Pulmonary Critical Care Medicine Research Articles

Critical Care Ultrasound Competency of Fellows and Faculty in Pulmonary and Critical Care Medicine: A Nationwide Survey

Purpose: Competency assessment standards for Critical Care Ultrasonography (CCUS) for Graduate Medical Education (GME) trainees in pulmonary/critical care medicine (PCCM) fellowship programs are lacking. We sought to answer the following research questions: How are PCCM fellows and teaching faculty assessed for CCUS competency? Which CCUS teaching methods are perceived as most effective by program directors (PDs) and fellows. Methods: Cross-sectional, nationwide, electronic survey of PCCM PDs and fellows in accredited GME training programs. Results: PDs and fellows both reported the highest rates of fellow competence to use CCUS for invasive procedural guidance, but lower rates for assessment of deep vein thrombosis and abdominal organs. 54% and 90% of PDs reported never assessing fellows or teaching faculty for CCUS competency, respectively. PDs and fellows perceived hands-on workshops and directly supervised CCUS exams as more effective learning methods than unsupervised CCUS archival with subsequent review and self-directed learning. Conclusions: There is substantial variation in CCUS competency assessment among PCCM fellows and teaching faculty nationwide. The majority of training programs do not formally assess fellows or teaching faculty for CCUS competence. Guidelines are needed to formulate standardized competency assessment tools for PCCM fellowship programs.

Creation and Validation of a Massive Hemoptysis Simulator

Simulation for the management of massive hemoptysis is limited by the absence of a commercially available simulator to practice procedural skills necessary for management. Is it feasible to create and validate a hemoptysis simulator with high functional task alignment? Pulmonary and critical care medicine (PCCM) attending physicians from four academic institutions in the Denver, Colorado, area and internal medicine residents from the University of Colorado participated in this mixed-methods study. A hemoptysis simulator was constructed by connecting a 3-D-printed airway model to a manikin that may be intubated. Attending PCCM physicians evaluated the simulator through surveys and qualitative interviews. Attendings were surveyed to determine simulation content and appropriate assessment criteria for a hemoptysis simulation. Based on these criteria, expert and novice performance on the simulator was assessed. The manikin-based hemoptysis simulator demonstrated adequate physical resemblance, high functional alignment, and strong affective fidelity. It was universally preferred over a virtual reality simulator by 10 PCCM attendings. Twenty-seven attendings provided input on assessment criteria and established that assessing management priorities (eg, airway protection) was preferred to a skills checklist for hemoptysis management. Three experts outperformed six novices in hemoptysis management on the manikin-based simulator in all management categories assessed, supporting construct validity of the simulation. Creation of a hemoptysis simulator with appropriate content, high functional task alignment, and strong affective fidelity was successful using 3-D-printed airway models and existing manikins. This approach can overcome barriers of cost and availability for simulation of high-acuity, low-occurrence procedures.

Massive Hemoptysis Simulation Curriculum Improves Performance

Massive hemoptysis is a rare, high-acuity presentation, which requires the integration of both cognitive and procedural skills. Simulation has been recommended to improve preparation for high-acuity, low-occurrence procedures; however, the effect of a simulation curriculum for massive hemoptysis management has never been investigated. Does simulation for hemoptysis management improve competence? Kern's six steps for medical education curriculum design were used iteratively to develop a simulation curriculum for the management of massive hemoptysis. Pulmonary and critical care medicine fellows from the University of Colorado participated in a local needs assessment and a massive hemoptysis simulation curriculum. Using a manikin-based massive hemoptysis simulator developed for this curriculum, the simulation session used repetitive practice, clinical variation, a range of difficulties, and directed feedback in a group practice setting. Time to management and performance were assessed for each management attempt; competence was assessed using a combined metric of management-related priorities and global entrustment. During the needs assessment, fellows viewed massive hemoptysis management skills as important, while expressing their current confidence as low. Nineteen fellows participated in a 90-min case-based hemoptysis simulation during which each was exposed to five different cases and acted as the primary manager for two cases. There was significant improvement in performance from the first to final simulation attempts measured by time to successful management (14.24 vs10.26 min, P= .0067) and entrustment (Global Assessment Scale, 1 [should not perform] to 5 [independent]; 4.11 vs4.61; P= .015). Fellow self-assessed knowledge and confidence in hemoptysis management and endobronchial blocker placement improved significantly after the simulation. Hemoptysis simulation experience improves fellow confidence and skill for management of this high-acuity, low-occurrence presentation.

Gender, Race, and Ethnicity in Critical Care Fellowship Programs in the United States From 2016 to 2021.

The purpose of this study is to determine the trends in gender, race, and ethnicity of U.S. critical care fellowships over the past 6 years (2016-2021). Data on gender, race, and ethnicity of critical care fellows in five Accreditation Council on Graduate Medical Education-accredited training programs (internal medicine, pulmonary and critical care, anesthesiology, surgery, and pediatrics) from 2015 to 2016 to 2020-2021 were obtained from the joint reports of the American Medical Association (AMA) and Association of American Medical Colleges published annually in the Journal of the AMA. From 2016 to 2021, the number of U.S. critical care fellows increased annually, up 23.8%, with the largest number of fellows in pulmonary critical care medicine (60.1%). The percentage of female critical care fellows slightly increased from 38.7% to 39.4% (p = 0.57). White fellows significantly decreased from 57.4% to 49.3% (p = 0.0001); similarly, Asian fellows significantly decreased from 30.8% to 27.5% (p = 0.004). The percentage of Black or African American fellows was not statistically significantly different (4.9% vs 4.4%; p = 0.44). The number of fellows who self-identified as multiracial significantly increased from 52 (1.9%) to 91 (2.7%) (p = 0.043). The percentage of fellows who identified as Hispanic was not significantly different (6.7% vs 7.5%; p = 0.23). The percentage of women and racially and ethnically minoritized fellows (Black and Hispanic) remain underrepresented in critical care fellowship programs. Additional research is needed to better understand these demographic trends in our emerging critical care physician workforce and enhance diversity.

A Pilot Standardized Simulation-Based Mechanical Ventilation Curriculum Targeting Pulmonary and Critical Care Medicine and Critical Care Medicine Fellows.

Introduction The mastery of mechanical ventilation (MV) management is challenging, as it requires the integration of physiological and technological knowledge with critical thinking. Our aim was to create a standardized curriculum with assessment tools based on evidence-based practices to identify the skill deficit and improve knowledge in MV management. Methods For 3 years, 3 hours of standardized curriculum for each first-year pulmonary critical care medicine (PCCM) and critical care medicine (CCM) fellows was integrated into the orientation (chronologically): (1) a baseline knowledge pretest; (2) a 1-hour one-on-one case-based simulation session with debriefing. A 34-item competency checklist was used to assess critically thinking and skills and guide the debriefing; (3) a 1-hour group didactic on respiratory mechanics and physiology; (4) a 45-minute hands-on session in small groups of one to three fellows for basic knobology, waveforms, and various modes of mechanical ventilators; (5) a 15-minute group bedside teaching of vented patients covering topics such as techniques to alleviate dyssynchrony and advanced ventilator modes; (6) a one-on-one simulation reassessment session; (7) a knowledge posttest. Fellows' performances at baseline, 1-month posttest, and end-of-first year post-test were compared. Results Fellows ( n = 24) demonstrated significant improvement at 1-month posttest in knowledge (54.2% ± 11.0 vs. 76.6 ± 11.7%, p < 0.001) and MV competency (40.7 ± 11.0% vs. 69.7 ± 9.3%, p < 0.001), compared with pretest. These improvements were retained at the end-of-year reassessments (knowledge 75.1 ± 14.5% and MV competency 85.5 ± 8.7%; p < 0.001). Conclusion Standardized simulation-based MV curriculum may improve the medical knowledge competency, and confidence of first-year PCCM and CCM fellows toward MV management before encountering actual ventilated patients.

AMBULATORY BLOCK STRUCTURE TO IMPROVE FELLOW OUTPATIENT PULMONARY MEDICINE EXPOSURE AND EDUCATION

AMBULATORY BLOCK STRUCTURE TO IMPROVE FELLOW OUTPATIENT PULMONARY MEDICINE EXPOSURE AND EDUCATION

Gendered Language in Letters of Recommendation for Applicants to Pulmonary Critical Care Fellowships.

BackgroundPrevious work has demonstrated letters of recommendation for women in academic medicine are shorter and emphasize communal traits over grindstone or agentic traits.ObjectiveTo determine if there are sex-based differences in letters of recommendation written for applicants applying to pulmonary critical care medicine fellowships and if the sex of the letter writer impacts these differences.MethodsAll fellowship applications submitted to a pulmonary critical care medicine fellowship program in 2020 were included in this study. The applicant demographics and self-reported accomplishments were extracted from their application. The sex of letter writers was identified through public online searches. Word count and language differences in the letters of recommendation were analyzed for each applicant using the Linguistic Inquiry and Word Count (LIWC2015) program. Multivariable linear regressions were performed controlling for applicant characteristics to identify if applicant sex was associated with total word counts and total agentic word counts.ResultsOf the 529 complete applications, 2,024 letters of recommendation were reviewed. A majority of the applicants (70%, n = 370/530) and letter writers (75%, n = 1,515/2,024) were male. When adjusting for applicant demographic and accomplishments, female applicants had longer letters of recommendation (30.91 words longer, 95% confidence interval [CI], 1.53–60.29; P = 0.04) and more supportive letters (3.27 words longer, 95% CI, 1.59–4.95; P < 0.01) as compared with male applicants. Female letter writers wrote longer and more supportive letters than male letter writers, and this difference was greatest for female applicants.ConclusionFemale applicants received longer and more supportive letters of recommendation. Further work is needed to understand if this finding is the beginning of a change in the letters of recommendation for female applicants.

Implementation of a Longitudinal Critical Care Fellowship Ultrasound Curriculum.

BackgroundThe use of point-of-care ultrasound as a diagnostic and interventional tool is rapidly becoming standard of care in critical care medicine; a standardized training curriculum is needed to ensure provider proficiency.ObjectiveThis study aimed to describe a longitudinal critical care ultrasound (CCUS) curriculum in a pulmonary critical care medicine (PCCM) fellowship training program. It evaluated the curriculum’s impact on fellows’ knowledge, skills, and self-reported confidence and retention of these attributes.MethodsWe conducted a prospective observational study of a longitudinal CCUS training program within a single PCCM fellowship training program. Knowledge, skills, and confidence of 22 fellows were assessed at baseline; after initial training; and at 6, 12, and 18 months in five domains (ultrasound basics, vascular, lung/pleural, abdomen, and cardiac). We quantified changes in CCUS knowledge, confidence, and skills by fellowship class and assessed for longitudinal retention of these three attributes. The difference in scores between new first-year fellows undergoing formal training and second-year fellows with previous informal training was compared at matched time points.ResultsAfter the initial formal training, there was a significant increase in knowledge, skills, and confidence scores, which were maintained or continued to increase up to 18 months. Fellows with 1 year of formal training also had a higher level of knowledge and skills than fellows with 1 year of informal training, although they had similar levels of self-reported confidence in their skills.ConclusionA formal, longitudinal CCUS curriculum implemented in a PCCM fellowship program improves trainees’ knowledge and skills in various ultrasound domains in addition to their confidence in using ultrasound for patient care. A longitudinal curriculum results in retention of all three attributes and appeared to be more effective than an informal training program based on teaching during rounds, but this needs to be replicated in a larger cohort.

Training Pulmonary Critical Care Medicine Fellows in Thoracentesis Using a Head-Mounted Video Camera.

BackgroundDetermination of competence to perform procedures during pulmonary critical care medicine fellowship training has traditionally been based on subjective faculty opinion and numerical requirements.ObjectiveTo describe an objective means of assessing competence of fellows to perform thoracentesis using a head-mounted video camera with offline scoring of the thoracentesis performed on an actual patient.MethodsTo test competence in performance of thoracentesis after a multimodality training program, a total of eight first-year fellows performed a thoracentesis on an actual patient while recording the procedure with a lightweight head-mounted video camera in 2017 and 2018. The recordings were scored offline by two faculty members using a 30-point checklist. The percentage agreement between scorers was measured, as was the opinion of the fellows and the scorers on the testing process. If a fellow failed completion of all checklist items, they were provided with further training and retested to assure competence. As part of their training, fellows reviewed the video record of their procedures.ResultsEight first-year fellows were tested, of whom seven successfully completed key checklist items as determined by the video scorers. One failing fellow passed after further training and testing. The percentage agreement between the scorers was high, and fellows indicated that the video device was useful for training.ConclusionThis study supports the use of video-based testing for assessment of competence and for training in performance of thoracentesis by fellows.

THE IMPACT OF COVID-19 PANDEMIC ON THE CHOICE OF SUB-SPECIALTY TRAINING IN US MEDICAL RESIDENCY PROGRAMS

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: The Covid-19 pandemic led to critical shortage of personal protective equipment worldwide & challenged the motto of safety in healthcare occupations. Pulmonary & critical care medicine (PCCM) is one of the specialties that was heavily involved in care of Covid-19 infected patients. It is not yet determined how an active pandemic can shape the minds of Internal Medicine (IM) residents who wished to pursue fellowship training. While some may deem PCCM to be too high a risk and avoid it altogether, others may process it as a calling. The purpose of this survey study was to determine these effects. METHODS: We surveyed the IM residents enrolled in ACGME accredited residency programs in the United States. The survey invitation link was distributed to the preferred contact email listed on the American Medical Association: Residency & Fellowship Database (FREIDA™) using a mass emailing service. Programs were requested to distribute the survey to IM residents to complete voluntarily. Study data were collected & managed using REDCap electronic data capture tools hosted at Case Western Reserve University. A reminder email was sent at 2-week period to the programs that didn't open the initial enrollment email. Data analysis was completed using REDCap & Microsoft Excel. RESULTS: Of the 258 responses, 12 were excluded due to incomplete data or not meeting criteria. A total of 245 responses were used for analysis of which 48.4% self-identified as male & 51.6% as female. Subgroups based on year of training were: PGY1(66, 26.9%), PGY2(94, 38.4%), PGY3(75, 30.6%) & PGY4(10, 4.1%). Majority of residents were in age group 26-35 (226, 92.2%) with geographical distribution into Northeast (55, 22.4%), Midwest (82, 33.5%), South (61, 24.9%) & West (47, 19.2%). Of the respondents, 179/245(73.1%) were residents aspiring for fellowship positions, 30/245(12.2 %) were undecided & 36/245(14.69%) were not interested in pursuing fellowship. The pandemic events of year 2020 altered the decision to pursue fellowship with an average influence factor of 59.08 (SD 23.4) on a linear scale of 0-100. This change affected 10.6% (26/245) of the respondents, swaying 46.1% of these residents against the field of PCCM & 23% for it. CONCLUSIONS: The COVID-19 pandemic affected only a small proportion of residents into altering their decisions to pursue fellowship of their original choice. However, when applicable it mostly deterred residents from applying to a high risk fellowship such as PCCM. This survey study is limited by the relatively small number of respondents, general limitations of voluntary surveys & lack of responses from some geographic locations. CLINICAL IMPLICATIONS: Covid-19 pandemic may have influenced the decision to pursue fellowship training with a potentially deleterious effect on PCCM. This could be due to ongoing concerns for personal safety. Additional studies are needed to determine underlying factors. DISCLOSURES: No relevant relationships by Samantha DiBenedetto, source=Web Response No relevant relationships by Enambir Josan, source=Web Response No relevant relationships by Ziad Shaman, source=Web Response No relevant relationships by vikrant singh, source=Web Response

Droplet Size and Distribution of Nebulized 3% Sodium Chloride, Albuterol, and Epoprostenol by Phase Doppler Particle Analyzer

BackgroundAerosolized drug therapy administered to mechanically ventilated patients is a standard part of pulmonary critical care medicine. Aerosol particle size and distribution are important factors in the optimal delivery of aerosolized drugs to ventilated patients.ObjectiveThe objective of this study was to characterize aerosol droplet size and distribution with laser diffraction for nebulized 3% sodium chloride, albuterol, and epoprostenol sodium (containing glycine) delivered via Aeroneb Solo Mesh Nebulizers (Aerogen, Mountain View, California).MethodsA series of functional flow tests were run on each of 8 Solo mesh nebulizers before the study to verify accuracy of flow rates in milliliters per minute. Aerosolized droplets exiting the nebulizer heads were then measured using a phase Doppler particle analyzer. Data collected during delivery of 3% sodium chloride, albuterol, and epoprostenol sodium included aerosol droplet size distribution, mass median aerodynamic diameter (MMAD), and geometric standard deviation. For each Solo nebulizer, droplet size measurements were taken 2 cm away from the nebulizer head and 2 cm away from the wye of a heated, humidified adult ventilator circuit. For measurements taken at the wye, 4 distinct, continuous flow rates (2, 10, 20, and 40 L/min) were generated by an air pump to simulate inspiratory flows delivered with mechanical ventilation. The expiratory limb was capped, and the nebulizer head was inserted into the breathing circuit upstream of the humidifier.ResultsEach Solo nebulizer met Aerogen's recommended minimum flow rate of 0.2 mL/min, ranging from 0.23 to 0.31 mL/min. The MMAD of the 3 tested aerosols was several times smaller when measured at the wye outlet of the heated/humidified breathing circuit (0.82–2.73 µm) compared with droplets measured directly at the nebulizer outlet (MMAD, 4.6–7.3 µm). There was also significant variability across Solo heads with some ventilator flow rates. The mean MMAD at the wye for the 3% sodium chloride solution, albuterol, and epoprostenol test solutions was 1.62 µm, 1.09 µm, and 1.18 µm, respectively. The mean MMAD at the nebulizer for the 3% sodium chloride solution, albuterol, and epoprostenol test solutions was 5.37 µm, 5.73 µm, and 6.73 µm, respectively.ConclusionsResults from this study suggest that particle size of aerosolized drugs administered via a commonly used setup for delivery of in-line aerosols to mechanically ventilated patients may be several times smaller than expected and may result in less drug being delivered to the patient than previously realized.(Curr Ther Res Clin Exp. 2021; 82:XXX–XXX)© 2021 Elsevier HS Journals, Inc.

Impact of Novel Multiinstitutional Curriculum on Critical Care Fellow Ventilator Knowledge

Background: Management of mechanical ventilation (MV) is a curricular milestone for trainees in pulmonary critical care medicine (PCCM) and critical care medicine (CCM) fellowships. Though recognition of ventilator waveform abnormalities that could result in patient complications is an important part of management, it is unclear how well fellows recognize these abnormalities.Objective: To study proficiency of ventilator waveform analysis among first-year fellows enrolled in a MV course compared with that of traditionally trained fellows.Methods: The study took place from July 2016 to January 2019, with 93 fellows from 10 fellowship programs completing the waveform examination. Seventy-three fellows participated in a course during their first year of fellowship, with part I occurring at the beginning of fellowship in July and part II occurring after 6 months of clinical work. These fellows were given a five-question ventilator waveform examination at multiple time points throughout the two-part course. Twenty fellows from three other fellowship programs who were in their first, second, or third year of fellowship and who did not participate in this course served as the control group. These fellows took the waveform examination a single time, at a median of 23 months into their training.Results: Before the course, scores were low but improved after 3 days of education at the beginning of the fellowship (18.0 ± 1.6 vs. 45.6 ± 3.0; P < 0.0001). Scores decreased after 6 months of clinical rotations but increased to their highest levels after part II of the course (33.7 ± 3.1 for part II pretest vs. 77.4 ± 2.4 for part II posttest; P < 0.0001). After completing part I at the beginning of fellowship, fellows participating in the course outperformed control fellows, who received a median of 23 months of traditional fellowship training at the time of testing (45.6 ± 3.0 vs. 25.3 ± 2.7; P < 0.0001). There was no difference in scores between PCCM and CCM fellows. In anonymous surveys, the fellows also rated the mechanical ventilator lectures highly.Conclusion: PCCM and CCM fellows do not recognize common waveform abnormalities at the beginning of fellowship but can be trained to do so. Traditional fellowship training may be insufficient to master ventilator waveform analysis, and a more intentional, structured course for MV may help fellowship programs meet the curricular milestones for MV.

Variation in Intensive Care Unit Intubation Practices in Pulmonary Critical Care Medicine Fellowship.

Background: Endotracheal intubation in the intensive care unit (ICU) is a high-risk procedure. Competence in endotracheal intubation is a requirement for Pulmonary and Critical Care Medicine (PCCM) training programs, but fellow experience as the primary operator in intubating ICU patients has not been described on a large scale.Objective: We hypothesized that significant variation surrounding endotracheal intubation practices in medical ICUs exists in U.S. PCCM training programs.Methods: We administered a survey to a convenience sample of U.S. PCCM fellows to elicit typical intubation practices in the medical ICU.Results: Eighty-nine discrete U.S. PCCM and Internal Medicine Critical Care Medicine training programs (77% response rate) were represented. At 43% of programs, the PCCM fellow was “always or almost always” designated the primary operator for intubation of a medical ICU patient, whereas at 21% of programs, the PCCM fellow was “rarely or never” the primary operator responsible for intubating in the ICU. Factors influencing this variation included time of day, hospital policies, attending skill or preference, ICU census and acuity, and patient factors. There was an association between location of the training program, but not program size, and whether the PCCM fellow was the primary operator.Conclusion: There is significant variation in whether PCCM fellows are the primary operators to intubate medical ICU patients during training. Further work should explore how this variation affects fellow career development and competence in intubation.

EVALUATING PULMONARY/CRITICAL CARE FELLOWS’ PRACTICE HABITS REGARDING NICOTINE USE AFTER IMPLEMENTING A NOVEL INTERNET-BASED EDUCATIONAL SERIES

SESSION TITLE: Tobacco Cessation and Prevention Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Smoking remains the leading preventable cause of death in the US. Pulmonologists are positioned to identify nicotine use disorders and intervene with evidence-based treatments. However, limited education exists for pulmonary/critical care medicine (PCCM) trainees on this topic. This quality improvement project aimed to evaluate PCCM fellows’ practice patterns regarding nicotine use disorders after introducing an internet-based educational series. METHODS: At a single, academic US fellowship program PCCM fellows were introduced to a videocast series on nicotine use disorders. We performed a retrospective chart review of select PCCM fellow outpatient encounters at a large university-based practice during two timeframes: (i) pre-intervention period (3 months immediately prior), (ii) post-intervention period (3 months immediately after). We manually reviewed the electronic medical record for each encounter including social history, progress note, diagnostic codes, prescriptions, and patient instructions. Information reviewed included whether any care team member addressed nicotine history, fellow addressed nicotine history, patient was an active nicotine user, pack-year history was documented, diagnostic code used, prescription provided for nicotine use treatment, and referral was provided to quit-line and/or nicotine use treatment specialist. RESULTS: A total of 7 fellows were included in the analysis and chart review. 377 fellow outpatient encounters were reviewed, including 195 pre- and 182 post-intervention period encounters. Overall, a nicotine history was obtained by the collective care team in 99.2% of encounters, in which 58.0% of active nicotine users had documented “pack-year” history and 41.9% with diagnostic codes. Notably, after implementing education series, there was a statistically significant increase in the number of outpatient encounters in which the fellow captured information about patient nicotine use (66.7% vs 76.3%, p<0.05). There was a non-significant increase in treatments prescribed in the post-intervention group (41.9% vs 51.6%, p=0.45). CONCLUSIONS: In conclusion, we demonstrated that implementation of an online educational series to PCCM fellows resulted in a measurable increase the proportion of outpatient encounters in which the fellow captured history of nicotine use. There were no significant differences found in the reported “pack-year” history, diagnostic codes, and prescriptions for treatment, likely due to our small cohort. Such novel-based curricula should be evaluated in larger cohorts including repeated educational reinforcement. CLINICAL IMPLICATIONS: By implementing a brief online educational series on nicotine use disorders for fellows in-training, fellows can capture nicotine use in a higher proportion of patients. Further efforts should be explored in educating providers regarding nicotine use treatment and referrals. DISCLOSURES: No relevant relationships by Janaki Deepak, source=Web Response No relevant relationships by Jason Stankiewicz, source=Web Response No relevant relationships by Avelino Verceles, source=Web Response

Academic careers in global pulmonary and critical care medicine: perspectives from experts in the field

Academic global pulmonary/critical care medicine (PCCM) remains a relatively novel concept not fully embraced by all training programs, so PCCM early-career professionals may have little guidance in building successful careers in this field. To highlight various approaches used by current PCCM faculty to incorporate global health into their academic careers, speakers from a global health careers mini symposia held at the 2017 and 2018 American Thoracic Society International Conferences were invited to submit perspectives reflecting on academic PCCM and global health. The collection of essays was collated into a single manuscript. Eight current global PCCM faculty from diverse geographic and professional backgrounds provide experiential guidance for early-career professionals interested in global academic PCCM. Trainees and junior faculty interested in academic global PCCM will find innumerable obstacles to developing this non-traditional career pathway, but there exist diverse pathways to success.

Characteristics of Pulmonary Critical Care Medicine and Pulmonary Medicine Applicants and Fellowships.

Background: Little is known about historical and recent application trends for pulmonary critical care medicine (PCCM) or pulmonary medicine (PM) fellowship programs. Describing trends in and characteristics of PCCM and PM applications, applicants, and fellowship programs can help program directors and medical educators understand trainees’ interest in and application patterns for these fellowship programs.Objective: The objective of this study was to use National Residency Match Program data to assess recent trends in PCCM and PM fellowship applications and compare characteristics of applicants and fellowship programs.Methods: In 2019, we used National Residency Match Program data to evaluate applicant ranking and matching in PCCM and PM fellowship programs and to compare applicant and fellowship program characteristics.Results: From 2008 through 2019, the majority of applicants (59.1%) matched into PCCM were graduates of U.S. allopathic or osteopathic medical schools, whereas 87% of PM fellows were non-U.S. graduates. PCCM was the preferred specialty for 90.8% of matched applicants versus only 31.6% of matched PM applicants (P < 0.001). The match rate for PCCM applicants was 67.2% versus 23.8% for PM applicants (P < 0.001). Of PCCM applicants, 36.6% matched into their top choice versus 10.8% of PM applicants (P < 0.001). There are far fewer PM fellowship positions (n = 23) and programs (n = 12) than PCCM positions (n = 450) and programs (n = 131). The mean fill rates from the 2004 through 2016 appointment years are 94.1% in PCCM and 97.4% in PM (P = 0.009).Conclusion: PCCM is a prevailing specialty choice over PM among residency graduates, with matched applicants more likely to list PCCM than PM as their preferred specialty. Further exploration into applicants’ interest in critical care compared with PM may prove beneficial in guiding applicants to programs that will best meet their career goals.

Simulation Training for Critical Care Airway Management: Assessing Translation to Clinical Practice Using a Small Video-Recording Device

Critical care airway management (CCAM) is a key skill for critical care physicians. Simulation-based training (SBT) may be an effective modality in training intensivists in CCAM. Is SBT of critical care fellows an effective means of providing training in CCAM, in particular in urgent endotracheal intubation? Thirteen first-year pulmonary critical care medicine (PCCM) fellows at an academic training program underwent SBT with a computerized patient simulator (CPS) in their first month of fellowship training. At the end of the training period, the fellows underwent video-based scoring using a 46-item checklist (of which 40 points could be scored) while performing a complete CCAM sequence on the CPS. They were then tested, using video-based scoring on their first real-life CCAM. Maintenance of skill at CCAM was assessed during the fellows' second and third year of training, using the same scoring method. For the first-year fellows, the score on the CPS was 38.3 ± 0.75 SD out of a maximum score of 40. The score on their first real-life patient CCAM was 39.0 ± 0.81 SD (P= .003 for equivalence; 95%CI for difference between real-life patient CCAM and CPS scores, 0.011-1.373). Sixteen second- and third-year fellows were tested at a real-life CCAM event later in their fellowship to examine for maintenance of skill. The mean maintenance of skill score of this group was 38.7 ± 1.14 SD. Skill acquired through SBT of critical care fellows for CCAM transfers effectively to the real-life patient care arena. Second- and third-year fellows who had initially received SBT maintained skill at CCAM.

Chest Ultrasonography in Diagnosing Etiology of Acute Respiratory Failure

&#x0D; &#x0D; &#x0D; &#x0D; Introduction: Lung ultrasonography (LUS) is a useful diagnostic tool in critical care setting. Lung ultrasound at bed side is relatively easy to perform, cost effective and reproducible. Analysis of various sign and profile, alone or in combination is as accurate as gold standard test like Computed Tomography scan of the chest in detection of etiology of acute respiratory failure. The aim of our study was to perform bed side lung ultrasound in patent with ARF and to find out the diagnostic accuracy of lung ultrasound when compared with diagnosis made by the clinician.&#x0D; Methods: This descriptive observational study was conducted at tertiary care teaching centre in Nepal between February 2019 and July 2019. Consecutive samples of acute respiratory failure patient were included. Lung ultrasound was performed at bed side by fellows of pulmonary critical care medicine. Specific 10 signs of blue protocol were assessed in six different sites of both the chest. Findings of LUS was recorded and analysed to formulate a diagnosis, and finally compared with the final diagnosis.&#x0D; Results: Forty eight patients of acute respiratory failure with median age of 66 years (17 to 89 years) were included with 66.7% being females. 97.9 % of the patient presented with acute shortness of breath of less than one week duration. A total of 13 different diagnosis was made at the end of the treatment for all the patient. LUS accurately diagnosed them in 43 cases, with an overall accuracy of 89.6 %. Chronic obstructive pulmonary disease, pulmonary edema, pneumonia, pleural effusion, pneumothorax were accurately diagnosed with LUS however in acute respiratory distress syndrome and interstitial lung disease, lung ultrasound had poor diagnostic accuracy.&#x0D; Conclusions: Lung ultrasound is useful tool in diagnosing etiology of acute respiratory failure. Diagnosis made by lung ultrasound was 89.6% correct when compared with final diagnosis made by clinician.&#x0D; &#x0D; &#x0D; &#x0D;

Graduating Fellows' Procedural Comfort Level With Pulmonary Critical Care Procedures.

Graduating fellows from pulmonary and critical care programs are expected to independently perform bronchoscopy and common medical procedures in the intensive care unit. Given variable exposure and learning opportunities at different training programs, little is known about how comfortable graduating fellows are with these procedures. A survey concerning the ACGME required procedures for pulmonary and critical care fellowship was sent to graduating fellows and program directors at all ACGME accredited subspecialty fellowship programs in pulmonary, critical care, and combined pulmonary critical care medicine. Critical care fellows performed the most intubations, paracenteses, arterial lines, central venous catheter insertions, and cardioversions, but did not perform as many bronchoscopy related procedures as the other subgroups. Pulmonary and combined pulmonary/critical care fellows performed and felt confident in most procedures. Program directors from all specialties agreed with the fellows overall about the procedural confidence gained during training. There also appeared to be a correlation between number of procedures performed and the confidence of the proceduralist. There appears to be a certain threshold number of successful completions to achieve confidence for independent practice for each surveyed procedure. There is a correlation between a fellow's procedural comfort with independent practice and the number of successful attempts by a graduating fellow. There are no universal guidelines that outline the appropriate number of successful attempts needed for independent practice, and our data strongly suggests that there is a threshold for each procedure across these three subspecialties.

Intensive Care Unit Rotations and Predictors of Career Choice in Pulmonary/Critical Care Medicine: A Survey of Internal Medicine Residency Directors.

Background The United States (US) is experiencing a growing shortage of critical care medicine (CCM) trained physicians. Little is known about the exposures to CCM experienced by internal medicine (IM) residents or factors that may influence their decision to pursue a career in pulmonary/critical care medicine (PCCM). Methods We conducted a survey of US IM residency program directors (PDs) and then used multivariable logistic regression to identify factors that were predictive of residency programs with a higher percentage of graduates pursuing careers in PCCM. Results Of the 249 PDs contacted, 107 (43%) completed our survey. University-sponsored programs more commonly had large ICUs (62.3% versus 42.2%, p=0.05), primary medical ICUs (63.9% versus 41.3%, p=0.03), and closed staffing models (88.5% versus 41.3%, p < 0.001). Residents from university-sponsored programs were more likely to pursue specialty fellowship training (p < 0.001) overall but equally likely to pursue careers in PCCM as those from community-sponsored programs. Factors predictive of residencies with a higher percentage of graduates pursuing training in PCCM included larger ICUs (>20 beds), residents serving as code leaders, and greater proportion of graduates pursuing specialization. Conclusions While numerous differences exist between the ICU rotations at community- and university-sponsored IM residencies, the percentage of graduates specializing in PCCM was similar. Exposure to larger ICUs, serving as code leaders, and higher rates of specialization were predictive of a career choice in PCCM.