In a crossover design, Kerstjens et al randomized 100 patients with uncontrolled severe asthma (despite high dose inhaled corticosteroid and long-acting beta agonist) to also receive tiotropium 5 mcg, tiotropium 10 mcg, and placebo (in random order) for 8 weeks each. Tiotropium improved peak FEV1 at both doses (increase of 139-170 mL, the primary endpoint). [… read more]
Muscedere J. Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: A systematic review and meta-analysis. Crit Care Med 2011;39:1985-1991. In short, it probably works to prevent ventilator-associated pneumonia (13 randomized trials, n=2,442. 12 were positive, pooled risk ratio 0.55, associated with 1-1.5 shorter days in the ICU and on the ventilator). So why not use [… read more]
An excellent free full text review by Paul O’Byrne. What’s new here: Did you know that formoterol is used as a first-line rescue inhaler, outside the U.S.? Formoterol has a steeper dose-response curve than salmeterol: repeated doses have an additive bronchodilator effect. The use of budesonide/formoterol as a combination maintenance AND rescue inhaler (added prn [… read more]
Obesity was named as a risk factor for severe H1N1 influenza during the pandemic. What about for influenza in general? Kwong et al analyzed community survey data in Ontario over 12 influenza seasons, 1996-2008. Severe obesity (BMI >= 35) carried an odds ratio of 2.1 for respiratory hospitalization during flu season. In those with no [… read more]
Drager LF et al. Obstructive Sleep Apnea: An Emerging Risk Factor for Atherosclerosis. CHEST 2011;140:534-542. OSA and CAD review.
Semenza GL. Oxygen sensing, homeostasis, and disease. NEJM 2011;365:537-547. An acronym-rich summary of decades of work by dozens of investigators eavesdropping on the secret messages cells send in response to hypoxia through HIF-1a, mTOR, VEGF and DMOG. I don’t understand a word of it, frankly. (Review)
For 10 years, Zahar et al prospectively observed 3,588 patients developing severe sepsis & septic shock who ended up in French ICUs. Their sample captured a broad array of infections acquired in the community, the hospital ward, or the ICU (about 1/3 each). After multivariate assessment, they could not find an independent influence on mortality [… read more]
Schuetz et al review the 16 randomized controlled trials (n=4,647) testing procalcitonin-guided vs. standard care on the outcomes of antibiotic use, mortality, and infection control. Most of these studies were done in Europe; 6 were in ICU patients. Using procalcitonin reduced antibiotic use in all settings (primary care, emergency department, ICU) with no detectable differences [… read more]
Influenza, RSV, human metapneumovirus, CMV, EBV, herpesviruses, rhinovirus, coronavirus, adenovirus … viruses are increasingly recognized as a cause of pneumonia in adults. Read all about it in this special issue & review. Semin Resp Crit Care Med 2011; 4.
Obstructive sleep apnea and other sleep disorders have long been associated with cognitive dysfunction, but so far not in a prospective study. So, Yaffe et al followed 298 older women (~82 years) who had already had polysomnography as part of an osteoporosis study. 105 had sleep disordered breathing (cases), defined as an apnea-hypopnea index >= [… read more]
A minority of people develop central sleep apneas during polysomnography with continuous positive airway pressure titration for obstructive sleep apnea. Others develop central apneas later, discovered on interrogation of their CPAP machine. The fact is, no one knows much about this so-called complex sleep apnea — its natural course, prognosis / risks, and whether or [… read more]
Johnson et al reviewed charts in a retrospective case-control cohort study on 754 consecutive patients at Barnes-Jewish with severe sepsis or shock due to Gram-negative bacteremia. The exposure was receipt of antibiotics in the previous 90 days. 310 of the bacteremic patients had received antibiotics previously. Compared to unexposed controls, the previously antibiotic-exposed had a [… read more]
Self-reported adherence is usually overestimated. Most people prescribed chronic daily medication take it ~60% of the time, but say/believe they take it 90% of the time. People with cystic fibrosis are instructed to spend more than an hour a day sitting through up to 7 nebulizer treatments. Daniels et al used a smart nebulizer machine [… read more]
Accountability for Medical Error: Moving Beyond Blame to Advocacy. CHEST 2011;140:519-526. Bell et al’s great essay on the dysfunctional mechanics and culture of liability / safety / blame surrounding medical errors in hospitals and our medical care system in general. They propose steps toward “collective accountability,” e.g., we MDs should sit on hospital safety committees. But [… read more]
Unimpressed by the unimpressive results of the CAPACITY trials testing pirfenidone for idiopathic pulmonary fibrosis, the FDA bucked its advisory panel (which had recommended approval) and insisted on another randomized trial in order to reconsider the drug. In July 2011 InterMune started enrollment for ASCEND, which plans to provide results on pirfenidone vs. placebo in [… read more]
Do we need to worry about pre-existing heparin-induced thrombocytopenia antibodies in people admitted with pulmonary embolism / deep venous thrombosis? Or can we keep happily slinging heparin at first sight? Warkentin et al analyze data from the Matisse VTE studies, which enrolled 3,994 patients with DVT or PE. All had ELISA HIT antibodies collected at [… read more]
In the “why didn’t I think of that?” department: Menzies et al performed pleural fluid sampling on 62 patients with clinical pleural infection, and sent samples to the lab in both standard tubes and in blood culture bottles inoculated at the bedside. 20 standard samples were culture-positive; adding the positive inoculated samples identified an additional [… read more]
Hersh et al analyzed spirometry and patient-reported data on family history from the COPDGene study, comparing 821 people with COPD to 776 smoking controls. Subject-recalled parental history of COPD had an odds ratio of 1.7 for COPD in the subject. The population attributable risk from family history for COPD was 18.6%. They acknowledge the vulnerability [… read more]
Mavros et al did the heavy lifting required to review 998 studies relating in some way to atelectasis and postoperative fever. They felt only 8 of those studies deserved analysis (990 were excluded either for not reporting sufficient data, or not focusing on the question at hand). One study reported an association between atelectasis and [… read more]
Bronchiolitis Obliterans Syndrome: The Final Frontier. No, it’s not the new Star Trek movie featuring a breathless William Shatner. It’s Todd JL, Palmer SM’s review on BOS, the lung transplantation scourge, in CHEST 2011;140:502-508.