JAMA Archives - Page 2 of 4 - PulmCCM
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JAMA Articles

Jan 182013
 
Come One, Come All – Low tidal volumes improve outcomes

Low Tidal Volumes Improve Outcomes in Non-ARDS Patients Since the landmark ARDSnet trial of low tidal volume ventilation published in the NEJM in 2000, protecting the injured lung with low tidal volumes has been widely adopted. In case you missed it, that trial showed that low tidal volume ventilation (6 ml/kg IBW) improved mortality from [... read more]

Jan 062013
 
Sedation vacations don't improve outcomes in large trial (RCT)

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]

Jan 062013
 
Precedex as good as Versed or Propofol, but with cardiovascular effects (RCT)

Precedex Takes Step Toward FDA Indication for Longer-Term Use Precedex (dexmedetomidine) only has existing FDA indications for short-term sedation (< 24 hours) in both mechanically ventilated and non-intubated patients. That short leash is because of dexmedetomidine’s tendency to produce  hypotension and bradycardia, and has limited Precedex’s approved uses mainly to elective surgeries and other invasive procedures. Many intensivists use Precedex off-label for critically [... read more]

Jan 032013
 
At treating asthma, patients may be as good as their doctors (BASALT trial)

Consensus guidelines advise that patients with regular symptoms of asthma should take inhaled corticosteroids every day, and when they’re having poor asthma control, they should tell their doctor, who can increase the steroid dose or add other “step-up” therapies. But asthma symptoms vary daily and can worsen at any time. And it can be hard [... read more]

Dec 302012
 
Meet the New ARDS: Expert panel announces new definition, severity classes

(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]

Dec 262012
 
Pleural catheters equal to pleurodesis for dyspnea relief from malignant effusions (TIME2)

(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]

Dec 222012
 
Trophic feeding equal to full enteric feeding in acute lung injury (EDEN trial)

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]

Dec 222012
 
Lansoprazole didn't help kids with uncontrolled asthma (RCT)

Proton Pump Inhibitors No Help for Kids’ Asthma Gastroesophageal reflux (GER) is a mysterious co-conspirator with asthma. Many people with uncontrolled asthma have reflux (either symptomatic by history, or asymptomatic and detected on esophageal pH studies). Randomized trials in adults suggest that treating symptomatic GERD (gastroesophageal reflux DISEASE) improves asthma, but treating asymptomatic GER does not [... read more]

Dec 212012
 
Moderate pot smokers' lung function better than nonsmokers

Smoking marijuana moderately over years is strongly associated with small improvements in lung function, even compared to people who have never smoked cigarettes or marijuana, according to a study in JAMA. But the popular news media and the study authors downplayed that finding of the study, apparently to avoid sending a pro-marijuana message. Mark Pletcher, [... read more]

Nov 292012
 
Normal saline: toxic to kidneys? Chloride solutions may cause renal failure

Does Normal Saline Cause Acute Renal Failure? To internal medicine-trained physicians in the U.S., normal saline solution seems as harmless and healthy as mother’s milk. Intensivists trained in anesthesia or surgery might more often mention normal saline’s hypertonicity compared to blood, and its propensity to cause hyperchloremia, compared to lactated Ringer’s or similar solutions. But [... read more]

Nov 232012
 
Intensive glucose control in kids: no brain injury vs. standard care 3 yrs later (RCT)

Intensive Glucose Control: Safe for Critically Ill Kids’ Brains? After evangelizing globally for intensive glucose control (~100 mg/dL) to be the standard of care for virtually all critically ill adults for a decade, Greet van den Berghe might be disappointed that mounting evidence shows that a fanatical approach to maintenance of normoglycemia in critical illness [... read more]

Oct 262012
 
Vitamin D is for "doesn't do diddly" for the common cold (RCT)

Extra Vitamin D Doesn’t Prevent Colds in Healthy Adults (JAMA) It looks like you can add Vitamin D to list of supplements (echinacea, vitamin C, etc.) who’ve gone up against the common cold and lost. (Scorekeepers will note that zinc held its own, though, in a Cochrane analysis.) Vitamin D plays an important role in immune responses, [... read more]

Sep 262012
 
How to take care of older people with COPD (Review)

Caring For Older Folks With COPD Terri Fried, Carlos Fragoso, and Michael Rabow argue in the September 26, 2012 JAMA that older adults (age ~80 or above) with COPD and significant dyspnea are a distinct, complex group of patients with unique features and needs, and their doctors should think broadly and be willing to go [... read more]

Jul 092012
 
Meropenem + moxifloxacin: no improvement over meropenem alone in severe sepsis (RCT)

In the first randomized trial of its kind, patients with severe sepsis or septic shock who were given meropenem alone had equivalent clinical outcomes to patients who were given combination therapy including meropenem and moxifloxacin. The results, reported in JAMA, provide ethical support to critical care physicians who prefer to be conservative antibiotic stewards. But [... read more]

Jun 302012
 
Ventilator bundles (VAP bundles) not evidence-based, shouldn't be standard care

(image: Wikipedia) Anyone who has ever rounded in an ICU with a nurse manager knows that challenging or questioning the utility of the ventilator associated pneumonia (VAP) bundle is a losing proposition — one likely to get you labeled as a wiseguy troublemaker. Thanks to ventilator bundles’ endorsement by the nonprofit Institute for Healthcare Improvement, [... read more]

Jun 142012
 
Most clinical trials are too small, often underpowered

The past decade has seen an explosion in the number of clinical trials; there are now more than 10,000 new trials registered each year. Although clinical trials’ quality is improving somewhat, most are still small and single-center and a large proportion do not adhere with reporting requirements, raising serious questions as to what we are [... read more]

Jun 072012
 
Inhaled hypertonic saline for young kids with cystic fibrosis: no benefit? (RCT)

(image: Bennett Gamel blog) Inhaled hypertonic saline (7% NaCl) increases clearance of mucus by airway cilia, making it an attractive treatment for cystic fibrosis. Hypertonic saline has been a cornerstone of daily therapy for CF ever since a 2006 NEJM randomized trial showed that ~80 adults and kids older than 6 using hypertonic saline for [... read more]

May 162012
 
Tattletales rain on private cardiologists' cash-grabbing parade

Did you know that about half of cardiologists’ $400,000+ average income comes from self-referring patients to undergo imaging studies on scanners owned in part or in whole by the physicians themselves? This type of arrangement violates the spirit but not the letter of the Stark Law, created in 1992 to address the inevitable economic and medical inequities that result when physicians are permitted [... read more]

May 052012
 
Fellows: This is your brain on protocols (JAMA)

(image: flickrCC) Do protocols make trainees’ brains go soft? That’s the assertion of more than a few crusty hard-liners who miss the good old days — when you got 2-liter tidal volumes for your ARDS and liked it, dad-gum-it!! Prasad et al can’t say whether critical care fellows can actually run ventilators in the post-protocol [... read more]

May 032012
 
Epinephrine in field no help after out-of-hospital cardiac arrest? (JAMA)

(image: Hospira) Akihito Hagihara et al present suggestive data in the March 21 JAMA that giving epinephrine to people with out of hospital cardiac arrest increases their chances of making it to the hospital with a pulse, but not of making it home with decent brain function or functional status. In a prospective observational analysis [... read more]