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.
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.”
Today we’re back with another stop on our Fellows’ Case Files journey and making our way to the University of Rochester. Tune in to hear about this fascinating case and learn some key teaching points along the way.
Meet Our Guests
Dr. Shiv Patel completed his IM residency and a Chief year at the California Pacific Medical Center- Van Ness Campus and is currently a second-year PCCM fellow at the University of Rochester.
Dr. Mary Anne Morgan is an Associate Professor of Medicine and the Fellowship Program Director for the PCCM Fellowship at the University of Rochester. Her clinical interests range from the care of critically ill patients in the ICU to the diagnosis and management of rare lung disease in her role as Director of the University of Rochester LAM Clinic. She loves unwrapping clinical reasoning with trainees, exploring issues around communication and teamwork in the ICU, and is excited about curriculum revitalization in the growing URMC PCCM fellowship program.
Case Presentation
A 75 y.o. female with a history of Hypertension, Hyperlipidemia, and Type 2 Diabetes presented for evaluation of hypoglycemia and generalized fatigue. She had felt poorly for about a week with symptoms of back pain, generalized weakness, and dyspnea, all of which acutely worsened on the day of presentation.
She was found to be hypoglycemic with a blood glucose level in the to 40’s. Initial vital signs included a heart rate of 56, blood pressure of 70/40, respiratory rate of 30, and temperature of 28.5 degrees Celsius.
Key Learning Points
Lactic Acidosis: Type A, Type B and Type D
Type A: Typically secondary to conditions that impair oxygen delivery (respiratory failure, PE) to tissues or decrease tissue perfusion (severe anemia, shock). Patients typically present with hypotension, tachycardia, tachypnea, altered mental status, and signs of organ dysfunction.
Type B: Typically secondary to conditions that directly affect cellular metabolism or lactate clearance and characterized by the presence of hyperlactatemia without evidence of tissue hypoperfusion or hypoxia. Conditions associated include liver dysfunction (e.g., liver failure, cirrhosis), malignancies (especially hematological malignancies), medications/toxins (e.g., metformin, cyanide poisoning), inborn errors of metabolism, and mitochondrial disorders.
Type D: Less common presentation and can be seen in patients with short gut syndrome.
References
1.Blough B, Moreland A, Mora A Jr. Metformin-induced lactic acidosis with emphasis on the anion gap. Proc (Bayl Univ Med Cent). 2015 Jan;28(1):31-3. doi: 10.1080/08998280.2015.11929178. PMID: 25552792; PMCID: PMC4264704.
2.Callelo et al. Extracorporeal Treatment for Metformin Poisoning: Systematic Review and Recommendations From the Extracorporeal Treatments in Poisoning Workgroup. DOI: 10.1097/CCM.0000000000001002
3.Friesecke, S., Abel, P., Roser, M. et al. Outcome of severe lactic acidosis associated with metformin accumulation. Crit Care14, R226 (2010). https://doi.org/10.1186/cc9376
Welcome to our second episode of ATS 2024 highlighting content featured through the ATS Critical Care Assembly. Today we are going to be talking about one of the Critical Care Assembly Symposiums entitled: “Care of Dying in the ICU: End of Life Care in 2024 and Beyond”
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 has a broad focus on research that understands 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. Molly Hayes is an Associate Professor of Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, the Director of the MICU at BIDMC, and the Director of External Education at the Carl J Shapiro Institute for Education and Research. She additionally is a co-founder of the BIDMC Center for Humanizing the ICU. Molly has been extensively involved with ATS with leadership roles in the Critical Care Assembly, and the newly minted Steering Committee on the Advancement of Learning.
Meet our Collaborators
The American Thoracic Society Critical Care Assembly is the largest Assembly in the American Thoracic Society. Their members include a diverse group of intensivists and care providers for both adult and pediatric critically ill patients. The primary goal of the Critical Care Assembly is to “improve the care of the critically ill through education, research, and professional development.”
We’re super excited to have a joint episode this week with Dr. Cyrus Askin and Dr. Nick Mark from Critical Care Time! We discuss all the ways that bronchoscopy can be your best friend in the ICU and how to be prepared for the unexpected scary situations that arise in the ICU. This ranges from airway bleeds, difficult intubations, lobar collapse, and trach emergencies. Don’t miss this great discussion!
Key Learning Points
Utility of bronchoscopy in people with critical illness
Bronchoscopy can be both diagnostic and therapeutic; both are potentially lifesaving.
General situations where bronchoscopy is useful in the ICU:
Placing (or confirming placement of) an endotracheal tube or tracheostomy tube
Removing a foreign body or mucous plugs from the lungs
Localizing the source of pulmonary hemorrhage or performing interventions to stop/contain the bleed
Diagnosing certain rare conditions, particularly those where the diagnosis can substantially change management (e.g. DAH, AEP, rare infections, etc).
Proficiency with bronchoscopy is important to realize the benefits. Simply “having the equipment” is insufficient, regular practice/simulation is essential
Anesthesiologists, emergency physicians, and other specialists may have limited experience with bronchoscopy in training. Even experienced pulmonologists, who may be good at diagnostic bronchoscopy often have limited experience deploying bronchial blockers, using retrieval baskets, etc.
Remember: “People don’t rise to the occasion, they sink to the level of their training.”
If you haven’t regularly practiced with a bronchoscope, you are not going to be able to use it effectively under stress when performing high acuity low occurrence (HALO) procedures such as in emergent airways, deploying bronchial blockers, retrieving foreign bodies, etc.
Two broad situations where a bronchoscope is generally used:
Awake intubation in the anticipated difficult airway (e.g. someone with abnormal anatomy, airway tumor, etc)
Rescue method in the unanticipated difficult airway (e.g. very anterior cords, difficulty with Bougie, etc)
Nasal vs Oral approach:
Oral approach is usually used in an unanticipated difficult airway
Nasal approach: More common if performing an awake intubation. Nasal is often better tolerated however epistaxis can make a difficult airway almost impossible.
Sedation strategy:
Full topicalization: lidocaine vs cocaine (equally effective and lidocaine is normally preferred, however the vasoconstriction action of cocaine may be helpful in preventing epistaxis).
Gurgling (Nick: from personal experience lidocaine is super gross)
Remember total dose of lidocaine: < 8 mg/kg
Ketamine
Ideal because it’s dissociative and analgesic, maintains respiratory drive and (maybe) airway reflexes
Consider scopolamine patch to reduce oral secretions
Dexmedetomidine
Great adjunct
One vs two operator
Especially in unanticipated difficult airways; the second operator can use VL/DL to facilitate visualization of the vocal cords.
Second operator can also be preparing for a surgical airway.
Equipment considerations:
Preload the endotracheal tube onto the bronchoscope. Use the bronchoscope as a bougie to guide the ETT through the vocal cords.
Suction! You want two – one connected to the bronch and one connected to a yankuer.
Disposable vs “good” scope
Remember to load the tube first!
Also remember to lube the tube!
Tracheostomy troubleshooting
Similarly to intubation, bronchoscopy can be very useful to confirm placement
Mechanics are similar to above
Goal is to avoid inadvertent placement of the tracheostomy tube into the soft tissues of the neck and to avoid putting air into those tissues (false lumen).
Advanced trick for exchanging tubes: You can use a disposable bronchoscope to exchange tubes: you can get it in, confirm placement, then cut it with trauma shears! Now you can slide the old tube out and put a new one in. (Don’t try this on a $40,000 fiberoptic bronchoscope!)
Ideally you should load the ETT onto the bronchoscope in advance (red arrow). If necessary however, you can cut the ETT and turn the disposable bronchoscope into a improvised exchange catheter. This technique is very useful for exchanging tracheostomy tubes.
Foreign Body Removal from airways
Bronchoscopy is invaluable for both diagnosis and treatment of foreign body aspirations.
Most commonly these aspirations are food (nuts, seeds, etc), teeth, pills, etc
Intubated is harder in many cases: no cough to help, hard to get foreign body out of the ETT.
Flexible vs rigid
Most objects can be retrieved using flexible bronchoscope; however 15-20% require rigid bronchoscopy
Flexible can reach smaller foreign bodies that are lodged more distally.
Rigid bronchoscopy is usually done if flexible bronchoscopy fails; an interventional pulmonologist wielding a rigid is superior but more invasive (requires GA)
Cryoprobe can be especially useful for frangible materials (e.g. food)
Mucous Plugs & Lobar collapse
Presentation can be subtle or dramatic.
Bronchoscopy can remove mucous plugs and help re-expand collapsed lung areas, which is potentially life saving.
Additionally, bronchoscopy can permit diagnosis of tracheal bronchus (bronchus sui)
Pig bronchus – 1-3% of people – have a RUL bronchus that comes off the trachea.
Often presents with RUL collapse in an intubated person.
Suction considerations and bronchoscope size
Remember that suctioning force is highly dependent (i.e. radius raised to the fourth power!) upon the working channel size. Use the largest size bronchoscopy possible when suctioning.
Remember that other interventions: regular inline suctioning, chest PT, adequate hydration, mucolytics are also important to prevent recurrent mucous plugging.
Localization & Isolation of Pulmonary Hemorrhage
Pre-bronch interventions
Stabilization
Nebulized TXA
Bad side down → counter-intuitive because shifting blood flow, but also the goal is to protect the non-bleeding lung.
etc
Bronch can localize the bleeding site. Bronch can also perform interventions such as:
Cold saline
Epinephrine 1:100,000
Bronchial blockers – comparison of types
CRE balloon
Fogarty
Cryo probe – great for removing clots
Delivering ETT to contralateral side → single lung ventilation
Making “bronchoscopy only” diagnoses
Diffuse Alveolar Hemorrhage (DAH)
Finding: Increasingly bloody returns on serial lavages
1) an unexpected diagnosis was made and followed by a management change (as the most rigorous estimate of utility)
13% of the time a diagnosis was only made because of bronchoscopy which changed management
2) the post-bronchoscopy diagnosis was discordant from the leading diagnosis considered before this procedure and was followed by a management change
48% of the time pre and post procedure leading diagnoses were different
26% of the time the change in leading diagnosis led to a change in therapy
3) a change in management was made following bronchoscopy regardless of whether the diagnosis was expected or considered.
32% escalation of antibiotics
30% de-escalation of antibiotics
9% addition of steroids
2% mold → surgery
Remember that in critically ill patients whose symptoms are unexplained or failing to resolve with therapy, diagnostic flexible bronchscopy can provide useful insights.
Hi everyone, we’re here with another Fellows’ Case Files. Today, we’re going virtually to Emory University School of Medicine. We’re joined by Associated Editor Luke Hedrick to dive into a critical care case. Listen in and let us know if you have any additional thoughts or questions!
Meet Our Guests
Luke Hedrick is a first-year pulmonary and critical care fellow at Emory University. He did his internal medicine residency at BIDMC in Boston. He is also one of our amazing Associate Editors here at Pulm PEEPs
Shirine Allam is an Associate Professor of Medicine at the Emory University School of Medicine where she is the Program Director of both the Pulmonary and Critical Care Medicine fellowship as well as the Critical Care Medicine fellowship. She completed her PCCM training at the Mayo Clinic in Rochester, followed by a Sleep Medicine fellowship at Stanford. She has received multiple teaching awards throughout her career
Case Presentation
A 32-year-old male is brought in by his coworkers unresponsive. He is a construction worker and was his usual self in the morning at the start of the day, but when they broke for lunch they noticed he was acting different—his arms were drooping, and while he initially was able to answer yes/no, he soon started babbling, then grunting, then vomited and became unresponsive. They laid him flat, threw cold water on him because it was 110 degrees and humid outside that day, and brought him to the ED.
When they arrive in the ED, he is unresponsive and warm to the touch. His vitals are notable for an oral temperature of 105, HR in the 160s, BP 76/34, a RR in the high 30s, and an SpO2 100% RA. His exam is relatively unremarkable other than for significant diaphoresis and both bowel and bladder incontinence.
Key Learning Points
Definition and recognition of heat stroke: Heat stroke is characterized by hyperthermia (>104°F or 40°C) accompanied by CNS dysfunction, primarily caused by exertion or exposure. Encephalitis without significant heat load does not constitute heat stroke.
Management priorities: Rapid cooling is paramount to minimize long-term complications and organ failure. Cooling should be initiated as soon as possible, even before transportation to a hospital, particularly in cases of exertional heat stroke.
Cooling methods: Surface cooling, such as immersion in ice water, is the most effective way to cool heat-stroke patients. Alternative methods include the TACO method and evaporative cooling, although they are less efficient. Refrigerated IV fluids can be used as an adjunct, but they do not replace the need for surface cooling.
Monitoring and goals: Shivering during cooling should be monitored to prevent excessive heat generation. The goal is to reach a normal core body temperature (~38°C or 100.4°F). Traditional antipyretics like aspirin and acetaminophen should be avoided due to ineffectiveness and potential toxicity.
Approach to endotracheal tube (ETT) exchange: ETT exchange requires preparation for potential complications. This includes ensuring the availability of airway equipment, sedation of the patient, and having additional personnel for assistance. Direct visualization using a video laryngoscope is recommended, along with measuring and marking the exchange catheter for proper insertion depth.
The following infographic can be downloaded from our website:
We’re starting off 2024 with a bang!! Today we’re hosting another expert Roundtable discussion and we’re joined by internationally recognized experts in the field. We’ll tackle everything from teaching about sepsis, to how to incorporate guidelines into education and practice, to future research directions in the field. This is a can’t-miss discussion. Let us know what you think and other sepsis questions you have!
Meet Our Guests
Dr. Derek Angus is a Professor at the University of Pittsburgh where he holds the Mitchell P. Fink Endowed Chair in Critical Care Medicine and is the Chair of the Department of Critical Care Medicine. He is a world-renowned researcher in a range of critical care topics including sepsis, has hundreds of publications, and has led numerous NIH-funded studies.
Dr. Hallie Prescott is an Associate Professor in Pulmonary and Critical Care Medicine at the University of Michigan. She is the Co-Chair of the Surviving Sepsis Campaign Guidelines and is also an internationally recognized expert due to her research in improving sepsis outcomes. She has been recognized by both medical journals and professional societies for her outstanding contributions to the field.
Summary of Episode Discussion Topics
1. Sepsis Guidelines and Education
Surviving Sepsis Guidelines: Stressed as essential reading for professionals in pulmonary and critical care. They provide a structured approach to sepsis management.
Teaching Approaches: Transition from during-rounds teaching to focused, separate teaching sessions for trainees. Emphasizes the need to go beyond guidelines to include discussions on seminal articles, management strategies, and areas lacking robust data.
2. Clinical Skills and Decision Making in Sepsis Care
Early Recognition and Polypharmacy: Highlighted the need for timely sepsis identification and caution against excessive polypharmacy.
Mental Models in Care: Encourages building comprehensive mental models for understanding sepsis, stressing the importance of not just treating symptoms but understanding underlying causes.
3. Implementation of Sepsis Guidelines
Guideline Application in Bedside Care: Discusses the challenge of applying guidelines while considering patient-specific factors.
Fluid Resuscitation Practices: Identifies fluid resuscitation as a key area for improvement, with a shift towards more conservative approaches.
Overcoming Institutional Barriers: Addresses the fear of causing harm as a significant barrier to guideline implementation and emphasizes the need for balanced decision-making.
4. Advances in Sepsis Care and Prevention
Pre-Hospital Sepsis Management: Explores the role of early intervention in community settings and the potential of wearables for early detection.
Paramedic Role in Early Antibiotic Administration: Underlines the importance of starting antibiotics in the ambulance for suspected sepsis cases.
5. Recovery and Post-Discharge Care
Post-Discharge Initiatives: Focuses on improving handoffs from ICU to ward and from hospital to home. Highlights the importance of medication reconciliation and clear communication with primary care.
Challenges in Continuity of Care: Discusses the need for clear documentation and communication during patient transitions to ensure continuity of care.
6. Future Directions in Sepsis Treatment and Research
Phenotyping for Targeted Treatment: The potential of identifying patient subgroups through phenotyping for more effective, tailored treatments.
Adaptive Trial Designs: Advocates for large-scale adaptive platform trials that can test multiple interventions across diverse patient populations.
7. Personal Involvements and Perspectives
Experts’ Current Work: The panelists share their ongoing projects and research in sepsis care, reflecting a commitment to advancing the field through comprehensive and adaptive approaches.
This week we are excited to bring you our podcast cross-over event as we are joined by Eddie Qian and Todd Rice, the co-founders of the ICU Ed and Todd-Cast. Listen today as we discuss the recent ACORN trial evaluating the use of Cefepime versus Pipercillin-Tazobactam in adults hospitalized with acute infection.
This week on Pulm PEEPs, we are excited to be cross-posting an episode that Dave Furfaro did on the ATS Breathe Easy Podcast. Listen to hear a discussion about the best way to create a positive learning environment in the ICU, and how to effectively prepare bedside teaching for learners of all levels.
Meet The Host
Matthew Stutz hosted this episode of the ATS Breathe Easy Podcast. He is an Attending Pulmonary and Critical Care physician at Cook County Health and an Assistant Professor at Rush University. He is a dedicated educator and an active member of the American Thoracic Society.
Key Learning Points
Empowerment: It’s crucial to empower both learners and teachers in an educational setting.
Open Communication: Learners should be encouraged to express their discomfort or challenges in learning. This will allow teachers to adapt and create a more effective learning environment.
Self-awareness and Continuous Improvement: Teachers should be self-aware and continuously strive for improvement. If a teacher knows their weak points or areas they want to enhance, such as bedside teaching or teaching on rounds, they should communicate this to their team. This will make the team more observant and supportive in giving feedback.
Honesty: A genuine and honest dialogue helps in building a strong and trusting educational relationship. It’s beneficial for both the teacher and learner to be candid about their needs and challenges.
Feedback Mechanism: Constructive feedback is an essential part of growth. By informing team members of areas you’re working on, you can receive specific and helpful feedback at the end of a rotation or session.
Appreciation: It’s important to appreciate and acknowledge contributions in an educational or collaborative setting.
We are thrilled to spend time with Dr. Jessica Zitter who is an expert in critical care and palliative care medicine, author, speaker, and documentary filmmaker. We are honored to have her join the show today to discuss her work on improving end-of-life and humanistic care as well as promoting conversations about death and dying.
Meet our Guest
Dr. Jessica Zitter received her medical degree from Case Western Reserve University Medical School, and her MPH from UC Berkeley. She completed her IM residency at BWH, her pulmonary and critical care training at UCSF, and is additionally board certified in Palliative Care. She is an author of multiple essays and articles that have appeared in publications ranging from the NY Times to the Journal of the American Medical Association, has authored a book, and is a documentarian whose work is Emmy and Oscar nominated.
Dr. Zitter’s first book, Extreme Measures: Finding A Better Path to the End of Life, offers an insider’s view of intensive care in America today and its impact on how we die. Her work is featured in the Oscar and Emmy-nominated short documentary Extremis, available to view on Netflix. She has also produced and directed the award-winning, 2020 short documentary Caregiver: A Love Story. Dr. Zitter is currently working on her third film, The Chaplain of Oakland, which explores the devastating problem of racial healthcare inequities at the end of life. She has also founded the production and education non-profit, Reel Medicine Media.
