Dr. Anil Maske, MD 🫁

Associate Professor & Head Dept. of Respiratory Medicine, SRTR Govt Medical College, Ambajogai, Maharashtra, India.🇮🇳

[𝗦𝗮𝗹𝗲𝗲𝗺 𝗡. 𝗛𝗮𝗺𝗶𝗹𝗮𝗵 🫁 @SaleemHamilah]

STATIC vs. DYNAMIC COMPLIANCE 🫁

Understanding lung compliance can help you identify whether the problem is coming from the lungs or the airways.

STATIC COMPLIANCE
Cstat = VT ÷ (Pplat − PEEP)

Measures compliance when airflow is zero.

↓ Cstat → Think decreased compliance / stiff lungs
• ARDS
• Pulmonary edema
• Atelectasis
• Pneumothorax
• Fibrosis

DYNAMIC COMPLIANCE
Cdyn = VT ÷ (PIP − PEEP)

Measures compliance during active airflow and is affected by airway resistance.

↓ Cdyn → Think:
• Bronchospasm
• Secretions
• Kinked ETT
• Airway obstruction

TMC TIP:

↓ Cstat + ↓ Cdyn → Decreased compliance

Normal Cstat + ↓ Cdyn → Increased airway resistance

Easy reminder:
STATIC → Pplat
DYNAMIC → PIP

Know the difference. Find the cause. Ace the TMC.

#RespiratoryCare #LungCompliance #StaticCompliance #DynamicCompliance #MechanicalVentilation

[theRadiologist @radiologistpage]

Middle aged female presents with right sided pain and has a chest X-Ray. What does it show?

Open thread for explanation

[𝗦𝗮𝗹𝗲𝗲𝗺 𝗡. 𝗛𝗮𝗺𝗶𝗹𝗮𝗵 🫁 @SaleemHamilah]

PEEP: POSITIVE END-EXPIRATORY PRESSURE

PEEP helps keep alveoli open at the end of expiration, increasing alveolar recruitment and improving oxygenation.

Key effects:
• Increases FRC
• Improves alveolar recruitment
• Reduces alveolar collapse
• Improves oxygenation

But too much PEEP can cause:
• Alveolar overdistension
• Decreased venous return
• Decreased cardiac output
• Hypotension
• Barotrauma

TMC TIP:

PEEP helps improve oxygenation primarily through alveolar recruitment and reducing shunt.

Remember:

FiO2 increases the amount of oxygen available.

PEEP helps keep alveoli open.

Understand PEEP. Protect the lungs. Ace the TMC.

#respiratorytherapist #PEEP #MechanicalVentilation #VentilatorManagement #RespiratoryTherapy

[𝗦𝗮𝗹𝗲𝗲𝗺 𝗡. 𝗛𝗮𝗺𝗶𝗹𝗮𝗵 🫁 @SaleemHamilah]

ARDS Management Beyond the Guidelines

🟦 This 2026 narrative review emphasizes that lung-protective ventilation in ARDS should not rely on fixed population-based targets alone. Because ARDS varies in recruitability, respiratory drive, chest-wall mechanics, body habitus, and hemodynamic response, ventilator settings must be individualized through repeated physiological assessment.[1]

🟩 Initial ventilation: In a passive, newly intubated patient, VCV is often practical because it guarantees VT delivery and permits measurement of Pplat and DP.
¤¤¤ A reasonable starting point is VT of approximately 6 mL/kg PBW , adjusted with respiratory rate to maintain acceptable pH and carbon dioxide.
¤¤¤ Oxygen saturation should generally be maintained around 92–96% , while avoiding unnecessary hyperoxia.

🟨 Monitoring and high driving pressure: Plateau pressure should remain below approximately 28–30 cmH₂O, and driving pressure below 15 cmH₂O.
¤¤¤ If driving pressure is high, clinicians should first investigate airway closure, intrinsic PEEP, chest-wall loading, and overdistension.
¤¤¤ Only after identifying these factors should tidal volume be reduced, potentially to 4 mL/kg, while minimizing circuit dead space and avoiding excessive respiratory rates and dynamic hyperinflation.

🟧 PEEP and gas exchange:
☆☆☆ PEEP should be selected according to recruitability rather than oxygenation alone. Higher PEEP may recruit collapsed lung, but in non-recruitable lungs it can cause overdistension, hypercapnia, hypotension, and right-ventricular injury.
☆☆☆ Oxygenation, carbon dioxide, pH, driving pressure, cardiac output, and right-ventricular function must therefore be interpreted together. ☆☆☆ Permissive hypercapnia may be acceptable when pH remains tolerable.

🟥 Patient effort and special populations: ☆☆☆ Excessive respiratory effort and dyssynchrony can produce occult lung injury; ventilator adjustments should precede deeper sedation or neuromuscular blockade.
☆☆☆ Obesity may require higher PEEP because elevated pleural pressure does not necessarily indicate lung overdistension. During ECMO, ultra-protective ventilation and careful PEEP individualization are recommended. Liberation should begin early but only with systematic monitoring of respiratory effort. Proportional modes such as PAV+ or NAVA may improve synchrony in selected patients.

🔵 I consider this review highly valuable because it converts lung protection from a rigid protocol into a dynamic bedside process.
¤¤ Its strongest contribution is reminding clinicians that a “normal” oxygen saturation or airway pressure does not prove that ventilation is safe. However, several physiological techniques require expertise, and their use should complement—not replace—established ARDS guidelines and clinical judgment.

[1]:https://t.co/0Fczi2tyuC "ARDS management beyond the guidelines: a practical physiology-based approach to individualized care"

[Aravind Palraj @Rheumat_Aravind]

🧵 ACUTE-PHASE REACTANTS: 8 rules every rheumatologist should know

CRP ↑
Ferritin ↑
Fibrinogen ↑
Albumin ↓

And ESR?

🚨 ESR is NOT an acute-phase reactant.

It is an indirect marker of inflammation.

High-yield pearls 👇
@IhabFathiSulima @docakx #MedTwitter

[𝗦𝗮𝗹𝗲𝗲𝗺 𝗡. 𝗛𝗮𝗺𝗶���𝗮𝗵 🫁 @SaleemHamilah]

Lung Recruitment Manoeuvre & Optimal PEEP Selection.

#respiratorytherapist #mechanicalventilation #be_anRT #peep

[Aravind Palraj @Rheumat_Aravind]

Methotrexate pneumonitis is real—but it is not the same as chronic RA-associated ILD.

Stable RA-ILD does not automatically mean stopping methotrexate. New fever, dry cough or breathlessness, however, demands urgent evaluation and exclusion of infection.

Know the difference.

#Methotrexate #RheumatoidArthritis #RAILD #Rheumatology #MedEd @IhabFathiSulima @docakx

[𝗦𝗮𝗹𝗲𝗲𝗺 𝗡. 𝗛𝗮𝗺𝗶𝗹𝗮𝗵 🫁 @SaleemHamilah]

🫁 Patient–Ventilator Asynchrony: When Every Breath Isn’t in Sync

#RespiratoryCare #PatientVentilatorAsynchrony #MechanicalVentilation #RespiratoryTherapy #CriticalCare

[Ravi Kumar @RheumattDoc]

🧵 ANA Profile: Beyond a Positive ANA

A positive ANA is often the beginning not the end of the diagnostic journey.

The ANA profile helps identify disease-specific autoantibodies that support the diagnosis of connective tissue diseases when interpreted in the right clinical context.

Whenever available, confirm clinically relevant autoantibodies with disease-specific immunoassays (e.g., ELISA or other validated antigen-specific assays) rather than relying solely on the ANA profile.

Let’s break it down. 👇

#RheumattDoc #MedTwitter #RheumTwitter #Medicine #rheumatology @docakx @IhabFathiSulima @CelestinoGutirr @DurgaPrasannaM1

[Aravind Palraj @Rheumat_Aravind]

Rheumatoid arthritis management continues to evolve.

The 2025 EULAR recommendations reinforce the importance of early diagnosis, treat-to-target, individualized use of biologic/JAK inhibitors, and cautious DMARD tapering only after sustained remission.

The goal remains unchanged: achieve remission early, prevent irreversible joint damage, and improve long-term outcomes.

What do you think is the most practice-changing update in the 2025 EULAR recommendations?

#Rheumatology #RheumatoidArthritis #EULAR2025 #TreatToTarget #MedEd @IhabFathiSulima @docakx @eular_org

[Marcus Pinto, MD, MS @MarcusVPinto]

One of my missions is to make Peripheral Neuropathies more understandable for non-experts. Recognizing that physicians often find PNs challenging, especially in the hospital setting, I collaborated with @MayoClinicNeuro Neuromuscular hospitalists, @ReeceHass and @SantilliAshley, and my former NM co-fellow #JMartinezThompson to develop an engaging infographic that simplifies how to approach neuropathies leading to hospitalization. The incredible artistic skills and creativity of @ReeceHass truly brought this project to life, exceeding all expectations. We hope you find this helpful. https://t.co/HjEJbfOkqh

[Aravind Palraj @Rheumat_Aravind]

Pneumocystis jirovecii pneumonia (PJP) remains one of the most preventable opportunistic infections in rheumatology—but prophylaxis should never be based on a single drug alone.

The decision depends on the overall immunosuppressive burden, including glucocorticoid dose, combination therapy, lymphopenia, underlying disease, and individual patient risk.

This infographic summarizes:
• When to consider PJP prophylaxis
• Key risk amplifiers
• Preferred and alternative prophylactic agents
• When to reassess and discontinue prophylaxis
• Common clinical mistakes to avoid

Risk assessment should always be individualized—rituximab alone is not an automatic indication for PJP prophylaxis.

#Rheumatology #Immunology #PJP #Pneumocystis #PatientSafety #MedicalEducation @DurgaPrasannaM1 @IhabFathiSulima @docakx

[Ravi Kumar @RheumattDoc]

C3 & C4: How to Interpret Complement Levels

Low complement levels often raise concern for autoimmune disease - but they don’t always mean lupus.

Here’s what every clinician should know.👇

#RheumattDoc #MedTwitter #RheumTwitter #Medicine #rheumatology @do@docakx @IhabFathiSulima @CelestinoGutirr @DurgaPrasannaM1

[Dr.Mukesh , MD , DM @dr_immuno29]

🚨ARIA–EAACI 2024–25 (Part II): Key changes in Allergic Rhinitis management

🔹INCS > OAH ⭐ (↑ nasal control, ↑ QoL)
🔹OAH > LTRA ⭐ (↑ safety; Montelukast ⚠️ neuropsychiatric risk)
🔹Avoid OAH+LTRA (no meaningful added benefit)
🔹2nd-gen OAH > 1st-gen (↓ sedation, ↑ adherence)
🔹OAH > OcAH (except rapid ocular relief)
🔹OcAH > Mast cell stabilisers (faster onset)
🔹OAH > no Rx ✅
🔹INAH ↔ OAH (INAH ↑ efficacy; OAH ↑ adherence/availability)
🔹Best OAH selected by efficacy + sedation + cost + availability
🔹Cetirizine/Rupatadine ↑ efficacy • Loratadine/Fexofenadine ↓ sedation
🔹WHO Essential Medicines: Cetirizine, Loratadine, Fexofenadine
🔹Shared decision-making + affordability + patient preference now emphasized.

DOI: 10.1111/all.70305 Allergy - 2026 - Vieira - Allergic Rhinitis and Its Impact on Asthma

#ARIA #EAACI #AllergicRhinitis #Allergy #EvidenceBasedMedicine #MedTwitter #FOAMed #ENT #Immunology #RespiratoryMedicine

[Aravind Palraj @Rheumat_Aravind]

ANCA is a powerful diagnostic tool—but only when used in the right clinical context.

A positive ANCA does not diagnose ANCA-associated vasculitis, and a negative ANCA does not exclude it.

This infographic summarizes when to order ANCA, how to interpret PR3-ANCA and MPO-ANCA, common diagnostic pitfalls, and why clinical phenotype always comes before laboratory results.

Interpret the patient—not just the antibody.

#Rheumatology #ANCA #Vasculitis #MedEd #EvidenceBasedMedicine @IhabFathiSulima @docakx @vasculitisES @anzvasc @IRAeNewsLetter

[D @complicateur]

This is just so beautiful to listen to. Youth is wasted on the young.

[Deji Adegunsoye, MD, PhD @drdayjee]

Prof. Luca Richeldi @Lucaric dissects IPF and PPF as presented in the new guidelines.

Examines the case for combining ‘typical’ and ‘probable’ UIP into one category; and the choice for “PPF” as a new terminology - not a distinct clinical diagnosis.

#ERS2022 #CurePF

[ERS @EuroRespSoc]

ERJ Podcast: Listen as Chief Editor @ProfJDChalmers speaks to Associate Editor Prof. Dave Singh about pre- and post-bronchodilator spirometry in COPD.

Listen to the episode: https://t.co/Qk0vHDM64z

[Aravind Palraj @Rheumat_Aravind]

A subtle myositis clue can completely change the diagnosis.

Ulcerative Gottron papules, tender palmar papules, mild CK elevation, and early ILD—what is the most likely autoantibody?

Think before you answer.

#Rheumatology #Dermatomyositis #InterstitialLungDisease #MedicalEducation #ClinicalChallenge @IhabFathiSulima

[CardiovascularCorner @TrackYourHeart]

Important antithrombotic drugs in acute myocardial infarction (ACS)

Aspirin
- Loading: 150-300 mg PO (or 75–250 mg IV if oral administration is not possible)
- Maintenance: 75-100 mg once daily

P2Y12 inhibitors

Prasugrel (preferred over ticagrelor in ACS patients undergoing PCI when no contraindications exist)
- Loading: 60 mg
- Maintenance: 10 mg once daily
- 5 mg once daily if body weight ≤60 kg
- Contraindicated in patients with prior stroke/TIA
- Generally avoided in patients ≥75 years unless the expected benefit outweighs the bleeding risk

Ticagrelor
- Loading: 180 mg
- Maintenance: 90 mg twice daily
- If extended beyond 12 months: 60 mg twice daily

Clopidogrel
- Loading: 600 mg
- Maintenance: 75 mg once daily
- Use when prasugrel or ticagrelor are contraindicated, unavailable, or not suitable

Unfractionated heparin (UFH)
◻️ 70-100 IU/kg IV bolus during PCI
◻️ 50-70 IU/kg IV bolus if used with a GP IIb/IIIa inhibitor

Treatment should always be individualized based on the clinical presentation, bleeding risk, reperfusion strategy, and need for oral anticoagulation.

Reference: 2023 ESC Guidelines for the Management of Acute Coronary Syndromes (Eur Heart J. 2023).