“Decolonizing” New ICU Patients Reduces Bloodstream Infections: NEJM In humankind’s battle against bacteria, the ICU is the front line. And with MRSA infection rates doubling in the past 5 years, and the more recent and scary spread of lethal pan-resistant Enterobacteriae, lately the bugs have won a few rounds. The problem isn’t just catching a deadly [... read more]
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Ultrasound in the ICU: Case 1 Hypotension after a Cholecystectomy: Why? From Philippe Rola and the Critical Care Ultrasound Institute, the first in a series of educational ultrasound cases on PulmCCM: A 64 year-old male is admitted to the ICU from the surgical ward with hypotension, 3 days post-cholecystectomy. He is intubated for airway protection [... read more]
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I was recently scanning the literature in preparation for our symposium, and came across what should have been a 2003 instead of a 2013 publication in the march issue of the CCM Journal, entitled “Point-of-Care Ultrasound to estimate Central Venous Pressure: A Comparison of Three Techniques.” I have to admit this is a pet peeve [... read more]
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The PulmCCM “Wall of Fame” THANKS to all of you who supported PulmCCM during the successful campaign to raise funding for development of high-quality iPhone and Android mobile apps. I really appreciate each and every one of your help (in chronological order): Anonymous Manish Aggarwal Lewis Satterwhite Robert Deutsch Mehdi Shelhamer Manuel Figueroa Mark Bloore [... read more]
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Managing Anticoagulation Therapy For Surgery and Procedures (NEJM) See also: How to manage anticoagulation perioperatively (ACCP Guidelines) NOTE: This is a summary of an article in a medical journal, provided as a service to physicians. It is not medical advice. No one should never make changes to their anticoagulation treatment except under a physician’s supervision. [... read more]
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image: Olympus EBUS Complication Rates <1% at Experienced Centers Endobronchial ultrasound (EBUS) — an ultrasound probe on the tip of a bronchoscope — allows real-time viewing of tissues beyond the bronchial wall. It enables more accurate and safer needle biopsies of lymph nodes and masses that abut the bronchial wall. EBUS is an exciting new [... read more]
The post How safe is EBUS? Complication rates <1% at experienced centers (Chest) appeared first on PulmCCM.
How to Prevent Acute COPD Exacerbations Acute exacerbations of chronic obstructive pulmonary disease (COPD) are a major problem for many people living with COPD. Acute exacerbations or attacks occur more often in people with more severe COPD (about 1-2 per year), and these disease flares may either signal or cause a more rapid progression of [... read more]
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Prone Positioning Saves Lives in Severe ARDS Patients: NEJM It’s long been known that positioning patients with ARDS on mechanical ventilation face-down (prone) improves their oxygenation. (There are various theories why prone positioning helps; reducing ARDS’s heterogeneous alveolar overdistension is favored.) The improved oxygen levels have never translated into improved outcomes in ARDS patients treated with [... read more]
The post A turn for the best? Prone positioning saves lives in ARDS trial (NEJM) appeared first on PulmCCM.
image: Lighthouse Med. Equip. No Benefit Seen From Monitoring Gastric Volume in Ventilated Patients on Tube Feedings Starting tube feedings early for patients on mechanical ventilation is considered the standard of care. It’s been assumed that delayed gastric emptying, resulting in a stomach full of liquid nutrition, predisposes patients to have aspiration events and develop [... read more]
The post “Checking residuals” during tube feeding on mechanical ventilation: unnecessary? (JAMA) appeared first on PulmCCM.
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]
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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]
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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]
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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]
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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]
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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]
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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]
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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]
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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]
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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]
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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]
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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]
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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]
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