Pub Date : 2019-09-01DOI: 10.1097/CPM.0000000000000320
D. Zappetti
Synopsis: This crossover trial evaluated the efficacy of inhaled corticosteroids and long-acting muscarinic antagonists compared with placebo in asthmatic patients in relation to sputum eosinophil counts. No statistical significance was found between the Mometasone versus placebo or the Tiotropium versus placebo groups, and the responses to the active drugs were not greater than the responses to the placebo medications in those with a low sputum eosinophil count. Source: Lazarus SC, Krishnan JA, King TS, et al. Mometasone or Tiotropium in mild asthma with a low sputum eosinophil level. NEJM. 2019;380:2009–2019.
摘要:本交叉试验评估了吸入皮质类固醇和长效毒蕈碱拮抗剂与安慰剂对哮喘患者痰嗜酸性粒细胞计数的影响。莫米松组与安慰剂组或噻托品组与安慰剂组之间没有统计学意义，并且在痰嗜酸性粒细胞计数低的患者中，对活性药物的反应并不大于对安慰剂药物的反应。来源:Lazarus SC, Krishnan JA, King TS等。莫米松或噻托溴铵治疗痰嗜酸性粒细胞水平低的轻度哮喘。NEJM。2019; 380:2009 - 2019。
{"title":"Are We Using the Correct Inhaled Medication to Treat Mild Asthma With Low Sputum Eosinophilia?","authors":"D. Zappetti","doi":"10.1097/CPM.0000000000000320","DOIUrl":"https://doi.org/10.1097/CPM.0000000000000320","url":null,"abstract":"Synopsis: This crossover trial evaluated the efficacy of inhaled corticosteroids and long-acting muscarinic antagonists compared with placebo in asthmatic patients in relation to sputum eosinophil counts. No statistical significance was found between the Mometasone versus placebo or the Tiotropium versus placebo groups, and the responses to the active drugs were not greater than the responses to the placebo medications in those with a low sputum eosinophil count. Source: Lazarus SC, Krishnan JA, King TS, et al. Mometasone or Tiotropium in mild asthma with a low sputum eosinophil level. NEJM. 2019;380:2009–2019.","PeriodicalId":10393,"journal":{"name":"Clinical Pulmonary Medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/CPM.0000000000000320","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42697964","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1097/CPM.0000000000000327
D. Genin, L. Sanso, D. Zappetti
and lower lung function.1 The approach of combining an inhaled corticosteroid (ICS) with a beta-agonist is not new, having been shown in 2007 that a SABA/ICS combination as needed was superior to SABA as needed in preventing exacerbations in mild asthma.2 In 2018, there were 2 trials exploring the role of budesonide-formoterol as needed for mild asthma.3,4 In these randomized controlled trials, the safety and efficacy of budesonide-formoterol as needed was demonstrated. Budesonide-formoterol as needed resulted in lower risk of exacerbation than SABA as needed and was similar to budesonide daily plus SABA as needed. The authors of the study to be reviewed here argued that, given these were placebo-controlled trials, participants all took inhalers twice a day plus a rescue inhaler, which removed the advantage of a one-inhaler-as-needed approach. In addition, these trials had run-in periods and stricter inclusion criteria inconsistent with clinical practice. In order to expand the external validity of these findings, an open-label clinical trial was performed to further investigate the budesonide-formoterol as needed strategy in mild asthma. “Controlled Trial of Budesonide-Formoterol as Needed for Mild Asthma” is a multinational, multicenter, randomized, openlabel, parallel-group controlled trial. Patients were randomized into 3 treatment groups: albuterol (100 μg 2 inhalations from a pressurized metered-dose inhaler as needed) (albuterol group), budesonide (200 μg, one inhalation through a Turbuhaler twice daily) plus as-needed albuterol (budesonide maintenance group), or budesonide-formoterol (200 μg of budesonide and 6 μg of formoterol, one inhalation through a Turbuhaler as needed) (budesonide-formoterol group). The inclusion criteria were 18 to 75-year-old patients with physician-diagnosed asthma using SABA as needed as the sole treatment. SABA had to be used at least twice in the last 3 months and no more than twice per day. If there was a severe exacerbation in the last year, there was no minimum SABA use. Exclusion criteria were hospitalization in the last year, a 20-pack-year or more smoking history, or onset of respiratory symptoms after the age of 40 with either a 10-pack-year history of smoking or currently smoking. A total of 675 patients were randomized in a 1:1:1 manner between the 3 groups. The definition of exacerbation was an urgent medical visit, steroid use, or 16 albuterol puffs or 8 budesonide-formoterol puffs in 24 hours. Severe exacerbation was defined as requiring systemic steroids for at least 3 days or hospitalization or an emergency department visit leading to systemic steroids. Patients were withdrawn from the study for severe exacerbation, 3 exacerbations separated by 7 days, or unstable asthma symptoms. The primary outcome was exacerbations per patient per year. Secondary outcomes were number of exacerbations, time to first exacerbation, severe exacerbation, Asthma Control Questionnaire-5 (ACQ-5) score, forced expirato
{"title":"Pity The Fool Who Extubates Too Soon: Does T-Piece Weaning Have Better Outcomes Compared With Standard Pressure Support Weaning?","authors":"D. Genin, L. Sanso, D. Zappetti","doi":"10.1097/CPM.0000000000000327","DOIUrl":"https://doi.org/10.1097/CPM.0000000000000327","url":null,"abstract":"and lower lung function.1 The approach of combining an inhaled corticosteroid (ICS) with a beta-agonist is not new, having been shown in 2007 that a SABA/ICS combination as needed was superior to SABA as needed in preventing exacerbations in mild asthma.2 In 2018, there were 2 trials exploring the role of budesonide-formoterol as needed for mild asthma.3,4 In these randomized controlled trials, the safety and efficacy of budesonide-formoterol as needed was demonstrated. Budesonide-formoterol as needed resulted in lower risk of exacerbation than SABA as needed and was similar to budesonide daily plus SABA as needed. The authors of the study to be reviewed here argued that, given these were placebo-controlled trials, participants all took inhalers twice a day plus a rescue inhaler, which removed the advantage of a one-inhaler-as-needed approach. In addition, these trials had run-in periods and stricter inclusion criteria inconsistent with clinical practice. In order to expand the external validity of these findings, an open-label clinical trial was performed to further investigate the budesonide-formoterol as needed strategy in mild asthma. “Controlled Trial of Budesonide-Formoterol as Needed for Mild Asthma” is a multinational, multicenter, randomized, openlabel, parallel-group controlled trial. Patients were randomized into 3 treatment groups: albuterol (100 μg 2 inhalations from a pressurized metered-dose inhaler as needed) (albuterol group), budesonide (200 μg, one inhalation through a Turbuhaler twice daily) plus as-needed albuterol (budesonide maintenance group), or budesonide-formoterol (200 μg of budesonide and 6 μg of formoterol, one inhalation through a Turbuhaler as needed) (budesonide-formoterol group). The inclusion criteria were 18 to 75-year-old patients with physician-diagnosed asthma using SABA as needed as the sole treatment. SABA had to be used at least twice in the last 3 months and no more than twice per day. If there was a severe exacerbation in the last year, there was no minimum SABA use. Exclusion criteria were hospitalization in the last year, a 20-pack-year or more smoking history, or onset of respiratory symptoms after the age of 40 with either a 10-pack-year history of smoking or currently smoking. A total of 675 patients were randomized in a 1:1:1 manner between the 3 groups. The definition of exacerbation was an urgent medical visit, steroid use, or 16 albuterol puffs or 8 budesonide-formoterol puffs in 24 hours. Severe exacerbation was defined as requiring systemic steroids for at least 3 days or hospitalization or an emergency department visit leading to systemic steroids. Patients were withdrawn from the study for severe exacerbation, 3 exacerbations separated by 7 days, or unstable asthma symptoms. The primary outcome was exacerbations per patient per year. Secondary outcomes were number of exacerbations, time to first exacerbation, severe exacerbation, Asthma Control Questionnaire-5 (ACQ-5) score, forced expirato","PeriodicalId":10393,"journal":{"name":"Clinical Pulmonary Medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/CPM.0000000000000327","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46136108","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1097/CPM.0000000000000328
S. Mahmud, S. Alam, Tasbirul Islam
mally symptomatic patients, and the addition of long-acting anticholinergics for more symptomatic patients.1 Severe cases warrant the use of systemic glucocorticoids to control COPD exacerbations. The benefits of smoking cessation, vaccinations, antibiotic therapy, and pulmonary rehabilitation are well established.1 Multiple researchers have linked the use of aspirin to the overall improvement in mortality in COPD.2–5 It reduces the need for mechanical ventilation and hospital stay, and it has also been linked to a reduction in the progression of emphysema.2–6 Pavasani et al5 carried out a meta-analysis of 5 observational studies and concluded that there is a decrease in mortality rate associated with the use of aspirin at different phases of COPD, in both the outpatient and inpatient settings. Schwameis et al7 carried out a randomized, double-blinded, single-center study, to evaluate the addition of aspirin to the standard treatment. In the study, 40 patients (sufficient power) were randomized to either aspirin therapy or to placebo, with the primary endpoint of FEV1 and secondary endpoints of changes in mean peak expiratory flow and SGRQ scores, but no statistically significant differences were identified in the 12-week observation period.7 Because the existing medications to treat COPD and its exacerbations only produce modest improvements despite combinations, new therapies are being evaluated.8 Harrison et al4 found that thrombocytosis (>400×109 cells/mm3) was associated with a 137% increase in the risk of inpatient mortality and a 53% increase in 1-year mortality for COPD, and that antiplatelet therapy with aspirin or clopidogrel led to a 3-fold reduction in the 1-year mortality.4 In the current observational cohort study, Fawzy et al2 reported a novel correlation between aspirin use and several morbidities, such as acute exacerbation of COPD, respiratory symptoms, and quality of life. They followed-up patients aged 40 to 80 years, across 12 clinical sites in the United States, for up to 36 months. The primary outcome of interest was the number of moderate and severe acute exacerbations, while secondary outcomes included baseline COPD status using the mMRC scale, SGRQ, and 6-minute walk test. As this was an observational cohort study, a propensity score–matched analysis was required.2 Of the 1843 initial participants, a total of 1698 had consistent follow-up and acute exacerbation data. A total of 764 (45%) reported using aspirin daily at baseline, but, after matching, 503 pairs of participants with balanced baseline characteristics between aspirin users and nonusers were identified.2 The participants were on average 66.5 years old, with postbronchodilator FEV1 of 62% predicted, of male sex, white, and with fewer than 2 cardiovascular comorbidities.2 At baseline, the sample consisted of 30% current smokers and 23% home oxygen users, 43% statin users, 48% inhaled corticosteroid users, and 58% long-acting bronchodilator users during the previ
{"title":"Inhaled Tranexamic Acid: A Therapeutic Option For Hemoptysis","authors":"S. Mahmud, S. Alam, Tasbirul Islam","doi":"10.1097/CPM.0000000000000328","DOIUrl":"https://doi.org/10.1097/CPM.0000000000000328","url":null,"abstract":"mally symptomatic patients, and the addition of long-acting anticholinergics for more symptomatic patients.1 Severe cases warrant the use of systemic glucocorticoids to control COPD exacerbations. The benefits of smoking cessation, vaccinations, antibiotic therapy, and pulmonary rehabilitation are well established.1 Multiple researchers have linked the use of aspirin to the overall improvement in mortality in COPD.2–5 It reduces the need for mechanical ventilation and hospital stay, and it has also been linked to a reduction in the progression of emphysema.2–6 Pavasani et al5 carried out a meta-analysis of 5 observational studies and concluded that there is a decrease in mortality rate associated with the use of aspirin at different phases of COPD, in both the outpatient and inpatient settings. Schwameis et al7 carried out a randomized, double-blinded, single-center study, to evaluate the addition of aspirin to the standard treatment. In the study, 40 patients (sufficient power) were randomized to either aspirin therapy or to placebo, with the primary endpoint of FEV1 and secondary endpoints of changes in mean peak expiratory flow and SGRQ scores, but no statistically significant differences were identified in the 12-week observation period.7 Because the existing medications to treat COPD and its exacerbations only produce modest improvements despite combinations, new therapies are being evaluated.8 Harrison et al4 found that thrombocytosis (>400×109 cells/mm3) was associated with a 137% increase in the risk of inpatient mortality and a 53% increase in 1-year mortality for COPD, and that antiplatelet therapy with aspirin or clopidogrel led to a 3-fold reduction in the 1-year mortality.4 In the current observational cohort study, Fawzy et al2 reported a novel correlation between aspirin use and several morbidities, such as acute exacerbation of COPD, respiratory symptoms, and quality of life. They followed-up patients aged 40 to 80 years, across 12 clinical sites in the United States, for up to 36 months. The primary outcome of interest was the number of moderate and severe acute exacerbations, while secondary outcomes included baseline COPD status using the mMRC scale, SGRQ, and 6-minute walk test. As this was an observational cohort study, a propensity score–matched analysis was required.2 Of the 1843 initial participants, a total of 1698 had consistent follow-up and acute exacerbation data. A total of 764 (45%) reported using aspirin daily at baseline, but, after matching, 503 pairs of participants with balanced baseline characteristics between aspirin users and nonusers were identified.2 The participants were on average 66.5 years old, with postbronchodilator FEV1 of 62% predicted, of male sex, white, and with fewer than 2 cardiovascular comorbidities.2 At baseline, the sample consisted of 30% current smokers and 23% home oxygen users, 43% statin users, 48% inhaled corticosteroid users, and 58% long-acting bronchodilator users during the previ","PeriodicalId":10393,"journal":{"name":"Clinical Pulmonary Medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/CPM.0000000000000328","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46201815","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1097/CPM.0000000000000318
C. Jokerst, E. Jensen, P. Panse, K. Cummings, M. Gotway
Pulmonary cysts are frequently encountered at thoracic computed tomography, often incidentally detected. For patients older than 40 years of age, a few pulmonary cysts found at thoracic computed tomography can be a normal finding. The etiologies of pulmonary cysts are numerous, and cysts should be distinguished from other focal lucent lung lesions, such as the numerous causes of cavitary lung disease, bronchiectasis, honeycombing, and emphysema. When pulmonary cysts are encountered in older children or adult patients, a number of specific disorders, collectively referred to as diffuse cystic lung diseases, merit consideration. These conditions include Langerhans cell histiocytosis, lymphangioleiomyomatosis, Birt-Hogg-Dubé syndrome, follicular bronchiolitis, and lymphocytic interstitial pneumonia, and even light-chain deposition disease and amyloidosis. More recently, etiologies of small airway obstruction, including asthma, hypersensitivity pneumonitis, and bronchiolitis obliterans, have been reported to cause diffuse cystic lung disease. When diffuse cystic pulmonary disorders are encountered, the combination of the clinical history, presentation, and the imaging appearance of the pulmonary cysts may be sufficiently characteristic to offer a specific diagnosis. However, not infrequently, tissue sampling procedures are required to establish the correct diagnosis because the imaging features of diffuse cystic pulmonary disorders may overlap. Distinguishing among the various etiologies of diffuse pulmonary cysts is important because the treatment approaches to these conditions differ substantially.
{"title":"A Case of Vanishing Lung Cysts","authors":"C. Jokerst, E. Jensen, P. Panse, K. Cummings, M. Gotway","doi":"10.1097/CPM.0000000000000318","DOIUrl":"https://doi.org/10.1097/CPM.0000000000000318","url":null,"abstract":"Pulmonary cysts are frequently encountered at thoracic computed tomography, often incidentally detected. For patients older than 40 years of age, a few pulmonary cysts found at thoracic computed tomography can be a normal finding. The etiologies of pulmonary cysts are numerous, and cysts should be distinguished from other focal lucent lung lesions, such as the numerous causes of cavitary lung disease, bronchiectasis, honeycombing, and emphysema. When pulmonary cysts are encountered in older children or adult patients, a number of specific disorders, collectively referred to as diffuse cystic lung diseases, merit consideration. These conditions include Langerhans cell histiocytosis, lymphangioleiomyomatosis, Birt-Hogg-Dubé syndrome, follicular bronchiolitis, and lymphocytic interstitial pneumonia, and even light-chain deposition disease and amyloidosis. More recently, etiologies of small airway obstruction, including asthma, hypersensitivity pneumonitis, and bronchiolitis obliterans, have been reported to cause diffuse cystic lung disease. When diffuse cystic pulmonary disorders are encountered, the combination of the clinical history, presentation, and the imaging appearance of the pulmonary cysts may be sufficiently characteristic to offer a specific diagnosis. However, not infrequently, tissue sampling procedures are required to establish the correct diagnosis because the imaging features of diffuse cystic pulmonary disorders may overlap. Distinguishing among the various etiologies of diffuse pulmonary cysts is important because the treatment approaches to these conditions differ substantially.","PeriodicalId":10393,"journal":{"name":"Clinical Pulmonary Medicine","volume":"26 1","pages":"161 - 166"},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/CPM.0000000000000318","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46964446","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1097/CPM.0000000000000326
A. Gandler, F. West, D. Zappetti
{"title":"Is This the End of Albuterol?","authors":"A. Gandler, F. West, D. Zappetti","doi":"10.1097/CPM.0000000000000326","DOIUrl":"https://doi.org/10.1097/CPM.0000000000000326","url":null,"abstract":"","PeriodicalId":10393,"journal":{"name":"Clinical Pulmonary Medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/CPM.0000000000000326","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47003615","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1097/CPM.0000000000000329
S. Alam, S. Mahmud, Tasbirul Islam
M echanical ventilation is used often in the intensive care unit (ICU). The term “weaning” is still used to describe the gradual process of decreasing ventilator support but the spontaneous breathing trial (SBT), an assessment of the patient’s ability to breathe while receiving minimal or no ventilator support (eg, 5 cmH2O pressure support and 5 cmH2O end-expiratory pressure),1 is often the decision point for when to extubate a patient. A “T-piece” trial is literally removing the patient from the ventilator but keeping the endotracheal tube in place with supplemental oxygen, only. This requires the patient to ventilate through the tube, but without any extra pressure support, at all. Although many studies performed have failed to show a significant difference in the success of extubation between T-piece and pressure support ventilation (PSV) trials, it is generally accepted that patients tolerate a shorter SBT trial. In this paper, Subirá and colleagues hypothesized that less demanding SBTs could result in higher rates of successful extubation without increasing reintubation rates. To test their hypothesis, they implemented 2 different weaning strategies: a more demanding 2-hour T-piece trial versus a less demanding SBT using 8 cm H2O with zero positive end-expiratory pressure for 30 minutes. The study was conducted over a 16-month period (January 2016 to April 2017) in 18 Spanish ICUs. The patients were randomized into one of the weaning strategies; however, before randomization, the attending physicians had to decide on the extubation strategy. Extubation strategies included reconnecting the patient to the ventilator for 1 hour after the weaning test before attempting extubation and the administration of nasal intermittent positive pressure ventilation or high-flow nasal cannula after extubation. Patients successfully completing an SBT were extubated, no arterial blood gases were required, and they utilized the Borg Dyspnea Scale to record reported dyspnea at the beginning and end of the SBT. Patients who failed SBT were placed back on the ventilator. During the study period, a total of 2649 patients received mechanical ventilation for at least 24 hours in the participating ICUs. Of the 2649 patients, 1501 fulfilled the inclusion criteria, with 578 patients undergoing randomization to undergo a 2-hour T-piece SBT and 575 patients were randomized to undergo a 30-minute SBT with 8 cmH2O PSV. The study team defined successful extubation as remaining free of mechanical ventilation for 72 hours after extubation, which occurred in 473 patients (82.3%) in the PSV group and 428 patients (74%) in the T-piece group. There was a significant difference between the 2 groups, with a higher successful extubation rate in the PSV group. Reintubation within 72 hours occurred in 59 patients (11.1%) in the PSV group, with a median time of 23 hours, whereas reintubation occurred in 58 patients (11.9%) in the T-piece group, with a median time of 24.5 hours. Reasons
{"title":"Does Aspirin Use Influence Exacerbations and Morbidity of Chronic Obstructive Pulmonary Disease?","authors":"S. Alam, S. Mahmud, Tasbirul Islam","doi":"10.1097/CPM.0000000000000329","DOIUrl":"https://doi.org/10.1097/CPM.0000000000000329","url":null,"abstract":"M echanical ventilation is used often in the intensive care unit (ICU). The term “weaning” is still used to describe the gradual process of decreasing ventilator support but the spontaneous breathing trial (SBT), an assessment of the patient’s ability to breathe while receiving minimal or no ventilator support (eg, 5 cmH2O pressure support and 5 cmH2O end-expiratory pressure),1 is often the decision point for when to extubate a patient. A “T-piece” trial is literally removing the patient from the ventilator but keeping the endotracheal tube in place with supplemental oxygen, only. This requires the patient to ventilate through the tube, but without any extra pressure support, at all. Although many studies performed have failed to show a significant difference in the success of extubation between T-piece and pressure support ventilation (PSV) trials, it is generally accepted that patients tolerate a shorter SBT trial. In this paper, Subirá and colleagues hypothesized that less demanding SBTs could result in higher rates of successful extubation without increasing reintubation rates. To test their hypothesis, they implemented 2 different weaning strategies: a more demanding 2-hour T-piece trial versus a less demanding SBT using 8 cm H2O with zero positive end-expiratory pressure for 30 minutes. The study was conducted over a 16-month period (January 2016 to April 2017) in 18 Spanish ICUs. The patients were randomized into one of the weaning strategies; however, before randomization, the attending physicians had to decide on the extubation strategy. Extubation strategies included reconnecting the patient to the ventilator for 1 hour after the weaning test before attempting extubation and the administration of nasal intermittent positive pressure ventilation or high-flow nasal cannula after extubation. Patients successfully completing an SBT were extubated, no arterial blood gases were required, and they utilized the Borg Dyspnea Scale to record reported dyspnea at the beginning and end of the SBT. Patients who failed SBT were placed back on the ventilator. During the study period, a total of 2649 patients received mechanical ventilation for at least 24 hours in the participating ICUs. Of the 2649 patients, 1501 fulfilled the inclusion criteria, with 578 patients undergoing randomization to undergo a 2-hour T-piece SBT and 575 patients were randomized to undergo a 30-minute SBT with 8 cmH2O PSV. The study team defined successful extubation as remaining free of mechanical ventilation for 72 hours after extubation, which occurred in 473 patients (82.3%) in the PSV group and 428 patients (74%) in the T-piece group. There was a significant difference between the 2 groups, with a higher successful extubation rate in the PSV group. Reintubation within 72 hours occurred in 59 patients (11.1%) in the PSV group, with a median time of 23 hours, whereas reintubation occurred in 58 patients (11.9%) in the T-piece group, with a median time of 24.5 hours. Reasons ","PeriodicalId":10393,"journal":{"name":"Clinical Pulmonary Medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/CPM.0000000000000329","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44956705","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1097/CPM.0000000000000331
L. Ghazala, J. Hanks, Duggal Abhijit, U. Hatipoğlu, J. Stoller
Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States. Acute exacerbation of COPD is associated with a faster decline in lung function, lower quality of life, and increased mortality. Management of acute exacerbation of COPD in the intensive care unit includes pharmacotherapy and mechanical ventilatory support. Noninvasive mechanical ventilation has led to significant improvement in outcomes of COPD and reduced morbidity and mortality compared with invasive mechanical ventilation. An emerging modality, extracorporeal carbon dioxide removal is now being studied to reduce the need for ventilatory assistance in acute ventilatory failure due to COPD exacerbation.
{"title":"Acute Respiratory Failure Due to Acute Exacerbation of Chronic Obstructive Pulmonary Disease: The Spectrum of Ventilator Strategies","authors":"L. Ghazala, J. Hanks, Duggal Abhijit, U. Hatipoğlu, J. Stoller","doi":"10.1097/CPM.0000000000000331","DOIUrl":"https://doi.org/10.1097/CPM.0000000000000331","url":null,"abstract":"Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States. Acute exacerbation of COPD is associated with a faster decline in lung function, lower quality of life, and increased mortality. Management of acute exacerbation of COPD in the intensive care unit includes pharmacotherapy and mechanical ventilatory support. Noninvasive mechanical ventilation has led to significant improvement in outcomes of COPD and reduced morbidity and mortality compared with invasive mechanical ventilation. An emerging modality, extracorporeal carbon dioxide removal is now being studied to reduce the need for ventilatory assistance in acute ventilatory failure due to COPD exacerbation.","PeriodicalId":10393,"journal":{"name":"Clinical Pulmonary Medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/CPM.0000000000000331","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48035517","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-07-01DOI: 10.1097/CPM.0000000000000313
Ali Hasan, Noormah Mehmood, J. Brownlee
Plastic bronchitis is a rare but serious clinical disorder characterized by the formation of widespread casts in the bronchial airways. This is primarily encountered in the pediatric population following a cardiac surgery (particularly post-Fontan procedure). Various treatment and management strategies have been used with differing success for cast removal and symptomatic relief. We describe one such case, wherein all the traditionally described medical therapies did not provide sustained amelioration of symptoms and required transfer for thoracic duct ligation. The patient’s clinical and radiographic features, management strategies, and clinical course are reviewed, alongside a brief review of the currently available management strategies for the clinical practitioner in dealing with plastic bronchitis.
{"title":"Relapsing Plastic Bronchitis: A Brief Review of Currently Available Management Strategies","authors":"Ali Hasan, Noormah Mehmood, J. Brownlee","doi":"10.1097/CPM.0000000000000313","DOIUrl":"https://doi.org/10.1097/CPM.0000000000000313","url":null,"abstract":"Plastic bronchitis is a rare but serious clinical disorder characterized by the formation of widespread casts in the bronchial airways. This is primarily encountered in the pediatric population following a cardiac surgery (particularly post-Fontan procedure). Various treatment and management strategies have been used with differing success for cast removal and symptomatic relief. We describe one such case, wherein all the traditionally described medical therapies did not provide sustained amelioration of symptoms and required transfer for thoracic duct ligation. The patient’s clinical and radiographic features, management strategies, and clinical course are reviewed, alongside a brief review of the currently available management strategies for the clinical practitioner in dealing with plastic bronchitis.","PeriodicalId":10393,"journal":{"name":"Clinical Pulmonary Medicine","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/CPM.0000000000000313","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41554582","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-07-01DOI: 10.1097/CPM.0000000000000322
P. Póvoa, L. Coelho, L. Bos
Pneumonia, either community acquired or hospital acquired, is the most frequent severe infection. Despite all new tools and developments, pneumonia is difficult to diagnose clinically, resulting from the lack of a “gold standard” method of diagnosis. This uncertainty is at least in part responsible for the overuse and misuse of antibiotics in the community and in the hospital, and this practice is probably a main drive for antibiotic resistance. Biomarkers may improve the clinical evaluation of a patient with a clinical suspicion of pneumonia. Among all the potential biomarkers, C-reactive protein and procalcitonin are the most extensively studied and used in clinical practice, and their role in triage, diagnosis, risk stratification, monitoring clinical course, and antibiotic stewardship has been extensively assessed. Both biomarkers showed that their use as an additional tool could be useful in the management of pneumonia. More recently “omics” technologies began to be used as new approaches in pneumonia. These promising technologies could in the near future improve the management of pneumonia.
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Pub Date : 2019-07-01DOI: 10.1097/CPM.0000000000000317
D. Zappetti
{"title":"Living in a Poor, Rural Community Is an Independent Risk Factor for Developing Chronic Obstructive Pulmonary Disease","authors":"D. Zappetti","doi":"10.1097/CPM.0000000000000317","DOIUrl":"https://doi.org/10.1097/CPM.0000000000000317","url":null,"abstract":"","PeriodicalId":10393,"journal":{"name":"Clinical Pulmonary Medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/CPM.0000000000000317","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42268020","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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