Josh Farkas MD 💊

🚨Radiologists, read this if you don't want to get sued 🚨

I see this mistake a lot and it drives me bananas.

Radiology sees an opacity on chest radiograph and diagnoses pneumonia.

But, pneumonia is a *clinical* diagnosis that shouldn't be made in the radiology reading room.

When the radiologist makes an excessively confident diagnosis of pneumonia, this may lead to premature diagnostic closure & unnecessary antibiotics. (These over-aggressive "pneumonia" interpretations put a LOT of pressure on the treating team to give antibiotics.)

Usually in the cases I'm involved with the "pneumonia" ends up being atelectasis or CHF, but it could also be an unusual cancer or PE. Chest radiograph is a blunt survey tool that isn't good at making a specific diagnosis.

Folks make fun of radiologists for hedging on their reads, but that's a conservative & safe way that they should be practicing.

(PS - There's also a LOT else wrong with this case, like not getting a PE protocol CT scan. The differential diagnosis on this retrocardiac opacity may include pulmonary infarct due to PE. For a patient with 30 pack-years tobacco history presenting with hemoptysis, only getting a chest radiograph is like bringing a knife to a gun fight. The chest radiograph will generally be insufficient and you're almost always going to need a PE protocol CT. Not ordering a CT angiogram isn't the radiologist's fault.)

I love this format for sharing research on social media.

More detail than an infographic.

More readability than the journal abstract.

None of the BS of a movie.

Winter is coming. These are updated guidelines from trusted societies (pediatricians, family medicine, OBGYNs, & pulmonary/critical care).

I just updated the IBCC chapter on pulmonary vasodilators, here are new pearls I learned 🤯

🫁 The dosing of inhaled pulmonary vasodilators is a little different for ARDS versus for treatment of RV failure. In ARDS, you're shooting for selective vasodilation of the best-ventilated alveoli to maximize V-Q matching, so you want a mid-range dose (too high and you start vasodilating the worse-ventilated alveoli). In RV failure you're trying to vasodilate every alveoli as much as possible to bring down the pulmonary vascular resistance, so go high.

🫁 Nebulized milrinone causes selective pulmonary vasodilation for ~20-30 minutes, then gets systemically absorbed. One dose of nebulized milrinone in the OR is great, but scheduling milrinone nebs q4hr doesn't make pharmacological sense (it doesn't achieve consistent pulmonary vasodilation and there are risks of systemic accumulation in renal failure). IMHO milrinone nebs don't have much role in ICU. If you want to give milrinone just give it IV.

🫁 There's a gradually escalating amount of evidence supporting combined simultaneous use of inhaled epoprostenol and inhaled NO to treat RV failure. See the article by Andre Denault below. This may be a good option for RV failure before escalating to an Impella RP Flex. It's pretty easy to trial a patient on inhaled pulmonary vasodilators - if they work great, if they don't work you haven't lost much.

#1/2, link in next post.

some purists will ask: “Why are you getting that CT scan? Exactly what diagnosis are you looking for to justify this scan?”

But the great thing about CT scans is they allow us to diagnose entities we DIDN’T consider.

Sometimes its better to be thorough than smart 🤷‍♂️