Who Needs In-Flight Oxygen? New Method May Help by Brett Ley, MD COPD patients without a long-term indication for supplemental oxygen may still be at risk for severe hypoxemia during air travel since cabin pressures are generally maintained to simulate altitudes of about 8000 feet. In-flight supplemental oxygen is recommended when the partial pressure of [... read more]
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]
Pulmonary Vasculitis Update / Review Part 2: Treatment and Prognosis (Go to Part 1: Clinical Features and Diagnosis) by Brett Ley, MD Treatment of the ANCA-associated pulmonary vasculitides consists of systemic corticosteroids and cytotoxic therapies given in two phases, induction and maintenance, where the aggressiveness of the regimen is based on disease severity. The standard [... read more]
Thanks to you, PulmCCM had an incredible year in 2012, growing from Internet blip to one of the most-visited medical blogs, with over 50,000 visits and 150,000 page views monthly worldwide. Now, I’m asking you for your financial support, and in return, offering you the chance to share in PulmCCM’s success in 2013. To grow [... read more]
Pulmonary Vasculitis Update / Review Part 1: Clinical Features & Diagnosis (Go to Part 2: Treatment and Prognosis) by Brett Ley, MD Vasculitides are disorders of inflammation and necrosis of the blood vessel wall. Pulmonary vasculitides can present in multiple ways: with alveolar hemorrhage, infiltrates, nodules, cavities, or airway disease. They are categorized by the [... read more]
Chronic Cough and GERD: A Tangled Connection by Michael Peters, MD Gastroesophageal reflux disease (GERD) is considered to be one of the cardinal causes of chronic cough. A study in Chest challenges that fundamental concept, but comes up short in refuting it. What They Did Samantha Decalmer, Rachel Stovold, Jaclyn A. Smith et al conducted [... read more]
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]
Intensive glucose control in critically ill patients — keeping glucose below 120 with a continuous insulin drip — was all the rage for a few years in the early 2000s after it was shown to improve survival in surgery patients, and then seemed to do the same in non-surgical, critically ill MICU patients who were [... read more]
(image: Wikipedia) As we reported a few months ago, the PANTHER-IPF trial was stopped early for safety, when it became clear that the combination of prednisone and azathioprine was hurting people with idiopathic pulmonary fibrosis (IPF). Ganesh Raghu (U-Washington), Kevin Anstrom (Duke), Talmadge King (UCSF) et al report the final results in the May 24 New [... read more]
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]
Tranexamic Acid: Underused for Uncontrolled Bleeding? Tranexamic acid is a simple little molecule, just a synthetic derivative of the amino acid lysine. But it’s also a potent pro-hemostatic drug that binds plasminogen and plasmin and stops the degradation of fibrin (the stuff in blood clots). In the U.S., tranexamic acid is sold as Lysteda (oral) [... read more]
(image: Rxhealthdrugs.com) Azithromycin for Prevention of COPD Exacerbations Azithromycin taken daily prevents exacerbations of chronic obstructive pulmonary disease (COPD exacerbations), but seems to also carry risks for cardiovascular death and hearing loss. The true balance of risks and benefits with use of azithromycin to prevent COPD exacerbations is unknown, but physicians who choose to prescribe [... read more]
Azithromycin for non-CF Bronchiectasis Bronchiectasis — the permanently dilated, tortuous bronchi that can result after previous lung infections — is a frustrating problem for pulmonologists to treat, but not nearly as frustrating as it can be for patients to live with. People with bronchiectasis are plagued by chronic coughing, and many experience a steady decline [... read more]
“We’ve got to get that femoral line out of there!” The attending’s face as he says it shadowed with a simmer of fear, a dash of anger. How could the moonlighter have been so incompetent or lazy as to choose the benighted femoral site for a central venous line when the internal jugular and subclavian [... read more]
Procalcitonin to Guide Treatment of Pneumonia (More PulmCCM Topic Reviews) With mounting evidence for its utility as a biomarker for pneumonia, procalcitonin is one of the hottest 2012 topics in pulmonary & critical care. Procalcitonin tends to rise quickly as bacterial infections (but not viral infections) develop, increase with the severity of infection, and decline [... read more]
Daily Inhaled Steroids Stunt Kids’ Growth, Study Shows If you’re a half-inch shy of six feet, the next time you’re getting your jump shot blocked by your non-asthmatic friend, you can blame the inhaled corticosteroids your Mom made you take as a kid. Studies have consistently showed children’s height slows down for a few years [... read more]
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]
Spiriva (Tiotropium) for Uncontrolled Asthma Most people with asthma can achieve good control with inhaled corticosteroids (ICS) and a long-acting beta-agonist (LABA). Some people living with asthma, though, experience persistent symptoms despite maximum doses of these inhaled medications. Fairly or not, LABAs have also been sullied with an FDA black-box warning for worsening bronchospasm in a [... read more]
The use of positron emission tomography — better known as PET scans — has grown dramatically over the past 15 years, thanks to their seemingly magical ability to identify foci of undetected metastatic cancer. But PET scans’ perceived high accuracy in diagnosing metastatic non-small cell lung cancer (NSCLC) — a published 94% sensitivity and 83% [... read more]
(This post is originally from March 2012, but a few people requested to see it again, so here it is. -MH) It started with a friendly pro/con debate in the December 2011 Chest, about whether lactate clearance or mixed venous oxygen saturation is a better “goal” for early goal-directed therapy in severe sepsis and septic shock. [... read more]