Dec 082017
 
FDA Approves First Nebulized LAMA for COPD

by Salynn Boyles, Contributing Writer, MedPage Today The FDA approved a nebulized formulation of glycopyrrolate (Lonhala Magnair) for long-term maintenance treatment of patients with moderate-to-severe COPD, said manufacturer Sunovion Pharmaceuticals. It’s the first long-acting muscarinic antagonist (LAMA) to be sold in this form. Recommended dosing is 25 mcg twice daily. The approval was made on the strength [… read more]

Dec 022017
 
A Great Lecture on Applied Respiratory Physiology

Jon-Emile S. Kenny MD [@heart_lung] -What is the world record for longest breath hold? -Why does the diagnosis of brain death require a rise in PaCO2 to at least 60 mmHg? -What minute ventilation can a human achieve? -What’s the difference between an elevated PaCO2 in someone who ‘won’t’ versus ‘can’t’ breathe? I’d like to [… read more]

Dec 012017
 
Should patients watch videos of CPR before code status decisions?

Physicians and patients alike tend to avoid frank discussions about “code status” — whether a patient would want CPR or mechanical ventilation in the event of a cardiac or respiratory arrest. When doctors address code status at all, they tend to phrase the questions in such a way to cut off any thoughtful discussion: “If [… read more]

Nov 262017
 
Sepsis, Diastolic Dysfunction & Hypernatremia

Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD “… And you may ask yourself … well, how did I get here? … And you may tell yourself … my God!  What have I done?” -David Byrne A 92 year old woman is transferred to the coronary care unit for treatment of pulmonary edema.  She [… read more]

Nov 192017
 
Oral steroids don't improve cough due to colds (but are prescribed anyway)

Oral corticosteroids are frequently prescribed for persistent cough after the common cold in patients without respiratory disease. Like much of what physicians offer or advise, steroids for ordinary cough are traditionally provided not based on evidence, but on the premise that “it might help.” A new study in JAMA substantially undermines that premise. Authors randomized [… read more]

Nov 192017
 
Should intensivists routinely perform bedside echos in suspected PE?

In pulmonary embolism (PE), right ventricular (RV) strain on transthoracic echocardiography increases the likelihood of shock and mortality. One study showed among patients with PE and normal blood pressure, 10% of those with RV strain on echocardiogram developed shock, and 5% died in hospital. Those without RV strain maintained their blood pressure and survived (but important [… read more]

Nov 112017
 
DIPSHIS in the ICU: An emerging phenomenon?

This would be a very informative case report (and it’s true and unexaggerated), but I anticipate staunch editorial resistance (even sans puns), so I’ll describe it here and have some fun with it. Background:  The author has anecdotally observed for many years that so-called “septic shock” follows rather than precedes intubation and sedation.  This raises [… read more]

Nov 112017
 
ICU Physiology in 1000 Words: Venous Excess & the Myth of Venous Return

Jon-Emile S. Kenny MD [@heart_lung] In the last few weeks I have been contacted by curious clinical physiologists craving my conceptions of ‘venous excess’ [1].  These words will address this model, concisely and – I pray – clearly. The Myth of Venous Return The roots of venous excess took hold within the fertile soil of [… read more]

Nov 092017
 
FDA approves new phrenic nerve stimulator for central sleep apnea

The US Food and Drug Administration (FDA) approved an implanted phrenic nerve-stimulator device as a new treatment for moderate-to-severe central sleep apnea (CSA). The remedē System (Respicardia) consists of a pacemaker-like battery pack that’s surgically implanted in the upper chest beneath the skin. Wires electrically stimulate the phrenic nerve as it travels from the neck [… read more]

Nov 032017
 
Mepolizumab reduced exacerbations in COPD with eosinophilia, but missed target

The injectible monoclonal antibody mepolizumab (Nucala, GSK) is FDA-approved for severe asthma with blood eosinophilia, uncontrolled with standard controller inhaler treatments. Two randomized placebo-controlled trials keep alive for GSK the possibility of an FDA indication to reduce exacerbations in people with chronic obstructive pulmonary disease (COPD) with high blood eosinophil counts, expanding the drug’s market. The ~1,500 [… read more]

Nov 012017
 
Doctors aren't complying with the CMS sepsis quality measure

When the Centers for Medicare and Medicaid Services (CMS) released its 2015 performance measure for the treatment of sepsis — called SEP-1 or the Severe Sepsis/Septic Shock Early Management Bundle, physicians responded with general befuddlement: the measure demanded they follow such unusual practices as giving 3-liter boluses of saline to anuric, hypertensive, hypoxemic patients with [… read more]

Oct 282017
 
Home BiPAP reduced readmissions after COPD exacerbations

Acute exacerbations of chronic obstructive pulmonary disease (COPD) are one of the top causes of hospital admission — and readmission: up to 30% of patients “bounce back” to the hospital within 90 days after a COPD exacerbation. Patients with severe COPD exacerbations with acute hypercapneic respiratory failure often receive noninvasive ventilation (NIV), commonly known as [… read more]

Oct 252017
 
Empiric micafungin didn't save lives in ICU-acquired sepsis

The antifungal micafungin is often given empirically to patients in ICUs with sepsis who are also at high risk for invasive fungal infections. IDSA guidelines endorse the use of empiric antifungals for patients with unresolving ICU-acquired sepsis, but any benefits of this are unknown. A randomized trial published in JAMA sheds light on the practice. French [… read more]

Oct 202017
 
Pain Control and Sedation in Mechanically Ventilated Patients: Review

Treating Pain in Mechanically Ventilated Patients Adult patients in the intensive care unit (ICU) frequently experience pain, resulting from acute and chronic illness as well the positioning and interventions standard to ICU care.1,2 Besides being ethical and humane, adequately treating pain prevents agitation and delirium in mechanically ventilated patients. There are also many physiologic responses to [… read more]

Oct 192017
 
ICU Physiology in 1000 Words: Fighter Pilots!

Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD Pilots of high-performance, tactical fighter jets each have continuous positive airway pressure [i.e. CPAP] masks as a part of their flight suit.  Strikingly, beyond the clinically-commonplace airway pressure of 5-15 cm of H2O, a fighter pilot may endure a mask-applied pressure of 90 [… read more]

Oct 132017
 
Don't give Kayexalate within 3 hours of other drugs, says FDA

The FDA is warning physicians not to provide other enterally-absorbed drugs within 3 hours before or after giving sodium polystyrene sulfonate (Kayexalate, Concordia Pharmaceuticals) for hyperkalemia. In testing performed 59 years after its launch, it was discovered that Kayexalate can bind to many prescription drugs, potentially rendering them ineffective. For patients with gastroparesis or ileus, FDA [… read more]

Oct 122017
 
Age of transfused red cells had no effect on mortality (TRANSFUSE)

U.S. medical centers vary widely in the average shelf life of the blood in their blood banks. Trauma and high-volume surgical centers receive the oldest blood from the Red Cross, on the premise that they’ll be likely to transfuse it. All blood banks tend to dispense the oldest units first. This reduces waste of donated [… read more]