated ICP
Most patients with elevated ICP can still be proned, including those with:
Global cerebral edema (e.g., post-anoxic brain injury, liver failure)
Focal lesions (e.g., traumatic brain injury, large ischemic strokes, intracerebral hemorrhage)
Situations where proning might be more concerning:
Severe hemodynamic instability (multi-pressor shock)
Morbid obesity (e.g., >300 lbs), where physically flipping the patient is a major challenge
Theoretical Concerns with Proning in Elevated ICP
Loss of neurological exam access (sedation + flipped position makes pupil and motor exam difficult)
Jugular venous compression (especially if the head is turned to one side)
Cerebrospinal fluid (CSF) flow obstruction, depending on the lesion
Risk of increased ICP if venous outflow is impaired or head positioning is not optimized
Best Practices for Proning Patients with Elevated ICP
Patients with invasive ICP monitors vs. without monitors:
If possible, placing an ICP monitor (EVD or parenchymal bolt) before proning provides better guidance.
Without a monitor, providers must rely on other practices like maintaining strict MAP goals and sodium targets, and indirect signs of increased ICP.
Positioning considerations:
Keep the head midline to prevent jugular venous compression.
If head positioning is not neutral, place the dominant/internal jugular facing upward to maintain venous drainage.
Maintain the head of the bed elevated even while prone (reverse Trendelenburg positioning).
Hemodynamic management:
Target a higher MAP (e.g., 70–75 mmHg, sometimes 75–80 mmHg) to ensure adequate cerebral perfusion pressure (CPP) if there is no ICP monitor
Avoid hypotension, as MAP – ICP = CPP, and low MAP could critically reduce cerebral perfusion.
A normal intracranial pressure is 7 – 15 mmHg
The recommended CPP is between 60 – 70 mmHg
Sedation & Sodium Management:
Consider deep sedation (RASS -5) to reduce metabolic demand and intracranial blood volume.
Consider keeping sodium >145 mmol/L prophylactically to mitigate brain swelling if no ICP monitor in place
When to Reconsider Proning (i.e. when to supinate)
If a patient’s ICP spikes significantly (e.g., from 20 to 60 mmHg) despite medical management (hypertonic saline, sedation, paralysis, etc.).
If new signs of neurological deterioration emerge (e.g., changes in pupil exam once patient is repositioned).
Hemodynamic instability that is unmanageable in the prone position.
Literature and Future Considerations
Small case series have demonstrated success in proning patients with traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage.
While more formal research is needed, the neurocritical care community has begun embracing proning for neuro patients, provided that proper precautions are taken.
Bottom Line
Proning is not an absolute contraindication for patients with elevated ICP—it can be done safely with proper monitoring, patient selection, and precautions.
Having an ICP monitor makes the process more controlled and allows clinicians to adjust treatment in real time.
Key considerations: Maintain cerebral perfusion, optimize head positioning, monitor hemodynamics, and have a plan for reversing if ICP becomes unmanageable.
17 min
February 18, 202594. The Impact of Reduced NIH Indirect Cost Payments
On February 7, 2025 it was announced that the National Institutes of Health (NIH) would be capping indirect cost payments for research grants at 15%. This is a massive reduction from the current standard, and will have widespread impacts on research, healthcare delivery, and trainee and young faculty development throughout the United States. We have a special episode today to try to explain what this change really means, the broad impact it will have on the healthcare system and scientific research, and what we as a the healthcare community can / should be doing. Please feel free to reach out to us with any thoughts or questions from the episode.
Meet Our Guests
Dr. Theodore “Jack” Iwashyna is a Bloomberg Distinguished Professor at Johns Hopkins School of Medicine and the Johns Hopkins Bloomberg School of Public Health. Jack is a critical care physician and focuses on research to understand the broader context of critical illness, and the long term impact on patients’ lives. He is an enormously productive and successful researcher with numerous publications in the field of critical care, and is a pioneer in the field of ICU survivorship. He is a devoted mentor and has received accolades from numerous societies
Dr. Kathryn Hibbert is an Assistant Professor of Medicine at Harvard Medical School and a pulmonary and critical care physician at Massachusetts General Hospital. She is the MICU Director at MGH, as well at the Vice Chair for Critical Care.
Summary of Key Points
Overview of NIH Funding
NIH research funding is divided into direct costs (salaries, supplies, specific project expenses) and indirect costs (infrastructure, utilities, administrative support).
Indirect costs support shared research resources like lab space, IT infrastructure, and institutional overhead.
Recent Policy Change & Impact
A sudden 15% cap on indirect cost reimbursement for NIH grants was announced late on a Friday, catching the academic community off guard.
Many universities typically receive 50-60% in indirect cost reimbursements, making this a drastic cut.
This change could severely affect research institutions by reducing available funding for shared infrastructure, education, and clinical care.
Broader Ramifications
Threat to Medical Research: Loss of funding for essential research infrastructure could slow or halt key medical advancements, such as cancer therapies, CF treatments, and more.
Impact on Education & Clinical Care: Reduced research funding could lead to cuts in trainee programs, fewer job opportunities, and diminished support for clinical services, particularly those serving vulnerable populations.
Economic Consequences: Academic medical centers are often major employers in states across the U.S. A reduction in funding could lead to job losses and economic downturns in affected regions.
Political and Institutional Response
Legal challenges were quickly filed, resulting in a temporary restraining order against the policy change.
The administration’s actions were seen as an attack on academic freedom and scientific independence.
The impact extends beyond select universities or states. States like Texas, Ohio, Florida, and Iowa stand to lose millions in research funding.
Advice for Early-Career Researchers
Continue applying for NIH grants as normal, following institutional guidance.
Stay informed about evolving policies.
Engage in advocacy—contact representatives, raise awareness, and contribute to public discussions.
Call to Action
The speakers urge medical professionals, researchers, and the public to share knowledge about what the impact of these changes would be, and prevent them from becoming permanent.
They emphasize the critical role of NIH-funded research in improving healthcare outcomes worldwide and encourage continued engagement in the conversation.
References and Further Reading
https://www.al.com/news/2025/02/katie-britt-vows-to-work-with-rfk-jr-after-nih-funding-cuts-cause-concern-in-alabama.html
https://www.forbes.com/sites/michaeltnietzel/2025/02/10/what-the-nih-cut-to-indirect-cost-payments-could-cost-red-states
https://www.npr.org/2025/02/12/nx-s1-5292359/what-cuts-to-nih-funding-could-mean-for-american-universities
https://www.press.jhu.edu/books/title/53759/transformation-american-health-insurance?srsltid=AfmBOoqvR5-TrqcsIC6ELO3AdZgjFWkIJ9jdlawJpyxJDus1cM–LxLr
https://global.oup.com/academic/product/time-to-heal-9780195181364?cc=us&lang=en&
https://www.africa.upenn.edu/Articles_Gen/Letter_Birmingham.html
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