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.
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.
Today, we continue our review of the Global Initiative for Asthma (GINA) guidelines on asthma. We’ve covered asthma diagnosis and phenotyping, and the initial approach to therapy. On today’s episode we’re talking about biologic therapies for asthma and will cover everything from when to consider starting them, which to choose, and what to monitor for after a patient is started. To help us with this exciting topic we’re joined by an expert in the field. We again have a great infographic prepared along with the episode, and a boards-style question for your review.
Meet Our Guest
Megan Conroy is an Assistant Professor of Medicine at The Ohio State University, and is also the associate program director for curriculum and quality in the Pulmonary and Critical Care Medicine Fellowship. Megan’s clinical area of expertise involves asthma and biologic therapies and she was recently recognized for her work in this area as the 2024 CHEST Airway Disorders Network Rising Star Award.
Meet OurCo-Hosts
Rupali Sood grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.
Tom Di Vitantonio is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.
Key Learning Points
Core Themes and Clinical Relevance
Biologic therapies represent a paradigm shift in managing severe asthma, especially those with type 2 inflammation.
Understanding how to select and monitor biologics is crucial for pulmonary fellows and practicing clinicians.
Key Concepts and Definition
Difficult-to-control asthma ≠ severe asthma:
~20% of asthma patients have difficult-to-control asthma.
Only ~5% have severe asthma after optimizing inhaler use, addressing comorbidities, and ensuring adherence.
Type 2 inflammation: Driven by eosinophils, IgE, IL-4, IL-5, IL-13, and TSLP. Markers include:
Elevated eosinophils (≥150/µL)
High IgE
High fractional exhaled nitric oxide (FeNO)
Choosing the Right Biologic
Clinical phenotype + biomarkers + comorbidities are used together.
Example considerations:
Nasal polyps, EoE, atopic dermatitis → Dupilumab
Strong allergic sensitization → Omalizumab
T2-low or mixed features → Tezepelumab
Consider patient lifestyle, needle aversion, travel, and insurance in decision-making.
Monitoring and Follow-Up
Reassess at 3 and 6 months:
Look for ≥50% reduction in exacerbations or steroid use
Check spirometry, asthma control, and side effects
Special considerations:
Dupilumab → monitor eosinophils (risk of HES)
Omalizumab → ensure access to epinephrine auto-injector
Special Populations
Pregnancy:
Limited data, but omalizumab has most evidence supporting safety.
Expert consensus supports continuing or initiating biologics if benefits outweigh risks.
T2-low asthma:
Only Tezepelumab is indicated.
Clinical Pearls
Always reassess inhaler technique and adherence before escalating to biologics.
Shared decision-making is vital when choosing therapies.
Biologics take time—avoid early discontinuation without a full trial (4–6 months).
New biologics are on the horizon (e.g., ultra-long-acting anti-IL-5 agents).
In this episode, we add another article to our Rapid Fire Journal Club. Luke Hedrick and Dave Furfaro discuss the MIST 2 trial published in NEJM in 2011 evaluating enzymatic therapy for complex parapneumonic effusions and empyemas.
Article and Reference
We are talking today about the MIST 2 trial evaluating the use of intrapleural tPa and DNase for intrapleural infections.
Infections in the pleural space are common and morbid, often requiring surgical intervention. Unfortunately, antibiotics and chest tube drainage often fail. The MIST1 trial (NEJM, 2005) of intrapleural streptokinase showed no benefit. MIST2 studied intrapleural tPA and DNase to ease drainage by breaking down septations and thinning pleural fluid.
Study Design (design, primary outcome, participants, etc)
Design:
Double-blind, double-dummy, 2×2 factorial RCT at 11 UK hospitals from 12/2005 to 11/2008
By double dummy, we mean that there was a sham placebo for each of the study drugs
Primary Outcome
Change in the percent of the hemithorax taken up by effusion on CXR at day 7 compared to day 1
Key secondary outcomes:
Referral for surgery
Hospital LOS
All cause 3 month and 12 month mortality
AEs
Participants
Inclusion:
Clinical evidence of infection (assessed by recruiting MD; EG, fever, CRP, WBC) and
Pleural fluid with any of:
Grossly purulent
Positive pleural fluid culture or gram stain
pH < 7.2
Exclusion: aiming to exclude patients with increased bleeding risk or who can’t re-expand the lung after drainage
Age < 18
Previous intrapleural fibrinolytics, DNase, or both for empyema
Allergy to tPA or DNase
Coincidental stroke (hemorrhage risk)
Major hemorrhage or trauma
Major surgery in the last 5 days
Previous pneumonectomy on the infected side
Pregnancy, lactation
Expected survival < 3 months from something other than what caused the pleural problem
Summary: Middle-aged, mostly male patients with complicated pleural effusion or empyema occupying 1/3 to 2/5 hemithorax with mostly small-bore CDs for mostly community-acquired infections
Small-bore here meant < 15 Fr
Intervention/Limitations
N = 210 (193 analyzed) randomized approximately 1:1 to one of the following 4 arms:
tPA/Dnase (10mg and 5mg)
tPA and placebo
DNase and placebo
Double placebo
Medications were given BID for 3 days with clamping of the CD for 1 hour after each dose (to keep the drug in the pleural space)
Outcomes/Safety
Power: with N = 210 (actual analysis = 193), 80% power to detect 1 in 5 more patients with a 50% reduction in pleural opacity on CXR
We’ll discuss the outcomes of tPA/DNase in combination because there was a highly significant interaction between the two (P = 0.002) for the primary outcome
Efficacy:
Primary (pleural effusion size reduction): -29.5% hemithorax vs baseline and -7.9% effusion size vs placebo (P = 0.005)
Neither drug worked on their own
Secondary:
Referral for surgery: 4% vs 16% (OR 0.17, P = 0.03)
Hospital LOS (excluding 391d outlier in placebo group): mean 11.8 vs 17 days (P = 0.006)
Mortality: no difference
Safety:
No difference in AE between groups
6 serious events across all groups, mostly related to bleeding (intra-pleural, GI, hemoptysis); other AE were made up of pain with drug administration, transient AMS, rash
Takeaway
Combination intrapleural enzyme therapy (IET) with tPA and DNase improves drainage of infected pleural fluid, and reduces need for surgery and hospital LOS
We’re back with our second episode in our guideline initiative, and continuing our review of the Global Initiative for Asthma (GINA) guidelines on asthma. In our first episode of this series, we talked about making the diagnosis of asthma, the importance of appropriate phenotyping, and doing an initial assessment of asthma severity. Today, we’re discussing the initial management of asthma and discussing but pharmacologic and non-pharmacologic treatments. We have a great infographic prepared along with the episode, and a boards-style question for your review.
Meet OurCo-Hosts
Rupali Sood grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.
Tom Di Vitantonio is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.
Key Learning Points
Introduction to Asthma Guidelines
The podcast continues a guideline series on asthma, focusing on the Global Initiative for Asthma (GINA) 2024 guidelines.
Emphasizes practical applications for clinicians managing asthma in different settings.
Importance of Evidence-Based Asthma Management
Asthma treatment must be systematic and personalized, considering recent clinical evidence.
Previous reliance on short-acting beta agonists (SABAs) as rescue inhalers has shifted towards inhaled corticosteroid (ICS)-containing therapies.
Over-reliance on SABAs is linked to increased exacerbations, airway inflammation, and poor long-term outcomes.
Stepwise Approach to Asthma Management (GINA 2024)
The Track 1 approach (preferred) centers around ICS-formoterol as both maintenance and reliever therapy (MART).
Track 2 (alternative approach) includes daily ICS or ICS-LABA with a separate SABA as a reliever.
Stepwise Therapy
Step 1-2 (Mild asthma): Low-dose ICS-formoterol as needed for symptom relief.
Today we have a mini-episode / clinical pearl. We previously discussed the PROSEVA trial and the evidence for prone positioning in ARDS. In that trial, patients with elevated intracranial pressure (ICP) were excluded. We are joined now by Dr. Jon Rosenberg, a neuro intensivist, to discuss his how prone positioning can still be employed for patients with neurologic injuries and elevated ICP.
Meet Our Guest
Dr. Jon Rosenberg is an assistant professor of neurology and neurosurgery at Westchester Medical Center, New York Medical College. He’s also the associate program director of the Neurocritical Care Fellowship at Westchester Medical Center and a frequent contributor to the Neurocritical Care Society podcast.
Key Learning Points
Elevated Intracranial Pressure (ICP) and Proning: A Common Misconception
Elevated ICP is often considered a contraindication to proning, but this is more of a relative caution rather than an absolute contraindication.
Many neuro ICUs have successfully proned patients with elevated ICP, particularly since the COVID-19 pandemic, when critical care units had to manage both respiratory failure and neurological conditions simultaneously.
Patient Selection for Proning with Elevated ICP
Most patients with elevated ICP can still be proned, including those with:
Global cerebral edema (e.g., post-anoxic brain injury, liver failure)
Situations where proning might be more concerning:
Severe hemodynamic instability (multi-pressor shock)
Morbid obesity (e.g., >300 lbs), where physically flipping the patient is a major challenge
Theoretical Concerns with Proning in Elevated ICP
Loss of neurological exam access (sedation + flipped position makes pupil and motor exam difficult)
Jugular venous compression (especially if the head is turned to one side)
Cerebrospinal fluid (CSF) flow obstruction, depending on the lesion
Risk of increased ICP if venous outflow is impaired or head positioning is not optimized
Best Practices for Proning Patients with Elevated ICP
Patients with invasive ICP monitors vs. without monitors:
If possible, placing an ICP monitor (EVD or parenchymal bolt) before proning provides better guidance.
Without a monitor, providers must rely on other practices like maintaining strict MAP goals and sodium targets, and indirect signs of increased ICP.
Positioning considerations:
Keep the head midline to prevent jugular venous compression.
If head positioning is not neutral, place the dominant/internal jugular facing upward to maintain venous drainage.
Maintain the head of the bed elevated even while prone (reverse Trendelenburg positioning).
Hemodynamic management:
Target a higher MAP (e.g., 70–75 mmHg, sometimes 75–80 mmHg) to ensure adequate cerebral perfusion pressure (CPP) if there is no ICP monitor
Avoid hypotension, as MAP – ICP = CPP, and low MAP could critically reduce cerebral perfusion.
A normal intracranial pressure is 7 – 15 mmHg
The recommended CPP is between 60 – 70 mmHg
Sedation & Sodium Management:
Consider deep sedation (RASS -5) to reduce metabolic demand and intracranial blood volume.
Consider keeping sodium >145 mmol/L prophylactically to mitigate brain swelling if no ICP monitor in place
When to Reconsider Proning (i.e. when to supinate)
If a patient’s ICP spikes significantly (e.g., from 20 to 60 mmHg) despite medical management (hypertonic saline, sedation, paralysis, etc.).
If new signs of neurological deterioration emerge (e.g., changes in pupil exam once patient is repositioned).
Hemodynamic instability that is unmanageable in the prone position.
Literature and Future Considerations
Small case series have demonstrated success in proning patients with traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage.
While more formal research is needed, the neurocritical care community has begun embracing proning for neuro patients, provided that proper precautions are taken.
Bottom Line
Proning is not an absolute contraindication for patients with elevated ICP—it can be done safely with proper monitoring, patient selection, and precautions.
Having an ICP monitor makes the process more controlled and allows clinicians to adjust treatment in real time.
Key considerations: Maintain cerebral perfusion, optimize head positioning, monitor hemodynamics, and have a plan for reversing if ICP becomes unmanageable.
On February 7, 2025 it was announced that the National Institutes of Health (NIH) would be capping indirect cost payments for research grants at 15%. This is a massive reduction from the current standard, and will have widespread impacts on research, healthcare delivery, and trainee and young faculty development throughout the United States. We have a special episode today to try to explain what this change really means, the broad impact it will have on the healthcare system and scientific research, and what we as a the healthcare community can / should be doing. Please feel free to reach out to us with any thoughts or questions from the episode.
Meet Our Guests
Dr. Theodore “Jack” Iwashyna is a Bloomberg Distinguished Professor at Johns Hopkins School of Medicine and the Johns Hopkins Bloomberg School of Public Health. Jack is a critical care physician and focuses on research to understand the broader context of critical illness, and the long term impact on patients’ lives. He is an enormously productive and successful researcher with numerous publications in the field of critical care, and is a pioneer in the field of ICU survivorship. He is a devoted mentor and has received accolades from numerous societies
Dr. Kathryn Hibbert is an Assistant Professor of Medicine at Harvard Medical School and a pulmonary and critical care physician at Massachusetts General Hospital. She is the MICU Director at MGH, as well at the Vice Chair for Critical Care.
Summary of Key Points
Overview of NIH Funding
NIH research funding is divided into direct costs (salaries, supplies, specific project expenses) and indirect costs (infrastructure, utilities, administrative support).
Indirect costs support shared research resources like lab space, IT infrastructure, and institutional overhead.
Recent Policy Change & Impact
A sudden 15% cap on indirect cost reimbursement for NIH grants was announced late on a Friday, catching the academic community off guard.
Many universities typically receive 50-60% in indirect cost reimbursements, making this a drastic cut.
This change could severely affect research institutions by reducing available funding for shared infrastructure, education, and clinical care.
Broader Ramifications
Threat to Medical Research: Loss of funding for essential research infrastructure could slow or halt key medical advancements, such as cancer therapies, CF treatments, and more.
Impact on Education & Clinical Care: Reduced research funding could lead to cuts in trainee programs, fewer job opportunities, and diminished support for clinical services, particularly those serving vulnerable populations.
Economic Consequences: Academic medical centers are often major employers in states across the U.S. A reduction in funding could lead to job losses and economic downturns in affected regions.
Political and Institutional Response
Legal challenges were quickly filed, resulting in a temporary restraining order against the policy change.
The administration’s actions were seen as an attack on academic freedom and scientific independence.
The impact extends beyond select universities or states. States like Texas, Ohio, Florida, and Iowa stand to lose millions in research funding.
Advice for Early-Career Researchers
Continue applying for NIH grants as normal, following institutional guidance.
Stay informed about evolving policies.
Engage in advocacy—contact representatives, raise awareness, and contribute to public discussions.
Call to Action
The speakers urge medical professionals, researchers, and the public to share knowledge about what the impact of these changes would be, and prevent them from becoming permanent.
They emphasize the critical role of NIH-funded research in improving healthcare outcomes worldwide and encourage continued engagement in the conversation.
Today we are launching a new Pulm PEEPs initiative! We are going to be reviewing some of the major guidelines that are available in pulmonary and critical care. We are starting by diving into the Global Initiative for Asthma (GINA) guidelines on asthma. The goal of this initiative is to breakdown the guidelines into digestible and helpful discussions, and to talk about key issues that are pointed out by the guideline authors. Our first episode will be the start of the GINA guidelines and we’re discussing the initial diagnosis and evaluation of patients with asthma.
Meet OurCo-Hosts
Rupali Sood grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.
Tom Di Vitantonio is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.
Key Learning Points
Understanding Asthma & the GINA Guidelines
Asthma is a heterogeneous disease characterized by recurring respiratory symptoms (breathlessness, wheezing, cough, chest tightness) with variable airflow limitation.
The 2023 & 2024 Global Initiative for Asthma (GINA) guidelines emphasize phenotyping asthma to improve diagnosis and treatment.
Asthma differs from other obstructive lung diseases due to reversible airway obstruction, which can be demonstrated through diagnostic testing.
Diagnosing Asthma
Clinical history is crucial, particularly identifying symptom triggers (cold air, exercise, allergens).
Spirometry is the standard diagnostic tool, looking for an increase in FEV1 or FVC ≥12% and 200 mL after bronchodilator use.
Alternative tests include:
Peak expiratory flow monitoring over time.
Bronchoprovocation tests (e.g., methacholine challenge) to assess airway hyperresponsiveness.
Fractional exhaled nitric oxide (FENO) and blood eosinophils as markers of type 2 inflammation.
Asthma Phenotypes & Precision Medicine
Different asthma phenotypes guide personalized treatment approaches:
Type 2 inflammation: Characterized by eosinophilic inflammation, high FeNO, good steroid responsiveness, and potential for biologic therapy.
Non-Type 2 inflammation: Associated with neutrophilic inflammation, poor steroid responsiveness, and potential benefit from macrolides or bronchodilators.
Asthma-COPD overlap requires a distinct treatment approach due to persistent obstruction.
Imaging & Adjunctive Tests
Imaging is not routinely needed in asthma but can be useful for:
Today is our second 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 lung health, COPD, and emphysema.
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.
Ewan Mackay is a Respiratory Clinical Research Fellow who has started his PhD in London. His research focus is on chronic cough and in the development of new patient-reported outcome measures as well as respiratory physiology, particularly in relation to exercise and disease.
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.
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.
