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Ian M. Carrese PA-S2 South University PA Program July 21, 2012

Ian M. Carrese PA-S2 South University PA Program July 21, 2012. Update in Pulmonary and critical care medicine: evidence published in 2011. Annals of Internal Medicine. Twelve summaries of the most accessed articles from ACP (American College of Physicians) Journal Club Plus in 2011

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Ian M. Carrese PA-S2 South University PA Program July 21, 2012

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  1. Ian M. Carrese PA-S2South University PA ProgramJuly 21, 2012 Update in Pulmonary and critical care medicine: evidence published in 2011

  2. Annals of Internal Medicine Twelve summaries of the most accessed articles from ACP (American College of Physicians) Journal Club Plus in 2011 Six articles in Pulmonary Medicine Six articles in Critical Care

  3. Pulmonary Medicine Low-Dose CT for Lung CA Improves Survival Compared With Chest Radiography Screening Tiotropium Dry Powder Inhalation Is More Effective Tan Inhaled Salmeterol for the Prevention of Acute Exacerbations of COPD Daily Azithromycin Reduces the Frequency of Moderate or Severe Exacerbations of COPD Tiotropium Delivered by Mist Inhaler, Not Dry Powder, May Increase the Risk for Mortality

  4. Pulmonary Medicine Dexamethasone Decreases Hospital LOS for Patients with CAP Acid-Suppressive Drug Use Is Associated With Increased Risk for Pneumonia

  5. Critical Care Medicine Real-Time Ultrasound Guidance Improves the Rate of Subclavian Vein Cannulation and Decreases Complications The CAM-ICU Is Less Sensitive and Specific in Routine Care Settings Than in Research Settings A Program of Active Surveillance and Increased Barrier Precautions Did Not Decrease the Transmission of Resistant Bacteria Procalcitonin Levels Are Not Useful for Guiding the Escalation of Antibiotic Therapy

  6. Critical Care Intravenous β2-Agonists Did Not Decrease Mortality in Patients With ARDS Survivors of Acute Lung Injury Have Long-Term Sequelae

  7. Low-Dose CT for Lung CA Improves Survival Compared With Chest Radiography Screening Lung CA is detected at earlier stages with newer, low-radiation-dose helical CT This study looked at survival, there was no data to support decrease mortality CXR only detected possible CA in 6.9% of patients, CT detected 24.2% RRR (relative risk reduction) of 20% in low-dose CT Most abnormalities detected by CT were not CA Before implementation, further research is needed to define risk stratification Efforts should be increased to help pts to stop smoking

  8. Tiotropium Dry Powder Inhalation Is More Effective Than Inhaled Salmeterol This study looked at the prevention of acute exacerbations of COPD There is no evidence to support long acting anticholinergic or β2-Agonist bronchodilators as being more effective One year double-blinded, randomized placebo controlled study showed that Tiotropium increased the time to first exacerbation by 42 days (187 vs. 145) Caution: fewer pts given Tiotropium withdrew from the study, so the data may be skewed towards Tiotropium because it was studied longer

  9. Daily Azithromycin Reduces the Frequency of Moderate or Severe Exacerbations of COPD Use of antibiotics in the Macrolide family like Azithromycin may produce favorable immunomodulatory effects on COPD which reduce episodes of exacerbation There have not been any large, randomized trials yet to support this Azithro 250mg PO daily reduced the time to first exacerbation by 92 days (266 vs. 174) Pts with prolonged QT, hearing loss or resting tachycardia were excluded

  10. Tiotropium Delivered by Mist Inhaler, Not Dry Powder, May Increase the Risk for Mortality A meta-analysis of 5 randomized, placebo controlled studies of COPD pts showed that those that used Tiotropium mist inhaler were 1.52 times more likely to die or suffer a cardiovascular event leading to death Caution: there were no studies that looked at mortality related to the dry powder Tiotropium Also, the Tiotropium mist is not approved for use in the United States

  11. Dexamethasone Decreases Hospital LOS for Patients With CAP Antibiotics are the mainstay for patients with CAP, but carry with them risks such as increased morbidity, mortality and high costs A prospective, randomized placebo-control study showed that Dexamethasone 5mg IV daily times four days was associated with a 1.5 day sooner discharge from the hospital This study was conducted at two teaching hospitals in the Netherlands, so these results may not be applicable to other areas as pathogens for CAP vary slightly Immunosuppressed patients were not studied and patients with COPD were underrepresented

  12. Acid-Suppressive Drug Use Is Associated With Increase Risk for Pneumonia PPIs are widely prescribed and lower stomach pH—this allows for an increase in bacterial gut flora A meta-analysis of 8 observational studies showed that patients on PPIs were 1.27 times more likely to acquire pneumonia Another meta-analysis showed that patients on H2-blockers were 1.22 times more likely to acquire HAP (hospital-acquired pneumonia) These studies did not take into consideration that the presence of GERD or ETOH consumption increase the risk for aspiration pneumonia, so these are potential confounders

  13. Critical Care: U/S Guidance Improves the Rate of Subclavian Vein Cannulation and Decreases Complications U/S guidance for central line placement via the internal jugular vein is becoming the standard of care at many institutions ICUs prefer the subclavian approach because it is associated with fewer catheter-related infections, but U/S guidance is not routinely used A prospective, randomized trial showed that successful cannulation of the subclavian was significantly faster and safer (1.1 vs. 1.9 attempts and 26.8 vs. 44.8 seconds) Caution: patients that required emergent access were excluded

  14. The CAM-ICU Is Less Sensitive and Specific in Routine Care Settings Than in Research Settings 89% of ICU patients suffer from delirium. Delirium is often associated with increased morbidity and mortality and often goes unrecognized The CAM-ICU (confusion assessment method-ICU) is a commonly used tool to assess for delirium A panel of experts (intensivists, neurologists, psychiatrists and geriatricians) recognized delirium in 75 out of 181 non-comatose patients Bedside nurses using the CAM-ICU only recognized 35 with a specificity of 98% and sensitivity of 47%

  15. A Program of Active Surveillance and Increased Barrier Precautions Did Not Decrease the Transmission of Resistant Bacteria Extraordinary measures of attempting to decrease the transmission of MRSA and VRE have fallen short A cluster randomized trial of greater than 9,000 ICU patients showed that despite expanded use of barrier precautions and active surveillance (cultures and other diagnostics), the spread of MRSA and VRE did not differ much from the control group Compliance with barrier protection and hand hygiene was also lacking: gloves and gowns were only used 82% and 77% of the time, respectively Hand hygiene was only performed 69% of the time

  16. Procalcitonin Levels Are Not Useful for Guiding the Escalation of Antibiotic Therapy Procalcitonin levels correlate with waxing and waning of bacterial infection Some providers use this as a marker to help guide the use of antibiotics A randomized, controlled trial conducted in 9 hospitals with a total of 1,200 patients showed that monitoring procalcitonin levels and escalating abx therapy did not change mortality rates Caution: this study was done in Denmark which has a low occurrence of abx-resistant bacteria

  17. Intravenous β2-Agonists Did Not Decrease Mortality in Patients with ARDS ARDS is responsible for a high percentage of ICU morbidity and mortality ARDS is associated with severe inflammation and alveolar edema The only studied and proven intervention that helps is low tidal volume ventilation β2-Agonists in some animal models have been shown to decrease inflammation, promote the reabsorption of alveolar fluid and increase sodium transport (thus reducing edema) A randomized, controlled trial of 324 patients was actually stopped after treatment with Salbutamol was associated with a 1.47 times increase in mortality vs. placebo

  18. Survivors of Acute Lung Injury Have Long-Term Sequelae 109 patients that suffered from ARDS were studied in a 5 year prospective, longitudinal cohort study that examined physical, mental and QOL (quality of life) PFTs, Short Form-36 (QOL), 6-minute walk and CXRs were examined at 3, 6 and 12 months, then again at 2, 3, 4 and 5 years post ICU discharge All of the above measures were significantly lower in patients that previously suffered from ARDS Caution: 26 of the 109 patients were lost to F/U at one year and 45 at five years, so the data may be slightly skewed

  19. Questions or Comments? Works Cited: C. Gregory Elliot, MD and Polly E. Parsons, MD. “Update in Pulmonary and Critical Care Medicine: Evidence Published in 2011”. American College of Physicians: Annals of Internal Medicine. April 19, 2012.

  20. Questions or Comments?

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