New Prediction Model Selects Best Lung Cancer Screening Candidates In the National Lung Screening Trial (NLST), screening for lung cancer with low-dose chest CT scans resulted in a 20% reduction in death from lung cancer. The consumer-serving American Lung Association recommended that older people with heavy smoking histories should get lung cancer screening; leading professional societies [... read more]

The post New lung cancer prediction tool promises better use of screening CT (NEJM) appeared first on PulmCCM.

Staph Vaccine Fails in Cardiothoracic Surgery Patients Staphyloccocus aureus wound infections and bacteremia commonly complicate cardiothoracic surgery, even with meticulous attention to infection prevention. Staph mediastinitis, a deep infection of the surgical wound, is particularly feared and lethal. Vance Fowler et al randomized 8,031 people undergoing sternotomy to receive the V710 vaccine against S. aureus, [... read more]

The post Staph vaccine fails in cardiothoracic surgery patients (JAMA) appeared first on PulmCCM.

Apixaban (Eliquis) Prevents Recurrent DVT-PE Long-Term People with unprovoked venous thromboembolic disease (pulmonary embolism or deep venous thrombosis, or DVT) are at high risk for recurrence, and current ACCP guidelines advise consideration of “indefinite” anticoagulation. Warfarin (Coumadin) is a wonder drug efficacy-wise, reducing the risk of pulmonary embolism and deep venous thrombosis by ~90%. However, [... read more]

The post Taking Apixaban (Eliquis) after completing Coumadin prevents recurrent DVT/PE (NEJM) appeared first on PulmCCM.

FDA Approves Breo Ellipta, Once-Daily LABA/ICS for COPD The FDA approved the new drug Breo Ellipta as a once-daily inhaled therapy for chronic obstructive pulmonary disease (COPD). Breo Ellipta includes the corticosteroid fluticasone, and vilanterol — a once-daily long acting beta agonist — in a combination dry powder inhaler. This was the FDA’s first approval [... read more]

The post FDA approves Breo Elipta, a new once-daily COPD inhaler treatment appeared first on PulmCCM.

Killer Carbapenem-Resistant Bacteria Spreading Across U.S. Gut-living bacteria like Klebsiella are gaining resistance to carbapenems at an alarming rate, and long-term acute care hospitals (LTACs) and nursing homes seem to be the incubators for these killer bugs spreading across the U.S. Carbapenems  like meropenem and doripenem have been the gold standard to treat infections from [... read more]

The post Killer carbapenem-resistant bacteria spreading through LTACs appeared first on PulmCCM.

Families Allowed to Witness CPR Felt Better, Had Fewer Regrets Should family members be allowed, or even encouraged, to witness the health care team’s attempts to revive their family member with CPR after a cardiac arrest? In the interests of openness and transparency, many have argued “yes,” with the thought that witnessing the heroic efforts [... read more]

The post Allowing families to witness CPR had positive effects (RCT, NEJM) appeared first on PulmCCM.

PulmCCM’s entire staff (me) will be on vacation and as far offline as possible for the next couple of weeks. Posts will resume the week of May 13. In my absence, all PulmCCM-related issues will be handled by my wife’s cat Gabe, who will try to respond to emails the best he can. Meanwhile, check [... read more]

The post An overdue vacation … appeared first on PulmCCM.

image: wikimedia Pulse Oximetry: The 30-Second Time Machine Why does it seem to take so long to re-oxygenate your crashing patient? Because your pulse oximeter is lying to you, no matter how good it is. Telescopes show us how a star looked millions or billions of years ago; pulse oximeters create a similar, though tiny [... read more]

The post Pulse oximetry as time machine: Lag times confuse doctors, complicate intubations (EMCrit) appeared first on PulmCCM.

Use of Procalcitonin to Reduce Unnecessary Antibiotics by Blair Westerly, MD Acute respiratory tract infections have a wide range of disease severity and the use of antibiotics for self-limited infections contributes to antibiotic overuse and antimicrobial resistance, though we have all probably been guilty of it a time or two when we just weren’t sure [... read more]

The post Using procalcitonin to guide antibiotics for pneumonia (JAMA) appeared first on PulmCCM.

Whenever I have residents rounding with me, there are a few exercises I have them go through. Often the most revealing to them is when I ask them to spend a day recording each diagnostic or therapeutic act they do, and classifying them as based on either evidence, physiology, or culture – meaning they learned [... read more]

The post The fight against dogma in critical care appeared first on PulmCCM.

Chronic Cough and Reflux: A Tangled Relationship Although we’re taught that gastroesophageal reflux disease (GERD) is a major cause of chronic cough, the truth may be more complicated, and confusing. A meta-analysis by Peter Kahrilas et al in Chest examining trials of acid-suppressing treatments for chronic cough found no significant benefit of treatment in 7 [... read more]

The post Anti-reflux therapy no help for most with chronic cough (Chest) appeared first on PulmCCM.

image: Radiology Assistant Ground-Glass Nodules: If Growing, Assume Cancer Blair Westerly, MD The more CT scans that are performed, the more ground-glass opacities (GGO’s) are seen and what to do with these abnormalities can be difficult to ascertain for clinicians. With the National Lung Cancer Screening Trial showing a mortality benefit from low dose CT [... read more]

The post How dangerous are ground glass nodules over time? (Chest) appeared first on PulmCCM.

image: Wikimedia Inferior Vena Cava Filters: What’s the Harm? Do inferior vena cava filters actually create more harm than health? That’s the provocative question being posed by authors and editorialists in JAMA Internal Medicine. Inferior vena cava filters are frequently placed after a pulmonary embolism (PE) or deep venous thrombosis (DVT) in patients with a [... read more]

The post Inferior vena cava filters: debatable benefit; rarely removed (JAMA Int Med) appeared first on PulmCCM.

In ARDS, Obesity May Protect Life (But Not Kidneys) by Blair Westerly, MD Obesity is an epidemic and common in intensive care units in the United States.  Furthermore, while acute kidney injury (AKI) is also common in critically ill patients, obese patients carry additional risk for AKI because of increased baseline comorbidities. Both obesity and [... read more]

The post Obesity may improve survival in ARDS, but with renal failure (Crit Care Med) appeared first on PulmCCM.

Acetazolamide Improved Obstructive Sleep Apnea at High Altitudes by Blair Westerly, MD Obstructive sleep apnea (OSA) is common, and so is travel to the mountains for work and play, therefore encounters with patients with OSA who travel to mountain destinations is not infrequent.  We all learn early in training that altitude affects oxygenation, and patients [... read more]

The post Got sleep apnea? Climbing Everest? Pack your Diamox (RCT, JAMA) appeared first on PulmCCM.

The 2011 GOLD classification for COPD: Old GOLD vs. New GOLD Guidelines by Brett Ley, MD Ever had a COPD patient with an awful FEV1, yet who seems to be cruising along, doing fine for years? How about a COPD patient with a relatively preserved FEV1, yet always seems to be in your clinic or [... read more]

The post New GOLD guidelines 2013: Better than the old GOLD appeared first on PulmCCM.

As I described at the launch of the PulmCCM crowdfunding campaign, advertising pays the basic bills for PulmCCM but not the expenses needed to help get to the next level: authors’ fees, iPhone / Android app redesigns and development, website programming services and steps toward CME certification. Together these will run well into the low [... read more]

The post Last Week To Help PulmCCM on Indiegogo appeared first on PulmCCM.

PulmCCM Debuts the New “Doximity Button” Are you on Doximity yet? It’s the brainchild of Internet visionary Nate Gross and the founders of Epocrates. It’s been called “Facebook for doctors,” but Doximity is more than that. It’s a protected online environment for physicians to communicate securely, and has the potential to change how we work and [... read more]

The post A New Way to Share: PulmCCM on Doximity appeared first on PulmCCM.

Interventions to Improve Symptoms, Quality of Life in Fibrotic ILD: Do They Work? by Brett Ley, MD Patients with fibrotic interstitial lung diseases (e.g. idiopathic pulmonary fibrosis) have a poor overall prognosis, and there are no therapies proven to halt disease progression or extend life. Further, many of these patients have debilitating symptoms, limited functional [... read more]

The post What works to help people with pulmonary fibrosis feel better? (Review, Thorax) appeared first on PulmCCM.

Why Patients with PEs Shouldn’t Love the Weekend Hospitals big and small struggle with weekend staffing models.  Mortality has been shown to be higher on the weekend for several common life-threatening illnesses, including CHF exacerbations, acute MI, upper GI bleeds and intracerebral hemorrhage. All these conditions are known to benefit from early intervention; however, whether [... read more]

The post Having a pulmonary embolism? Don’t wait for the weekend appeared first on PulmCCM.

The following is a guest post from Dr. Jonathan Weiss; the views expressed are his own. Submit your own guest post to PulmCCM, and be heard by thousands of your colleagues.  Maintenance of Certification: Good or Bad? Dear Colleagues, A short history lesson: For years, physicians, upon completing a residency or fellowship, went through a [... read more]

The post Maintenance of board certification needs overhaul, now (Jonathan Weiss) appeared first on PulmCCM.

Passive Leg Raise Improved Management of Patients in Shock (some assembly required) by Blair Westerly, MD Providing the right amount of fluid is vital in a critically ill patient, as both too little and too much can result in poor outcomes. Yet even with this understanding, the clinical assessment of fluid responsiveness remains a challenge [... read more]

The post Passive leg raise offers promise in predicting fluid responsiveness (Chest) appeared first on PulmCCM.

Feds to Big Tobacco on Cigarette Labeling Fight: “Uncle!” The feds are admitting defeat for now in their fight for graphic, negative imagery to be displayed on all cigarette packaging and advertisements. Attorney General Eric Holder announced yesterday that the Justice Department will not ask the Supreme Court to reverse their loss in a federal [... read more]

The post Big Tobacco win: Feds to take breather in fight for scary cigarette labeling appeared first on PulmCCM.

Hi all, The built-in search engine with PulmCCM’s blogging platform has been good, but not great. As of today, it now has Google search integrated into it (invisibly, but it’s there). After testing it, I have to say it’s now pretty great, thanks to Google’s secret ingredients. Specifically, it’s much more intelligent and accurate with [... read more]

The post PulmCCM’s new & improved search engine: now with Google appeared first on PulmCCM.

FDA Warns of Sudden Cardiac Death Risk from Azithromycin Last summer, PulmCCM reported on a New England Journal paper suggesting an increased risk of sudden cardiac death in patients taking even a short 5-day course of azithromycin. Yesterday, the FDA expressed its official concern in a Drug Safety Communication and statement to the press on [... read more]

The post FDA warns of sudden cardiac death with use of azithromycin appeared first on PulmCCM.

(image: Wikipedia) High-Frequency Oscillatory Ventilation (HFOV) for ARDS Two Randomized Trials: Early HFOV Doesn’t Help, May Harm High-frequency oscillatory ventilation (HFOV) has been proposed as a first-line therapy for acute respiratory distress syndrome (ARDS). By delivering 3-15 breaths per second of tiny tidal volumes (~70 mL), HFOV has appeal as the “ultimate” lung protective ventilator [... read more]

The post High frequency oscillation ventilation fails as 1st-line treatment for ARDS (RCTs, NEJM) appeared first on PulmCCM.

Fecal Transplants Cure C. difficile Infections, When Drugs Can’t Antibiotics are what cause Clostridium difficile infection to emerge in the first place, so it’s perhaps no surprise that the usual treatment — more antibiotics — often fails. From 15-25% of patients with C. difficile are not permanently cured by their initial treatment with metronidazole, and among those [... read more]

The post Hope floats: Fecal transplants cure >90% of recurrent C. difficile (RCT, NEJM) appeared first on PulmCCM.

Ultrafiltration No Better Than Diuresis for CHF Exacerbations by Blair Westerly, MD Cardiorenal syndrome — simultaneous heart failure and renal failure — is a frequently encountered problem in people with acute decompensated heart failure.  Treatment with diuretics for congestive heart failure exacerbations is standard care, but diuretics may at times worsen renal function. Venovenous ultrafiltration [... read more]

The post Diuretics beat ultrafiltration at treating congestive heart failure with acute renal failure (RCT, NEJM) appeared first on PulmCCM Central.

“Trach Collar” Trials Beat Pressure Support for Long-Term Ventilator Weaning By Blair Westerly, MD Patients requiring prolonged mechanical ventilation linger in ICUs and long-term acute care hospitals for weeks, accounting for a significant portion of intensive care unit costs and often suffering serious complications while dependent on the ventilator. Despite this issue’s rising importance, the [... read more]

The post “Trach collar” beats pressure support trials for long-term ventilator weaning (RCT, JAMA) appeared first on PulmCCM Central.

Weaning From Mechanical Ventilation Update (See More PulmCCM Topics) by Brett Ley, MD Nearly 800,000 patients require mechanical ventilation yearly. There’s no doubt it is a life-saving intervention, but it is one that is fraught with the potential for iatrogenesis, especially if continued for longer than necessary. That is the main message of this review in [... read more]

The post Weaning from Mechanical Ventilation Update (Review, NEJM) appeared first on PulmCCM Central.