(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]
Everyone knows that when you’re really sick, going to the ICU–that place with all the beeping monitors, hypervigilant staff, and high-tech invasive gadgetry–might save your life. But what if in certain situations, transfer to an ICU bed could actually worsen a person’s condition, or even hasten their demise? Hannah Wunsch of Columbia U. suggests it’s [... read more]
Pneumonia and Respiratory Infections: 2012 Review (More PulmCCM Topic Updates) This review document on pneumonia and respiratory infections is updated periodically as new research findings are published. The listed date reflects its most recent update. Please suggest important articles for inclusion in future updates, either in the comments section below or by email. The Distal [... read more]
Most studies on smoking and its well-known health risks have been performed in middle-aged adults (younger than 60). In a large epidemiological study published in the June 11, 2012 Archives of Internal Medicine, Carolin Gellert, Ben Schottker, and Hermann Brenner showed that (spoiler alert!!) smoking’s excess risks extend to older adults, as well. Just as importantly, [... read more]
Want to keep up with sleep, without falling asleep? We’ll try to make it easy for you: Here are some of the latest and most notable articles in sleep medicine. (This summary will be updated and re-posted as new research is published. Please suggest articles for inclusion in the comments or by email.) Obstructive Sleep [... read more]
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]
Remember that weird advice we were taught as physicians-in-training to give to smoking patients before an upcoming surgery? “You should quit smoking, but not within the 2 weeks just before your surgery.” (It sounds off-key to me even as I write it now.) Based on … what? Some medical lore passed down from a decades-old study [... read more]
Prevention & Treatment of DVT/PE in Pregnant Women 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 Low-Molecular Weight Heparin [... read more]
Drowning: 2012 Review (More PulmCCM Topic Updates) There are a thousand ways to die (it’s even a TV show), but few seem as horrible and inspire such primal fear as death by drowning. Drowning is uncommon but by no means rare in the U.S.: it’s the second leading cause of death by injury in the [... read more]
(image: GE) Exhaled Nitric Oxide Analysis for Respiratory Disease: ATS Guideline A blue ribbon panel led by Raed Dweik releases this ATS practice guideline, recommending when & how to use exhaled nitric oxide (FE-NO) for use in diagnosing and treating inflammatory respiratory conditions. FE-NO’s uses, they say, include: Predicting responsiveness to corticosteroid therapy Helping diagnose [... read more]
(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]
Cystic Fibrosis 2012 Review (More 2012 Topic Updates) From the excellent summary by Felix Ratjen (U-Toronto) and Susanna McColley (Northwestern) in the May 2012 AJRCCM (Blue Journal), and our own cystic fibrosis literature review. Pulmonary Infection in Cystic Fibrosis The standard practice of early eradication of Pseudomonas aeruginosa in cystic fibrosis patients — giving inhaled [... read more]
Non-ST Elevation Myocardial Infarction (NSTEMI) and Unstable Angina (UA): 2012 Review (More 2012 Topic Updates) From concise clinical reviews by the don of cardiovascular disease, Eugene Braunwald (Harvard) in the May AJRCCM (Blue Journal) and Jeff Trost (Johns Hopkins) in Critical Care Medicine. These review articles on the diagnosis and treatment of non-ST-elevation acute coronary syndrome or NSTE-ACS (NSTE-myocardial infarction and unstable [... read more]
(image: People’s Pharmacy) Sure to re-light controversy around Pfizer’s varenicline (Chantix): a new study concludes the smoking cessation drug likely carries no increased risk for cardiovascular events. Judith Prochaska and Joan Hilton (University of California – San Francisco) report the results in the May 4 BMJ. Sonal Singh (Johns Hopkins) et al’s previous meta-analysis, reported in CMAJ [... read more]
Mechanical Ventilation in ARDS: 2012 Review (More 2012 Topic Updates) People with acute respiratory distress syndrome (ARDS) are by definition severely hypoxemic, and nearly all require invasive mechanical ventilation. Yet mechanical ventilation itself can further injure damaged lungs (so-called ventilator-induced lung injury); minimizing any additional damage while maintaining adequate gas exchange (“compatible with life”) is the [... 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]
Chronic Obstructive Pulmonary Disease (COPD) 2012 Update From the excellent Seminar in Lancet April 2012, the 2004 ATS statement, and our reviews of recent articles on COPD. Epidemiology of COPD Globally, ~10% of people older than 40 have airflow limitation of GOLD stage 2 or worse (FEV1 < 80% predicted); up to 25% may have GOLD stage 1 (FEV1 ≥ 80% [... 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]
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]