The following is a guest post from Dr. Jonathan Weiss; the views expressed are his own. Submit your own guest post to PulmCCM, and be heard by thousands of your colleagues. Maintenance of Certification: Good or Bad? Dear Colleagues, A short history lesson: For years, physicians, upon completing a residency or fellowship, went through a [… 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]
Feds to Big Tobacco on Cigarette Labeling Fight: “Uncle!” The feds are admitting defeat for now in their fight for graphic, negative imagery to be displayed on all cigarette packaging and advertisements. Attorney General Eric Holder announced yesterday that the Justice Department will not ask the Supreme Court to reverse their loss in a federal [… read more]
Bactrim/Septra for Idiopathic Pulmonary Fibrosis? by Brett Ley, MD Idiopathic pulmonary fibrosis (IPF) is a fatal fibrotic lung disease that lacks proven, effective treatments. Many novel medications have been trialed and painfully failed. So I commend Ludmila Shulgina and colleagues for trying an old medication, trimethoprim-sulfamethoxazole (TMP-SMX), with some preliminary evidence for potential benefit. What [… read more]
FDA Warns of Sudden Cardiac Death Risk from Azithromycin Last summer, PulmCCM reported on a New England Journal paper suggesting an increased risk of sudden cardiac death in patients taking even a short 5-day course of azithromycin. Yesterday, the FDA expressed its official concern in a Drug Safety Communication and statement to the press on [… 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]
Fecal Transplants Cure C. difficile Infections, When Drugs Can’t Antibiotics are what cause Clostridium difficile infection to emerge in the first place, so it’s perhaps no surprise that the usual treatment — more antibiotics — often fails. From 15-25% of patients with C. difficile are not permanently cured by their initial treatment with metronidazole, and among those [… 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]
Intubation for Out-of-Hospital Cardiac Arrest May Harm, Not Help by Blair Westerly, MD Out of hospital cardiac arrest is a major public-health problem, and despite advances in care, survival is still low. Improved survival has been associated with early CPR, rapid defibrillation, and integrated post cardiac arrest care, but pre-hospital “advanced airway management” (i.e., intubation [… read more]
Time to Retire Routine Replacement of Peripheral IVs Study question: Do peripheral I.V.s need to be changed every 72-96 hours per the CDCs recommendations or can they be changed as clinically indicated? How many times as a resident did you receive a call at 4 a.m., often at the very moment you were about to [… read more]
Pulmonary Hypertension 2013 Update/Review Part 2 of 2: Treatment of PH Read Part 1: Diagnosis and Classification of Pulmonary Hypertension by Brett Ley, MD There are 3 classes of pulmonary vasodilator drugs: phosphodiesterase-5 inhibitors (PDE-5 inhibitors, e.g. sildenafil, tadalafil), endothelin receptor antagonists (ERAs, e.g. bosentan, ambrisentan), and prostacyclins (epoprostenol, iloprost, treprostinil). Because the large trials [… read more]
Blood Transfusion: Deadly for GI Bleeds? You read the headline right: in a randomized trial published in the New England Journal of Medicine, liberal blood transfusions (to a hemoglobin of 9 g/dL) seemed to harm people with acute upper gastrointestinal bleeding, as compared to transfusing when hemoglobin fell below 7 g/dL. People with mild to moderate [… read more]
Pulmonary Hypertension Update/Review Part 1 of 2: Classification and Diagnosis Read Part 2: Treatment of PAH by Brett Ley, MD Pulmonary hypertension (PH) is defined simply as a mean pulmonary artery pressure of 25 mmHg or greater. However, this entity encompasses a heterogeneous group of patients and underlying etiologies where accurate diagnosis, correct physiologic classification, and careful evaluation for [… read more]
Visual learners can see continuous positive airway pressure (CPAP) work for obstructive sleep apnea in realtime in this NEJM video. But how on earth does someone sleep inside an MRI machine? See the Sleep Apnea Video
Etomidate: Unsafe for Intubation in Patients with Sepsis? by Blair Westerly, MD Etomidate is commonly used for rapid sequence intubation; however, even after one dose, it has been associated with adrenal axis suppression in critically ill patients. Though both adrenal insufficiency and increased mortality in sepsis have been associated with etomidate, the relationship of the [… read more]
In Most Patients with Pulmonary Embolism, Central Clot is Worse than Peripheral by Brett Ley, MD Pulmonary embolism (PE) presents with a wide range of clinical severity and course. Management decisions (level of care, length of observation, and aggressive therapies such as thrombolysis) are generally based on a patient’s risk of a poor outcome. Guidelines recommend risk [… read more]
Continuing Selective Beta Blockers Safe During COPD Exacerbations by Blair Westerly, MD Many COPD patients also have congestive heart failure or ischemic heart disease, two conditions where beta blocker therapy improves survival, but it has consistently been underutilized. The fear physicians have of instituting beta blockers in COPD is mostly secondary to the theoretical concern [… read more]
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