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Tiotropium as add-on “triple therapy” for COPD associated with better outcomes

 Clinic and Consults, COPD  Comments Off on Tiotropium as add-on “triple therapy” for COPD associated with better outcomes
Dec 172012
 
Tiotropium as add-on "triple therapy" for COPD associated with better outcomes

Adding Spiriva to LABA and Inhaled Steroid Might Improve COPD No strong outcomes-based evidence exists as to the benefits in treating chronic obstructive pulmonary disease (COPD) with tiotropium, long-acting beta-agonist and inhaled corticosteroid together — so called “triple therapy.” LABA and tiotropium together do provide additive bronchodilation over either agent alone, evidence suggests. However, only [… read more]

Omega-3 fatty acids for acute lung injury/ARDS are useless-to-harmful (OMEGA RCT, JAMA)

 ARDS and ALI, Critical Care, Mechanical Ventilation, Randomized Controlled Trials  Comments Off on Omega-3 fatty acids for acute lung injury/ARDS are useless-to-harmful (OMEGA RCT, JAMA)
Jan 012012
 

Numerous small (n~100), single-center randomized trials have shown a benefit of omega-3 fatty acids in acute lung injury and ARDS (reduced mortality, length of stay, and organ failure; improved oxygenation and respiratory mechanics). A meta-analysis combining these studies suggested a stat.significant benefit in mortality (risk ratio 0.67), ventilator requirement (-5 days), and ICU stay (-4 [… read more]

Jan 012012
 

Air Travel for Patients with Lung Disease (BTS Recommendations) Some interesting facts, figures, and recommendations on air travel for those with chronic lung disease, thanks to Ahmedzai et al who produced this 32 page document for the British Thoracic Society: At 8,000 feet in a commercial aircraft, you’re breathing 15% O2, and normal people’s SpO2 [… read more]

Current Approach to the Diagnosis of Acute Nonmassive Pulmonary Embolism (Review)

 Pulmonary Embolism / DVT / VTE, Review Articles  Comments Off on Current Approach to the Diagnosis of Acute Nonmassive Pulmonary Embolism (Review)
Dec 262011
 

Moores LK et al. Current Approach to the Diagnosis of Acute Nonmassive Pulmonary Embolism. CHEST 2011;140:509-518.  Review. Where is the best area under the curve, or the “overdiagnosis sweet spot?” It seems no approach gets us off the hook as we seek to avoid anticoagulating people without PEs (without missing any, of course): CT-angiography  is more sensitive [… read more]

For most with OHS, ventilatory drive was oxygen-sensitive

 Randomized Controlled Trials, Sleep, Obesity-related disease  Comments Off on For most with OHS, ventilatory drive was oxygen-sensitive
Dec 262011
 

Wijesinghe et al randomized and crossed-over 24 people who were recently diagnosed with obesity hypoventilation syndrome to breathe either 100% oxygen or room air for 20 minutes on 2 separate days, while measuring their minute ventilation, expired tidal pCO2, and dead space-to-tidal volume ratio. In 44% of patients, pCO2 increased by at least 4 mm [… read more]

Surprise: Bronchoconstriction (not just inflammation) causes airway remodeling in asthma

 Asthma  Comments Off on Surprise: Bronchoconstriction (not just inflammation) causes airway remodeling in asthma
Dec 262011
 

Grainge et al collected bronchial biopsies from 48 allergic asthmatics, then randomly gave them either inhaled dust mite allergen; methacholine; saline (control); or albuterol followed by methacholine (control). Those inhaling allergen or methacholine had immediate bronchoconstriction, followed by an increase in bronchial wall thickness (on repeat bronchial biopsy 4 days later) compared to controls. Dogma [… read more]

High-concentration oxygen caused hypoventilation in asthma exacerbation pts (RCT)

 Asthma, Critical Care, Randomized Controlled Trials  Comments Off on High-concentration oxygen caused hypoventilation in asthma exacerbation pts (RCT)
Nov 242011
 

Even my neighbor’s cat knows that giving high-concentration oxygen to people with COPD and acute hypercapneic respiratory failure can cause them to hypoventilate further, causing life-threatening respiratory failure. (And he’s not even a very smart cat.) Perrin, Beasley et al asked, does a similar mechanism operate in severe asthma exacerbations? They randomized 106 patients presenting [… read more]

Chronic thromboembolic pulmonary hypertension registry reveals new insights (Circulation)

 Pulmonary Embolism / DVT / VTE, Pulmonary Hypertension, Radiology & Imaging, Review Articles  Comments Off on Chronic thromboembolic pulmonary hypertension registry reveals new insights (Circulation)
Nov 162011
 

Chronic thromboembolic pulmonary hypertension is a “new” condition (in terms of our recognition and understanding of it), whose true prevalence, natural history, and response to therapies continue to be elucidated. Meanwhile, specialized surgical centers continually make thromboendarterectomy safer, providing definitive cures that are nothing short of miraculous for those affected by this otherwise usually fatal [… read more]

Nov 092011
 

Duke’s Momen Wahidi and other luminaries bring you a consensus statement on use of peri-procedure medications during bronchoscopy. I’m assuming you’ve done a few already, so here are some highlights (with slight liberties in paraphrasing): Use topical anesthesia as well as moderate sedation in all patients, unless there are contraindications or you practice at a secret CIA prison. [… read more]

Oct 222011
 

Is bronchoalveolar lavage useful in the diagnosis and management of interstitial lung disease? Meyer and Raghu believe so (although their manuscript title suggests they’re not 100% sure). They explain why in the October ERJ. They argue that if interpreted in the right clinical context, certain bronchoalveolar lavage findings can help cinch the diagnosis of ILD: Lymphocytes >= 25%: [… read more]

Oct 112011
 

In 2006, Medicare (we) spent 25% of our dollars on treatment for people in their last year of life. The debate rages, waged with euphemism in public and painful, conflicting emotions in private: how can we let Grandma go peacefully and with dignity, without feeling too guilty or ending up in front of a Senate subcommittee? [… read more]

EBUS good at diagnosing TB in thoracic lymph nodes

 Infectious Disease and Sepsis, Interventional Pulmonology  Comments Off on EBUS good at diagnosing TB in thoracic lymph nodes
Oct 042011
 

On the off chance you someday need to diagnose tuberculosis from intrathoracic lymphadenopathy (I suppose in the rare patient with smear-negative sputum, which is more common in HIV co-infection), endobronchial ultrasound can help you out, say Navani et al. They report on 156 consecutive patients (over 2 years at 4 centers) found to have tuberculous [… read more]

Is your stage III NSCLC patient truly “downstaged” to N0? EUS helpful only if positive

 Interventional Pulmonology, Lung Cancer  Comments Off on Is your stage III NSCLC patient truly “downstaged” to N0? EUS helpful only if positive
Oct 022011
 

So you’ve referred your patient with stage III non-small cell lung cancer (N2 or N3 mediastinal nodes) to receive neoadjuvant chemoradiation therapy in the hopes of eliminating cancer from the mediastinal nodes, “downstaging” her to a resectable N0 status. How do you re-evaluate the lymph nodes to ensure resection may be curative? von Bartheld et [… read more]

Montelukast improved peak flow during acute asthma exacerbations

 Asthma, Randomized Controlled Trials  Comments Off on Montelukast improved peak flow during acute asthma exacerbations
Sep 272011
 

Leukotrienes are important inflammatory mediators in both chronic asthma and acute exacerbations. Well-known for their benefits in the management of chronic asthma, leukotriene receptor antagonists haven’t been tested in acute asthma. Ramsay et al randomized 87 adults admitted to the hospital for asthma exacerbations to receive daily montelukast 10 mg or placebo for 4 weeks, [… read more]

EBUS FNA very good at finding lymph node mets from extrathoracic malignancy

 Interventional Pulmonology, Lung Cancer  Comments Off on EBUS FNA very good at finding lymph node mets from extrathoracic malignancy
Sep 222011
 

In 161 patients with known extrathoracic malignancy and enlarged hilar/mediastinal lymph nodes, endobronchial ultrasound FNA was very helpful at identifying metastasis to the chest. EBUS found lymph node mets in 44% of the patients and a new lung cancer in 12%. Sarcoidosis was discovered in 9%. Neal et al followed-up these 161 patients for 6 months [… read more]

Number of positive lymph nodes predicts survival in N1 non-small cell lung cancer

 Interventional Pulmonology, Lung Cancer  Comments Off on Number of positive lymph nodes predicts survival in N1 non-small cell lung cancer
Aug 252011
 

Wisnivesky et al crunched through the SEER data on 3,399 people who underwent resection for N1 non-small cell lung cancer. They found that the number of cancerous lymph nodes predicted survival: 1 positive N1 lymph node: 8.8 years mean lung cancer-specific survival 2-3 positive N1 lymph nodes: 8.2 years 4-8 positive N1 lymph nodes: 6.0 [… read more]

Cystic fibrosis patients’ nebulizer adherence under 40%

 Cystic Fibrosis  Comments Off on Cystic fibrosis patients’ nebulizer adherence under 40%
Aug 162011
 

Self-reported adherence is usually overestimated. Most people prescribed chronic daily medication take it ~60% of the time, but say/believe they take it 90% of the time. People with cystic fibrosis are instructed to spend more than an hour a day sitting through up to 7 nebulizer treatments. Daniels et al used a smart nebulizer machine [… read more]

Trophic vs full-calorie enteric feedings for ventilated patients (RCT)

 Critical Care, GI and Nutrition, Randomized Controlled Trials  Comments Off on Trophic vs full-calorie enteric feedings for ventilated patients (RCT)
May 262011
 

Rice et al randomized 200 mechanically ventilated patients to either trophic feedings (10 mL/hr) or full enteric feedings for 6 days. There were no differences in mortality or ventilator-free days. The trophic-fed patients had fewer episodes of “high residuals.” (n=200) Crit Care Med 2011;39:967-974.

Phase III trials for aclidinium, a “me-too” antimuscarinic, in COPD (ACCLAIM I & II)

 COPD, Randomized Controlled Trials  Comments Off on Phase III trials for aclidinium, a “me-too” antimuscarinic, in COPD (ACCLAIM I & II)
May 202011
 

Jones et al randomized 1,647 people with moderate to severe COPD for the two trials, to receive either aclidinium inhaled (a potential tiotropium competitor) once daily or placebo for 1 year. Aclidinium improved FEV1 by ~65 mL. An absolute ~8% more people taking the drug achieved a 4-point SGRQ improvement over those taking placebo. Time [… read more]

Leukotriene antagonists as good as inhalers for asthma? (RCT)

 Asthma, Clinic and Consults, Randomized Controlled Trials  Comments Off on Leukotriene antagonists as good as inhalers for asthma? (RCT)
May 202011
 

Most clinical trials for asthma drugs exclude ~95% of potential subjects and test under highly controlled conditions, limiting their results’ generalizability. Price et al publish results of 2 “pragmatic” open-label trials set in the real world. In #1, they randomized 300 symptomatic asthmatics in 53 U.K. primary care clinics to get either a leukotriene receptor [… read more]