Entrustable professional activities and curricular milestones for fellowship training in pulmonary and critical care medicine: executive summary from the Multi-Society Working Group.

Assessment of graduate medical trainee progress via the accomplishment of competency milestones is an important element of the Next Accreditation System of the Accreditation Council for Graduate Medical Education. This article summarizes the findings of a multisociety working group that was tasked with creating the entrustable professional activities and curricular milestones for fellowship training in pulmonary medicine, critical care medicine, and combined programs. Using the Delphi process, experienced medical educators from the American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine, and Association of Pulmonary and Critical Care Medicine Program Directors reached consensus on the detailed curricular content and expected skill set of graduates of these programs. These are now available to trainees and program directors for the purposes of curriculum design, review, and trainee assessment.

Monitoring of oesophageal pressure.

PURPOSE OF REVIEW: Studies in patients with acute respiratory distress syndrome (ARDS) have been unable to demonstrate a survival advantage with higher levels of positive end-expiratory pressure (PEEP) to open atelectatic lung regions or prevent their cyclic collapse. This review will discuss the challenges of accurately measuring pleural pressure with balloon-tipped catheters in the oesophagus, and the utility of such pressure monitoring to set PEEP and assess lung mechanics, focusing on patients with ARDS. RECENT FINDINGS: Recent investigations have suggested that the monitoring of oesophageal pressure in ARDS patients may help individualize PEEP settings to optimize lung recruitment based on transpulmonary pressure. SUMMARY: Changes in oesophageal pressure likely accurately reflect global changes in pleural pressure in supine patients with ARDS. However, absolute oesophageal pressure values in such patients may be subject to local artefacts and may substantially overestimate pleural pressure in other lung regions. Setting PEEP high enough to achieve a targeted end-expiratory transpulmonary pressure in the region of the oesophageal balloon catheter could overdistend other lung regions. Measurement of oesophageal pressure is feasible, but its clinical utility to titrate PEEP, compared with routine assessment, awaits experimental confirmation.

Undergraduate medical education in critical care.

OBJECTIVE: To review the current status of critical care education of medical students, focusing on how early, vigorous undergraduate training may address the needs of the learners and society. DATA SOURCES: Literature review of focused PubMed searches, online databases, and reference lists of recent publications. RESULTS: Although management of unstable and critically ill patients is required of most interns, undergraduate education in these skills remains largely elective, scattered, and highly variable. Critical care competencies for medical school graduates have not been established in the United States, and many students feel unprepared for these responsibilities that they assume as interns. Several successful approaches to medical student education in critical care have been demonstrated, and the availability of simulation technology provides new educational opportunities. Early exposure to other medical disciplines has influenced medical student career choice, although this has not been studied in regards to critical care fields. CONCLUSIONS: Undergraduate medical education in critical care would be advanced by consolidation and organization into formal curricula. These would teach biomedical and humanistic skills essential to critical care but valuable in all medical settings. Early, well-planned exposure to critical care as a distinct discipline might increase student interest in careers in the field. The effects of educational interventions on the acquisition of knowledge, attitudes, and skills as well as long-term career choice should be subjected to rigorous study.

How We Review a Medical Education Research Manuscript.

Peer review is a necessary and important component of scholarly publication. When done well, it benefits both the reviewer and authors and improves the science itself. However, the skills of effective peer review are rarely taught. In the adolescent field of medical education research, peer review is especially important to advance the scientific rigor of the field. From our experience reviewing biomedical and medical education research, we have found that a thorough review takes multiple readings and multiple hours. The first reading provides a general overview of the aims and methods. Subsequent readings focus on the details of the methodology, results, and interpretation. The written review should provide firm but gentle feedback that the authors can use to improve their work, even if we have recommended rejection for this submission. We hope that this description of our process for reviewing a medical education research manuscript will assist others and thereby advance the quality of publications in our field.

Pulmonary hypertension and computed tomography measurement of small pulmonary vessels in severe emphysema.

RATIONALE: Vascular alteration of small pulmonary vessels is one of the characteristic features of pulmonary hypertension in chronic obstructive pulmonary disease. The in vivo relationship between pulmonary hypertension and morphological alteration of the small pulmonary vessels has not been assessed in patients with severe emphysema. OBJECTIVES: We evaluated the correlation of total cross-sectional area of small pulmonary vessels (CSA) assessed on computed tomography (CT) scans with the degree of pulmonary hypertension estimated by right heart catheterization. METHODS: In 79 patients with severe emphysema enrolled in the National Emphysema Treatment Trial (NETT), we measured CSA less than 5 mm(2) (CSA(<5)) and 5 to 10 mm(2) (CSA(5-10)), and calculated the percentage of total CSA for the lung area (%CSA(<5) and %CSA(5-10), respectively). The correlations of %CSA(<5) and %CSA(5-10) with pulmonary arterial mean pressure (Ppa) obtained by right heart catheterization were evaluated. Multiple linear regression analysis using Ppa as the dependent outcome was also performed. MEASUREMENTS AND MAIN RESULTS: The %CSA(<5) had a significant negative correlation with Ppa (r = -0.512, P < 0.0001), whereas the correlation between %CSA(5-10) and Ppa did not reach statistical significance (r = -0.196, P = 0.083). Multiple linear regression analysis showed that %CSA(<5) and diffusing capacity of carbon monoxide (DL(CO)) % predicted were independent predictors of Ppa (r(2) = 0.541): %CSA (<5) (P < 0.0001), and DL(CO) % predicted (P = 0.022). CONCLUSIONS: The %CSA(<5) measured on CT images is significantly correlated to Ppa in severe emphysema and can estimate the degree of pulmonary hypertension.

Are esophageal pressure measurements important in clinical decision-making in mechanically ventilated patients?

Low-tidal-volume ventilation strategies are clearly beneficial in patients with acute lung injury and acute respiratory distress syndrome, but the optimal level of applied positive end-expiratory pressure (PEEP) is uncertain. In patients with high pleural pressure on conventional ventilator settings, under-inflation may lead to atelectasis, hypoxemia, and exacerbation of lung injury through "atelectrauma." In such patients, raising PEEP to maintain a positive transpulmonary pressure might improve aeration and oxygenation without causing over-distention. Conversely, in patients with low pleural pressure, maintaining a low PEEP would keep transpulmonary pressure low, avoiding over-distention and consequent "volutrauma." Thus, the currently recommended strategy of setting PEEP without regard to transpulmonary pressure is predicted to benefit some patients while harming others. Recently the use of esophageal manometry to identify the optimal ventilator settings, avoiding both under-inflation and over-inflation, was proposed. This method shows promise but awaits larger clinical trials to assess its impact on clinical outcomes.

Should prone positioning be routinely used for lung protection during mechanical ventilation?

Prone positioning has been known for decades to improve oxygenation in animals with acute lung injury and in most patients with acute respiratory distress syndrome (ARDS). The mechanisms of this improvement include a more uniform pleural-pressure gradient, a smaller volume of lung compressed by the heart, and more uniform and better-matched ventilation and perfusion. Prone positioning has an established niche as an intervention to improve gas exchange in patients with severe hypoxemia refractory to standard ventilatory manipulations. Because the lung may be more uniformly recruited and the stress of mechanical ventilation better distributed, prone positioning has also been proposed as a form of lung-protective ventilation. However, several randomized trials have failed to show improvements in clinical outcomes of ARDS patients, other than consistently better oxygenation. Because each of these trials had design problems or early termination, prone positioning remains a rescue therapy for patients with acute lung injury or ARDS.

Miles to Go Before We Sleep. Reforming the Pulmonary and Critical Care Milestones to Improve Trainee Assessment.

The Accreditation Council for Graduate Medical Education (ACGME) Milestones are a systematic assessment framework for medical trainees within the six core competencies of practice. Their use by internal medicine subspecialties, including semiannual reports to the ACGME, was mandated beginning in 2014. The Milestones, which were based on specific, observable behaviors, improved upon the prior subjective, global comparisons of each fellow with an "average" fellow in his or her field and served the goals of competency-based medical education. However, the original set of Milestones has proven challenging to apply and interpret. Part of the challenge stems from the use of identical Milestones across all medicine subspecialties, which led to unclear relevance of the patient care and medical knowledge domains to the practice of pulmonary and critical care. This also precluded their use for individualized feedback or development of a learning plan for fellows. In addition, verbose behavioral descriptors, which were designed to provide specificity, ultimately led to rater fatigue among assessors and clinical competency committees. Therefore, the ACGME convened committees for each of the medical subspecialties to revise the original Milestones in an effort to improve subspecialty relevance, minimize educational jargon, and simplify the current iteration. New patient care and medical knowledge Milestones were created to be subspecialty specific and improve utility. The remaining four Milestones were developed as a common set of shorter Milestones, harmonized across specialties. For pulmonary, critical care, and combined fellowship programs, the resulting Milestones 2.0 aims to simplify the use, implementation, and interpretation of this framework for program directors, trainees, and society.

Feasibility of very high-frequency ventilation in adults with acute respiratory distress syndrome.

OBJECTIVE: To assess the feasibility of using respiratory frequencies up to 15 Hz during high-frequency oscillatory ventilation (HFO) of adults with acute respiratory distress syndrome (ARDS). DESIGN: Observational study. SETTING: Medical intensive care unit at a tertiary care university hospital. PATIENTS: Thirty adult patients receiving HFO at the discretion of their physicians for management of severe ARDS. INTERVENTIONS: Clinical management algorithm for HFO that minimized delivered tidal volumes by encouraging the use of the highest frequency that allowed acceptable clearance of carbon dioxide. This contrasts with the typical use of HFO in adults, in which frequencies generally do not exceed 6 Hz. MEASUREMENTS AND MAIN RESULTS: Patients were 42 +/- 15 yrs old, weighed 83 +/- 25 kg, and had failed conventional lung-protective ventilation due to refractory hypoxia or respiratory acidosis and high plateau airway pressures. During HFO, 25 of 30 patients maintained acceptable gas exchange at frequencies > 6 Hz; 12 reached maximal frequencies of > or = 10 Hz. Among patients whose maximal frequencies exceeded 6 Hz, mean maximal frequency was 9.9 +/- 2.1 Hz, at a mean oscillation pressure amplitude of 81 +/- 11 cm H2O. At those settings, blood gases were pH 7.31 +/- 0.06, PaCO2 was 58 +/- 21 mm Hg, and PaO2 was 82 +/- 33 mm Hg. Survival to hospital discharge among this severely ill cohort was 37%. CONCLUSIONS: Most adults can maintain adequate gas exchange using HFO frequencies well above 5-6 Hz. Use of higher frequencies should minimize tidal volume and we speculate might thereby reduce ventilator-associated lung injury.

Continuous oxygen use in nonhypoxemic emphysema patients identifies a high-risk subset of patients: retrospective analysis of the National Emphysema Treatment Trial.

BACKGROUND: Continuous oxygen therapy is not recommended for emphysema patients who are not hypoxemic at rest, although it is often prescribed. Little is known regarding the clinical characteristics and survival of nonhypoxemic emphysema patients using continuous oxygen. Analysis of data from the National Emphysema Treatment Trial (NETT) offers insight into this population. METHODS: We analyzed demographic and clinical characteristics of 1,215 participants of NETT, stratifying by resting PaO(2) and reported oxygen use. Eight-year survival was evaluated in individuals randomized to medical therapy. RESULTS: At enrollment, 33.8% (n = 260) of participants nonhypoxemic at rest reported continuous oxygen use. When compared to nonhypoxemic individuals not using oxygen (n = 226), those using continuous oxygen had worse dyspnea, lower quality of life, more frequent exercise desaturation, and higher case-fatality rate. After adjusting for age, body mass index, and FEV(1) percentage of predicted, the presence of exercise desaturation accounted for the differential mortality seen between these groups. CONCLUSIONS: In the NETT, the use of continuous oxygen in resting nonhypoxemic emphysema patients was associated with worse disease severity and survival. The differential survival observed could nearly all be accounted for by the higher prevalence of exercise desaturation in those using continuous oxygen, suggesting that it is not a harmful effect of oxygen therapy contributing to mortality. It remains unclear whether continuous oxygen therapy improves survival in normoxic patients with exercise desaturation.

Implementation of a Comprehensive Curriculum in Personal Finance for Medical Fellows.

INTRODUCTION: Many residents and fellows complete graduate medical education having received minimal unbiased financial planning guidance. This places them at risk of making ill-informed financial decisions, which may lead to significant harm to them and their families. Therefore, we sought to provide fellows with comprehensive unbiased financial education and empower them to make timely, constructive financial decisions. METHODS: A self-selected cohort of cardiovascular disease, pulmonary and critical care, and infectious disease fellows (n = 18) at a single institution attended a live, eight-hour interactive course on personal finance. The course consisted of four two-hour sessions delivered over four weeks, facilitated by an unbiased business school faculty member with expertise in personal finance. Prior to the course, all participants completed a demographic survey. After course completion, participants were offered an exit survey evaluating the course, which also asked respondents for any tangible financial decisions made as a result of the course learning.  Results: Participants included 12 women and six men, with a mean age of 33 and varying amounts of debt and financial assets. Twelve respondents completed the exit survey, and all "Strongly Agreed" that courses on financial literacy are important for trainees. In addition, 11 reported that the course helped them make important financial decisions, providing 21 examples. CONCLUSIONS: Fellows derive a significant benefit from objective financial literacy education. Graduate medical education programs should offer comprehensive financial literacy education to all graduating trainees, and that education should be provided by an unbiased expert who has no incentive to sell financial products and services.

Respiratory controversies in the critical care setting. Should noninvasive positive-pressure ventilation be used in all forms of acute respiratory failure?

Noninvasive positive-pressure ventilation (NPPV) has been a major advance in the management of acute respiratory failure. Over the past decade alone, NPPV has been the subject of over 1,500 scientific papers, including 14 meta-analyses. NPPV's utility in many clinical settings has been well established, with demonstration in randomized trials of lower intubation rate, mortality, hospital stay, and advantages in other important clinical outcomes. However, it is still used in a minority of patients with acute respiratory failure. While there probably are situations in which NPPV is commonly under-utilized, there are other situations in which it is unlikely to be of benefit or likely to inflict harm. This paper debates the data for and against the more widespread application of NPPV. It will assist the clinician to identify both good and poor candidates for NPPV and thereby devote respiratory care resources where they will be most effective, and optimize patient outcomes.

Respiratory controversies in the critical care setting. Does high-frequency ventilation offer benefits over conventional ventilation in adult patients with acute respiratory distress syndrome?

High-frequency ventilation is the application of mechanical ventilation with a respiratory rate > 100 breaths/min. High-frequency oscillatory ventilation (HFOV) is the form of high-frequency ventilation most widely used in adult critical care. The principles of lung-protective ventilation have matured in parallel with the technology for HFOV. The 2 basic principles of lung-protective ventilation are the use of small tidal volume and maintenance of adequate alveolar recruitment. Research in animal models and humans demonstrate that HFOV can support gas exchange with much smaller tidal volume than can be achieved with conventional ventilation. HFOV also provides more effective lung recruitment than conventional mechanical ventilation. However, at present, evidence is lacking that survival in adults with acute respiratory distress syndrome is improved by HFOV. Although HFOV may improve P(aO(2)) in some patients, this improvement is often transitory. Available evidence does not support that pulmonary inflammation is reduced with HFOV in adult acute respiratory distress syndrome. Heavy sedation and often paralysis are necessary. The promise of HFOV as a lung-protective ventilation strategy remains attractive, but additional clinical trials are needed to determine whether this approach is superior to lung-protective ventilation with conventional mechanical ventilation.