Chest
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A 72-year-old man with metastatic pancreatic cancer was admitted to the ICU with increased oxygen demand and confusion, likely related to pulmonary metastases. In the presence of his son, the health care agent, and the team, the patient requested to be do-not-attempt-resuscitation (DNR) and do-not-intubate (DNI) before losing decision-making capacity. ⋯ Numerous discussions over subsequent days revolved around the attempt to honor the patient's wishes in the setting of the surrogate's unwillingness or inability to make decisions in alignment with his father's wishes. This case reviews and analyzes the ethical options available to the clinical team in responding to requests for potentially inappropriate treatment at a patient's end of life and explores the roles of relational autonomy, beneficence vs nonmaleficence, and holding the balance of clinicians' and ethicists' professional, legal, and ethical responsibilities.
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The advanced practice respiratory therapist (APRT) is a new health care practitioner trained to provide a scope of practice that exceeds that of the registered respiratory therapist (RRT) and is aligned with an advanced practice provider (APP) role. As part of a physician-led team, APRTs are trained to provide diagnostic and therapeutic patient care services in multiple settings across the health care spectrum, including critical care, acute and subacute inpatient care, and outpatient care such as preventative, ambulatory, and chronic care. Competency domains that must be included in accredited APRT education programs include medical knowledge, interpersonal and communication skills, patient care, professionalism, practice-based learning and improvement, and systems-based practice. ⋯ APRT students also complete a variety of patient simulations using standardized patients, task trainers, and patient simulators to ensure they are prepared to complete clinical education. The clinical courses include a minimum of 1200 hours of supervised practice by a licensed physician in outpatient clinics, interventional pulmonology, inpatient pulmonary services, perioperative services, and ICUs. The APRT is trained to assess patients, develop care plans, and order, evaluate, and modify care based on each patient's response, and can be incorporated as a valuable member of the cardiopulmonary patient care team.
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Alpha-1 antitrypsin (AAT) deficiency is a genetic disorder most commonly due to a single G to A point mutation (E342K), leading to debilitating lung and/or liver disorders and is associated with increased mortality. The E342K point mutation causes a conformational change of the AAT protein resulting in its retention in liver hepatocytes. This reduces AAT secretion into the serum resulting in higher protease activities due to the lack of inhibition from AAT, causing damage to healthy lung tissue. The current standard of care for lung manifestations involves weekly IV augmentation therapy and is considered suboptimal for these patients. Furthermore, there is currently no approved treatment for liver manifestations. The unmet medical need for patients with AAT deficiency remains high, and new treatment options are needed to treat the underlying disease etiology. ⋯ In this review, we will discuss the pathophysiology of AAT deficiency and emerging treatment options with particular focus on RNA editing as a disease-modifying treatment for both liver and lung disease.
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As interstitial lung abnormalities (ILAs) are increasingly recognized on imaging and in clinical practice, identification and appropriate management are critical. We propose an algorithmic approach to the identification and management of patients with ILAs. ⋯ We anticipate this algorithmic approach will aid clinicians in interpreting the radiologic pattern described as ILA within the clinical context of their patients.
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A universal nomenclature of the anatomic extent of lung cancer has been critical for individual patient care as well as research advances. As progress occurs, new details emerge that need to be included in a refined system that aligns with contemporary clinical management issues. The ninth edition TNM classification of lung cancer, which is scheduled to take effect in January 2025, addresses this need. ⋯ Key features of the ninth edition include validation of the significant changes in the T component introduced in the eighth edition, subdivision of N2 after exploration of fundamentally different ways of categorizing the N component, and further subdivision of the M component. This has led to reordering of the TNM combinations included in stage groups, primarily involving stage groups IIA, IIB, IIIA, and IIIB. This article summarizes the analyses and revisions for the TNM classification of lung cancer to familiarize the broader medical community and facilitate implementation of the ninth edition system.