Jon-Emile S. Kenny

Dr. Kenny is slowly curating the 'Finnegans Wake of Critical Care Blogs.' His favourite places are: Pier 64, The Hall of Ocean Life, Grand Central Station and the cafe at the top of Fotografiska. He has inherited his grandmother's fascination with the cosmos and Carl Sagan. Enjoy his homage to classical cardiorespiratory physiology at www.heart-lung.org

Sep 122020
 
More on Corticosteroids in COVID-19 – Part 2: REACT meta-analysis

Jon-Emile S. Kenny MD [@heart_lung] “As human beings, don’t we need questions without answers as well as questions with answers?” -Alan Lightman With the publication of REMAP-CAP, CAPE-COVID and CoDEX, the World Health Organization [WHO] Rapid Evidence Appraisal for COVID-19 Therapies [REACT] Working Group combined these results with 4 other randomized trials of corticosteroids in COVID-19.  [… read more]

Sep 102020
 
Prone Position in COVID-19 Studied with 3-Dimensional Trans-esophageal Echocardiography

Jon-Emile S. Kenny MD [@heart_lung] “In that day there’s a moment when it all goes away …” -The Tallest Man on Earth A recent case series reporting experience with 3-dimensional trans-esophageal echocardiography in moderate-to-severe COVID-19 associated lung injury was published in Intensive Care Medicine.  With only 9 patients described the findings are, nevertheless, noteworthy because of [… read more]

Sep 102020
 
More on Corticosteroids in COVID-19 – Part 1: REMAP-CAP, CAPE-COVID & CoDEX trials

Jon-Emile S. Kenny MD [@heart_lung] “Let us try to assume our fundamental ambiguity.” -Simone de Beauvoir When the pre-peer review RECOVERY trial was released in mid-June of this year, clinicians lost equipoise to enroll hospitalized patients receiving at least oxygen for COVID-19 into trials including a treatment arm without corticosteroids.  This brought to an early-halt three [… read more]

Aug 182020
 
ICU Physiology in 1000 Words: Cardiothoracic Uncoupling & Venous Ergotrauma

Jon-Emile S. Kenny MD [@heart_lung] Pulmonary Elastic Ergotrauma There are hidden hemodynamics in respiratory mechanics, as previously discussed.  Recall that these relationships are illustrated by comparing volume-pressure, or compliance curves.  Trans-pulmonary pressure, which approximates pulmonary stress, is the pressure in the airway compartment less the pleural pressure [1].  In a passive, mechanically-ventilated patient, the trans-pulmonary pressure [… read more]

Jul 302020
 
ICU Physiology in 1000 Words: Patient Self-Inflicted Lung Injury – Part 2

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]

Jul 302020
 
ICU Physiology in 1000 Words: Patient Self-Inflicted Lung Injury – Part 1

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]

Jun 302020
 
A Brief Overview of Corticosteroids in COVID-19

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]

Jun 282020
 
A Brief Update on Angiotensin & Aldosterone Inhibition in COVID-19

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]

May 302020
 
COVID-19 Associated Coagulopathy: a contentious conundrum

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]

May 242020
 
Does the 65 Trial Dial Down the Mean Arterial Pressure in Sepsis?

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]

Apr 302020
 
COVID-19 Associated ARDS: ‘CARDS’ & the L-Phenotype

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]

Mar 252020
 
An Illustrated Primer on COVID-19 Therapy: part 2

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]

Mar 212020
 
An Illustrated Primer on COVID-19 Therapy: part 1

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]

Mar 162020
 
An Illustrated Guide to the Chest CT in COVID-19

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]

Mar 092020
 
ICU Physiology in 1000 Words: All Perfusion Is Local

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]

Feb 092020
 
The ‘Lacto-Bolo Reflex’

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]

Jan 062020
 
ICU Physiology in 1000 Words: Shorthand Equations for Respiratory System Power

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]

Dec 272019
 
The PHARLAP Trial: Recruitment Maneuvers Buy Stairway to Heaven?

Jon-Emile S. Kenny MD [@heart_lung] “Dying is a wild night and a new road.” -Emily Dickinson Background In 2006, a recruitment maneuver to achieve an ‘open lung’ was circulated; it has since been dubbed ‘stairway recruitment’ given its stepwise upthrusts in airway pressure [see figure 1]: Plodding up this ladder of airway pressure was meant to [… read more]