Jon-Emile S. Kenny MD [@heart_lung] In the previous segment, time constants [t] – and their limitations – were described as a lesson in applied respiratory physiology for setting T-Low and prediction of auto-PEEP in airway pressure release ventilation [APRV]. In this brief missive an alternative approach to titrating T-low is described and critiqued. As well, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] While the lung in the throes of acute respiratory distress syndrome [ARDS] is shrunken, edematous and inflamed, a basic management maneuver is to ‘recruit’ lost pulmonary surface area. In other words, unfold alveolar-capillary units with the ventilator like a respirothoracic party horn. One ‘unconventional’ method of maximizing and maintaining lung [… read more]
In their 2018 update, the Surviving Sepsis Campaign’s guidelines attempt to accelerate care delivery for sepsis, advising that within one hour, physicians and health care teams should collect blood cultures and lactate, begin 30 ml/kg fluid resuscitation for hypotension or lactatemia, and start vasopressors for selected patients. Previously, these interventions were advised within three- and [… read more]
by Crystal Phend, Senior Associate Editor, MedPage Today Thrombolytics delivered to acute proximal deep-vein thrombus (DVT) with clot removal did not reduce the risk of post-thrombotic syndrome but did raise major bleeding risk over anticoagulant treatment alone in the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) clinical trial. The proportion of patients with post-thrombotic [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “The real process of education should be the process of learning to think through the application of real problems.” -John Dewey On April 18 & 19, 2018, I had the pleasure of participating in the inaugural conference “The Hospitalist and the Resuscitationist” in Montreal. The entirety of this meeting was [… read more]
Procalcitonin (PCT) levels can be useful (although limited) in deciding whether and when to start, de-escalate, and stop antibiotic therapy in patients with suspected infection. Physicians’ use of procalcitonin in antibiotic decisions has exploded since the FDA approval of a PCT assay whose manufacturer provides specific (albeit oversimplified) cut-off values at which to consider infection [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD “Each time new experiments are observed to agree with the predictions, the theory survives and our confidence in it is increased; but if ever new observation is found to disagree, we have to abandon or modify the theory.” — Stephen Hawking A 47 [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I grow old … I grow old … I shall wear the bottoms of my trousers rolled.” -T. S. Eliot Background While it is tempting to isolate nasal high flow [NHF] into one’s cognitive schema for hypoxemia, NHF rightly deserves an esteemed position within one’s cerebral scaffolds for both hypercapnia [… read more]
Bi-level noninvasive ventilation (NIV) in patients with obesity hypoventilation syndrome (OHS) can help reverse left ventricular hypertrophy, according to a study from Spain. Patients with OHS treated with continuous positive airway pressure (CPAP) did not experience the same benefits. Bi-level NIV (commonly referred to by its most popular trade name, BiPAP) is known to improve pulmonary [… read more]
By Salynn Boyles, Contributing Writer, MedPage Today Regular aspirin use was associated with a more than 50% reduction in emphysema/chronic obstructive pulmonary disease (COPD) progression in an elderly cohort over a decade in a longitudinal analysis of data from a large lung study. The association was seen across aspirin doses, and was greatest in older study participants [… read more]
The U.S. FDA is warning physicians against prescribing the antibiotic clarithromycin to patients with coronary artery disease. In long-term follow up of a randomized controlled trial, there was an unexpectedly higher rate of death in patients who received a two-week treatment course of clarithromycin, compared to placebo. FDA has added a new warning to clarithromycin’s [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “… when you walk around a kitchen, you will say to yourself, this is interesting, this is grand, this is beautiful like Chardin.” -Marcel Proust Background Titration of positive end-expiratory pressure [PEEP] in the acute respiratory distress syndrome [ARDS] is achieved by a diverse assortment of practices undergirded by equally [… read more]
By Salynn Boyles, Contributing Writer, MedPageToday Self-taught breath retraining proved to be an effective, readily available and cost efficient strategy for improving quality of life among patients with asthma in a randomized trial. The training involved video instruction designed to teach patients breathing exercises such as diaphragmatic breathing, nasal breathing, slow breathing, controlled breath holds, and relaxation [… read more]
The combination of the antibiotics piperacillin-tazobactam and vancomycin is so often used as empirical antibiotic coverage for severe infections in hospitalized patients that it’s been dubbed “Vosyn.” Vancomycin’s nephrotoxicity is well-known, requiring close monitoring of serum levels; pip-tazo has been seen to prolong increased creatinine levels (without significant known direct nephrotoxicity). Reports have surfaced in [… read more]
Patients with septic shock who received hydrocortisone and fludrocortisone together had improved survival compared to patients receiving placebo, according to a large randomized trial (APROCCHSS) published in the New England Journal of Medicine. From 2008-2015, investigators enrolled 1,241 patients in France with septic shock for less than 24 hours to receive either hydrocortisone 50 mg [… read more]
Stress-dose corticosteroids appear safe and generally beneficial in patients with septic shock undergoing mechanical ventilation, without improving survival. That’s the takeaway from the ADRENAL trial recently published in the New England Journal of Medicine. Investigators (led by the famed ANZICS collaborative) randomized 3,800 patients with septic shock requiring mechanical ventilation in 69 medical-surgical ICUs around the [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “The truth is rarely pure and never simple.” -Oscar Wilde In part 1, the crux of this ‘Great Lactate Debate’ was distilled into the unclear origin of the proton in the setting of ‘lactic acidosis.’ Is the [H+] secondary to biochemical work and ATP hydrolysis or is the proton from [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “…. She was here on earth to grasp the meaning of its wild enchantment and to call each thing by its right name …” -Boris Pasternak Background Over the last half-decade, there has been a distinct shift in the approach to lactate elevation. The long-held belief that elevated serum lactate [… read more]
People with chronic obstructive pulmonary disease (COPD) had an increased rate of heart attacks and strokes in the first month after starting long-acting inhaled bronchodilators. That’s the conclusion of an observational study from Taiwan, published in JAMA Internal Medicine. Researchers analyzed data on 284,220 Taiwanese adults with COPD who had never used bronchodilators, and were started on [… read more]
By Scott Aberegg, M.D., M.P.H. This post is going to be an in-depth “journal club” style analysis of the PROPER trial. In this week’s JAMA, Freund et al report the results of the PROPER randomized controlled trial of the PERC (pulmonary embolism rule -out criteria) rule for safely excluding pulmonary embolism (PE) in the emergency department (ED) [… read more]
Get PulmCCM’s Weekly Email Update
Stay up-to-date in pulmonary and critical care. No spam.