Ciclesonide, a new inhaled corticosteroid that seems to cause thrush less often than others, reached for equivalency with salmeterol/fluticasone in mild persistent asthma. Ciclesonide was better than placebo in controlling asthma but Advair users had a longer time to first asthma exacerbation. CHEST 2011;139: online supplement. A Cochrane review on ciclesonide could not establish its [… read more]
In a very small trial (n=24), inhaled RNA (ALN-RSV01) appeared to improve outcomes in lung transplant patients with RSV respiratory infections, by interfering with viral replication. Symptoms were reduced, and at 90 days, incidence of bronchiolitis obliterans syndrome was 6% vs 50% in the control group. AJRCCM 2011;183:531-538.
Patients with on-site evaluation of TBNA samples had fewer sites sampled (1 vs. 2) and general complications (6% vs. 20%), with an equivalent yield compared to patients undergoing usual TBNA (n=168). CHEST 2011;139:395-401.
12 months of nebulized gentamicin (80 mg bid) markedly reduced symptoms, exacerbations, and bacterial density in people with bronchiectasis from causes other than cystic fibrosis. None of these benefits were sustained after 3 months without therapy, though. (n=65). AJRCCM 2011;183:491-499.
Louie et al report results of a phase 3 industry-funded trial of fidaxomicin, a poorly absorbed oral macrolide that’s bacteriocidal vs C. difficile. The new drug was equivalent to oral vanco in curing C.diff infections (~90%), and superior at preventing recurrences (~14% vs 24%). It did not prevent recurrences of the more lethal and increasingly [… read more]
Inspiratory muscle training in COPD: Gosselink R, ERJ 2011;37:416-425.
The hygiene hypothesis got a boost from Ege et al, who analyzed dust from 16,000 European children’s bedrooms and mattresses (stored with clinical/demographic data in two huge repositories, GABRIELA and PARSIFAL), for bacterial DNA or growth on bacterial/fungal culture media. Children living on farms had odds ratios for asthma of 0.49 to 0.76, compared to [… read more]
ICU patients have a 5-10% risk of deep venous thrombosis, even with appropriate prophylaxis. Ultrasound screening can detect many of these asymptomatic and clinically unsuspected DVTs. However, since many DVTs disappear without incident, and complications can result from additional testing and treatment with anticoagulation, and all of this costs money, the best approach to prevention [… read more]
Priou et al followed 130 patients with OHS after initiation with noninvasive positive pressure ventilation. Mean follow up was 4 years. Most (96) were started on NPPV in the stable state; 38 had had an acute hypercapneic exacerbation. Survival at 1 year was 97.5%; 2 years (93%); 3 years (88%); 5 years (77%). The large [… read more]
In case there was any question, no you can’t use the femoral vein to collect ScvO2 samples. Davison et al found a bias of 4% between femoral and nonfemoral sources in 39 critically ill patients (with an interestingly wide standard deviation of 12% in blood obtained from either source). In more than half the patients, [… read more]
Cavallazzi et al reviewed 10 cohort studies and concluded that compared to daytime admission, being admitted to an ICU at night did not increase the odds ratio for mortality. Being admitted on a weekend supposedly did, but the odds ratio was only 1.08. CHEST 2010;138:68-75. FREE FULL TEXT
Meade MO et al. (Lung open ventilation study investigators) Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2008; 299:637-45. Higher PEEP provided no benefit in 28-day mortality (28 vs 32%, p = 0.2), although it reduced refractory hypoxia (~5% [… read more]
Brower RG et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 2004;351:327-36. Randomized trial among 549 patients with ARDS/ALI conducted by NHLBI/ARDSNet. Compared high and low PEEP strategies, and found no significant difference in mortality, ventilator-free days, ICU-free days, or organ failure-free days between [… read more]
Herridge MS et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med. 2003; 348:683-93. Non-pulmonary problems are usually dominant in impairment of ARDS survivors. Low exercise tolerance, fatigue, and weakness are common a year after discharge. Pulmonary function tests usually normalized, other than a diffusion impairment. At 12 months, only 6% [… read more]
ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for ALI and ARDS. N Engl J Med 2000;342:1301-8. The ARMA study found the use of low (6 ml/kg predicted weight) rather than “standard” (12 ml/kg predicted weight) tidal volumes reduced mortality from 40 to 30%. This paper established the standard of low [… read more]
Ultrasound in the ICU: Case 1 Discussion Go Back to Ultrasound Case 1 Ultrasound Case 1 Answer: Hypovolemia. Hypotension may be caused by diverse pathophysiologic states that are hard to differentiate by clinical exam. Bedside ultrasound can provide immediate visual information that can help to rapidly make diagnoses of life-threatening conditions, without dependence on radiology [… read more]
Hudson LD et al. Clinical risks for development of ARDS. Am J Respir Crit Care Med 1995;151:293-301. Incidence of ARDS in patients with various risk factors. Showed that ARDS develops within 48 to 72 hours of the time clinical risk is identified in the vast majority of patients.