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]
When it comes to airway management skills, muscle memory rules, and there’s no substitute for hands-on experience. But in between intubations and endotracheal tube changes, what’s the best way to bolster your skills and knowledge base? Reading textbooks and journal articles provides truthful information, but I suspect it gets filed away and stashed in your [… read more]
Management of Opioid Overdose in the ICU: Review (More PulmCCM Topic Updates) Thanks to a 700% increase in the number of opioid prescriptions for pain management, combined with a perhaps greater rise in the rate of prescription opioid abuse, the number of serious opioid overdoses in the US has climbed dramatically over the past decade. [… read more]
We may see it more often, but we doctors don’t really know anything more about death than anyone else, and we find it just as scary. Yet we are expected to spontaneously discuss death-as-a-coming-event with seriously ill patients who (we assume) probably want to avoid the subject, well, like the plague. Maybe they do. But [… read more]
Human recombinant granulocyte macrophage colony stimulating factor (GM-CSF or Leukine) did not reduce ventilator-days in patients with acute lung injury / ARDS in a randomized trial published in the January 2012 Critical Care Medicine. Why would it have? Interestingly, patients with ARDS with higher levels of GM-CSF in their BAL fluid are more likely to survive. GM-CSF maintains [… read more]
(image: Wikipedia) Anyone who has ever rounded in an ICU with a nurse manager knows that challenging or questioning the utility of the ventilator associated pneumonia (VAP) bundle is a losing proposition — one likely to get you labeled as a wiseguy troublemaker. Thanks to ventilator bundles’ endorsement by the nonprofit Institute for Healthcare Improvement, [… read more]
Everyone knows that when you’re really sick, going to the ICU–that place with all the beeping monitors, hypervigilant staff, and high-tech invasive gadgetry–might save your life. But what if in certain situations, transfer to an ICU bed could actually worsen a person’s condition, or even hasten their demise? Hannah Wunsch of Columbia U. suggests it’s [… read more]
(image: flickrCC) Half of patients transferred to long-term acute care facilities (LTACs) on prolonged mechanical ventilation will die within a year, according to a 2010 review. Only a small minority will ever go home without needing significant caregiver assistance. For those over age 65, the prognosis is even worse. It seems rude, or even cruel, [… read more]
Mechanical Ventilation in ARDS: Overview Mechanical ventilation in ARDS is almost always required, as people with acute respiratory distress syndrome are by definition severely hypoxemic. Yet mechanical ventilation itself can further injure damaged lungs(so-called ventilator induced lung injury); minimizing any additional damage while maintaining adequate gas exchange (“compatible with life”) is the central goal of mechanical [… read more]
(image: flickrCC) Do protocols make trainees’ brains go soft? That’s the assertion of more than a few crusty hard-liners who miss the good old days — when you got 2-liter tidal volumes for your ARDS and liked it, dad-gum-it!! Prasad et al can’t say whether critical care fellows can actually run ventilators in the post-protocol [… read more]
An observational trial by Jim Kutsoguiannis, Cathy Alberda, Daren Heyland et al published in the December 2011 Critical Care Medicine showed no difference in 60-day survival among critically ill, mechanically ventilated patients started on parenteral nutrition (TPN) “early” (within 48 hours of ICU admission) or “late” (after 48 hours). Only 258 patients were included in the [… read more]
Diaphragmatic dysfunction can result from nerve damage, primary muscle problems, or problems with the muscle’s interaction with the chest wall. The true incidence of diaphragmatic paralysis is unknown, since many patients are asymptomatic. Treatment for diaphragmatic dysfunction usually consists of watchful waiting, addressing underlying causes, with mechanical ventilation if respiratory failure develops. Causes of Diaphragmatic [… read more]
It wasn’t such a crazy idea, injecting beta-agonists continuously into the veins of people with acute respiratory distress syndrome (ARDS) for a week. After all, if you spray some albuterol on alveolar epithelial cells in a dish, it upregulates their cAMP production and doubles the rate at which they clear fluid across their basement membranes. [… read more]
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