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Dec 192014
 
Age-adjusted D-dimer to rule out PE: coming of age?

Put a CT scanner in every U.S. emergency department, add the non-specific signs and symptoms of pulmonary embolism, stir in its potential lethality and morbidity, and line up a few thousand lawyers on the sidelines ready to capitalize on any missed diagnoses, and it’s no wonder that the use of CT-angiograms to rule out pulmonary embolism has risen 11-fold [… read more]

Dec 072014
 

Ignoring its advisory panel, the Centers for Medicare and Medicaid Services (CMS) announced that annual low-dose CT lung cancer screening for high-risk individuals will be covered by Medicare. However, CMS applied restrictions that will limit access to screening, avoiding the chaotic marketplace free-for-all that would have resulted from an unrestricted approval. Medicare will pay for one lung cancer [… read more]

Dec 052014
 

In Defense of the Central Venous Pressure Jon-Emile S. Kenny M.D. In the waning days of my fellowship I received a hemoptysis consult in the cardiac care unit. Sifting through CT scans, I overheard two house-officers giving sign-out for the evening. When reviewing the clinical data, one of the residents referred to the central venous pressure [… read more]

Oct 312014
 
Life after sepsis protocols: What now? (You decide.)

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]

Oct 312014
 
Safe to stop inhaled steroids in COPD (and start more expensive drugs)?

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]

Oct 172014
 
FDA approves pirfenidone (Esbriet) and nintedanib (Ofev) for IPF

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]

Oct 162014
 
ICU Physiology in 1,000 Words: Stroke Volume Variation and the Concept of Dose-Response

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]

Oct 142014
 
Total parenteral nutrition vs enteral nutrition: no difference in critically ill? (CALORIES trial)

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]

Oct 102014
 
Transfusion for hemoglobin above 7 g/dL: no benefit in septic shock (TRISS Trial)

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]

Oct 052014
 
Are traditional protocols for goal directed therapy for sepsis dead? (ARISE trial)

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]

Sep 122014
 

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]

Sep 052014
 
New 2014 Pulmonary Hypertension guidelines released

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]

Sep 012014
 
ICU Physiology in 1000 Words: The Hemodynamics of Prone

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]

Aug 162014
 
Which cancer patients need prophylaxis for DVT and pulmonary embolism?

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]

Jul 302014
 
What are Ventilator-Associated Events (and why should you care)?

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]

Jul 202014
 
PulmCCM Roundup #5

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]

Jul 172014
 
Inspiratory collapse of the inferior vena cava: What is it telling us?

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]

Jul 112014
 
Prone positioning reduces ARDS mortality by 26%: meta-analysis

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]

Jul 082014
 
Using bronchoalveolar lavage to evaluate ILD

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]