PAINE #PANCE Pearl – Pulmonary



57yo man is referred to your practice due to an incidental 1.1cm single pulmonary nodule found on computed tomography.  He is a never smoker and denies any known family history of lung cancer.  He has no pulmonary medical history and reports no pulmonary symptoms.


Image result for single pulmonary nodule ct


What is the next step in the management of this patient?



  1. The first step in the management of this patient should be investigate if there are any previous studies to compare.  This will allow us to be able to assess if any growth has taken place.  For this patient, there are no previous studies to compare.
  2. The next step would be assess malignancy risk since it is larger than 8mm.  Up to Date uses the Brock University Cancer Equation, which I happen to like as well, though there are several out there and all use clinical, historical, and radiographical criteria.
  3. Our patient has a predicted malignancy risk of 3.54% and using the below algorithm, this patient needs a follow-up CT scan in 3 months to evaluate growth.


  1. Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013; 143(5 Suppl):e93S-e120S. [pubmed]
  2. Callister ME, Baldwin DR, Akram AR, et al. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax. 2015; 70 Suppl 2:ii1-ii54. [pubmed]
  3. McWilliams A, Tammemagi MC, Mayo JR, et al. Probability of cancer in pulmonary nodules detected on first screening CT. The New England journal of medicine. 2013; 369(10):910-9. [pubmed]
  4. Up-To-Date.  Diagnostic Evaluation of the Incidental Pulmonary Nodule.  2018.


Westermark’s Sign


Other Known Aliasesnone


Definitionfocal peripheral hyperlucency resulting from collapsed vessels distal to a pulmonary thromboembolism.



Clinical SignificanceOccurs as a result of oligemia of perfusion to the lung parenchyma and can be seen in up to 10% of patients with acute PTE.  Similar to Hampton’s Hump, it has a low sensitivity, but a high specificity


History – Named after Nils Johan Hugo Westermark (1892-1980), a Swedish radiologist who first described this finding in his 1938 paper entitled ” On the roentgen diagnosis of lung embolism”.  He was also an accomplished sailor and won a silver medal in the 1912 Olympics.




  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved
  4. Whonamedit – dictionary of medical eponyms.
  5. Up To Date.
  6. Krishnan AS, Barrett T. Images in clinical medicine. Westermark sign in pulmonary embolism. NEJM. 2012; 366(11):e16. [pubmed]
  7. Radiopaedia.  Westermark Sign.
  8. Westermark N. On the roentgen diagnosis of lung embolism. Acta Radiol 1938;19:357‑72.

PAINE #PANCE Pearl – Pulmonary


57yo man is referred to your practice due to an incidental 1.1cm single pulmonary nodule found on computed tomography.  He is a never smoker and denies any known family history of lung cancer.  He has no pulmonary medical history and reports no pulmonary symptoms.


Image result for single pulmonary nodule ct


What is the next step in the management of this patient?


Hampton’s Hump


Other Known Aliasesnone


Definitionwedge-shaped opacity in the periphery of the lung on chest radiography usually with its base along the pleural margins.


Clinical SignificanceOccurs as a result of infarction and subsequent hemorrhage from the bronchial arteries classically due to a pulmonary embolism, but can also be from anything that causes infarction of lung parenchyma.  The sensitivity and specificity of this finding is not robust and is, by definition, a late finding that is really no longer seen in modern medicine.


History – Named after Aubrey Otis Hampton (1900-1955), an American radiologist who received his medical degree from Baylor University in 1925.  He rose through the ranks quickly in the field of radiology ultimately taking a position as chief of radiology at Massachussetts General in 1941.  He first described his eponymous finding in 1940 in his manuscript entitled “Correlation of postmortem chest teleroentgenograms with autopsy findings”.

Image result for Aubrey Otis Hampton



  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved
  4. Whonamedit – dictionary of medical eponyms.
  5. Up To Date.
  6. Radiopaedia. Hamptons’ Hump.
  7. Schatzki R, Lingley JR. Aubrey O. Hampton, 1900-1955. The American journal of roentgenology, radium therapy, and nuclear medicine. 1956; 75(2):396-7. [pubmed]
  8. Ladeiras-Lopes R, Neto A, Costa C, et al. Hampton’s hump and Palla’s sign in pulmonary embolism. Circulation. 2013; 127(18):1914-5. [pubmed]
  9. Hampton AO, Castleman B.  Correlation of postmortem chest teleroentogenograms with autopsy findings.  Am J Roentgenol Radium Ther. 1940;34:305-326.

#36 – Basics of the Ventilator with Wes Johnson, PA-C



Guest Information


Wes Johnson, MSPAS, PA-C, (soon to be), DHSc was a former student of mine at UAB and was a respiratory therapist prior to PA school.  He is the Regional Director of Clinical Education for Island Medical Management Emergency group in North Alabama.  He won the Preceptor of The Year award from UAB in 2016 and currently finishing up his doctorate degree from A.T. Still University.

Twitter – @wesj2288



For the purposes of this podcast and post, we will be using the Puritan Bennett 840 ventilator (pictured below).  All the term we use are synonymous with all vents, but the screens will be different.

Puritan Bennett 840

Big Concepts of The Ventilator


  1. Mode
    1. Assist Control (AC)
      1. Every breath is either a machine driven (set by rate) or fully assisted (initiated by the patient)
        1. Uses either pressure (ACPC) or volume (ACVC)
    2. Synchronized Intermittent Mechanical Ventilation (SIMV)
      1. Set number of machine driven breaths, and patient intitated breaths are partially assisted
    3. Pressure Support (PS)
      1. No machine driven breaths and all breaths are initiated by the patient and partially assisted
  2. Delivery
    1. Pressure
      1. Static Controls
        1. Pressure
        2. Time (inspiratory)
        3. Peak flow
      2. Variable Factors
        1. Volume
        2. Total flow
    2. Volume
      1. Static Controls
        1. Tidal volume (cc)
        2. Flow (L/min)
      2. Variable Factors
        1. Pressure
  3. Positive End Expiratory Pressure (PEEP)
    1. The pressure left in the circuit at the end of expiration
    2. Prevents alveolar collapse and improves oxygenation
    3. Can cause barotrauma and affect hemodynamics

Static Controls


(For this section, refer back to the vent picture above)

  1. Fraction of Inspired Oxygen (FiO2)
    1. Start at 100% and titrate down to 21%
  2. f (machine breath rate)
  3. Control
    1. Pressure Control (PC)
      1. Inspiratory pressure (Pi)
        1. Peak pressure in circuit
        2. Initial setting = < 20 cm H20
      2. Inspiratory time (I-time)
        1. Initial setting = 1.25 seconds
    2. Volume Control (VC)
      1. Vt (tidal volume of each breath)
        1. Initial setting = 6-8 cc/kg IBW
      2. Vmax (flow rate)
  4. Spontaneous Support
    1. Trigger for spontaneous support
      1. Volume = V-trig
      2. Pressure = P-trig
    2. Pressure Support (PS)
      1. I was always taught at least 5 cm H20 to overcome circuit resistance

Real-Time Controls


  1. Flashing “C” and “S”
    1. Lets you know what breaths are controlled (machine) or spontaneous (patient)
  2. Airway Pressure
    1. Ppeak (max airway pressure)
      1. A marker of resistance
    2. Pmean (average airway pressure)
      1. A measure of alveolar pressure
    3. Pplat (small airway and alveoli pressure)
      1. A measure of compliance
  3. fTotal (machine + spontaneous breaths)
  4. I:E (inspiratory:expiratory ratio)
    1. Normal = 1:2 (at rest)
    2. Inverse ratio (2:1) can improve oxygen due to intention auto-PEEP

Wes Johnson’s Approach to Setting Up a Ventilator (after RSI)


Mode: AC

Vt: 6-8 mL/kg based on pt’s IBW

Rate: 12-16 bpm

FiO2: 100%

PEEP: 5.0

At the 5-minute mark:

  • Check an ABG
    • Titrate FiO2 off of PaO2 and pulse oximeter
    • Adjust minute ventilation off of PaCO2 and/or ETCO2


  1. Respiratory Review YouTube Channel
  2. Deranged Physiology.  Mechanical Ventilation.
  3. Weingart SD – “Spinning Dials – How to Dominate the Ventilator” –
  4. Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Annals of emergency medicine. 2016; 68(5):614-617. [pubmed]
  5. Air Link Regional West – “Initial Adult Ventilator Settings” –
  6. Open Anesthesia. Modes of Mechanical Ventilation.
  7. Modern Medicine Network.  A Quick Guide to Vent Essentials.
  8. Tobin MJ. Extubation and the myth of “minimal ventilator settings”. American journal of respiratory and critical care medicine. 2012; 185(4):349-50. [pubmed]

PAINE #PANCE Pearl – Pulmonology


When following low-risk, small single pulmonary nodules,

  1. What is the time sequence for the follow-up CT scans?
  2. How long do you re-image them for?


  1. It depends on the size of the nodule and consistency after the initial CT scan.  The current guidelines state:
    1. For solid nodules:
      1. < 6mm recommend no further imaging
      2. > 6mm but < 8mm recommend CT scan at 6-12 months
      3. > 8mm recommend CT scan at 3-6 months, 9-12 months, and 18-24 months
    2. For non-solid (ground glass) nodules:
      1. < 5mm recommend no further imaging
      2. > 5mm recommend annual CT for 3 years
    3. For part-solid (>50% ground glass) nodules:
      1. < 8mm recommend CT scan at 3 months, 12 months, 24 months, and annual for 1-3 years
      2. > 8mm recommend CT scan at 3 months and PET or biopsy
  2. Low-risk nodules can be serially scanned for 2 years and if no change, can stop repeat imaging as malignant nodules will show some form of change in 2 years.


  1. Gould MK, Donington J, Lynch WR. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013; 143(5 Suppl):e93S-e120S. [pubmed]

#32 – Pulmonary Thromboembolism




  • 300,000-600,000 cases per year in the United States
  • It is estimated that up to 50% will have post-thrombotic syndrome

Why Are We So Scared?

  • As many as 20% of patients with 1st onset PTE have no identifiable risk factors
  • 10-30% 1-month mortality with up to 25% presenting as sudden death
  • Fear of litigation is #1 reason clinicians work-up low risk PTE

Why Can’t We Test Everyone?

  • Up to $16,000 per patient in total health care costs
  • 6 times more deaths with testing and treatment

Signs and Symptoms

The majority of the classic signs and symptoms come from PIOPED II study and EMPEROR registry.  These include:

  • Dyspnea (73%)
  • Chest Pain (64%)
  • Tachypnea (57%)
  • DVT findings or leg pain/swelling (47%)
  • Tachycardia (26%)
  • Dizziness (12%)
  • Hemoptysis (10%)

The EMPEROR registry took it a step further and determined mean vital sign measurements of:

  • Heart rate – 95 bpm
  • Respiratory rate – 20 bpm
  • Oxygen saturation – 95%

A recent trail in the NEJM called PESIT concluded as many as 1 in 6 patients with first time syncope has a PTE on inpatient work-up.  This study has been largely panned by the EM community and you can read their take from the links below:

Pre-Test Probability Scores

The most well know score is the Wells Criteria first published in 1998 and then revised and simplified in 2000 and 2001.


A second calculation is the Geneva Score first published in 2001 and revised and simplified in 2006 and 2008.


The Pulmonary Embolism Rule-Out Criteria was published in 2008 by Jeff Kline and is a second set of criteria to definitively rule-out PTE in patients ALREADY SCORE AS LOW RISK by Wells or Geneva.


What about just good ol’ clinical gestalt?  An interesting study was performed in 2013 looking at the accuracy of Wells vs Geneva vs Gestalt and found:

  • Clinical gestalt had a lower missed rate of PTE in low-risk patients
  • Clinical gestalt had a high accuracy of diagnosing PTE in high-risk patients

The Work-Up of Suspected PTE

  1. Electrocardiogram is not senstitive nor specific for PTE but should be ordered on every patient with chest pain and/or shortness of breath to rule-out ACS
    1. The EMCMD talks about the 10 ECG findings of PTE in the best video I have every scene
  2. D-Dimer
    1. High senstivity = good for rule-out
    2. Should only be used after pre-test probability due to the false positives and unnecessary work-ups
    3. ADJUST-PE Study
      1. Found D-Dimer go up with age and created an age adjusted D-Dimer cutoff of:
        1. Age (yr) x 10 as diagnostic threshold
  3. Radiographic Imaging
    1. Computed tomography is gold standard but has higher radiation exposure and contrast loads
    2. Image result for CT PTE
    3. Ventilation/Perfusion scan is safer in renal patients but up to 2/3rd are non-diagnostic
    4. Image result for V/Q PTE

Risk Assessment

Once you diagnose a patient with a PTE, you have determine the patient’s risk and severity of disease.

  1. Echocardiogram
    1. Looking for RV strain
      1. RV:LV ≥ 1
      2. RV hypokinesis
      3. Paradoxical septal movement
      4. Tricuspid regurgitation
  2. Biomarkers
    1. Brain Natriuretic Peptide (BNP)
      1. > 90 pg/mL has been associated with increased mortality
    2. Troponin
      1. > 0.01 ng/mL suggests evidence of RV dysfunction
  3. Pulmonary Embolism Severity Index (PESI)
    1. Published in 2005 and simplified 2010
    2. Developed to help prognosticate 30d mortality and found low-risk patients (PESI – 0) can be safely treated as outpatient

Definitions/Grades of PTE

Treatment Strategies for PTE

  1. Anticoagulation
    1. Started with confirmation of PTE or with high pre-test probability during workup
    2. Lots of options (heparin, LMWH, direct thrombin inhibitors, Factor Xa inhibitors)
  2. Fibrinolytics
    1. Lots of recent research on who to lyse and who not to
    2. Original research showed benefit if full dose lytics were given to massive PTE, but harm in submassive patients
    3. This led to MOPPET in 2013 evaluating 1/2 dose lytics in submassive patients and found:
      1. Reduction in overall mortality
      2. No difference in bleeding complications
      3. Reduction in hospital stay
    4. PEITHO came next in 2014 and looked at full dose lytics vs anticoagulation only for submassive PTE and found:
      1. No mortality benefit
      2. Reduction in hemodynamic compromise
      3. Increase in major bleeding and intracranial hemorrhage
  3. Catheter Directed Therapy
    1. Good options in patients with a high risk of bleeding with systemic fibrinolytic therapy
    2. This can include:
      1. Focal fibrinolytic therapy at the clot
      2. Mechanical thombectomy
        1. AngioJet system
        2. AngioVac system
      3. Ultrasound Assisted Local Fibrinolytic Therapy
        1. ULTIMA and SEATTLE-II studies found reduction in RV:LV ratio and decreased bleeding complications
  4. Surgical Thrombectomy
    1. Can be used as a last resort option and mortality from these procedures has dramatically improved from 57% in the 1960s to < 6% in 2005

Putting It All Together

This is a graphic I modified from Jeff Kline and EmCrit that encompasses everything into a nice, neat package and as I have said before “algorithms will set you free”



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  9. Wells PS. Excluding pulmonary embolism at the bedside without diagbnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer.  Ann Intern Med. 2001;135:98-107
  10. van Belle A. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295(2):172-179
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