PulmCCM Roundup #3

All the best in pulmonary and critical care we've found lately. Browse all the PulmCCM Roundups.

Surviving Sepsis Campaign Responds to ProCESS Trial

In the wake of the ProCESS trial demonstrating no benefit from use of protocols for septic shock, the Surviving Sepsis Campaign released a statement in which they "continue to recommend all elements of the current bundles" for treatment of severe sepsis and septic shock. Their primary argument: sepsis protocols in place for years at the participating institutions are why "usual care" was good enough to result in a negative trial.

ACE inhibitors protect against rapid lung function decline in COPD?

In a cohort of 1,170 current or former smokers (with or without COPD), one-third had rapid decline in FEV1. Among that third, those taking angiotensin-converting enzyme (ACE) inhibitors were much less likely to experience rapid decline over 3 years. Watch out for a future randomized trial testing ACE inhibitors in people with COPD. (Chest)

Beta Blockers and Asthma

A meta-analysis of 32 randomized trials concluded that following administration of cardioselective beta blockers (e.g., metoprolol, bisoprolol, atenolol), FEV1 in asthmatics fell by 7% on average. About 12% of asthmatics experienced a drop in FEV1 by >20%. Noncardioselective beta blockers produced a ~10% FEV1 decline, with a similar proportion experiencing >20% decline in FEV1. The analysis could not report on the effects of longer term beta blocker use or exacerbations. Although some guidelines generally advise against beta blocker use in asthmatic patients, other researchers are investigating whether chronic beta blocker use could actually be beneficial in asthma. (Chest)

Genetics of LABA Risk in Asthma

The ADRB2 gene encodes for the β-2 adrenergic receptor in airway epithelium. Six rare variants of ADRB2 were recently associated with markedly increased risk for asthma exacerbations among patients using LABAs. The finding needs replication and widespread screening is currently not feasible, but could theoretically protect against risk of rare adverse events from LABA use among susceptible individuals. (Lancet Respiratory Medicine)

Bupropion Added to Varenicline for Smoking Cessation

Bupropion (Wellbutrin or Zyban) added to varenicline (Chantix) did not improve smoking cessation rates at one year of followup, as compared to varenicline alone. Bupropion did help quitters achieve longer periods of abstinence during the trial, and seemed to prevent weight gain, a common complaint of quitters who relapse. (JAMA)  In another recent issue of JAMA, 1 in 5 nurses surveyed admitted to being smokers (wow), but only 2% of doctors did.

Bosentan for Sarcoidosis-Related Pulmonary Hypertension

Over 16 weeks, 23 patients with pulmonary hypertension due to sarcoid who were treated with bosentan (Tracleer) had improvements in mean pulmonary artery pressure (-4 mm Hg) and pulmonary vascular resistance, but no improvement in 6 minute walk distance compared to 12 patients treated with placebo. (Chest)

DVT/PE Prophylaxis: Quality Quagmire

It turns out that using actual rates of venous thromboembolism as a quality measure for U.S. hospitals has a fatal flaw: surveillance bias. The best-performing hospitals (by multiple quality measures, including adherence with DVT-PE prophylaxis) often have the highest rates of venous thromboembolism -- because they're more diligent at looking for VTE. This fact casts doubt on the use of this metric (and likely others) to compare hospitals publicly, or reward or penalize them with differential government payments. (JAMA)

CPAP for OSA Improves Blood Pressure Slightly

In a meta-analysis of 31 randomized trials, continuous positive airway pressure as therapy for obstructive sleep apnea reduced systolic blood pressure only by about 3 mm Hg, on average. Patients with more severe OSA had slightly greater blood pressure improvements than the average. (Chest)

From the New England Journal

Lung auscultation. A must-read for teaching attendings who need to proclaim breath sounds as vesicular, bronchial, or rhonchorous with aplomb, although I'm not sure reading about listening to lungs can make you better at it. (NEJM) Videos and radiographic images. The NEJM also posted videos and images on:

• Vanishing lung syndrome

• Pulmonary artery catheterization

• Endotracheal extubation

• Laryngeal mask airways (LMA)

For Interstitial Lung Disease, Mind the GAP

The GAP index (gender, age, physiology) predicts survival in idiopathic pulmonary fibrosis. A new database review of patient outcomes suggests it is equally useful for prognosis of other types of ILD. (Chest)

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