Pulmonary and Critical Care Medicine
Astra Clinical Library
Pulmonology
Practical pulmonology guides for clinical decisions, with cited evidence, testing strategies, and actionable next steps.
40 guides
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Pulmonary and Critical Care Medicine
Respiratory Failure
Acute respiratory failure requires parallel stabilization and etiologic diagnosis. Distinguish hypoxemic from hypercapnic physiology, identify airway or ventilatory-support failure early, select oxygen, high-flow, noninvasive, or invasive support by mechanism and trajectory, and reassess continuously for treatment failure.Pulmonology
Chronic Obstructive Pulmonary Disease
COPD requires confirmation with post-bronchodilator spirometry, then treatment guided by symptoms, exacerbation history, inhaler delivery, eosinophils, and comorbidity rather than FEV₁ alone. Long-acting bronchodilation is foundational; escalation should target the dominant residual problem while minimizing avoidable inhaled corticosteroid and treatment toxicity.Pulmonology
Lung Cancer Screening
Annual low-dose CT reduces lung cancer mortality in appropriately selected high-risk adults, but benefit depends on excluding symptomatic patients, assessing fitness for diagnostic workup and curative treatment, integrating tobacco treatment, and ensuring reliable longitudinal nodule follow-up.Pulmonology and Medical Oncology
Lung Cancer
Lung cancer management depends on rapid histologic confirmation, accurate stage assignment, and—particularly in non-small cell lung cancer—tumor biomarker characterization before selecting surgery, radiation, systemic therapy, or symptom-directed care. Multidisciplinary coordination is central to preserving curative options and matching treatment intensity to patient goals.Pulmonary and Critical Care Medicine
Acute Pulmonary Embolism
Acute pulmonary embolism requires probability-guided testing, rapid assessment for cardiopulmonary failure, immediate anticoagulation when indicated, and selective escalation to reperfusion therapy. Contemporary multisociety guidance emphasizes integrated clinical, hemodynamic, respiratory, biomarker, and right-ventricular assessment to guide disposition and treatment.Pulmonary and critical care medicine
Pneumothorax
Pneumothorax management hinges on immediate recognition of physiologic compromise, accurate imaging in stable patients, and selecting observation, aspiration, drainage, ambulatory care, or definitive surgery according to cause, symptoms, recurrence risk, and ability to ensure follow-up.Pulmonology
Asthma
Asthma care depends on confirming variable expiratory airflow limitation, assessing current control and exacerbation risk, and selecting the lowest effective anti-inflammatory regimen while repeatedly addressing inhaler technique, adherence, triggers, and diagnostic alternatives.Pulmonology and Transplant Medicine
Bronchiolitis Obliterans
Bronchiolitis obliterans is an irreversible small-airway fibrotic syndrome most often encountered after lung or allogeneic hematopoietic stem-cell transplantation. Early spirometric decline, infection exclusion, and transplant-team evaluation are central because established airflow obstruction is difficult to reverse.Pulmonary and Critical Care Medicine
Dyspnea
Dyspnea requires rapid separation of airway, pulmonary vascular, parenchymal, cardiac, metabolic, and neuromuscular causes. Initial physiologic severity determines disposition; targeted bedside imaging, ECG, biomarkers, pulmonary testing, and exercise evaluation then identify the mechanism driving symptoms and direct treatment.Pulmonary and Critical Care Medicine
Bacterial Pneumonia
Manage suspected bacterial pneumonia by establishing illness severity and site of care, confirming a compatible pulmonary process, obtaining targeted microbiology in severe disease, and rapidly reconsidering alternative diagnoses or complications when empiric therapy fails.Pulmonary and Critical Care Medicine
Aspiration Pneumonia
Manage suspected aspiration pneumonia as community-acquired pneumonia unless resistant-pathogen risk is independently present, while distinguishing infection from aspiration pneumonitis, pulmonary edema, and obstructing or cavitary disease. Prioritize oxygenation, radiographic confirmation, targeted microbiology, swallowing evaluation, and prevention of recurrent aspiration.Pulmonary and Infectious Disease
Community-Acquired Pneumonia
A decision-focused approach to confirming community-acquired pneumonia, selecting site of care, identifying severe disease and resistant-pathogen risk, obtaining targeted microbiology, and reassessing response when initial therapy fails.Pulmonary and Critical Care Medicine
Eosinophilic Pneumonia
Confirm pulmonary eosinophilia, triage hypoxemic acute disease, and identify an exposure, drug, infection, systemic disorder, or chronic idiopathic pattern before committing to corticosteroid treatment.Pulmonary and Sleep Medicine
Obesity-Hypoventilation Syndrome
Confirm awake hypercapnia in an obese patient, exclude alternative causes of hypoventilation, identify coexisting sleep-disordered breathing, and use positive-airway-pressure therapy to prevent recurrent acute-on-chronic hypercapnic respiratory failure.Sleep Medicine
Sleep Apnea Syndrome
Confirm suspected obstructive sleep apnea with polysomnography or appropriate home testing, stratify severity by respiratory-event burden, and match treatment to anatomy, positive-airway-pressure tolerance, and cardiometabolic risk.Pulmonology and Cardiology
Pulmonary Hypertension
Pulmonary hypertension requires invasive hemodynamic confirmation, separation of pre- from post-capillary physiology, and prompt identification of potentially curable chronic thromboembolic disease before PAH-targeted treatment is considered.Pulmonary and Critical Care Medicine
Pleural Effusion
Evaluate pleural effusion by identifying instability or pleural infection, obtaining paired pleural-serum studies when sampling is indicated, and using fluid patterns to direct microbiology, cytology, biopsy, drainage, fibrinolysis, surgery, or durable symptom control.Sleep Medicine
Central Sleep Apnea
Central sleep apnea requires phenotype confirmation and cause-directed management. Distinguish central from obstructive events on sleep testing, optimize heart failure or remove respiratory depressants, and avoid adaptive servo-ventilation in symptomatic heart failure with left ventricular ejection fraction 45% or less.Sleep Medicine
Obstructive Sleep Apnea
Diagnose suspected obstructive sleep apnea with appropriate sleep testing, prioritize symptom relief and blood-pressure control, and match PAP, mandibular advancement, weight management, positional therapy, or selected surgery to anatomy, severity, and treatment tolerance.Adult Congenital Heart Disease and Pulmonary Hypertension
Eisenmenger Syndrome
Eisenmenger syndrome requires confirmation of fixed pulmonary vascular disease and shunt physiology, exclusion of reversible mimics, avoidance of destabilizing interventions, and individualized PAH-directed therapy in an adult congenital heart disease–pulmonary hypertension center.Sleep Medicine
Restless Legs Syndrome
Restless legs syndrome is a clinical sensorimotor diagnosis requiring exclusion of mimics, identification of iron deficiency and medication triggers, and treatment proportional to symptom burden. Iron replacement and alpha-2-delta ligands generally reduce reliance on dopaminergic therapy and its augmentation risk.Pulmonology
Interstitial Lung Disease
Interstitial lung disease requires early separation of infection, drug toxicity, exposure-related disease, autoimmune ILD, and idiopathic pulmonary fibrosis through high-resolution CT, pulmonary function testing, exposure history, serology, and multidisciplinary review to direct treatment and monitor progression.Pulmonology
Restrictive Lung Disease
Confirm true restriction with total lung capacity, then separate intrinsic parenchymal disease from obesity, neuromuscular, chest-wall, and pleural causes using diffusion capacity, imaging, oxygenation, and targeted etiologic testing.Pulmonology
Alpha-1 Antitrypsin Deficiency
Test adults with fixed airflow obstruction, unexplained bronchiectasis, or unexplained liver disease; confirm deficiency genetically and direct management toward smoking cessation, standard organ-specific care, selective augmentation, and transplant evaluation for end-stage organ disease.Pulmonology
Chronic Bronchitis
Chronic bronchitis should trigger confirmation of persistent airflow obstruction, assessment for competing cough syndromes and occupational exposure, and COPD-directed risk reduction. Acute worsening requires triage for hypoxemia, hypercapnia, pneumonia, and need for systemic therapy or ventilatory support.Sleep Medicine
REM Sleep Behavior Disorder
Confirm REM sleep behavior disorder with attended video polysomnography demonstrating REM sleep without atonia, exclude mimics and medication effects, immediately mitigate injury risk, and distinguish isolated disease from secondary RBD because isolated RBD confers substantial long-term synucleinopathy risk.Pulmonary and Critical Care Medicine
High-Flow Nasal Oxygen Escalation
Escalate beyond high-flow nasal oxygen when oxygenation, respiratory effort, mental status, or hemodynamics worsen despite treatment; serial ROX assessment can identify patients needing prompt intubation evaluation before prolonged noninvasive support masks clinical deterioration.Pulmonology
Severe Asthma Biologic Selection
Select an asthma biologic only after confirming severe asthma, correcting modifiable drivers, documenting exacerbation burden, and matching allergic or type 2 biomarkers, oral corticosteroid dependence, and relevant comorbidities to a single targeted agent.Pulmonary and Critical Care Medicine
Pleural Effusion Thoracentesis Indications
Perform diagnostic thoracentesis for a safely accessible effusion without a clear systemic cause, especially when infection, malignancy, or another exudative process is possible. Use ultrasound to establish procedural feasibility, obtain paired serum studies, and let fluid pH, microbiology, and cytology determine urgent drainage or tissue diagnosis.Pulmonary and Critical Care Medicine
Pleural Fluid Interpretation
Interpret pleural fluid by first identifying infection requiring drainage, then applying Light criteria, correcting pseudoexudates, and directing targeted tests for malignancy, tuberculosis, chylothorax, and other high-consequence etiologies.Pulmonary and Critical Care Medicine
Parapneumonic Effusion Drainage Criteria
Drain parapneumonic effusions when pleural fluid is purulent, microbiologically positive, markedly acidotic, or anatomically large or loculated. Use immediate blood-gas pH measurement after diagnostic thoracentesis to distinguish patients likely to resolve with antibiotics from those requiring image-guided tube drainage and escalation.Pulmonary and Critical Care Medicine
Hemoptysis Airway and Imaging Strategy
Manage hemoptysis by physiologic threat rather than reported volume: protect oxygenation and isolate the bleeding lung first, then use contrast-enhanced CT angiography in stable patients to identify cause, laterality, and target vessels for embolization.Pulmonology
Pulmonary Nodule Follow-Up Thresholds
Choose the management pathway before applying a size cutoff: Fleischner thresholds apply to incidental CT nodules, whereas Lung-RADS governs screening findings. Nodule attenuation, size, multiplicity, prior stability, growth, and pretest malignancy probability determine surveillance, PET/CT, tissue sampling, or surgical diagnosis.Sleep Medicine
Obstructive Sleep Apnea Diagnostic Testing
Select home sleep apnea testing only for medically uncomplicated adults with a high likelihood of moderate-to-severe obstructive sleep apnea; use attended polysomnography when comorbidity, alternate sleep pathology, hypoventilation risk, or a nondiagnostic home study could change management.Pulmonary and Critical Care Medicine
Community-Acquired Pneumonia Admission Criteria
Determine CAP disposition by separating outpatient suitability from physiologic instability, then use PSI for mortality-oriented site-of-care assessment and ATS/IDSA severe-CAP criteria to identify patients needing ICU-level monitoring, ventilatory support, or vasopressors.Pulmonary and Critical Care Medicine
Aspiration Pneumonitis Versus Aspiration Pneumonia
Differentiate chemical lung injury after macroaspiration from bacterial aspiration pneumonia by exposure, tempo, trajectory, and complications; then prioritize airway protection, observation, standard pneumonia therapy when infection is likely, and prevention of recurrent aspiration.Infectious Diseases and Pulmonary Medicine
MRSA Nasal Screening for Pneumonia
Use MRSA nasal PCR or swab testing to narrow empiric anti-MRSA therapy in pneumonia when pretest risk is meaningful, while obtaining respiratory cultures in severe disease. A negative screen supports early withdrawal of MRSA coverage; a positive screen does not establish MRSA pneumonia.Cardiology and Pulmonary Medicine
Pulmonary Embolism Thrombolysis Selection
Select reperfusion therapy by hemodynamic status, RV injury, and bleeding risk: systemic thrombolysis remains standard for high-risk PE, whereas anticoagulation with monitored rescue escalation is preferred for most normotensive intermediate-risk patients.Pulmonary and Critical Care Medicine