Biomarkers Predict COPD Exacerbations (Sort Of) In addition to daily breathlessness, people with chronic obstructive pulmonary disease (COPD) often experience exacerbations of shortness of breath and coughing. Those with more severe COPD tend to have more frequent and severe exacerbations, lower enjoyment of life, and more rapid loss of lung function. The strongest predictor of [… read more]
Early Parenteral Nutrition (TPN) Didn’t Save Lives Under the high stress of critical illness, people lose fat and muscle quickly. Obesity appears to be protective during critical illness, possibly because those extra fat reserves come in handy during this period of accelerated catabolism. The strong physiological rationale and the psychological pressure not to appear to be [… read more]
Prone Positioning Saves Lives in Severe ARDS Patients: NEJM It’s long been known that positioning patients with ARDS on mechanical ventilation face-down (prone) improves their oxygenation. (There are various theories why prone positioning helps, such as by reducing ARDS’s injurious heterogeneous alveolar overdistension.) The improved oxygen levels have never translated into improved outcomes in ARDS [… read more]
No Benefit Seen From Monitoring Gastric Volume in Ventilated Patients on Tube Feedings Early enteral nutrition for patients on mechanical ventilation is considered the standard of care. It’s been assumed that delayed gastric emptying, resulting in a stomach full of liquid nutrition, predisposes patients to have aspiration events and develop ventilator associated pneumonia (VAP). Therefore, [… read more]
Killer Carbapenem-Resistant Bacteria Spreading Across U.S. Gut-living bacteria like Klebsiella are gaining resistance to carbapenems at an alarming rate, and long-term acute care hospitals (LTACs) and nursing homes seem to be the incubators for these killer bugs spreading across the U.S. Carbapenems like meropenem and doripenem have been the gold standard to treat infections from [… read more]
image: wikimedia Pulse Oximetry: The 30-Second Time Machine Why does it seem to take so long to re-oxygenate your crashing patient? Because your pulse oximeter is lying to you, no matter how good it is. Telescopes show us how a star looked millions or billions of years ago; pulse oximeters create a similar, though tiny [… read more]
In ARDS, Obesity May Protect Life (But Not Kidneys) by Blair Westerly, MD Obesity is an epidemic and common in intensive care units in the United States. Furthermore, while acute kidney injury (AKI) is also common in critically ill patients, obese patients carry additional risk for AKI because of increased baseline comorbidities. Both obesity and [… read more]
“Like this … kind of” Passive Leg Raise Improved Management of Patients in Shock* (*some assembly required) by Blair Westerly, MD Providing the right amount of fluid is vital in a critically ill patient, as both too little and too much can result in poor outcomes. Yet even with this understanding, the clinical assessment of [… read more]
(image: Wikipedia) High-Frequency Oscillatory Ventilation (HFOV) for ARDS Two Randomized Trials: Early HFOV Doesn’t Help, May Harm High-frequency oscillatory ventilation (HFOV) has been proposed as a first-line therapy for acute respiratory distress syndrome (ARDS). By delivering 3-15 breaths per second of tiny tidal volumes (~70 mL), HFOV has appeal as the “ultimate” lung protective ventilator [… read more]
Weaning From Mechanical Ventilation Update (See More PulmCCM Reviews) by Brett Ley, MD Nearly 800,000 patients require mechanical ventilation yearly. There’s no doubt it is a life-saving intervention, but it is one that is fraught with the potential for iatrogenesis, especially if continued for longer than necessary. That is the main message of this review in [… read more]
Ultrafiltration No Better Than Diuresis for CHF Exacerbations by Blair Westerly, MD Cardiorenal syndrome — simultaneous heart failure and renal failure — is a frequently encountered problem in people with acute decompensated heart failure. Treatment with diuretics for congestive heart failure exacerbations is standard care, but diuretics may at times worsen renal function. Venovenous ultrafiltration [… read more]
“Trach Collar” Trials Beat Pressure Support for Long-Term Ventilator Weaning By Blair Westerly, MD Patients requiring prolonged mechanical ventilation linger in ICUs and long-term acute care hospitals for weeks, accounting for a significant portion of intensive care unit costs and often suffering serious complications while dependent on the ventilator. Despite this issue’s rising importance, the [… read more]
Knowing When, When Knowing Is Impossible By Paul C. McLean The child was her first, and there were complications and aggressive therapies from the start and for months. She was unaware that the medical team was coming to believe the baby would not survive, that aggressive treatments no longer served a therapeutic purpose and were [… 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]
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]
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]
In most areas of life, it helps to be tall, and needing treatment for ARDS further proves the rule. Tall people are less likely to get harmful lung-distending tidal volumes during mechanical ventilation, simply by virtue of having bigger lungs. It’s bad enough that we intensivists might discriminate against the under-six-feet crowd (of which I [… read more]
(image: Wikipedia) An expert panel announced a new definition and severity classfication system for acute respiratory distress syndrome (ARDS) that aims to simplify the diagnosis and better prognosticate outcomes from the life-threatening pulmonary illness. The proposed “Berlin definition of ARDS” predicted mortality ever-so-slightly better than the existing ARDS criteria (created at the 1994 American-European Consensus [… read more]
DECAF Score Predicts COPD Exacerbation Mortality, But Needs Validation By Brett Ley, MD Despite improvements in care, death during hospitalization for acute exacerbation of COPD (AECOPD) is not uncommon. In the UK in 2008, almost 1 in 12 people admitted with a COPD exacerbation died in-hospital. In the U.S. in 1996, about 1 in 40 [… read more]
Image: EIMJM.com Evidence-based practice guidelines adopted by critical care societies in Canada, Germany, Australia and New Zealand recommend starting enteral nutrition for critical illness shortly after admission to an ICU. In observational studies, critically ill adults get only about 50-70% their caloric goals from enteral feeding; reduced gastric motility is often responsible for the limited [… read more]
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