(image: flickrCC) Why do we test chronic obstructive pulmonary disease (COPD) patients for bronchodilator responsiveness (besides getting to charging a few extra bucks for it)? If I am reading this article right, the answer is, there’s no good reason. Consider this: Bronchodilator responsiveness (BDR) or the lack thereof does not distinguish COPD from asthma. Bronchodilator [... read more]
Diagnosis of Deep Venous Thrombosis (DVT) of the Lower Extremity from the ACCP / Chest Guidelines, 9th Ed. The ACCP recommendations for diagnosis of DVT of the leg are based on these principles of safety: Reducing overall false-negatives to 2% or less (as defined by symptomatic DVT or PE within 3-6 months after a negative test); [... read more]
Reimbursement for Palliative Care in the ICU By Intensivists To an intensivist, providing palliative care often means having multiple time-consuming and emotionally challenging interactions with families struggling to cope with the impending loss of their loved one. The emotional content of these interactions can be strongly positive, negative, or somewhere in between, but frequently it’s [... read more]
Inferior Vena Cava Filters for Prevention of Pulmonary Embolism from the ACCP Guidelines, 9th Ed. Inferior vena cava filters should generally be placed in patients with acute pulmonary embolism (PE) or deep venous thrombosis (DVT) who have a contraindication to anticoagulation, according to the ACCP’s recommendations. The ACCP recommends against placing an IVC filter in patients [... read more]
(image: flickrCC) Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA), when performed by skilled physicians, reduces the need for mediastinoscopy and unnecessary thoracotomies with their associated morbidity, and is poised to permanently alter the landscape of lung cancer diagnosis and staging. Prior to 2008, Medicare seemed to recognize the potential value of EBUS by paying hospitals [... read more]
Thrombolytics for Acute Pulmonary Embolism from the ACCP Guidelines, 9th Ed. The ACCP’s recommendation classification system: 1 = “recommendation” 2 = “suggestion” A = based on strong evidence from randomized trials B = moderate evidence that may include randomized trials or observational studies C = weak evidence, mostly consensus opinion Which patients with acute pulmonary embolism [... read more]
(image: Cardinal Health) Should you routinely check pleural pressures with bedside manometry during thoracentesis? David Feller-Kopman of Johns Hopkins says, of course: it’s zero risk, zero cost, only seconds of extra time, and provides potentially useful clinical information. Specifically, one can identify people with “entrapped lung” and “trapped lung”: Identifying “Entrapped Lung” by Pleural Pressures [... read more]
From the excellent review by Lonny Yarmus and David Feller-Kopman in the April 2012 Chest, along with the British Thoracic Society and ACCP’s consensus statements: Mechanisms of Pneumothorax in the Critically Ill Air can accumulate in the pleural space in three ways: Rupture of the visceral pleura allowing air to travel from alveoli to the [... read more]
Treating Acute Pulmonary Embolism with Anticoagulant Therapy from the ACCP Guidelines, 9th Ed. The ACCP‘s new 9th edition of their authoritative clinical practice guidelines for prevention and treatment of venous thromboembolism (VTE) were published in February 2012, and we’ll be summarizing the 801-page long document piece by piece. (See also our summaries of the other sections of the 9th edition recommendations.) [... read more]
(Comments by first author James T. Good follow this post.) For 58 patients with refractory asthma at National Jewish, James Good et al devised a systematic, bronchoscopy-driven approach that they feel resulted in improved asthma symptoms and identification of potential phenotypes of refractory asthma among the enrolled subjects. Their methodology was highly detailed and time- and labor-intensive. It included using [... read more]
Managing Anticoagulation in the Perioperative Period: ACCP Guidelines from the ACCP Guidelines, 9th Ed. The ACCP‘s new 9th edition of their authoritative clinical practice guidelines for prevention and treatment of venous thromboembolism (VTE) were published in February 2012, and we’ll be summarizing the 801-page long document piece by piece. (See also “Preventing DVT-PE in hospitalized nonsurgical [... read more]
Preventing DVT and PE in Nonsurgical Patients from the ACCP Guidelines, 9th Ed. The ACCP‘s new 9th edition of their authoritative clinical practice guidelines for prevention and treatment of venous thromboembolism (VTE) were published in February 2012, and we’ll be summarizing the 801-page long document piece by piece. Here we review the section on prophylaxis of [... read more]
Mayo investigators reported back in 2001 that people with obstructive sleep apnea had a higher rate of perioperative complications including hypoxia and longer lengths of stay. Since then, there have been other signals that this is a real phenomenon, but perhaps surprisingly, the evidence hasn’t exactly piled up to unequivocally prove the intuitive point. That’s [... read more]
Starting and Managing Warfarin/Coumadin for Initial Treatment of DVT/PE from the ACCP Guidelines, 9th Ed. The ACCP’s new 9th edition of their clinical practice guidelines for prevention and treatment of DVT/PE were published in February 2012. Here we review their update on how to start a patient on warfarin (Coumadin) for deep venous thrombosis or pulmonary [... read more]
Daily interruption of sedation (daily awakening or sedation holidays) works like a charm to get patients off the ventilator, faster. After proving that a decade or so ago, practice-changers John Kress and William Schweickert have turned their attention to early mobilization as the next intervention that could help mechanically ventilated patients escape the ventilator faster. [... read more]
American College of Chest Physicians (ACCP)’s Guidelines for Diagnosis & Management of DVT / PE, 9th Ed. The ACCP‘s new 9th edition of their authoritative clinical practice guidelines for prevention and treatment of venous thromboembolism (VTE, DVT, PE) were published in February 2012, and we’re summarizing the 801-page long document piece by piece, helping you access the ACCP’s recommendations and [... read more]
In the face of criticism from insurers and the government for a perceived excessive zeal for profits, and mounting evidence that uncomplicated obstructive sleep apnea (OSA) can be diagnosed at home and managed by primary physicians, you can’t blame sleep specialists for feeling down-in-the-mouth lately. Sushmita Pamidi et al report some brighter news in the [... read more]
I knew I smelled something fishy about this paper when I read and commented on it last year. Now, Chest reports they’re giving this study a burial at sea, after the authors could not produce actual data supporting the trial. To help set the record straight: Chest published a retrospective study in March 2011, “Chest Tube [... read more]
C. difficile has always been a foul and disgusting adversary, but lately it’s becoming more formidable and deadly, according to Linda Bobo, Erik Dubberke and Marin Kollef. A few highlights of this excellent review: C.diff infections (CDI) have more than doubled since 2001, to > 340,000 discharges in 2008. Attributable mortality is 6-7%, but may [... read more]
As you know, the risk for DVT and PE in the ICU are high. How high? Depends on how you count them. Asymptomatic, ultrasound-surveillance-detected DVTs have an incidence of 5-10% during the ICU stay (from the PROTECT trial and a 2005 series), even when patients receive proper thromboprophylaxis. The incidence is even higher (up to 80%) in trauma [... read more]