Tag Archives: Critical Care

Critical Care

103. Fellows’ Case Files: University of Virginia

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Today, we’re virtually visiting the University of Virginia for another Fellows’ Case Files. This is a fantastic case that covers ARDS, the infectious work up of an immunosuppressed patient, and the evaluation of undifferentiated shock. Please let us know what you think of the episode and always feel free to reach out with interesting cases!

 

Meet Our Guests

John Popovich completed his residency training and chief year at UVA and has stayed on there for his pulmonary and critical care fellowship.

Tim Scialla is an associate professor of medicine at UVA. He completed his residency and fellowship at Johns Hopkins Hospital where he was also an ACS. His clinical and research focuses are advanced airways disease. He is also the program director of the PCCM fellowship.

Matt Freedman completed his residency training at Virginia Commonwealth University and is currently a second year fellow at University of Virginia.

 

Case Presentation

Patient: 52-year-old male with psoriasis, HIV/AIDS (CD4 count: 71), presenting with progressive shortness of breath, fever, non-productive cough, and weight loss.

Vital signs: Febrile (103°F), tachycardic (HR 110), hypoxemic on 6L O₂ (SpO₂ 90–92%).

Exam: Diffuse crackles, ill-appearing.

Imaging: CXR and CT showed bilateral upper lobe infiltrates, ground-glass opacities, septal thickening, and peripheral cystic changes.

 

Infographics

POCUS algorithms for investigating shock

Shock physiology:

 

Key Learning Points

Diagnostic Reasoning in Immunocompromised Hosts

  • Framework: Anchor the differential based on type of immunosuppression.
    • HIV/AIDS → T-cell dysfunction, affecting susceptibility to PCP, TB, CMV, fungi (e.g. histo/blasto), and common CAP organisms.
  • PCP considerations:
    • PCP can occur despite prophylaxis (e.g. Bactrim), especially if adherence or resistance issues exist.
    • Classic symptoms in AIDS: acute, febrile, hypoxemic respiratory failure.

Use of Serum Markers and Imaging

  • LDH: Elevated in PCP, but non-specific. High negative predictive value when normal.
  • 1,3-β-D-glucan: Elevated in PCP and other fungal infections. Very sensitive for PCP (up to 95%).
  • Imaging: Ground-glass opacities with cystic changes support PCP diagnosis.

Role of Bronchoscopy and Diagnostic Yield

  • BAL studies to obtain:
    • DFA for PCP (rapid, high specificity, lower sensitivity)
    • PCR for PCP (higher sensitivity, slower turnaround)
    • Cultures: bacterial, fungal, mycobacterial
    • Cytology, galactomannan, histo/blasto urine antigens
  • Bronch Risk-Benefit:
    • Can change management in 40–60% of cases.
    • Complication rate: ~10–15%, most often hypoxemia.
    • Heuristic for pre-bronch ABG on non-rebreather:
      • PaO₂ >150 → likely safe
      • 100–150 → ~25% risk of intubation
      • <100 → high risk of decompensation

Steroids in PCP and Severe CAP

  • Steroids indicated in PCP with significant hypoxemia (PaO₂ <70 mmHg).
  • With new CAP guidelines (Cape Cod trial), steroids may also be considered in severe bacterial CAP.

Shock Evaluation in ICU

  • Framework: Simplify into likely causes — distributive most common, but rule out cardiogenic, obstructive, hypovolemic.
  • Physical exam + POCUS essential early.
    • POCUS: cardiac views, IVC, lung US, abdominal free fluid.
    • Low EF doesn’t exclude distributive shock.
  • PA catheter (Swan) utility:
    • Useful when physiology unclear or when tracking response to therapy is critical.
    • Swan data in this patient: low CVP and wedge, high SVR → distributive shock, not cardiogenic despite low EF.

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102. Journal Club with BMJ Thorax – Sleep and Non-Invasive Ventilation

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Today is our third episode in our collaborative series with BMJ Thorax. Our mission at Pulm PEEPs is to disseminate and promote pulmonary and critical care education, and we highly value the importance of peer reviewed journals in this endeavor. Each month in BMJ Thorax, a journal club is published looking at high yield and impactful publications in pulmonary medicine. We will be putting out quarterly episodes in association with Thorax to discuss a journal club publication and synthesize four valuable papers. This week’s episode covers four articles related to obstructive sleep apnea therapies, and the use of non-invasive ventilation and high flow nasal cannula for intubation and COPD exacerbations.

Meet Our Guests

Chris Turnbull is an Associate Editor for Education at Thorax. He is an Honorary Researcher and Respiratory Medicine Consultant at Oxford University Hospitals. In addition to his role as Associate Editor for Education at BMJ Thorax, he is also a prominent researcher in sleep-related breathing disorders.

Natalie McLeod is  a resident in respiratory medicine and is currently doing a clinical fellowship in sleep and ventilation at Oxford University Hospitals.

Journal Club Papers

To submit a journal club article of your own to Thorax, you can contact Chris directly – christopher.turnbull@ouh.nhs.uk


To engage with Thorax, please use the social media channels (Twitter – @ThoraxBMJ; Facebook – Thorax.BMJ) and subscribe on your preferred platform, to get the latest episodes directly on your device each month.

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100. ATS 2025 Critical Care Assembly: The Future of Mechanical Ventilation

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We are podcasting today directly from ATS 2025 in San Francisco! Every year, in collaboration with the ATS Critical Care Assembly, we highlight some of the scientific symposium programming from the conference. Today, Furf and Monty sit down with the three chairs of the scientific symposium entitled: Mechanical Ventilation of the Future: New Foundations For Ventilator Strategies.

Meet Our Guests

Juliana Ferreira is an Associate Professor at the University of Sao Paulo, Brazil where she is also co-director of the pulmonary and critical care fellowship program. She is an MD, PhD, and a physician scientist with specific interests in mechanical ventilation and medical education. Finally, she serves ATS as the ATS MECOR Latin America Director.

Bhakti Patel is an Assistant Professor Medicine at the University of Chicago. She is a dedicated researcher and educator. Her research focuses on non-invasive ventilator support.

Akram Khan is an Associate Professor of Medicine at Oregon Health and Science University. Akram is a pulmonary, critical care, and sleep provider with specific clinical interests in critical illness, pulmonary vascular disease and sleep apnea. Additionally, he is an accomplished translational science researcher.

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99. Fellows’ Case Files: Rutgers – Robert Wood Johnson Medical School

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We’re back with another edition of Fellows’ Case Files! Today, we’re virtually visiting Rutgers University, Robert Wood Johnson Medical School to work through a fascinating pulmonary case. Enjoy, and let us know your thoughts.

Meet Our Guests

Khalil El Gharib completed his residency training at Northwell at Staten Island University Hospital Program and is currently a first year fellow at Rutgers Robert Wood Johnson Medical School.

Sabiha Hussain completed her residency training at Robert Wood Johnson Medical School and her fellowship training at Columbia Presbyterian Medical Center in New York. She is currently a Professor of Medicine and the fellowship Program Director.

Case Presentation

  • Patient: 28-year-old male with Asperger’s syndrome and IgA nephropathy.
  • Symptoms: 3-month history of progressive dry cough and dyspnea on exertion; later developed mild hemoptysis.
  • Notable exposure: Questionable black mold in the patient’s apartment.

Initial Workup and Diagnostic Reasoning

  • Vital signs: Hypoxemia (SpO₂ 91% on room air).
  • Exam: Inspiratory crackles.
  • ABG findings: Elevated A–a gradient (~50), indicating a gas exchange problem.
  • Chest X-ray: Bilateral, patchy infiltrates without specific lobar preference.
  • Initial management: Discharged with empiric antibiotics for presumed multifocal pneumonia.

Re-Presentation and Further Testing

  • Symptoms worsened; now with blood-tinged sputum.
  • Chest CT: Showed diffuse ground-glass opacities (GGOs) without fibrosis, consolidation, or lymphadenopathy.

Imaging and Pathology

Pathology images a courtesy to Dr Isago Jerrett, pathology resident at RWJMS

Key Learning Points

Diagnostic Framework for Hypersensitivity Pneumonitis (HP)

  • New classification: Based on fibrotic vs. non-fibrotic phenotype (not acute/chronic).
  • CT features of HP:
    • GGOs with lobular air trapping.
    • “Three-density sign” (normal lung, low-density air-trapping, and ground-glass opacities).
  • BAL: Typically shows lymphocytic predominance in chronic HP, neutrophilic in early stages.
  • Serum IgG testing: Helps identify antigen exposure but doesn’t confirm disease alone.
  • Lung biopsy (VATS): Revealed poorly formed granulomas and airway-centered inflammation—consistent with HP.

Differential Diagnosis of Granulomatous Disease

  • Infectious: TB, fungal (must rule out with stains/cultures).
  • Non-infectious: Sarcoidosis, HP, granulomatosis with polyangiitis.
  • Key pathology clues for HP: Loosely formed granulomas, airway inflammation, giant cells.

Management and Outcome

  • Primary treatment: Antigen avoidance (patient moved out of mold-exposed apartment).
  • Adjunct therapy: Oral prednisone with a slow taper.
  • Outcome: Symptomatic and radiographic improvement over six months.

Teaching Pearls

  • Always take a detailed environmental and occupational exposure history.
  • Hypoxemia with an elevated A–a gradient in a young adult should trigger concern for interstitial/parenchymal lung disease.
  • CT and history are often enough to diagnose HP—biopsy is reserved for uncertain cases.
  • Remember evolving terminology: think fibrotic vs. non-fibrotic HP, not acute/chronic.

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91. Tylenol Toxicity and Acute Liver Failure

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This week we’re talking about a case as a lens for discussing Tylenol toxicity and Acute Liver Failure. These relatively common critical care presentations are essential knowledge for anyone practicing in the ICU. Listen in for some key discussion both about toxicology and the diagnosis and management of acute livery injury and failure.

 

Meet Our Guests

Kalaila Pais received her MD from Howard University College of Medicine and is currently a second year internal medicine resident at BIDMC. She is interested in pulmonary and critical care, as well as medical education. She also had the idea for this episode and was essential in its writing and production.

Hima Veeramachaneni received her MD from University of Missouri-Kansas City School of Medicine, and her residency at Emory where she was also a Chief Resident at Grady Memorial Hospital. She is a gastroenterologist and completed her GI and transplant hepatology training at Emory. She is also now doing a critical care medicine fellowship year.

 

Case Presentation

Presentation: Patient found down, surrounded by liquor bottles, with coffee-ground emesis, hemodynamic instability, scleral icterus, and metabolic derangements.

Key Lab Findings:

  • Severe transaminitis (AST >10,000, ALT ~3,000).
  • Elevated bilirubin (5.8), lactate (16), and INR (>2).
  • Metabolic acidosis with a pH of 7.04.
  • Tylenol level: 41 (slightly elevated but inconclusive without ingestion timing).

 

Key Learning Points

Infographic:

Acute Liver Injury vs. Acute Liver Failure

  • Acute Liver Injury (ALI): Elevated liver enzymes without encephalopathy or significant synthetic dysfunction.
  • Acute Liver Failure (ALF): Defined by:
    • Presence of encephalopathy.
    • Coagulopathy (elevated INR).
    • Rapid onset (<26 weeks) in patients without pre-existing liver disease.
  • ALF often leads to complications such as cerebral edema, which necessitates aggressive management.

Tylenol Toxicity and Interpretation

  • Pathophysiology:
    • Tylenol overdose overwhelms liver glutathione, leading to accumulation of NAPQI, which causes hepatocyte necrosis.
  • Interpretation of Tylenol Levels:
    • Timing of ingestion is critical to interpreting levels.
    • The Rumack-Matthew Nomogram is used for acute ingestions but requires a known ingestion time.
  • Management:
    • N-acetylcysteine (NAC): Standard of care; acts as a glutathione precursor and mitigates liver damage.
    • Early use is recommended in suspected cases of Tylenol toxicity, even if ingestion timing is unclear.

Critical Management Principles

  • Stabilization: Focus on airway, hemodynamics, and perfusion.
    • Monitor for signs of cerebral edema (e.g., pupillary changes, seizures).
    • In select patients, use hypertonic saline to maintain sodium levels (145–150 mmol/L) to mitigate cerebral edema risks.
  • CRRT and Plasma Exchange:
    • Continuous renal replacement therapy (CRRT) for hyperammonemia and acidosis.
    • Plasma exchange (PLEX) may stabilize cytokine storms and improve survival.
  • Organ-Specific Considerations:
    • Renal failure: Common due to hepatorenal syndrome; requires CRRT.
    • Coagulopathy: Managed with blood products as needed but indicates worsening liver synthetic dysfunction.

Prognosis and Transplant Considerations

  • King’s College Criteria: Guides transplant listing for ALF patients.
    • Factors: Encephalopathy severity, INR, lactate, bilirubin trends.
  • Ethical considerations for liver transplant in patients with substance use or overdose:
    • Emphasis on assessing social support and addressing psychiatric needs.
    • Efforts are made to ensure equitable access to transplant when warranted.

Takeaways for Clinical Practice

  1. Broad Differential Diagnosis: Keep a wide perspective for acute liver presentations, considering toxins, infections, and systemic conditions.
  2. Early Use of NAC: Err on the side of initiating NAC when Tylenol toxicity is suspected.
  3. CNS Focus in ALF: Monitor and manage cerebral edema aggressively.
  4. CRRT & PLEX: Advanced liver support techniques are critical in select cases.
  5. Interdisciplinary Collaboration: Psychiatrists, neurocritical care, and hepatologists play pivotal roles in management.

 

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90. Rapid Fire Journal Club: ANDROMEDA-SHOCK

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We are excited to be back with a Rapid Fire Journal Club. Today’s episode is hosted by PulmPEEPs Associate Editor, Luke Hedrick, and will delve into the ANDROMEDA-SHOCK trial published in JAMA in 2019.

Meet our Guests

Jose Meade Aguilar is a second year Internal Medicine resident at Boston University Medical Campus (BUMC).

Article and Reference

Today the discussion highlights the ANDROMEDA-SHOCK trial (JAMA, 2019) which evaluated whether resuscitation guided by capillary refill time (CRT) is superior to lactate-guided resuscitation in reducing mortality in patients with septic shock.

Hernández G, Ospina-Tascón GA, Damiani LP, Estenssoro E, Dubin A, Hurtado J, Friedman G, Castro R, Alegría L, Teboul JL, Cecconi M, Ferri G, Jibaja M, Pairumani R, Fernández P, Barahona D, Granda-Luna V, Cavalcanti AB, Bakker J; The ANDROMEDA SHOCK Investigators and the Latin America Intensive Care Network (LIVEN); Hernández G, Ospina-Tascón G, Petri Damiani L, Estenssoro E, Dubin A, Hurtado J, Friedman G, Castro R, Alegría L, Teboul JL, Cecconi M, Cecconi M, Ferri G, Jibaja M, Pairumani R, Fernández P, Barahona D, Cavalcanti AB, Bakker J, Hernández G, Alegría L, Ferri G, Rodriguez N, Holger P, Soto N, Pozo M, Bakker J, Cook D, Vincent JL, Rhodes A, Kavanagh BP, Dellinger P, Rietdijk W, Carpio D, Pavéz N, Henriquez E, Bravo S, Valenzuela ED, Vera M, Dreyse J, Oviedo V, Cid MA, Larroulet M, Petruska E, Sarabia C, Gallardo D, Sanchez JE, González H, Arancibia JM, Muñoz A, Ramirez G, Aravena F, Aquevedo A, Zambrano F, Bozinovic M, Valle F, Ramirez M, Rossel V, Muñoz P, Ceballos C, Esveile C, Carmona C, Candia E, Mendoza D, Sanchez A, Ponce D, Ponce D, Lastra J, Nahuelpán B, Fasce F, Luengo C, Medel N, Cortés C, Campassi L, Rubatto P, Horna N, Furche M, Pendino JC, Bettini L, Lovesio C, González MC, Rodruguez J, Canales H, Caminos F, Galletti C, Minoldo E, Aramburu MJ, Olmos D, Nin N, Tenzi J, Quiroga C, Lacuesta P, Gaudín A, Pais R, Silvestre A, Olivera G, Rieppi G, Berrutti D, Ochoa M, Cobos P, Vintimilla F, Ramirez V, Tobar M, García F, Picoita F, Remache N, Granda V, Paredes F, Barzallo E, Garcés P, Guerrero F, Salazar S, Torres G, Tana C, Calahorrano J, Solis F, Torres P, Herrera L, Ornes A, Peréz V, Delgado G, López A, Espinosa E, Moreira J, Salcedo B, Villacres I, Suing J, Lopez M, Gomez L, Toctaquiza G, Cadena Zapata M, Orazabal MA, Pardo Espejo R, Jimenez J, Calderón A, Paredes G, Barberán JL, Moya T, Atehortua H, Sabogal R, Ortiz G, Lara A, Sanchez F, Hernán Portilla A, Dávila H, Mora JA, Calderón LE, Alvarez I, Escobar E, Bejarano A, Bustamante LA, Aldana JL. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019 Feb 19;321(7):654-664. doi: 10.1001/jama.2019.0071. PMID: 30772908; PMCID: PMC6439620.

Infographic

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83. RFJC 13 – ARDS Series – DEXA-ARDS

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In the penultimate episode in our ARDS Rapid Fire Journal Club Summer Series we are talking about the DEXA-ARDS trial (published in Lancet Respiratory Medicine in 2020). This trial evaluated the impact of dexamethasone in the treatment of ARDS.

 

Article and Reference

Today we’re discussing the DEXA-ARDS trial published in Lancet Respiratory Medicine in 2020. This trial evaluated the impact of dexamethasone on mortality and duration of mechanical ventilation for patients with ARDS.

Villar J, Ferrando C, Martínez D, Ambrós A, Muñoz T, Soler JA, Aguilar G, Alba F, González-Higueras E, Conesa LA, Martín-Rodríguez C, Díaz-Domínguez FJ, Serna-Grande P, Rivas R, Ferreres J, Belda J, Capilla L, Tallet A, Añón JM, Fernández RL, González-Martín JM; dexamethasone in ARDS network. Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial. Lancet Respir Med. 2020 Mar;8(3):267-276. doi: 10.1016/S2213-2600(19)30417-5. Epub 2020 Feb 7. PMID: 32043986.

 

Infographic

 

Article Notes

  • DEXA-ARDS; Lancet Respiratory Medicine, 2020
    • DOI:10.1016/S2213-2600(19)30417-5
    • Link: https://doi.org/10.1016/s2213-2600(19)30417-5
    • Background: ARDS is an intense inflammatory process without proven, specific pharmacotherapies. Previous work and a recent meta-analysis demonstrated improvements in inflammation, gas exchange, and ventilator and ICU liberation but did not adequately address mortality.
    • Study Design (design, primary outcome, participants, etc)
      • Design: investigator-initiated, multicenter, unblinded, randomized controlled trial in 17 academic ICUs in Spain, conducted from 3/2013 to 12/2018
      • Primary Outcome
        • VFD at 28d
        • Secondary:
          • 60d mortality
          • Actual duration of ventilation in ICU survivors
          • ICU acquired infections
      • Participants
        • Inclusion ARDS with P/F < 200 for < 24hr on LTVV
        • Exclusion:
          • Already receiving steroids or immunosuppression
          • CHF
          • Severe COPD
          • DNR
        • Summary: Middle aged, mostly male patients with < 24hr of moderate to severe ARDS receiving LPV without chronic heart or lung disease
          • Like many ARDS trials, just over 3/4 of patients’ ARDS was caused by PNA or sepsis. Mean P/F was ~140
    • Intervention/Limitations
      • N = 277, stratified by center and then randomized
      • Intervention: dexamethasone 20mg qd for 5d followed by 10mg qd for 5d
        • Stopped early for extubation before day 10
        • First dose given no more than 30 hours after P/F < 200
      • Control: no placebo, just SOC
      • All patients received LTVV
    • Outcomes/Safety
      • Power: with N = 314 (actual N = 277), 80% power to detect 2 additional VFD and 15% mortality reduction
        • As an aside, this seems to be a theme in ICU trials: massively ambitious proposed benefits during power calculations and then under-enrolling for that power calculation ultimately resulting with a point estimate that favors the intervention but is not statistically significant.
      • Efficacy:
        • 60d mortality: 21% vs 36%, P = 0.0047
          • NNT of just < 7!
        • VFD at 28d: 12.3 vs 7.5, P < 0.0001
        • Actual duration of ventilation in ICU survivors: 14.2d vs 19.5d (P = 0.0009)
      • Safety:
        • Hyperglycemia: 76% vs 70%, P = 0.33
          • Always interesting in steroid trials when no change in glucose control is seen. This isn’t the most EBM thing I’ll ever say, but frankly I disregard this and assume steroids will cause hyperglycemia regardless of the trial results.
        • ICU acquired infections: 24% vs 25%, P = 0.75
    • Takeaway
      • In a narrowly selected population of patients without chronic heart or severe lung disease and with early, moderate ARDS (mostly from sepsis or pneumonia), dexamethasone reduced mortality and duration of mechanical ventilation.
        • If time, insert soap-box about etiology of ARDS being very important (EG, flu, fungal, parasitic, mycobacterial infections)

 

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79. RFJC 10 – ARDS Series – FACTT

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In this podcast episode, we continue our summer series reviewing landmark ARDS studies. Today, Dave and Luke discuss the FACTT trial, which investigated fluid management strategies in ARDS. This was published in the NEJM in 2006.

Article and Reference

We’re talking about the FACTT trial today which was a “Comparison of Two Fluid-Management Strategies in Acute Lung Injury”

Reference: National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network; Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006 Jun 15;354(24):2564-75. doi: 10.1056/NEJMoa062200. Epub 2006 May 21. PMID: 16714767.

Infographic

Summary of discussion:

Background: The FACT trial aimed to address fluid balance in ARDS, given the complexity of managing pulmonary edema and systemic organ failure. The challenge has been finding the right balance between managing fluid to optimize cardiac function and avoiding exacerbation of pulmonary edema.

Study Design:

  • Randomized Controlled Trial: Conducted at 20 North American medical centers from 2000 to 2005.
  • Participants: Included intubated ARDS patients who required or were planned to receive a central venous catheter. Excluded patients with chronic diseases, recent MI, or irreversible conditions. Shock was not an exclusion criterion.
  • Interventions: Patients were randomly assigned to either a liberal or conservative fluid management strategy, and also received either a PA catheter or a central line.

Fluid Management Protocol:

  • Liberal Strategy: Aimed for higher filling pressures (CVP of 10-14 or wedge pressure of 14-18).
  • Conservative Strategy: Aimed for lower filling pressures (CVP less than 4 or wedge pressure under 14).
  • Fluid Balance: The liberal group had a net positive fluid balance of around 7 liters, while the conservative group had a net negative balance of about 130 cc.

    Results:

    • Mortality: No statistically significant difference in 60-day mortality between the liberal and conservative groups (25.5% vs. 28.4%, respectively).
    • Ventilator and ICU-Free Days: The conservative strategy resulted in more ventilator-free and ICU-free days.
    • Shock and Dialysis: There was no difference in shock rates, but the conservative group had a trend toward fewer dialysis requirements (10% vs. 14%, p=0.06).

    Conclusion: The trial indicated that a conservative fluid management strategy in ARDS patients can reduce ventilator dependence and ICU length of stay without worsening shock or end-organ function. It underscores the benefit of managing fluid conservatively to protect lung function, even though it didn’t significantly reduce mortality.

      Overall, the FACT trial supports the practice of conservative fluid management in ARDS, advocating that “dry lungs are happy lungs” for improving patient outcomes.

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      78. PREOXI Trial

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      Today, we’re going to be talking about pre-oxygenation methods for endotracheal intubation and the PREOXI Trial which is hot off the presses in the New England Journal of Medicine in June of 2024. This trial has potentially widespread, practice changing results and we’re lucky enough to be joined by two of the authors to discuss.

       

       

      Meet Our Guests

      Dr. Kevin Gibbs is an Associate Professor of Medicine at Wake Forest University School of Medicine. He obtained his MD at George Washington University School of Medicine, and completed his residency and fellowship training at Johns Hopkins. He is an active researcher in critical care, ARDS, mechanical ventilation, and pragmatic trial design.

      Dr. Jon Casey is an Assistant Professor of Medicine for the Division of Allergy, Pulmonary, and Critical Care Medicine at Vanderbilt University Medical Center. He obtained his MD from the University of Louisville School of Medicine, and completed his residency training at Brigham and Women’s Hospital before going to Vanderbilt for fellowship training. He is a physician scientist and also has his Masters of Science in Clinical Investigation. His research is focused on comparative effectiveness of ICU treatments and he also has a focus on pragmatic trials. He is supported with NIH funding and is active in the American Thoracic Society Critical Care Assembly.

      Summarized Key Points



      • Significance of the Problem: Tracheal intubation in emergency and ICU settings is common, with significant risks such as hypoxemia (10-20% incidence) and cardiac arrest (2% incidence) associated with the procedure. This makes effective pre-oxygenation crucial.

      • Methods of Pre-oxygenation: Common methods include face mask oxygen (e.g., non-rebreather, bag-mask devices) and more advanced techniques like non-invasive ventilation (used in about 15% of cases globally). Each method has pros (e.g., simplicity, no risk of aspiration for face masks; 100% oxygen delivery, positive pressure for non-invasive ventilation) and cons (e.g., potential for gastric insufflation with non-invasive ventilation).

      • Study Design: The study discussed in the podcast is a pragmatic trial aiming to optimize pre-oxygenation strategies to prevent peri-intubation hypoxemia. Eligibility criteria were broad, encompassing most patients undergoing tracheal intubation in the ED or ICU, with exclusions mainly for safety reasons.

      • Primary Outcome: The primary outcome of the trial was hypoxemia, defined as oxygen saturation < 85%. This threshold was chosen because it signifies a critical point on the oxygen dissociation curve, where patients are at higher risk of further desaturation and adverse outcomes.

      • Secondary Outcomes: Secondary exploratory outcomes included more severe levels of hypoxemia (oxygen saturation < 80% and < 70%), aiming to capture varying degrees of oxygenation failure during intubation. Rates of cardiac arrest during intubation were an additional outcome.

      • Intervention Comparison:

        • The trial compared two methods of pre-oxygenation: non-invasive ventilation (NIV) and oxygen mask (face mask)

        • Both methods aimed to provide at least three minutes of pre-oxygenation before intubation.

        • NIV group specifics: Expiratory pressure of 5 cm H2O, Inspiratory pressure of 10 cm H2O, respiratory rate of 10 breaths per minute, and 100% oxygen delivery

        • Oxygen mask group specifics: Non-rebreather or bag mask device with at least 15 liters per minute oxygen flow.

        • Nasal cannulas and HFNC could be used in both groups.



      • Logistics and Equipment Use:

        • The trial allowed flexibility in using available equipment (invasive ventilator capable of NIPPV vs. dedicated BiPAP machine).

        • Sites were encouraged to use the same ventilator for both pre-oxygenation and subsequent ventilation to streamline workflow and reduce logistical challenges.



      • Primary and Secondary Outcomes:

        • Results showed a significant reduction in hypoxemia incidents in the NIV group compared to the oxygen mask group.

        • There was also a reduction in severe hypoxemia and a notable decrease in cardiac arrest incidents in the NIV group.



      • Aspiration Safety:

        • There was no statistical difference in aspiration-related outcomes between the NIV and oxygen mask groups, indicating that NIV did not increase the risk of aspiration.



      • Conclusions:

        • The trial concluded that NIV for pre-oxygenation significantly reduced the incidence of hypoxemia and possibly cardiac arrest during tracheal intubation.

        • It also dispelled concerns about increased aspiration risk with NIPPV as pre-oxygenation, suggesting it can be safely used in clinical practice.


      Reference

      Gibbs KW, Semler MW, Driver BE, Seitz KP, Stempek SB, Taylor C, Resnick-Ault D, White HD, Gandotra S, Doerschug KC, Mohamed A, Prekker ME, Khan A, Gaillard JP, Andrea L, Aggarwal NR, Brainard JC, Barnett LH, Halliday SJ, Blinder V, Dagan A, Whitson MR, Schauer SG, Walker JE Jr, Barker AB, Palakshappa JA, Muhs A, Wozniak JM, Kramer PJ, Withers C, Ghamande SA, Russell DW, Schwartz A, Moskowitz A, Hansen SJ, Allada G, Goranson JK, Fein DG, Sottile PD, Kelly N, Alwood SM, Long MT, Malhotra R, Shapiro NI, Page DB, Long BJ, Thomas CB, Trent SA, Janz DR, Rice TW, Self WH, Bebarta VS, Lloyd BD, Rhoads J, Womack K, Imhoff B, Ginde AA, Casey JD; PREOXI Investigators and the Pragmatic Critical Care Research Group. Noninvasive Ventilation for Preoxygenation during Emergency Intubation. N Engl J Med. 2024 Jun 20;390(23):2165-2177. doi: 10.1056/NEJMoa2313680. Epub 2024 Jun 13. PMID: 38869091.

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      77. RFJC 9 – ARDS Series – ARMA

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      This episode is launching our 2024 Rapid Fire Journal Club summer series on ARDS! This summer we will be talking about landmark ARDS trials that have defined the literature and shaped patient care. Journal clubs often focus on new trials, and so learners may have a less thorough understanding of the baseline literature that defines many of our ICU practices. The goal of this series is to provide a quick, but in-depth look at these papers so that learners understand the modern landscape of ARDS.

      Today, we’re kicking this initiative off by looking at the ARMA or ARDSNet Trial published in the NEJM in 2000. Enjoy!

      Article and Reference

      We’re talking about the ARMA trial today which examined “Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome.”

      Reference: Acute Respiratory Distress Syndrome Network; Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000 May 4;342(18):1301-8. doi: 10.1056/NEJM200005043421801. PMID: 10793162.

      Infographic

      Correction:

      We mention a step-wise titration of tidal volume in the control group to achieve Pplats of 45-50. To clarify, there was no adjustment of Vt in the traditional Vt group unless Pplat > 50. If Vt had been decreased in the traditional Vt group because Pplat was > 50, it would not be subsequently increased back to 12 unless Pplat < 45 (to avoid a cycle of corrections and re-adjustments). Similarly in the lower Vt group, there was no adjustment (“titration”) of Vt unless Pplat > 30, and there was a similar protocol in place not to increase the Vt again unless the Pplat was < 25.

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