Randomized Controlled Trials

Mar 082019
 
How should we relate to "unreasonable" families in the ICU?

Most families have never suffered through a loved one experiencing prolonged critical illness and respiratory failure (defined as ventilator dependence for weeks, usually with a tracheostomy). But each year, more do. An estimated 400,000 people currently live with chronic critical illness in long-term acute care hospitals (LTACHs) and other facilities — a population that has [… read more]

Feb 232019
 
Should We Stop Trending Lactate in Septic Shock?  ANDROMEDA-SHOCK Published

Jon-Emile S. Kenny MD [@heart_lung] “The truth is balance, but the opposite of truth, which is unbalance, may not be a lie.” -Susan Sontag Case A 49 year old man presents with two days of hemoptysis, right-sided pleuritic chest pain and a few hours of ‘confusion’ according to his teammate in a pick-up hockey league.  One [… read more]

Feb 212019
 
Theophylline as add-on therapy was no use in preventing COPD exacerbations

Theophylline is derived from methylxanthine, naturally present in tea and cocoa beans. Initially used medically in 1895 as a diuretic, theophylline was one of the first drugs for asthma and COPD/emphysema (beginning in 1922), after its bronchodilation effects were discovered. Theophylline also has cardiac and central nervous system stimulant side effects and can produce tachyarrhythmias [… read more]

Feb 172019
 
Cricoid pressure no help during endotracheal intubation in large trial

Pressing fingers against the cricoid cartilage (the Sellick maneuver) during rapid sequence intubation compresses the esophagus beneath the firmer trachea. It has long been espoused that this prevents aspiration (emesis or reflux of gastric contents into the supraglottic space and airway, obscuring the operator’s view and harming the patient). The Sellick maneuver is believed to [… read more]

Feb 082019
 
Decontaminating patients did not reduce bloodstream infections

A large proportion of patients who remain in ICUs for more than a few days develop hospital-acquired infections, including bloodstream infections. Indwelling urinary or venous catheters, gut translocation, aspiration and impaired host defenses can all be causative. Bloodstream infection incidence has been reduced over time, but remains persistently ineradicable. One enticing method of prevention has been [… read more]

Jan 242019
 
For most critically ill patients, a 'starvation diet' seems just fine (TARGET trial)

Very little evidence guides nutrition in critical illness. Because of critically ill patients’ catabolic state, and probably influenced by the normalization fallacy, nutrition practices often include efforts to provide daily calories in the 1,800 – 2,000 range. However, anorexia may be adaptive during illness (since it is common to multiple disease states); greater enterally infused [… read more]

Jan 012019
 
Best of 2018 on PulmCCM

Best of 2018:       Prone positioning for severe ARDS advised by major societies    2018 Update to Surviving Sepsis Guidelines: Cue Backlash   Management of Ground Glass and Subsolid Pulmonary Nodules: Review   Vasopressors and Inotropes for Shock Syndromes: Review     Prophylactic Precedex prevented delirium in ICU patients   Corticosteroids do help [… read more]

Dec 162018
 
Dupilumab as add-on biologic improved allergic asthma outcomes

by Salynn Boyles, Contributing Writer, MedPage Today  SEATTLE — Add-on treatment with the biologic therapy dupilumab (Dupixent) was associated with reduced severe exacerbations and improved lung function in patients with allergic asthma in a post-hoc analysis of phase III data from the Liberty Asthma Quest study reported here. The analysis compared outcomes in patients with allergic disease versus those [… read more]

Dec 072018
 
Could anti-reflux surgery slow idiopathic lung fibrosis?

by Diana Swift, Contributing Writer, MedPage Today Laparoscopic anti-reflux surgery deserves further investigation for prevention of idiopathic pulmonary fibrosis (IPF) progression in some patients with gastroesophageal reflux disorder (GERD), after favorable results were seen in a phase II study. Known as the WRAP-IPF trial, the study found GERD surgery was safe and well tolerated, with fewer serious adverse [… read more]

Nov 292018
 
Delay renal replacement in severe sepsis with acute kidney injury: IDEAL-ICU

Another large study suggests that there is no benefit to early initiation of renal replacement therapy (RRT) in patients with severe sepsis with septic shock and acute kidney injury (AKI). And many patients whose renal replacement was delayed recovered sufficient kidney function to avoid dialysis entirely. Because AKI is associated with worse outcomes in critical [… read more]

Nov 102018
 
Intubation or bag-mask ventilation: Outcomes similar for cardiac arrest patients

Well-done bag-mask ventilation can produce adequate gas exchange for the vast majority of cardiac arrest patients, but does not provide a secure airway and is physically taxing. Patients in cardiac arrest undergoing CPR tend to immediately receive bag-mask ventilation, which is often interrupted to perform endotracheal intubation. To facilitate intubation, chest compressions may also be [… 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 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]

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]

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 122018
 
Increasing inhaled steroids to abort asthma attacks: does it work?

When patients with asthma feel their symptoms worsening and fear a full-blown exacerbation is imminent, what should they do? Doctors and researchers have never found a good answer to this question for most patients. The options are, generally: 1) continue current controller inhalers and observing; 2) increase the dose of inhaled steroid inhalers; or 3) [… read more]

Aug 032018
 
Scheduled nebulization with acetylcysteine didn't help ventilated patients

by Salynn Boyles, Contributing Writer, MedPage Today Regular nebulization proved to be no more effective than nebulization on demand in a randomized trial involving critically ill patients receiving invasive ventilation, researchers reported. Among ICU patients expected to need invasive ventilation for at least 24 hours, scheduled nebulization four times a day involving acetylcysteine with salbutamol did not [… read more]