PulmCCM

The PulmCCM team writes the posts under this moniker. Read the About page for more of the PulmCCM story.

Sep 082017
 
Tiotropium helped in early COPD in randomized trial

Tiotropium (trade names Spiriva, Stiolto) was originally FDA-approved after patients with severe chronic obstructive pulmonary disease (COPD) had improved lung function and fewer COPD exacerbations taking Spiriva compared to placebo.  In a recent randomized trial of 841 patients in China, tiotropium showed benefits in milder, early COPD as well. Patients with COPD GOLD stage 1 or [… read more]

Aug 242017
 
Procalcitonin Testing in Suspected Infection: Review

Procalcitonin Test: Overview Procalcitonin (PCT) is the precursor of the hormone calcitonin and is mainly produced by the thyroid. Procalcitonin is a so-called acute phase reactant, rising in response to tissue inflammation and injury. Outside the thyroid, PCT is secreted by the lungs, intestines and other tissues in increasing amounts in response to bacterial endotoxin [… read more]

Aug 232017
 

Scleroderma-Related Interstitial Lung Disease Scleroderma (SSc) is an autoimmune disease characterized by vasculopathy and fibrosis with multi organ involvement. Pulmonary complications such as interstitial lung disease (ILD) and pulmonary hypertension contribute significantly to mortality and morbidity of the disease. Up to 90% patients with scleroderma can have interstitial changes on high resolution CT scan (HRCT) [… read more]

Aug 202017
 
In ARDS, substandard ventilator care is the norm, not the exception

In acute respiratory distress syndrome (ARDS), anyone with the keys to a ventilator knows low tidal volume ventilation (~6 mL/kg ideal body weight) is standard care. Low tidal volume ventilation can prevent or ameliorate ventilator-associated lung injury ; if early clinical trials represent current reality, one in 11 people with ARDS treated by low tidal volume ventilation could have their [… read more]

Aug 202017
 
Contrast induced nephropathy: what's the true risk?

Iodinated IV contrast has long been considered a significant contributor to acute kidney injury in hospitalized patients. But so-called contrast induced nephropathy is hard to accurately identify in real clinical circumstances. Acute kidney injury (AKI) can happen from a variety of causes, or their combination, during acute illness. And no randomized trial has established the risk [… read more]

Aug 092017
 
Heparin-Induced Thrombocytopenia (HIT) Review

HIT Overview Heparin-induced thrombocytopenia (HIT) is a dangerous complication of heparin exposure. In HIT, the body creates an autoantibody against the complex of platelet factor 4 bound to heparin. The anti-PF4 autoantibodies can activate platelets and cause life- and limb-threatening thrombosis in arteries and veins. Platelets generally fall by more than 50% five to ten [… read more]

Jul 082017
 
Intubation during CPR was associated with worse survival and brain health

“Stop chest compressions for a minute while I intubate this patient!” That refrain must have been heard tens of thousands of times during CPR after cardiac arrest before 2010, when the American Heart Association’s (AHA) Advanced Cardiac Life Support (ACLS) guidelines advised resuscitation teams not to interrupt chest compressions to place advanced airways, unless a patient [… read more]

Jun 282017
 

The US Food and Drug Administration (FDA) approved betrixaban (Bevyxxa), a new oral anticoagulant for prevention of venous thromboembolism (VTE) in hospitalized medical patients with risk factors for DVT/PE. With betrixaban, manufacturer Portola will seek to expand a tiny market niche it could immediately dominate: prophylaxis of DVT/PE extending for about a month after hospital [… read more]

Jun 272017
 
Is hypothermia harmful after in-hospital cardiac arrest?

Will “therapeutic” hypothermia someday need to be renamed? After a rush of optimism surrounding small trials showing large benefits from hypothermia to 33° after out-of-hospital cardiac arrest, hospitals and intensivists flocked to provide hypothermia to all victims of cardiac arrest (in- or out-of-hospital). When the much more powerful TTM trial showed no benefit of deep cooling [… read more]

Jun 042017
 
Tight blood sugar control did not help critically ill kids

Remember when intensive glucose control in adults became all the “lifesaving” rage — and was then revealed to actually be harmful? Well, it doesn’t seem to work in kids either. Tight glucose control in critically ill children with hyperglycemia failed to reduce ICU days as compared with a higher target glucose range, in a large randomized [… read more]

Jun 042017
 

The FDA has expanded the indication for tiotropium (Spiriva Respimat) to include children age 6 and older, based on efficacy data similar to that in adults. Tiotropium (Spiriva Respimat) was approved by FDA in 2015 for adults with asthma after clinical trials showed benefit of Spiriva as an add-on therapy to patients with persistent asthma [… read more]

May 152017
 
Sepsis drives far more readmissions than we realized

Sepsis may contribute to far more hospital readmissions than previously recognized — more than any other monitored condition. Recognition of this by federal and private payers could result in increased intensity of oversight of health teams’ care delivery for patients with sepsis. Hospital readmissions are squarely in the sights of the Centers for Medicare and Medicaid [… read more]

May 142017
 
Heparin prophylaxis no help after knee arthroscopy or leg casting (POT-KAST, POT-CAST)

Low molecular weight heparin (LMWH) at preventive doses after arthroscopic knee surgery or leg casting did not prevent venous thromboembolism (DVT or PE), in two Dutch randomized trials. The study helps fill a large gap in knowledge regarding risks and benefits of prophylactic anticoagulation in patients undergoing these procedures. In one (POT-KAST), 1,543 patients received [… read more]

May 072017
 
Video laryngoscopy was no better than directly intubating in the ICU, and may have been worse (MACMAN)

Video laryngoscopy provides beautiful close-up views of the larynx, by navigating a sensor past the tongue and pharyngeal tissues that can obstruct direct laryngoscopy views. These visual advantages led to its wide adoption by anesthesiologists, emergency physicians, and intensivists after video laryngoscopy’s introduction in the late 1990s. The intuition that better visualization must result in improved intubation rates — [… read more]

May 072017
 
Fleischner Society Guideline Update 2017: Management of Solid Pulmonary Nodules

Updated 2017 Fleischner Society guidelines advise a less intensive approach to the management of most small pulmonary nodules incidentally discovered on CT scans. The Fleischner Society now recommends that solid nodules 6 mm or less in diameter in low-risk adults >35 years old generally need no further follow-up. In higher-risk patients, a follow-up CT scan should [… read more]

Apr 262017
 
Can early warning systems predict (and prevent) cardiac arrest?

The increasingly data-saturated modern health care milieu has been catnip to technologists and statisticians. If only we could manage and analyze the data better, as this appealing narrative has it, we could improve health outcomes in the hospital. Predictive modeling algorithms represent the apotheosis of this paradigm, offering hope to detect patients’ impending deterioration and cardiac arrest [… read more]

Apr 122017
 
Which position is safest for central line placement: subclavian, jugular, femoral? (3SITES)

Where to place a central venous catheter is a decision driven mainly by individual experience and preference. The limited evidence available has not established any site as superior; the subclavian position has been reported as being less infection-prone, but more likely to cause pneumothorax, compared to other sites. A large French randomized trial adds significantly to the evidence base. [… read more]

Apr 112017
 
600,000 albuterol (Ventolin) inhalers recalled

GlaxoSmithKline is voluntarily recalling more than 590,000 albuterol inhalers (brand name Ventolin), citing a defect that may cause the inhalers to deliver fewer doses of the medicine than prescribed, the British drugmaker announced. Patients complained about a bulging of the outside wrapper of Ventolin’s packaging; a leak of the medicine’s propellant is suspected to be [… read more]

Apr 102017
 

A document that looks like an unsigned, unpublished letter to the Wall Street Journal was posted on Scott Weingart’s EMCrit blog. It is signed only “The Department of Emergency Medicine – Henry Ford Hospital” and responds to the 2008 WSJ piece that suggested irregularities or mishandling of the data in the seminal 2001 trial on EGDT for sepsis. Scott’s [… read more]

Apr 052017
 
Meta-analysis confirms EGDT for sepsis is unhelpful and wasteful (PRISM)

Three large, well-conducted randomized trials around the world (ProCESS, ARISE, and ProMISe) all agreed: use of early goal-directed therapy (EGDT) for sepsis does not improve mortality or any other important clinical outcome. The Big Three sepsis trials were a death knell for the formerly ubiquitous “sepsis bundles,” protocols based on the single-center 2001 trial of EGDT [… read more]