Nov 042018
 
Don't use procalcitonin to withhold antibiotics in severe COPD exacerbations

Procalcitonin (PCT) is an FDA-approved test for use in guiding clinical decisions on starting, continuing, or stopping antibiotics in patients with lower respiratory tract infections, such as community-acquired pneumonia. Procalcitonin is also approved for use in determining whether to stop antibiotics. Most of the small studies testing procalcitonin-driven algorithms have shown the method to be generally safe [… read more]

Oct 302018
 
Point of Care Ultrasound Unhelpful in Undifferentiated Hypotension? The SHOC-ED trial & the 'Tale of the Eighth Mare'

Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD [@_carlemd_] “History does not repeat itself, but it often rhymes.” -Mark Twain Case An 89 year old man with a 100 pack-year smoking history is admitted with weakness and inability to take anything by mouth.  He was discharged 2 months prior after a treatment [… read more]

Oct 242018
 
FDA approves dupilumab, injectible biologic, for eosinophilic asthma

The US Food and Drug Administration (FDA) approved dupilumab (Dupixent, Sanofi/Regeneron) as “add-on maintenance therapy in patients with moderate-to-severe asthma aged 12 years and older with an eosinophilic phenotype or with oral corticosteroid-dependent asthma,” according to the manufacturer’s news release. In randomized trials, asthmatic patients with higher blood eosinophil counts (≥ 150 cells/µL) failing corticosteroid [… read more]

Oct 232018
 
Antipsychotics don't help in ICU delirium: MIND-USA

Neither typical antipsychotics (haloperidol) or newer antipsychotics (ziprasidone) were effective in treating delirium in critically ill patients, in a major randomized trial. The results call into question widely used pharmacologic treatments for ICU delirium. Authors enrolled 1,183 adult patients at medical or surgical ICUs at 16 U.S. medical centers who developed delirium while critically ill [… read more]

Oct 172018
 
Seven days (or fewer) of corticosteroids advised for severe COPD exacerbations: GOLD

How many days of steroids should be taken by people with COPD exacerbations severe enough to require hospitalization? In 2013, the REDUCE trial (JAMA) suggested five days of systemic corticosteroids are as good as longer 10-14 day courses, among 314 patients hospitalized with severe COPD exacerbations. This contradicted the prevailing GOLD guidelines at the time, [… read more]

Oct 162018
 
Near Apneic Ventilation & Extracorporeal Membrane Oxygenation: close the lungs & keep them closed?

Jon-Emile S. Kenny MD [@heart_lung] “Once had a love and it was a gas …” -Blondie Case A 56 year old professor returns from a hiking trip in the ‘Four Corners’ area of New Mexico.  She was previously well and decided to rent a secluded desert cabin whilst writing a novel on the ethical obligations [… read more]

Oct 142018
 
Procalcitonin strategy in the ED did not reduce antibiotic use (ProACT)

Procalcitonin-driven algorithms did not lead to lower antibiotic use for suspected pneumonias in the emergency department, in a large randomized trial. The multicenter ProACT trial enrolled 1,656 patients presenting with symptoms of pneumonia at multiple emergency departments. Patients were randomized to receive care guided by procalcitonin results (with thresholds to guide initiation or withholding of antibiotics), [… read more]

Oct 042018
 
Targeting normal oxygen saturation associated with death: meta-analysis

A new meta-analysis adds to the evidence that liberal use of supplemental oxygen may be harmful in acutely ill, hospitalized patients. Authors performed a meta-analysis of 25 randomized trials of acutely ill patients (total n ~ 16,000) treated with strategies of either “low” or “high” supplemental oxygenation. Although the cutoffs varied between studies, patients receiving [… read more]

Oct 022018
 
Dentists may be at high risk for idiopathic pulmonary fibrosis, data suggest

The CDC warned in its Morbidity and Mortality Weekly Report that dentists may be at significantly higher risk for developing idiopathic pulmonary fibrosis, compared to the general population. In a sample of 894 patients with IPF with records over 20 years at a Virginia specialty clinic, CDC discovered that 8 dentists (and one dental technician) [… read more]

Sep 282018
 
2018 IDSA Guidelines for Clostridium Difficile Infection: fecal transplant gets its moment in the sun

Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD [@_carlemd_] “My reputation’s never been worse, so …” -Taylor Swift Case A 54 year old woman with lupus nephritis – treated with mycophenolate mofetil and prednisone – is admitted with pancytopenia and worsening confusion.  She was recently discharged after receiving levofloxacin and clindamycin [… read more]

Sep 262018
 
Endobronchial valves now FDA approved for severe COPD

In the lungs of patients with severe emphysema (COPD), relatively large spaces previously containing lung tissue (obliterated by smoking) become filled with stagnant air that doesn’t circulate with breathing. This ominously-named “dead-space ventilation” reduces the overall mechanical efficiency of breathing, often causing disabling dyspnea. Lung volume reduction surgery (cutting out the dead space, usually at [… read more]

Sep 172018
 

by Salynn Boyles, MedPage Today Contributing Writer Treatment with the first approved once-daily, single inhaler triple therapy for COPD resulted in a significantly lower rate of exacerbations, as well as better lung function and quality of life compared to dual therapy in patients with a history of exacerbations, researchers reported. Results from the huge IMPACT trial supported an [… read more]

Sep 132018
 
ECMO fails as first-line treatment for ARDS. Or did it?

Extracorporeal membrane oxygenation (ECMO) is an accepted salvage therapy for severe acute respiratory distress syndrome (ARDS) after conventional mechanical ventilation with low tidal volumes, neuromuscular blockade and prone positioning have failed. ECMO has been proposed as the ultimate lung protection strategy for ARDS, because it bypasses the lungs entirely. So why shouldn’t it be first-line [… read more]

Sep 132018
 
New MRI technology could predict outcome after cardiac arrest

Brain damage with severe cognitive and functional impairment are common after cardiac arrest, but far from universal. Even after thorough testing, most comatose patients receive an indeterminate neurologic prognosis post-arrest. Physicians faced with this uncertainty have a difficult task in counseling family members trying to make decisions to maximize their loved one’s chances for recovery [… read more]

Sep 082018
 
High Flow Oxygen in Chronic Obstructive Pulmonary Disease: improved work of breathing or respiratory effort?

Jon-Emile S. Kenny MD [@heart_lung] “WANTED: Somebody to go back in time with me.  This is not a joke …” -John Silveira Case A 78 year old man with known moderate-to-severe emphysema is extubated in the ICU; he was initially admitted with hypercapneic respiratory failure secondary to influenza pneumonia and pulmonary edema from the medical [… read more]

Sep 052018
 
Subsegmental pulmonary embolism: anticoagulation or observation?

As the use of chest CT-angiograms in emergency departments and medical wards has risen by more than tenfold, so has the discovery of small pulmonary emboli of unclear clinical significance. These PEs are often isolated to distal (subsegmental) branches of the pulmonary artery, without concurrent deep venous thrombosis (DVT). Small distal PEs may be incidentally [… read more]

Aug 282018
 
Simvastatin & Hyper-inflammatory ARDS: re-analysis of the HARP-2 trial

Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD “For others, in spite of myself, from myself.” -Emmanuel Levinas Case A 52 year old man is admitted to the intensive care unit with bilateral pulmonary opacities, worsening gas-exchange and hypotension requiring peripherally-administered norepinephrine.  His PaO2-to-FiO2 ratio is less than 100; he is [… read more]

Aug 192018
 
Seven days of antibiotics were as good as 14 for gram-negative bacteremia

Two-week antibiotic courses have been considered standard care for most patients with bacteremia who do not have sepsis or an untreated primary source (e.g. endocarditis). No good evidence ever supported the practice, which was supported mainly by retrospective data in patients with sepsis. A new study suggests that treating gram-negative bacteremia for seven days is [… read more]

Aug 192018
 
Aspirin Appears Protective in COPD Patients

by Ed Susman, Contributing Writer, MedPage Today SAN DIEGO – Patients diagnosed with chronic obstructive pulmonary disease (COPD) who are also on aspirin therapy appear to have a lower rate of COPD exacerbations, researchers reported at the annual conference of the American Thoracic Society. The risk of experiencing any acute exacerbation of COPD was reduced by 18% among [… read more]