PulmCCM http://pulmccm.org/main All the best in pulmonary & critical care Sun, 02 Nov 2014 13:30:46 +0000 en-US hourly 1 http://wordpress.org/?v=4.0.1 Life after sepsis protocols: What now? (You decide.) http://pulmccm.org/main/2014/randomized-controlled-trials/life-sepsis-protocols-now-decide/ http://pulmccm.org/main/2014/randomized-controlled-trials/life-sepsis-protocols-now-decide/#comments Fri, 31 Oct 2014 19:43:13 +0000 http://pulmccm.org/main/?p=13862 2014 has been a rough year for advocates of sepsis protocols. First, the long-awaited ProCESS trial did not show any benefit from use of the original early goal-directed therapy (EGDT) protocol used in the single-center 2001 trial by Rivers et al that, despite criticism, became the standard of care for the following decade. Patients cared for in the 2 non-EGDT arms [... read more]

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Safe to stop inhaled steroids in COPD (and start more expensive drugs)? http://pulmccm.org/main/2014/randomized-controlled-trials/safe-stop-inhaled-steroids-copd-start-expensive-drugs/ http://pulmccm.org/main/2014/randomized-controlled-trials/safe-stop-inhaled-steroids-copd-start-expensive-drugs/#comments Fri, 31 Oct 2014 19:29:24 +0000 http://pulmccm.org/main/?p=13859 Olodaterol People with severe chronic obstructive pulmonary disease (COPD) often have persistent dyspnea or exacerbations despite the use of a single controller inhaler. (Controller inhalers for COPD most often include combination inhaled corticosteroid/long-acting beta agonists like Advair, Dulera and Symbicort [ICS/LABAs] and the long-acting anticholinergic agent Spiriva/tiotropium). These patients often take both a combination ICS/LABA and Spiriva, so-called [... read more]

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FDA approves pirfenidone (Esbriet) and nintedanib (Ofev) for IPF http://pulmccm.org/main/2014/interstitial-lung-disease-review/fda-approves-pirfenidone-esbriet-nintedanib-ofev-ipf/ http://pulmccm.org/main/2014/interstitial-lung-disease-review/fda-approves-pirfenidone-esbriet-nintedanib-ofev-ipf/#comments Fri, 17 Oct 2014 17:23:18 +0000 http://pulmccm.org/main/?p=13852 The U.S. FDA approved the first two drugs proven to slow progression of idiopathic pulmonary fibrosis (IPF): pirfenidone (Esbriet by Roche, which bought Intermune) and nintedanib (Ofev by Boehringer Ingelheim) on Wednesday October 15. Both drugs will offer new hope for patients, and new pain to the insurance companies and the government who pay for them. Pirfenidone [... read more]

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ICU Physiology in 1,000 Words: Stroke Volume Variation and the Concept of Dose-Response http://pulmccm.org/main/2014/review-articles/icu-physiology-1000-words-stroke-volume-variation-concept-dose-response/ http://pulmccm.org/main/2014/review-articles/icu-physiology-1000-words-stroke-volume-variation-concept-dose-response/#comments Thu, 16 Oct 2014 12:09:04 +0000 http://pulmccm.org/main/?p=13845 Stroke Volume Variation and the Concept of Dose-Response Jon-Emile S. Kenny M.D. Awareness of the undulating pattern of an arterial line tracing is high amongst health professionals in the intensive care unit; certainly this is an aftereffect of a cacophony of studies and reviews pertaining to pulse pressure variation and fluid responsiveness in the operating [... read more]

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Total parenteral nutrition vs enteral nutrition: no difference in critically ill? (CALORIES trial) http://pulmccm.org/main/2014/randomized-controlled-trials/total-parenteral-nutrition-vs-enteral-nutrition-difference-critically-ill/ http://pulmccm.org/main/2014/randomized-controlled-trials/total-parenteral-nutrition-vs-enteral-nutrition-difference-critically-ill/#comments Tue, 14 Oct 2014 18:09:55 +0000 http://pulmccm.org/main/?p=13819 Feeding patients enterally (nasogastric or nasojejunal tube feedings) has been the standard of care for critically ill patients, based on weak evidence that it reduces infection rates; hence the adage “feed the gut, if you can.” That last caveat is included because so many critically ill patients have gastric motility impairment (with inability to achieve [... read more]

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Transfusion for hemoglobin above 7 g/dL: no benefit in septic shock (TRISS Trial) http://pulmccm.org/main/2014/randomized-controlled-trials/transfusion-hemoglobin-7-gdl-benefit-septic-shock/ http://pulmccm.org/main/2014/randomized-controlled-trials/transfusion-hemoglobin-7-gdl-benefit-septic-shock/#comments Fri, 10 Oct 2014 19:47:11 +0000 http://pulmccm.org/main/?p=13786 Blood transfusions have been a central component of protocols for care of severe sepsis and septic shock, ever since the single-center 2001 Rivers trial included them in its interventions. Any benefit (or harm) caused by red cell transfusion independently was unknowable, and so the therapy became standard care as part of the so-called sepsis bundle. The Surviving [... read more]

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Are traditional protocols for goal directed therapy for sepsis dead? (ARISE trial) http://pulmccm.org/main/2014/randomized-controlled-trials/goal-directed-therapy-sepsis-dead-arise-trial/ http://pulmccm.org/main/2014/randomized-controlled-trials/goal-directed-therapy-sepsis-dead-arise-trial/#comments Sun, 05 Oct 2014 16:19:16 +0000 http://pulmccm.org/main/?p=13723 Update: As astute commenters have mentioned below, and as I stated in our post on the ProCESS trial, protocols of some kind could still have a place in the care of sepsis if they ensure more rapid recognition and thorough treatment. Accordingly, I changed the headline to clarify that it’s only traditional sepsis protocols to which I refer, not the [... read more]

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PulmCCM Journal Publishes First Issue http://pulmccm.org/main/2014/review-articles/pulmccm-journal-publishes-issue-1/ http://pulmccm.org/main/2014/review-articles/pulmccm-journal-publishes-issue-1/#comments Sun, 28 Sep 2014 16:14:01 +0000 http://pulmccm.org/main/?p=13703 I am proud to announce the publication of the first issue of PulmCCM Journal, a new online peer-reviewed journal in respiratory and critical care medicine. Please click through to read edition 1, volume 1, issue 1 online now:   Starting a journal as an extension of a blog designed to cope with an overabundance of journals may [... read more]

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All the best in PulmCCM (Roundup #6) http://pulmccm.org/main/2014/randomized-controlled-trials/best-pulmccm-roundup-6/ http://pulmccm.org/main/2014/randomized-controlled-trials/best-pulmccm-roundup-6/#comments Fri, 12 Sep 2014 04:36:24 +0000 http://pulmccm.org/main/?p=13666 All the best in the pulmonary and critical care medicine literature from our ongoing journal survey. Browse all the PulmCCM Roundups to stay up to date. Thrombolytics for Pulmonary Embolism: New Metaanalysis Most patients with massive pulmonary embolism (PE with shock) should receive thrombolytics, but it’s unclear from randomized trial data which patients with submassive pulmonary embolism [... read more]

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New 2014 Pulmonary Hypertension guidelines released http://pulmccm.org/main/2014/review-articles/new-2014-pulmonary-hypertension-guidelines-released/ http://pulmccm.org/main/2014/review-articles/new-2014-pulmonary-hypertension-guidelines-released/#comments Fri, 05 Sep 2014 16:45:39 +0000 http://pulmccm.org/main/?p=13616 The American College of Chest Physicians (unaffiliated with PulmCCM) published its new consensus guidelines in August 2014 for the drug treatment of pulmonary arterial hypertension (PAH). They’re free to view on the Chest website, and well worth a look. Remember that pulmonary arterial hypertension (PAH) is but one small subset (“Group 1″) of the much larger [... read more]

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ICU Physiology in 1000 Words: The Hemodynamics of Prone http://pulmccm.org/main/2014/ards-review/icu-physiology-1000-words-hemodynamics-prone/ http://pulmccm.org/main/2014/ards-review/icu-physiology-1000-words-hemodynamics-prone/#comments Tue, 02 Sep 2014 01:57:49 +0000 http://pulmccm.org/main/?p=13627 ICU Physiology in 1,000 Words  “The Hemodynamics of Prone” by Jon-Emile S. Kenny MD A physiological maelstrom has recently swirled about the hemodynamic effects of the prone position in severe ARDS [1-5]; but how exactly does this maneuver alter the cardiovascular system?  A good approach to this problem is a Guytonian one whereby we consider [... read more]

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Which cancer patients need prophylaxis for DVT and pulmonary embolism? http://pulmccm.org/main/2014/review-articles/cancer-patients-need-prophylaxis-dvt-pulmonary-embolism/ http://pulmccm.org/main/2014/review-articles/cancer-patients-need-prophylaxis-dvt-pulmonary-embolism/#comments Sat, 16 Aug 2014 16:18:01 +0000 http://pulmccm.org/main/?p=13594 People with cancer have the highest rates of deep venous thrombosis (DVT) and pulmonary embolism (PE). However, the risk of venous thromboembolism varies widely by cancer type and between patients. Daily anticoagulant use can reduce the risk of DVT and pulmonary embolism, but at a cost of increased bleeding risk, patient inconvenience and discomfort, and cost. [... read more]

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What are Ventilator-Associated Events (and why should you care)? http://pulmccm.org/main/2014/review-articles/ventilator-associated-events-care/ http://pulmccm.org/main/2014/review-articles/ventilator-associated-events-care/#comments Wed, 30 Jul 2014 17:12:05 +0000 http://pulmccm.org/main/?p=13566 Have you heard of ventilator-associated events (VAEs)? Like it or not, this neologism of healthcare-speak is coming to an ICU near you soon. Here’s the lowdown on VAEs and why they matter to the practicing intensivist. What are Ventilator-Associated Events? Ventilator-associated events are an invention of the Centers for Disease Control and Prevention (CDC), created in [... read more]

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PulmCCM Roundup #5 http://pulmccm.org/main/2014/randomized-controlled-trials/pulmccm-roundup-5/ http://pulmccm.org/main/2014/randomized-controlled-trials/pulmccm-roundup-5/#comments Mon, 21 Jul 2014 01:20:46 +0000 http://pulmccm.org/main/?p=13488 The PulmCCM Roundup gathers all the best in pulmonary and critical care from around the web.  Browse all the PulmCCM Roundups. Statins Fail for COPD, ARDS Statins have been optimistically tested as a tonic for everything from diabetes to dementia — so far, without success. That consistency was maintained in 2 recent trials showing statins’ [... read more]

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Inspiratory collapse of the inferior vena cava: What is it telling us? http://pulmccm.org/main/2014/critical-care-review/inspiratory-collapse-inferior-vena-cava-telling-us/ http://pulmccm.org/main/2014/critical-care-review/inspiratory-collapse-inferior-vena-cava-telling-us/#comments Thu, 17 Jul 2014 15:37:31 +0000 http://pulmccm.org/main/?p=13533 image: EM Ultrasonography ICU Physiology in 1,000 Words: “Inspiratory collapse of the inferior vena cava: What is it telling us?” Jon-Emile S. Kenny M.D. With the dissemination of small, portable, ultrasound devices [or SPUDs], it seems that it is every house-officer’s dream to own the ability and wherewithal to place an ultrasound probe on a [... read more]

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Prone positioning reduces ARDS mortality by 26%: meta-analysis http://pulmccm.org/main/2014/randomized-controlled-trials/prone-positioning-reduces-ards-mortality-26-meta-analysis/ http://pulmccm.org/main/2014/randomized-controlled-trials/prone-positioning-reduces-ards-mortality-26-meta-analysis/#comments Fri, 11 Jul 2014 16:55:27 +0000 http://pulmccm.org/main/?p=13502 Image: Rotoprone Acute respiratory distress syndrome (ARDS) injures the lungs in a heterogeneous pattern, and the damaged areas are particularly vulnerable to further ventilator-induced lung injury. This is why a lung-protective ventilator strategy using low tidal volumes reduces mortality from ARDS, experts believe. Tidal volumes of 6 mL/kg ideal body weight (calculated from height) using conventional [... read more]

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Using bronchoalveolar lavage to evaluate ILD http://pulmccm.org/main/2014/review-articles/ats-guideline-on-bronchoalveolar-lavage-bal-for-interstitial-lung-disease-ild-ajrccm/ http://pulmccm.org/main/2014/review-articles/ats-guideline-on-bronchoalveolar-lavage-bal-for-interstitial-lung-disease-ild-ajrccm/#comments Tue, 08 Jul 2014 10:43:10 +0000 http://pulmccm.org/main/?p=6490 Using BAL Cellular Analysis in Interstitial Lung Disease The role of bronchoalveolar lavage (BAL) in diagnosing and managing patients with interstitial lung disease (ILD) has always been uncertain and controversial. BAL findings are usually nonspecific, suggesting rather than proving the existence of any particular noninfectious condition (including interstitial lung disease). That said, in patients with [... read more]

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Azithromycin for COPD exacerbations: 2014 Update http://pulmccm.org/main/2014/review-articles/azithromycin-for-copd-exacerbations-update-review/ http://pulmccm.org/main/2014/review-articles/azithromycin-for-copd-exacerbations-update-review/#comments Fri, 27 Jun 2014 17:30:43 +0000 http://pulmccm.org/main/?p=13475 Azithromycin to Prevent COPD Exacerbations: What’s New? By Abhishek Biswas, MD Multiple previous studies have suggested likely benefits from using azithromycin as an immunomodulator for cystic fibrosis, bronchiectasis, diffuse panbronchiolitis, post-transplant obliterative bronchiolitis and COPD. This month, a new Cochrane analysis and clinical review in JAMA concludes that “continuous macrolide antibiotic use for prophylaxis [is] associated with a [... read more]

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CPAP better than oxygen for obstructive sleep apnea http://pulmccm.org/main/2014/randomized-controlled-trials/cpap-better-oxygen-obstructive-sleep-apnea-nejm/ http://pulmccm.org/main/2014/randomized-controlled-trials/cpap-better-oxygen-obstructive-sleep-apnea-nejm/#comments Thu, 26 Jun 2014 12:57:12 +0000 http://pulmccm.org/main/?p=13462 About half of people diagnosed with obstructive sleep apnea (OSA) can’t or won’t use the most effective therapy, overnight continuous positive airway pressure (CPAP). Most people with untreated OSA experience multiple episodes of hypoxemia — sometimes hundreds per night. For many patients declining CPAP treatment, their doctors provide overnight oxygen, in the hope that it might [... read more]

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PulmCCM Roundup #4 http://pulmccm.org/main/2014/randomized-controlled-trials/pulmccm-roundup-4/ http://pulmccm.org/main/2014/randomized-controlled-trials/pulmccm-roundup-4/#comments Sun, 08 Jun 2014 17:32:58 +0000 http://pulmccm.org/main/?p=13327 All the best in pulmonary and critical care from around the web. Browse all the PulmCCM Roundups. Asthma Childhood obesity increases the risk for asthma, and obesity is also strongly associated with asthma in adults. The mechanisms are likely multiple, complex and interdependent (pro-inflammatory mediators, etc.), not simply causative. Losing weight does seem to improve [... read more]

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Tenecteplase for submassive PE: more conflicting evidence (TOPCOAT) http://pulmccm.org/main/2014/randomized-controlled-trials/tenecteplase-for-submassive-pe-more-conflicting-evidence-topcoat/ http://pulmccm.org/main/2014/randomized-controlled-trials/tenecteplase-for-submassive-pe-more-conflicting-evidence-topcoat/#comments Thu, 05 Jun 2014 15:59:46 +0000 http://pulmccm.org/main/?p=13433 By Parth Rali, MD and Marvin Balaan, MD Submassive pulmonary emboli (PE) are those that are severe enough to produce right ventricular dysfunction on echocardiogram or elevated biomarkers (mainly troponin), but not hemodynamic instability (i.e., systemic blood pressure and cardiac output are preserved). The management of the patient with submassive PE is a matter of controversy with several [... read more]

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N-acetylcysteine: no benefit in idiopathic pulmonary fibrosis http://pulmccm.org/main/2014/randomized-controlled-trials/n-acetylcysteine-benefit-whatsoever-idiopathic-pulmonary-fibrosis/ http://pulmccm.org/main/2014/randomized-controlled-trials/n-acetylcysteine-benefit-whatsoever-idiopathic-pulmonary-fibrosis/#comments Fri, 30 May 2014 15:48:25 +0000 http://pulmccm.org/main/?p=13418 NAC for IPF: Fail (PANTHER-IPF Wrap-Up) Long ago, when pulmonologists were more ingenuous (in 2000), flawed clinical trials convinced the American Thoracic Society to recommend prednisone and either azathioprine or cyclophosphamide in its consensus guideline for some patients with idiopathic pulmonary fibrosis (IPF). By not including a true control arm, the also-flawed follow-up 2005 IFIGENIA trial reinforced this [... read more]

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Nintedanib protects lung function, prevents exacerbations of idiopathic pulmonary fibrosis (INPULSIS) http://pulmccm.org/main/2014/randomized-controlled-trials/nintedanib-protects-lung-function-prevents-exacerbations-of-idiopathic-pulmonary-fibrosis-inpulsis/ http://pulmccm.org/main/2014/randomized-controlled-trials/nintedanib-protects-lung-function-prevents-exacerbations-of-idiopathic-pulmonary-fibrosis-inpulsis/#comments Tue, 27 May 2014 17:39:39 +0000 http://pulmccm.org/main/?p=13406 In 2011 PulmCCM reported the findings of the phase 2 TOMORROW study, showing Boehringer Ingelheim’s tyrosine kinase inhibitor code-named BIBF 1120 reduced lung function decline and prevented exacerbations in people with idiopathic pulmonary fibrosis (IPF). At the 2014 American Thoracic Society annual meeting and in the New England Journal of Medicine, investigators announced their latest [... read more]

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Pirfenidone prolongs survival, preserves lung function in idiopathic pulmonary fibrosis (ASCEND) http://pulmccm.org/main/2014/randomized-controlled-trials/pirfenidone-prolongs-survival-preserves-lung-function-in-ipf-ascend/ http://pulmccm.org/main/2014/randomized-controlled-trials/pirfenidone-prolongs-survival-preserves-lung-function-in-ipf-ascend/#comments Fri, 23 May 2014 20:36:48 +0000 http://pulmccm.org/main/?p=13380 For idiopathic pulmonary fibrosis treatment pirfenidone, the third time wasn’t the charm; the fourth was. After reducing decline in forced vital capacity over one year in a Japanese trial of 275 IPF patients, pirfenidone went one-and-one in the multinational CAPACITY trials (n=779), meeting the primary outcome of FVC preservation in one but not the other. [... read more]

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Medicare bucks USPSTF, denies coverage for lung cancer screening http://pulmccm.org/main/2014/lung-cancer-review/medicare-bucks-uspstf-rations-lung-cancer-screening/ http://pulmccm.org/main/2014/lung-cancer-review/medicare-bucks-uspstf-rations-lung-cancer-screening/#comments Thu, 22 May 2014 20:37:23 +0000 http://pulmccm.org/main/?p=13370 The Centers for Medcare and Medcaid Services sent lung cancer screening’s forward momentum into a tailspin last month, when Medicare’s advisory panel shocked observers by voting  against covering lung cancer screening with annual low dose chest CT as a standard benefit. The U.S. Preventive Services Task Force (USPSTF) had already recommended lung cancer screening be [... read more]

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How to provide nutrition for critically ill patients (Review) http://pulmccm.org/main/2014/review-articles/provide-nutrition-critically-ill-patients-review/ http://pulmccm.org/main/2014/review-articles/provide-nutrition-critically-ill-patients-review/#comments Fri, 16 May 2014 21:12:08 +0000 http://pulmccm.org/?p=11591 Nutritional Support During Critical Illness This PulmCCM topic review will be periodically updated and expanded as new research is published. Originally published 22 September 2013. Most recent update: 16 May 2013. During critical illness, catabolism (breakdown of muscle protein, fat and other complex molecules) occurs faster than anabolism (synthesis of these same macromolecules). Historically, the [... read more]

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