Video laryngoscopy provides beautiful close-up views of the larynx, by navigating a sensor past the tongue and pharyngeal tissues that can obstruct direct laryngoscopy views. These visual advantages led to its wide adoption by anesthesiologists, emergency physicians, and intensivists after video laryngoscopy’s introduction in the late 1990s. The intuition that better visualization must result in improved intubation rates — [… read more]
Where to place a central venous catheter is a decision driven mainly by individual experience and preference. The limited evidence available has not established any site as superior; the subclavian position has been reported as being less infection-prone, but more likely to cause pneumothorax, compared to other sites. A large French randomized trial adds significantly to the evidence base. [… read more]
Three large, well-conducted randomized trials around the world (ProCESS, ARISE, and ProMISe) all agreed: use of early goal-directed therapy (EGDT) for sepsis does not improve mortality or any other important clinical outcome. The Big Three sepsis trials were a death knell for the formerly ubiquitous “sepsis bundles,” protocols based on the single-center 2001 trial of EGDT [… read more]
Therapeutic hypothermia after cardiac arrest was almost immediately accepted as standard care in 2002 when two smallish, unblinded randomized trials (n=77 and n=273) showed a significant benefit from hypothermia after out-of-hospital ventricular fibrillation cardiac arrest. Hospitals and their cardiac care units quickly adopted resource-intensive protocols to manage patients’ special needs while being cooled to an icy 33° [… read more]
Can fish oil supplements taken during pregnancy prevent asthma in children? According to a randomized trial in the New England Journal of Medicine, yes. Children of 736 pregnant women who took supplements containing given n-3 long-chain polyunsaturated fatty acid during their third trimester had a 31% relative reduction in risk of developing asthma or persistent [… read more]
In June 2009, then-President Barack Obama signed into law the Family Smoking Prevention and Tobacco Control Act, authorizing FDA to regulate the nicotine content of cigarettes. The only real limit to FDA’s new authority was a provision prohibiting FDA from “requiring the reduction of nicotine yields of a tobacco product to zero.” Prior to that [… read more]
After the Serevent Nationwide Surveillance (SNS) and SMART trials both appeared to link the use of long-acting beta agonists (LABAs) to an increased risk of asthma-related death, routine asthma care got scary. The FDA slapped a black box warning on LABAs like Serevent (salmeterol) and Foradil (formoterol) and also the combination treatments containing them (Advair, [… read more]
Cooling kids to 33ºC after resuscitation from in-hospital cardiac arrest brought no benefits compared to fever prevention (maintenance at 36.8°C), in the large THAPCA randomized trial. After one year, survival was 39% with hypothermia and 36% with management of body temperature in the normal range. There were no differences in neurologic outcomes or any other [… read more]
Oxygen is essential for life, but by forming superoxides and free radicals, supplemental oxygen can also inflict damage on lung and other body tissues. The sweet spot for oxygen delivery in critically ill patients is unknown, but increasing evidence suggests that when it comes to blood oxygen saturation during critical illness, “normal” levels might actually [… read more]
Reslizumab (CINQAIR) is a humanized, anti-IL-5 biologic agent approved by FDA in March 2016 as add-on treatment for asthma with peripheral blood eosinophilia, uncontrolled by usual treatments. In two randomized trials, reslizumab improved lung function and asthma symptoms in patients meeting these criteria. Patients without high eosinophil count in peripheral blood did not experience clinically [… read more]
When is the optimal time to initiate renal-replacement therapy in the ICU? Patients with acute renal failure (a.k.a. acute kidney injury or AKI) in the ICU experience worse outcomes than patients who do not. As the kidneys shut down, toxic electrolytes and metabolic waste products build up in the blood. Intuition says — screams, really [… read more]
Adding azithromycin to usual treatment for asthma exacerbations in adults did not improve asthma symptoms or speed their resolution, investigators reported in the AZALEA randomized clinical trial. Patients getting azithromycin also had no improvement in lung function. Azithromycin is known to have some activity against viruses that infect bronchial cells; viruses are causative or contributory [… read more]
Happy New Year! PulmCCM posts will return soon. In case you missed them, here are some of the top posts of 2016: Review: Lactate & Sepsis Recruitment Maneuvers & PEEP in the Morbidly Obese An Expected or Maladaptive Response to Infection? Sepsis Reconsidered IDSA Guidelines 2016: HAP, VAP & It’s the End of HCAP as [… read more]
GlaxoSmithKline recently got a boost for fluticasone-furoate + vilanterol (Breo Ellipta), its new once-daily COPD maintenance inhaler. Patients with COPD randomized to Breo Ellipta (called Relvar Ellipta in Europe), instead of usual care, had 8% fewer exacerbations and no increased risk for serious adverse events over one year. GSK presented the data at the ERS [… read more]
Every year, over a million people in the U.S. suffer respiratory failure requiring mechanical ventilation. They experience enormous catabolic stress, extended periods of inactivity, and usually go without their usual caloric intake. It’s no surprise that many are rendered profoundly debilitated by the experience. For many, this weakness and loss of muscle mass represents a second [… read more]
What’s the shelf life of human blood? Like the milk in your fridge, stored donated human blood has an expiration date: currently it’s 42 days, set by the FDA. But is fresher blood actually better? As with ordering wine by the glass, should patients about to be transfused blood ask for “whatever was opened most recently”? There’s [… read more]
Nightly use of continuous positive airway pressure (CPAP) did not prevent cardiovascular events in high risk patients with obstructive sleep apnea, according to a large randomized trial. The SAVE study suggests that CPAP has no cardiovascular benefits for the millions of people using it less than 4 hours a night. However, those using CPAP for more [… read more]
By Jon-Emile S. Kenny [@heart_lung] “I want to be your medicine, I want to feed the sparrow in your heart …” -Kristian Matsson Case A 39 year old woman is admitted to the intensive care unit for hypotension, anuria and altered mentation despite 3 litres of intravenous lactated ringers infusion. She is febrile and found to [… read more]
In patients with COPD with exertional hypoxemia, long-term supplemental oxygen did not improve survival or quality of life in a multicenter randomized trial published in the New England Journal of Medicine. The NIH-funded study calls into question the current practice of routinely treating moderately hypoxemic COPD patients with supplemental oxygen, and the billions spent for it [… read more]
The idea that augmenting cortisol levels to normal or supranormal levels must be somehow beneficial in septic shock has a compelling basis in physiology and intuition. For physicians, injecting powerful synthetic hormones to restore homeostasis to save a dying patient is a seductive fulfillment of the scientist-savior fantasy. So intensivists were primed to believe the results of [… read more]
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