Pulmonary and Critical Care Fellowship Program Directors' Perspective on the Virtual Interview Process.

Background: Since the start of the coronavirus disease (COVID-19) pandemic, the residency and fellowship recruitment process has changed significantly with the use of virtual interview (VI) platforms. Pulmonary and critical care medicine (PCCM) candidates reported in a survey that VIs hindered their ability to evaluate their fit within the program. However, the program directors' (PDs') opinion of this process remains unknown. Objective: We aim to provide insight into the PCCM fellowship PDs' perspective regarding the virtual recruitment process since the first class of fellows undergoing this process has now completed 1 year of training. Methods: An anonymous survey was sent to the PDs of PCCM programs participating in the National Resident Matching Program match process in 2020 and 2021. The survey consisted of five sections and 26 closed-ended questions and was distributed via email using the SurveyMonkey platform. The survey was conducted for a total of 6 weeks. A follow-up email to nonrespondents was sent every week. The collected responses were divided into two categories: favoring VIs versus not favoring VIs. A multivariable logistic regression analysis was performed to determine the factors associated with favoring VIs. Results: The survey was sent to 190 email accounts from the Fellowship and Residency Electronic Interactive Database Access System website. Over the course of 6 weeks, 64 respondents participated in the survey, with a response rate of 33.68%. Of 64 respondents, 56 (87.5%) fully completed the survey and 8 (12.5%) partially completed the survey. The final sample size was 59. Thirty-six (61.02%) of the PDs favored VIs for future recruitment, and 23 (38.98%) did not (P < 0.001). Ninety-seven percent of PDs who favored VIs versus 72.73% of those who did not perceived the current fellows to fit well in the program (P = 0.007). The multivariable logistic regression analysis showed a trend toward higher odds of favoring VIs if PDs believed they were able to represent the program well virtually (adjusted odds ratio, 6.99; 95% confidence interval, 0.79 - 61.58) and if they found that the current fellows fit the program well (adjusted odds ratio, 7.15; 95% confidence interval, 0.76-66.52); however, these results were not statistically significant. Conclusion: In this survey research, we found that the majority of the PCCM fellowship PDs favored a virtual process for future recruitment.

AWAreness during REsuscitation - II: A multi-center study of consciousness and awareness in cardiac arrest.

INTRODUCTION: Cognitive activity and awareness during cardiac arrest (CA) are reported but ill understood. This first of a kind study examined consciousness and its underlying electrocortical biomarkers during cardiopulmonary resuscitation (CPR). METHODS: In a prospective 25-site in-hospital study, we incorporated a) independent audiovisual testing of awareness, including explicit and implicit learning using a computer and headphones, with b) continuous real-time electroencephalography(EEG) and cerebral oxygenation(rSO2) monitoring into CPR during in-hospital CA (IHCA). Survivors underwent interviews to examine for recall of awareness and cognitive experiences. A complementary cross-sectional community CA study provided added insights regarding survivors' experiences. RESULTS: Of 567 IHCA, 53(9.3%) survived, 28 of these (52.8%) completed interviews, and 11(39.3%) reported CA memories/perceptions suggestive of consciousness. Four categories of experiences emerged: 1) emergence from coma during CPR (CPR-induced consciousness [CPRIC]) 2/28(7.1%), or 2) in the post-resuscitation period 2/28(7.1%), 3) dream-like experiences 3/28(10.7%), 4) transcendent recalled experience of death (RED) 6/28(21.4%). In the cross-sectional arm, 126 community CA survivors' experiences reinforced these categories and identified another: delusions (misattribution of medical events). Low survival limited the ability to examine for implicit learning. Nobody identified the visual image, 1/28(3.5%) identified the auditory stimulus. Despite marked cerebral ischemia (Mean rSO2 = 43%) normal EEG activity (delta, theta and alpha) consistent with consciousness emerged as long as 35-60 minutes into CPR. CONCLUSIONS: Consciousness. awareness and cognitive processes may occur during CA. The emergence of normal EEG may reflect a resumption of a network-level of cognitive activity, and a biomarker of consciousness, lucidity and RED (authentic "near-death" experiences).

Implementation of Early Rehabilitation in Severe COVID-19 Respiratory Failure: A Scoping Review.

The purpose of this scoping review is to describe current clinical practice guidelines (CPGs) for early rehabilitation for individuals hospitalized in an intensive care unit with COVID-19 and examine practice patterns for implementation of mobility-related interventions. Methods: PubMed, EMBASE, and CINAHL databases were searched from January 1, 2020, through April 1, 2022. Selected studies included individuals hospitalized with severe COVID-19 and provided objective criteria for clinical decision making for mobility interventions. A total of 1464 publications were assessed for eligibility and data extraction. The PRISMA-ScR Checklist and established guidelines for reporting for scoping reviews were followed. Results: Twelve articles met inclusion criteria: 5 CPGs and 7 implementation articles. Objective clinical criteria and guidelines for implementation of early rehabilitation demonstrated variable agreement across systems. No significant adverse events were reported. Conclusions: Sixty percent (3/5) of CPGs restrict mobility for individuals requiring ventilatory support of more than 60% Fio2 (fraction of inspired oxygen) and/or positive end-expiratory pressure (PEEP) greater than 10-cm H2O (positive end-expiratory pressure). Preliminary evidence from implementation studies may suggest that some individuals with COVID-19 requiring enhanced ventilatory support outside of established parameters may be able to safely participate in mobility-related interventions, though further research is needed to determine safety and feasibility to guide clinical decision making.

A Case Series of E-cigarette or Vaping-Associated Lung Injury With a Review of Pathological and Radiological Findings.

There has been a recent outbreak of e-cigarette or vaping-associated lung injury (EVALI) but the exact pathophysiology remains unknown. Tetrahydrocannabinol (THC) and vitamin E derivates are the major components in vaping-generated aerosols that are associated with EVALI. So far, there is no standard treatment for EVALI. Most cases are treated with antibiotics and steroids. Counseling for smoking cessation is an integral part of care for EVALI patients. Referral to addiction medicine may be beneficial. Considering the nonspecific presenting symptoms and the growing popularity of vaping devices, providers need to consider EVALI in the differential diagnosis of bilateral patchy ground-glass opacities with respiratory, constitutional, or gastrointestinal symptoms in patients using e-cigarettes. Here, we present four EVALI cases and review the pertinent imaging and pathological findings.

Prospective Randomized Controlled Pilot Study of High-Intensity Lightbox Phototherapy to Prevent ICU-Acquired Delirium Incidence.

Background This study aimed to evaluate the role of disturbed circadian rhythm in potentiating intensive care unit (ICU)-acquired delirium.Previous studies have demonstrated bright light therapy (BLT) as an effective modality to improve sleeping patterns and cognitive function in non-critically ill patients. However, its benefit in the ICU has not been clearly established. In this study, we aimed to evaluate the application of daily high-intensity phototherapy at the bedside to deter ICU delirium incidence and duration. Methodology This was a single center, prospective study conducted in ICUs at the Carilion Roanoke Memorial Hospital in Roanoke, VA. Adults patients admitted to the ICU from July 9, 2018 to March 20, 2020 were included in the study. The patients were subjected to 30-minute BLT session (10,000 lux) at the bedside starting at 0700 while in the ICU. Patients were randomized into either the control group (standard hospital lighting) or phototherapy group. Data were analyzed using Wilcoxon rank sum test for continuous variables, Pearson chi-square test for categorical variables, and logistic regression for multivariable analysis that examined significant risk factors for ICU delirium. Results Delirium incidence between BLT (18%) and control (17.5%) groups was non-significant. Total number of delirium-free, coma-free days, as determined by Confusion Assessment Method for the ICU, demonstrated no differences between groups with a median of 28 days (p = 0.516). In multivariable analysis, patients with a Sequential Organ Failure Assessment Score >3 also showed no significant change in ICU delirium incidence when provided bedside BLT compared to those with standard hospital lighting (odds ratio: 0.08; 95% confidence interval: 0.002-1.40; p = 0.867). Conclusions In this randomized control pilot study, daily morning 10,000 lux BLT of 30-minute duration alone was not associated with a significant decrease in ICU-acquired delirium incidence or duration compared to standard hospital lighting. Future studies should consider a nuanced approach to better elucidate the role of disturbed circadian rhythm in influencing ICU-acquired delirium by not only undertaking BLT during the day but also minimizing nighttime light exposure.

E-cigarettes: A novel therapy or a looming catastrophe.

Electronic cigarettes (e-cigarettes) were originally developed in 2003 as healthier alternatives to conventional tobacco cigarettes. Their popularity has since significantly increased and both users and nonusers are exposed to their aerosol and product constituents. Although some evidence suggests that e-cigarette use may facilitate smoking cessation, definitive data are lacking and e-cigarettes are not approved by the Food and Drug Administration as a cessation aid. While e-cigarette aerosol contains fewer toxins than conventional cigarette smoke, studies evaluating whether e-cigarettes are less harmful are inconclusive. The health impact of e-cigarettes for both users and nonusers cannot be determined with currently available data, and there are both environmental concerns and issues regarding nonuser exposure. Most of the currently available data related to the health effects of e-cigarettes do not evaluate their effects on the general population and evidence regarding the systemic health effects of e-cigarettes is limited. In addition, there has been a recent rise in vaping-related lung injuries. Therefore, the detrimental effects of e-cigarette use should be further investigated, and every effort should be made to increase public awareness of the harmful effects of e-cigarettes.

Airway metastasis of small cell lung carcinoma: A rare presentation.

Airway metastasis from primary lung carcinoma is rare and typically associated with non-small cell histology. While small cell lung cancer is a particularly aggressive form of cancer, few cases of endotracheal or endobronchial metastasis have been reported. Airway involvement can go undetected because of the spread along the perilymphatic drainage system with mostly submucosal involvement causing significant airway compromise before onset of symptoms. We present a patient with recurrent small cell lung cancer, presenting with wheezing, cough, and dyspnea as a result of metastasis to the trachea and bilateral bronchi without significant mediastinal or hilar lymphadenopathy. We discuss the related literature, as well as the suspected pathophysiology causing this unique presentation.

Endoscopic management of obstruction due to an acquired bronchial web.

Bronchial webs are thin, membrane-like diaphragms that may obstruct the airway. Several congenital cases have been reported. Though rare, the true incidence of these lesions is probably underestimated because many of them are unrecognized. The case of a 71-year-old woman with an acquired bronchial web causing right main stem bronchus obstruction that went unrecognized for 47 years post-trauma is reported. The lesion was successfully treated using rigid bronchoscopy with laser therapy, balloon dilation and stent placement. This is the first reported case of an acquired bronchial web formation. It is also the first reported case that was successfully treated with this technique.