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]
Providing appropriate sedation and analgesia to mechanically ventilated patients is of paramount importance in the ICU. John P. Kress changed clinical practice for the better by showing that daily sedation interruptions (sedation vacations or sedation holidays) reduce ventilator days and mortality. He and Shruti Patel of the University of Chicago provide a fresh update on [... read more]
It’s time to revise the traditional approach to the management of pulmonary nodules, abandon the concept of a “solitary pulmonary nodule,” and update our cognitive strategy incorporating the changes in practice and decision-making brought by the frequency of chest CT scanning and its vastly increased sensitivity over chest films of the old era. So say David Ost and Michael Gould, in their concise [... read more]
We have our hands full at PulmCCM Central just keeping up with the best published literature in pulmonary and critical care medicine. Somehow, the folks at NYU manage to vet the much larger volume of literature published in internal medicine, and offer it in a user-friendly review in their Clinical Correlations blog. Clinical Correlations is [... 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]
Bronchial Thermoplasty for Refractory Asthma Update Even with maximal treatment with medications, some patients with severe asthma remain symptomatic with impaired lung function and quality of life. Bronchial thermoplasty is a new treatment approved by the FDA in 2010 as a therapy for severe asthma not controlled by inhaled corticosteroids and long-acting beta agonists. Bronchial thermoplasty essentially [... read more]
Westermark sign: a focal area of decreased lucency on a plain chest film with an abrupt cut-off in the pulmonary artery, corresponding to a central occlusive pulmonary embolism. A.S. Krishnan and Tristan Barrett share a nice example of the Westermark sign in the March 15 New England Journal.
Can someone tell me why asthma gets no respect in academic pulmonology? I repeatedly hear otherwise intelligent physicians call asthma “boring,” as if we’ve conquered the disease (or maybe they think they have). In fact, severe asthma is a perenially humbling adversary that has proven largely resistant to a decades-long onslaught by both Pharma and the NIH. Severe asthma is a common cause of severe disability [... read more]
Diaphragmatic dysfunction can result from nerve damage, primary muscle problems, or problems with the muscle’s interaction with the chest wall. The true incidence of diaphragmatic paralysis is unknown, since many patients are asymptomatic. Treatment for diaphragmatic dysfunction usually consists of watchful waiting, addressing underlying causes, with mechanical ventilation if respiratory failure develops. Causes of Diaphragmatic [... 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]
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]
Use of noninvasive positive pressure ventilation (NIPPV) to treat acute exacerbations of chronic obstructive pulmonary disease (COPD) is on the rise, and the use of invasive mechanical ventilation is falling, according to researchers querying a large national database of hospital admissions. Coinciding with the shift in practice: a steady reduction in the overall mortality from [... read more]
Januel et al report findings of a systematic review and meta-analysis to estimate the total incidence of acute symptomatic venous thromboembolism (symptomatic DVT or pulmonary embolism) among patients receiving proper thromboprophylaxis after hip or knee replacements. They came up with rates of 1.1% after knee replacements, and 0.5% after hip replacements. The rate of pulmonary [... read more]
Despite more than 5 decades of study and debate, the role of corticosteroid treatment in patients with severe sepsis and septic shock remains controversial… … we await more definitive guidance from future multicenter, prospective, randomized, controlled trials designed to better answer these important therapeutic questions. When the review article’s opening paragraph starts and finishes like [... 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]
[poll id="3"] A 2005 meta-analysis of 5 studies (n=406) concluded that early tracheostomy reduced need for mechanical ventilation and ICU days. But then a 2006 randomized trial in trauma patients found no benefit to early trach, and an underpowered 2008 RCT also found no benefit. In a new meta-analysis and systematic review of 7 trials (n=1,044), Fei [... read more]
Many argue that as a limited resource serving unlimited needs, medical care is “rationed” by definition, and ICU resources (being more limited and expensive) are simply more overtly rationed. For example, in France, ICU admission is often denied to the very elderly critically ill, explicitly because of their age (this happens in the U.K., too, probably). In the U.S., [... read more]