Jon-Emile S. Kenny MD [@heart_lung] In part 1, evidence for and against spontaneous breathing effort in acute respiratory distress syndrome [ARDS] was briefly outlined. The mechanisms of patient self-inflicted lung injury [P-SILI] are touched upon herein with reconciliation of the clinical and experimental data. Mechanisms: basics A handful great reviews on spontaneous breathing in ARDS and [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Background In an excellent review from early 2016, Gattinoni and Quintel note that ventilator induced lung injury [VILI] is better considered ventilation induced lung injury because VILI can develop during spontaneous breathing [1]. To support this claim, they reference a classic experimental study from the late 1980s by Mascheroni and colleagues [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “ This is the way the world ends Not with a bang but with a whimper.” -T.S. Eliot As lightly discussed a few months ago, deploying corticosteroids in COVID-19 began, expectedly, with controversy. Russell and colleagues submitted a letter arguing against wholesale administration of corticosteroids in patients infected with SARS-CoV-2. They [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “We’re on a road to nowhere …” -David Byrne Background In early March of this year, Fang and colleagues published a letter noting that patients with diabetes and/or hypertension treated with ACE inhibitors or angiotensin II type-1 receptor blockers [i.e. ARBs] increase their expression of the ACE2 enzyme. Parenthetically, they also stated [… read more]
Tracheostomy in COVID-19: Many opportunities, limited evidence By Andrew DeMaio, M.D. and David Feller-Kopman, M.D. Let’s start with a case – one that unfortunately we have seen way too frequently over the past few months. A 61-year-old man with ESRD on hemodialysis and prior pulmonary embolism was admitted to the ICU for ARDS due to [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Knavery and flattery are blood relations.” -Abraham Lincoln Background SARS-CoV-2 is a positive-sense, single-stranded RNA virus with spiked surface glycoproteins emanating from its viral envelope. It is a member of the Coronaviridae family, similar to the first SARS [SARS-CoV] and the Middle East Respiratory Syndrome [MERS]. SARS-CoV-2 preferentially targets respiratory epithelium, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “This whole thing is not about heroism. It’s about decency. It may seem a ridiculous idea, but the only way to fight the plague is with decency.” -Albert Camus Background In 2013, Dünser and colleagues communicated a rogue viewpoint in shock resuscitation – let us do away with strict macro-hemodynamic goals [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “No facts are to me sacred; none are profane; I simply experiment, an endless seeker with no Past at my back.” -Ralph Waldo Emerson Background When Drs. Marini and Gattinoni author a letter describing a new phenotype of the acute respiratory distress syndrome [ARDS] encountered in patients infected with SARS-CoV-2, we [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD [@_carlemd_] “…fires had been put out by volunteers using brickmason’s ladders and buckets of water carried in from wherever it could be found, and methods so disorderly that they sometimes caused more damage than the fires.” – Gabriel García Márquez In this second primer [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD [@_carlemd_] “…but they all had an evasive tremor in their voices and an uncertainty in their eyes that belied their words.” – Gabriel García Márquez Background With early data illustrating upwards of 1 in 5 COVID-19 patients developing acute respiratory distress syndrome [ARDS], there is [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD [@_carlemd_] “He found a glimmer of hope in the ruins of disaster …” – Gabriel García Márquez Background The coronavirus moniker originates from the appearance of the virus under the electron microscope – protein peplomers radiating from the viral envelope like a crown. Prior [… read more]
Jon-Emile S. Kenny MD [@heart_lung] About a year ago, I explored blood pressure – underscoring mean arterial pressure [MAP] as a determinant, but not necessarily an indicator, of perfusion. The inspiration for that post were these excellent reviews [1, 2] by the legendary Dr. Magder. With the recent 65 Trial [3], a deeper exploration of tissue [… read more]
A new randomized trial showed no benefit from intravenous vitamin C in patients with sepsis, but delays in treatment baked into the trial design will keep hope alive for true believers in the novel therapy. Vitamin C, hydrocortisone, and thiamine have been promoted as a lifesaving adjunctive therapy for septic shock, based on anecdotal data [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Sich regen bringt Segen” -German proverb Background It is an overcast day in Bern, Switzerland. I have recently left Zermatt, having had the honour and pleasure of speaking at ‘The Big Sick’ conference. I spent the day roaming the narrowed passages of this old, beautiful city. In the midst of my [… read more]
REGISTER NOW! May 20, 8:00 a.m. – May 22, 5:00 p.m. Santa Cabrini Hospital, 5655 Rue Saint-Zotique E, Montréal, QC H1T 1P7, Canada
Vitamin D supplementation brought no measurable benefits to vitamin D-deficient critically ill patients, in a large randomized trial published in the New England Journal of Medicine. Vitamin D supplementation has long been hoped for as a potential lifesaving therapy in critical illness. Many critically ill patients are vitamin D deficient, and deficiency increases the risk [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “It is a narrow mind which cannot look at a subject from various points of view.” -George Eliot Background On background reading for the recent entry on ‘Asthmatic Mechanics,’ I happened across a delightful case report submitted as a letter to the editor of the New England Journal of Medicine in [… read more]
Best of 2019 on PulmCCM: Keep O2 saturations at 96% or below for hospitalized patients, says expert panel Major asthma guideline update: ICS-LABA as-needed replaces albuterol 2019 IDSA Guidelines for Community Acquired Pneumonia Prolonged hypothermia improved neurologic outcomes after non-shockable cardiac arrests Hospitals should not implement one-hour sepsis bundles, say SCCM and ACEP Vitamin C [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Background This synopsis will address the basic geometric calculation of respiratory system work for a single breath [in joules] and power [i.e. joules/seconds or watts] which is work multiplied by the respiratory rate. This geometric approach will then be used to explain two shorthand equations – the second of which was [… read more]
New Guideline Emphasizes Treatment of Drug-Resistant Tuberculosis with All-Oral Regimens for MDR-TB Patients The American Thoracic Society, Centers for Disease Control and Prevention, European Respiratory Society and the Infectious Diseases Society of America have published an official clinical guideline on the treatment of drug-resistant tuberculosis (DR-TB) in the Nov. 15 American Journal of Respiratory and [… read more]
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