PulmPEEPs

Jose Meade Aguilar, an Internal Medicine resident at Boston University, dives into the ANDROMEDA-SHOCK trial. He compares capillary refill time (CRT) to lactate-guided resuscitation in septic shock, highlighting CRT's advantages as a rapid assessment tool. The trial's aim and multicenter design are outlined, with a focus on the patient demographics and measuring techniques used. While the results showed an 8.5% mortality difference favoring CRT, it wasn't statistically significant. Jose also emphasizes the practical use of CRT in clinical settings.

In this engaging discussion, Robert Wharton, a pulmonary fellow at Johns Hopkins, and Nicole Ng, an Assistant Professor at Mount Sinai specializing in interstitial lung disease, delve into the complexities of treating Idiopathic Pulmonary Fibrosis (IPF). They analyze the landmark INPULSIS trials and the efficacy of Nintedanib, highlighting its impact on lung function. The duo discusses challenges like participant selection in clinical trials, adverse effects of the drug, and the importance of personalized treatment strategies to improve patient outcomes.

Dr. Jeremy Grossman, a second-year PCCM fellow at NYU, and Dr. Shari Brosnahan, an assistant professor focused on pulmonary embolism, delve into a complex case involving an 80-year-old patient with severe hypoxemia. They discuss the critical role of thorough history-taking and the differential diagnosis for hypoxemia in elderly patients. The dialogue highlights diagnostic insights, including echocardiographic findings and the importance of collaboration in care decisions. They also share valuable lessons on communication with families and the advantages of mentorship in clinical training.

Here at Pulm PEEPs we have always loved the CHEST Annual Meetings. We have enjoyed learning at them, reuniting with and meeting colleagues, and having conference specific episodes the past two years. This year, we had the opportunity to podcast live at CHEST 2024 and it was a real thrill! We talked to Maria Smilios about her wonderful book The Black Angels: The Untold Story of the Nurses Who Helped Cure Tuberculosis. . The book covers a range of fascinating topics including how treatments for tuberculosis were developed, the successes and plights of Black nurses working in this endeavor, an exploration of health care in New York City, and a discussion of Racism and civil rights in American healthcare. We were also thrilled that Virginia Allen, the last surviving Black Angel is at the conference and her and her colleagues (posthumously) are receiving an honorary FCCP. Meet Our Guests Maria Smiios is a native New Yorker but completed her master of arts in religion and literature right here in Boston. She completed her masters at Boston University, where she was a Luce scholar, and taught in the religion and writing program. Through her work, she found a love for history, medicine and women’s narratives. While working at Springer Publishing as a science book editor, she learned about the story of the Black Angels and was determined to tell their story. She spent years deeply engaged in the lives and stories of those who were closest to these remarkable women.

We are excited to be back with our colleagues from CHEST to be previewing the CHEST 2024 Annual Meeting. CHEST his year is in Boston, MA from October 5th to October 9th. Listen in to hear about some great new features at CHEST this year, some old favorites, and to learn how to optimize your conference experience. See you all in two weeks! Meet Our Guests Sandhya Khurana is a  Professor of medicine at University of Rochester school of medicine and Director of the Mary Parkes Asthma Center. Her clinical and research interest is in asthma. She is the Vice-Program Chair for CHEST 2024 and will be the program Chair for CHEST 2025 next year in Chicago. Gabe Bosslet is the Program Chair for CHEST this year. In addition he is a Professor of Clinical Medicine at Indiana University School of Medicine. He is also an Assistant Dean at IU, and the Director of Mentoring and Faculty Development for the Division Pulmonary, Critical Care, Allergy and Occupational Medicine. Huzaifah Salat is a clinician educator who is currently working as a consultant pulmonologist and intensivist at Advocate Aurora Health in Wisconsin. He completed his Pulmonary and Critical Care Fellowship at the University of Oklahoma Health Sciences Center

We are extremely excited today to announce a new collaboration 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. We hope you enjoy! 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.  Imran Howell is an Asthma Fellow at the Nuffield Department of Medicine, University of Oxford Journal Club Papers Journal club article from Thorax Blood eosinophil-guided oral prednisolone for COPD exacerbations in primary care in the UK (STARR2): a non-inferiority, multicentre, double-blind, placebo-controlled, randomised controlled trial Nutritional supplementation to prevent tuberculosis incidence in household contacts of patients with pulmonary tuberculosis in India (RATIONS): a field-based, open-label, cluster-randomised, controlled trial The airway microbiome mediates the interaction between environmental exposure and respiratory health in humans Respiratory syncytial virus infection during infancy and asthma during childhood in the USA (INSPIRE): a population-based, prospective birth cohort study 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.

The hosts dive into a pivotal study on Acute Respiratory Distress Syndrome, highlighting the significance of driving pressure in treatment. They explore lung protective ventilation strategies and the intricacies involved in ventilator management. A retrospective analysis of ARDS trials reveals critical survival prediction models. Predictors of 60-day mortality are examined, focusing on factors like treatment and illness severity. The discussion emphasizes the urgent need for further research on driving pressure's impact on patient outcomes.

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)  

Join third-year PCCM fellows Jen Kodela and Ariel McKenna from UMass Chan as they tackle a complex respiratory case involving a 75-year-old woman with intricate medical challenges. They share insights on the diagnostic dilemmas surrounding PL12 antisynthetase syndrome and discuss innovative treatment strategies, including the role of rituximab. The fellows also highlight the supportive and flexible nature of their fellowship program, showcasing the collaborative learning environment that fosters medical education.

In this podcast episode, we continue our summer series reviewing landmark ARDS studies. Today, Dave and Luke discuss the PROSEVA trial (published in NEJM in 2013) which evaluated the impact of early, prolonged proning in patients with severe ARDS. Article and Reference We are talking about the PROSEVA trial today which evaluated the patients with severe ARDS (P/F < 150) to undergo prone-positioning sessions of at least 16 hours or to be left in the supine position. Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, Clavel M, Chatellier D, Jaber S, Rosselli S, Mancebo J, Sirodot M, Hilbert G, Bengler C, Richecoeur J, Gainnier M, Bayle F, Bourdin G, Leray V, Girard R, Baboi L, Ayzac L; PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013 Jun 6;368(23):2159-68. doi: 10.1056/NEJMoa1214103. Epub 2013 May 20. PMID: 23688302. Infographic