Review Articles

Jul 152018
 
How to manage bleeding from oral anticoagulant drugs

The new generation of oral anticoagulants have revolutionized management of venous thromboembolism and atrial fibrillation. The changes in clinical practice have also created new questions and confusion around management of bleeding associated with these newer anticoagulants. The American College of Cardiology issued an expert consensus document in December 2017 to help guide physicians on the [… read more]

Jun 072018
 
Prolonged infusions of beta-lactam antibiotics save lives in sepsis: meta-analysis

Infusing antipseudomonal beta-lactam antibiotics over longer periods could save lives in sepsis over intermittent bolus dosing, according to a systematic review and meta-analysis of randomized trials. Vardakas et al aggregated data from studies of patients with sepsis receiving infusions of carbapenems, cephalosporins, and penicillins with antipseudomonal activity. Studies included compared prolonged infusion (over at least three [… read more]

Jun 052018
 
Varenicline May Increase Cardiovascular Risk

by Salynn Boyles, Contributing Writer, MedPage Today Cardiovascular event risk may increase in smokers who start using the cessation-assist drug varenicline (Chantix), according to findings from an observational study. The retrospective analysis of medical records for close to 57,000 new users of varenicline living in Ontario, Canada, showed a statistically significant 34% increased risk for [… read more]

May 242018
 

Introduction Respiratory failure is a commonly encountered disease process in both the emergency department (ED) and intensive care (ICU) setting.  Respiratory failure most frequently results from exacerbations of congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD), respiratory infections, encephalopathy, or a combination of these etiologies. Obesity, with or without obesity hypoventilation syndrome, reduces [… read more]

Apr 192018
 
Checking procalcitonin in the ICU saves lives? Maybe

Procalcitonin (PCT) levels can be useful (although limited) in deciding whether and when to start, de-escalate, and stop antibiotic therapy in patients with suspected infection. Physicians’ use of procalcitonin in antibiotic decisions has exploded since the FDA approval of a PCT assay whose manufacturer provides specific (albeit oversimplified) cut-off values at which to consider infection [… read more]

Mar 092018
 
Does Piperacillin-Tazobactam Cause Renal Failure?

The combination of the antibiotics piperacillin-tazobactam and vancomycin is so often used as empirical antibiotic coverage for severe infections in hospitalized patients that it’s been dubbed “Vosyn.” Vancomycin’s nephrotoxicity is well-known, requiring close monitoring of serum levels; pip-tazo has been seen to prolong increased creatinine levels (without significant known direct nephrotoxicity).  Reports have surfaced in [… read more]

Feb 222018
 
The Great Lactate Debate Part 2: can we ‘myth-bust’ the strong ion approach?

Jon-Emile S. Kenny MD [@heart_lung] “The truth is rarely pure and never simple.” -Oscar Wilde In part 1, the crux of this ‘Great Lactate Debate’ was distilled into the unclear origin of the proton in the setting of ‘lactic acidosis.’  Is the [H+] secondary to biochemical work and ATP hydrolysis or is the proton from [… read more]

Feb 192018
 
The Great Lactate Debate Part 1: should we be counting protons or strong ions?

Jon-Emile S. Kenny MD [@heart_lung] “….  She was here on earth to grasp the meaning of its wild enchantment and to call each thing by its right name …” -Boris Pasternak Background Over the last half-decade, there has been a distinct shift in the approach to lactate elevation.  The long-held belief that elevated serum lactate [… read more]

Feb 182018
 
Cardiovascular events were higher after starting a long-acting inhaler for COPD

People with chronic obstructive pulmonary disease (COPD) had an increased rate of heart attacks and strokes in the first month after starting long-acting inhaled bronchodilators. That’s the conclusion of an observational study from Taiwan, published in JAMA Internal Medicine. Researchers analyzed data on 284,220 Taiwanese adults with COPD who had never used bronchodilators, and were started on [… read more]

Feb 112018
 
Vasopressors and Inotropes for Shock Syndromes: Review

Overview Vasopressors and inotropes are cornerstones in the management of shock syndromes. Understanding vasopressors’ receptor activity and resultant pharmacological response enables clinicians to select the ideal vasopressor(s) for a patient suffering from shock. The following table outlines common vasopressors/inotropes and their general receptor activity profiles.1,2 Drug Dose α1 ß1 ß2 DA V1 V2 cAMP Norepinephrine [… read more]

Feb 062018
 
Meta-analysis: statins for COPD associated with better walk distance and quality of life

By Salynn Boyles, Contributing Writer, MedPage Today Treatment with statins may be beneficial in terms of improving exercise tolerance, pulmonary function and quality-of-life among chronic obstructive pulmonary disease (COPD) patients with co-existing cardiovascular disease, increased systemic inflammation or hyperlipidemia. That is the finding from meta-analysis of 10 randomized, controlled trials involving close to 1,500 patients, [… read more]

Jan 302018
 
Lung cancer screening with CT: Does it work in the real world?

The first real-world results from a population-based deployment of lung cancer screening are in, from a demonstration project at Veterans Affairs (VA) hospitals. Screening was generally effective at identifying early-stage lung cancer, but with far more effort per cancer detected than in the seminal National Lung Screening Trial. High false positive rates led to a [… read more]

Jan 172018
 
Vitamin D improved asthma symptoms and reduced exacerbations

Multiple randomized trials have suggested that vitamin D supplementation might improve asthma control and reduce severity of asthma attacks. A new meta-analysis bolsters that hypothesis, and may encourage more physicians and people with asthma to consider vitamin D supplements for low vitamin D levels. In a study in Lancet Respiratory Medicine, authors analyzed the experience [… read more]

Jan 152018
 
Weekend hospital admissions associated with increased risk of death

“Don’t get admitted to the hospital on a weekend.” Listen, and you might hear that rueful advice muttered under the breath of a frustrated physician unable to get a prompt Saturday consultation or procedure, the requested specialist being at another hospital, or maybe her son’s soccer game. The weekend effect — patients admitted on a [… read more]

Jan 072018
 
Management of Ground Glass and Subsolid Pulmonary Nodules: Review

Authors: Samuel Copeland, MD; Ebtesam Islam, MD, PhD Pulmonary nodules are small, generally spherical abnormalities, commonly noted incidentally on chest radiography or computed tomography1. Ground glass opacifications (GGO) are a subset of pulmonary nodules or masses with non-uniformity and less density than solid nodules. GGO are usually described as either pure ground glass or part solid [… read more]

Jan 012018
 
Best of 2017 on PulmCCM

Here are the top articles from 2017 on PulmCCM: Meta-analysis confirms EGDT for sepsis is unhelpful and wasteful (PRISM) Could vitamin C save lives in sepsis? These hospitals aren’t waiting for proof. Surviving Sepsis Guidelines: A Review and Analysis Intubation during CPR was associated with worse survival and brain health FDA Approves Angiotensin-II for Septic [… read more]

Dec 132017
 
Real-world bleeding risks of new anticoagulants similar to warfarin (or lower)

New-generation oral anticoagulants (NOACs) like dabigatran, rivaroxaban, and apixaban all had similar efficacy and bleeding risk compared to warfarin in the randomized trials that led to their FDA approval. That didn’t stop trial lawyers from filing bundles of lawsuits on behalf of patients experiencing hemorrhages after taking NOACs. (The large brand-name pharmaceutical manufacturers advertising new [… 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 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]