Once upon a time in 1964, it was noted that propranolol, a nonselective beta-blocker, could precipitate severe bronchospasm in patients with asthma, especially at high doses. Additional small studies showed propranolol and other nonselective beta blockers could increase airway resistance. British guidelines advise avoiding beta blockers in asthma generally. As a result, beta blockers are [… read more]
Because coagulopathies (an impairment of blood clotting), thrombotic states, and bleeding are all interrelated through the coagulation cascade, and because they occur often in critically ill patients, it makes sense to consider these bleeding and clotting disorders together. Don’t correct coagulopathies in critical illness unless there is a specific reason (e.g., bleeding or an upcoming [… read more]
Community-acquired pneumonia (CAP) is “ordinary” pneumonia, usually (but not always) caused by one of a short list of pathogens susceptible to common antibiotics. Pneumonia remains one of the main reasons for hospital admissions, and causes an estimated 3.5 million deaths yearly, including more than 50,000 in the U.S. Catching pneumonia also increases the risk for [… read more]
Resuscitation fluids may be the most common intervention in critical care, with more than 200 million liters of normal saline infused each year in the U.S. alone. However, there is scarce evidence to guide the best use of resuscitation fluids in the ICU. John Myburgh and Michael Mythen’s review article in the September 26 2013 [… read more]
Blogger Peer Review Corrects NEJM Article’s Error In June 2013, PulmCCM unquestioningly reported the results of a major randomized trial in the New England Journal of Medicine by Susan S. Huang et al, showing that decontaminating patients upon arrival to the ICU with chlorhexidine baths and nasal mupirocin resulted in a dramatic drop in nosocomial infections [… read more]
Welcome to issue #1 of the Critical Care Roundup, a new occasional feature on PulmCCM. Here we’ll touch briefly on all the interesting stuff there wasn’t time to thoroughly review. Got a study that should go in the next roundup? Post a link in the comments or by emailing [email protected] Or, browse all the PulmCCM [… read more]
Image: Dartmouth Nitric Oxide: No Benefit Even in Severe ARDS Giving inhaled nitric oxide to people with acute respiratory distress syndrome (ARDS) improves oxygenation, but has never been demonstrated to improve survival. Not many physicians seem to use nitric oxide for ARDS anymore, except possibly as salvage therapy in life-threatening refractory disease. Even that well-meaning [… read more]
The new USPSTF lung cancer screening guidelines are about to produce an enormous wave of abnormal chest CTs, with suspicious pulmonary nodules in millions of current and former U.S. smokers. Many will be surgically removed, and thousands of people will be saved from premature death from lung cancer. That’s great news — mostly. Less widely [… read more]
Dear colleagues, I am excited to announce the launch of PulmCCM Journal, a new online, open access, peer-reviewed journal serving the practicing physician in critical care and respiratory medicine. PulmCCM Journal’s primary mission will be publishing high-quality, highly useful reviews of important clinical topics to improve decision-making and the quality of care worldwide. Case reports, [… read more]
Delirium — sudden, severe confusion that occurs with acute illness — is very common in ICU patients. As a group, patients experiencing delirium in the ICU tend to have worse outcomes than patients without delirium, all other things being equal (as far as that equality can be determined). But no one knows if it is [… read more]
Intensive insulin therapy for critically ill adults was rapidly adopted as standard care after 2001 when an apparent benefit was established after cardiac surgery, then medical ICU patients. Eleven years later, after a wave of minor harm signals, the NICE-SUGAR study confirmed for most intensivists that the excess hypoglycemia from intensive glucose control was potentially lethal in adults, and [… read more]
After a stupefying amount of research on vitamin D — with 70 vitamin D studies published in PubMed in January 2014 alone — there is no consistent signal tying vitamin D supplementation to improvement in any health condition. A recent “futility analysis” (a form of meta-analysis) of 40 randomized trials suggests vitamin D does not [… read more]
Pain, agitation, and delirium are all extremely common in ICU patients–so much so that they’ve been termed the “ICU triad.” No one knows exactly how common each is, because ICU patients are often too delirious to complain of pain; or their agitation hides their delirium; or their unidentified pain may cause their agitation; or …. [… read more]
On-site, intra-procedure cytopathologic examination of aspirated tissue during transbronchial needle aspiration (either by EBUS or “blind” approach) is probably helpful during bronchoscopy. Why wouldn’t it be? You’ve got a trained professional there to tell you when you’ve made the diagnosis and can stop taking biopsies. Diagnostic yield should go up, complications down. Randomized trials have [… read more]
Last year, PulmCCM reported on the TIOSPIR safety trial comparing the Spiriva dry-powder HandiHaler against the Respimat mist-delivery device. TIOSPIR showed no difference in all-cause mortality or composite cardiovascular risk endpoints between either Spiriva preparation. But this week, a group of drug safety researchers report their granular analysis of TIOSPIR data shows the Respimat device [… read more]
For the 7th edition of our Annual Symposium, we’ve assembled a great cast of characters to bring your bedside ultrasound game to a whole new level! Whether you’re a novice or have some experience in bedside ultrasound, we’re sure you’ll find our program very interesting, as the perspective we have chosen to take is patient-based, [… read more]
Choosing Wisely is an initiative of the American Board of Internal Medicine (ABIM) with the stated goal of “promoting conversations between physicians and patients by helping patients choose care that is supported by evidence, not duplicative, free from harm, and truly necessary.” Sounds good, huh? Politically, ABIM’s Choosing Wisely demonstrates to policymakers responsible self-governance by us [… read more]
It’s official: the U.S. Preventive Services Task Force (USPSTF) announced its formal recommendation for yearly low-dose chest CT screening for lung cancer in high-risk individuals on December 30, 2013. The final grade B recommendation (“Suggestion: offer or provide this service”) was virtually unchanged from the draft recommendations the USPSTF made in July 2013. It advises [… read more]
Acute bronchitis with cough is overwhelmingly often due to viral infection, but that doesn’t stop coughers from seeking antibiotics, or their doctors from obligingly prescribing them. Most patients who ask for antibiotics get them, and the millions of excess antibiotic doses worldwide each year are believed to contribute to rising antibiotic resistance. Doctors seem almost [… read more]
Blair Westerly, MD Effective treatment for idiopathic pulmonary fibrosis continues to elude patients and clinicians alike. Multiple classes of medications have been studied, none with convincing data demonstrating efficacy. Because of the proposed contribution of endothelin-1 to the pathogenesis of IPF, receptor antagonists of this growth factor have previously been evaluated in IPF, but with [… read more]
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