Killer Carbapenem-Resistant Bacteria Spreading Across U.S. Gut-living bacteria like Klebsiella are gaining resistance to carbapenems at an alarming rate, and long-term acute care hospitals (LTACs) and nursing homes seem to be the incubators for these killer bugs spreading across the U.S. Carbapenems like meropenem and doripenem have been the gold standard to treat infections from [... read more]
image: wikimedia Pulse Oximetry: The 30-Second Time Machine Why does it seem to take so long to re-oxygenate your crashing patient? Because your pulse oximeter is lying to you, no matter how good it is. Telescopes show us how a star looked millions or billions of years ago; pulse oximeters create a similar, though tiny [... read more]
The 2011 GOLD classification for COPD: Old GOLD vs. New GOLD Guidelines by Brett Ley, MD Ever had a COPD patient with an awful FEV1, yet who seems to be cruising along, doing fine for years? How about a COPD patient with a relatively preserved FEV1, yet always seems to be in your clinic or [... read more]
FDA Warns of Sudden Cardiac Death Risk from Azithromycin Last summer, PulmCCM reported on a New England Journal paper suggesting an increased risk of sudden cardiac death in patients taking even a short 5-day course of azithromycin. Yesterday, the FDA expressed its official concern in a Drug Safety Communication and statement to the press on [... read more]
Knowing When, When Knowing Is Impossible By Paul C. McLean The child was her first, and there were complications and aggressive therapies from the start and for months. She was unaware that the medical team was coming to believe the baby would not survive, that aggressive treatments no longer served a therapeutic purpose and were [... read more]
Do “Sedation Vacations” Really Speed Weaning From Mechanical Ventilation? Daily interruptions of sedation (“sedation holiday” or “sedation vacation”) became the standard of critical care for weaning from mechanical ventilation in ICUs around the world after J.P. Kress et al’s landmark 2000 New England Journal of Medicine paper showing daily sedation interruptions freed ~64 patients from ventilators [... read more]
Tranexamic Acid: Underused for Uncontrolled Bleeding? Tranexamic acid is a simple little molecule, just a synthetic derivative of the amino acid lysine. But it’s also a potent pro-hemostatic drug that binds plasminogen and plasmin and stops the degradation of fibrin (the stuff in blood clots). In the U.S., tranexamic acid is sold as Lysteda (oral) [... read more]
Procalcitonin to Guide Treatment of Pneumonia (More PulmCCM Topic Reviews) With mounting evidence for its utility as a biomarker for pneumonia, procalcitonin is one of the hottest 2012 topics in pulmonary & critical care. Procalcitonin tends to rise quickly as bacterial infections (but not viral infections) develop, increase with the severity of infection, and decline [... read more]
(image: Wikipedia) Anyone with the keys to a ventilator knows, or should, that low tidal volume ventilation (~6 mL/kg ideal body weight) for patients with ARDS can be lifesaving: as many as one in 11 people with ARDS treated by low tidal volume ventilation will have their lives saved or extended while in the hospital. [... read more]
In most areas of life, it helps to be tall, and needing treatment for ARDS further proves the rule. Tall people are less likely to get harmful lung-distending tidal volumes during mechanical ventilation, simply by virtue of having bigger lungs. It’s bad enough that we intensivists might discriminate against the under-six-feet crowd (of which I [... read more]
(image: Wikipedia) A consensus panel led by V. Marco Ranieri, Gordon Rubenfeld, Arthur Slutsky et al announced a new definition and severity classfication system for acute respiratory distress syndrome (ARDS) that aims to simplify the diagnosis and better prognosticate outcomes from the life-threatening pulmonary illness. The proposed “Berlin definition” predicted mortality ever-so-slightly better than the [... read more]
The American College of Chest Physicians (ACCP) has issued its long-awaited recommendations on lung cancer screening with chest CT — and far from a ringing endorsement of screening, they are conservative and subdued, emphasizing the potential risks of an uncontrolled approach to lung cancer screening in the general population. The American Society of Clinical Oncology [... read more]
The American Lung Association has become the largest advisory body to recommend lung cancer screening for high-risk people, advising nearly all people aged 55-74 with a 30+ pack-year smoking history (the entry criteria for the National Lung Screening Trial, or NLST) to undergo low-dose CT scanning to detect early lung cancer. The National Comprehensive Cancer Network, [... read more]
(image: Wikipedia) In the TIME2 randomized trial published in the June 13 2012 JAMA, indwelling pleural catheters and talc pleurodesis were equivalent at reducing dyspnea over the 6 weeks following the procedure among 106 patients with malignant pleural effusions. Most patients receiving pleural catheters required no hospital stays, and overall had fewer repeat procedures than those [... read more]
There’s no use in sugar-coating the truth: Nicotine is an appetite suppressant, and smoking prevents weight gain. Not wanting to gain weight is a common reason why body-obsessed teenage girls say they smoke–and as far as we know, they’re “right:” teens who smoke gain slightly less weight than teens who don’t. It’s also long been believed [... read more]
Where should we set the dial for caloric delivery to our patients with acute lung injury and acute respiratory distress syndrome (ARDS)? Weak observational trials suggest low caloric intake might be associated with poor outcomes [ref1, 2]. On the other hand, other observational data suggests just the opposite: restricting calories early on may reduce ventilator [... read more]
Linezolid (Zyvox) for XDR-TB: New Hope, New Caution Approved by the FDA in 2000 for drug-resistant gram positive bacterial infections, linezolid (Zyvox, Pfizer) has in clinical practice been mainly used for skin infections and the occasional pneumonia due to methicillin-resistant Staph aureus (MRSA). Now linezolid looks to be effective as an adjunct therapy for multi-drug resistant [... read more]
Preventing Hospital Acquired Infections: Stopping Payment Had No Effect In October 2008, the U.S. Centers for Medicare and Medicaid Services (CMS) stopped paying for two hospital-acquired infections: urinary infections due to indwelling catheters (UTIs) and central catheter-associated bloodstream infections (CABSI). At the time the policy was announced years ago, it was described as an incentive [... read more]
(image: Wikipedia) As one after another specialty society endorses routine lung cancer screening with chest CT scans, we all know a Nodule Storm is coming to a pulmonology clinic near you. Thankfully, smart people are asking how we can systematically and successfully handle this soon-to-be-common outpatient clinical problem. Most of these many thousands of nodules [... read more]
When it comes to airway management skills, muscle memory rules, and there’s no substitute for hands-on experience. But in between intubations and endotracheal tube changes, what’s the best way to bolster your skills and knowledge base? Reading textbooks and journal articles provides truthful information, but I suspect it gets filed away and stashed in your [... read more]