The Latest in Critical Care, 6/26/23 (Issue #6)

An expert panel broadened the definition of acute respiratory distress syndrome (ARDS).

They announced this at the American Thoracic Society meeting in May 2023. Thirty-two experts virtually to update the 2012 update (in Berlin), and declared that ARDS shall henceforth include anyone with:

• PaO2/FiO2 ≤300 mmHg (on an arterial blood gas) or

• SpO2/FiO2 ≤315mmHg with SpO2 ≤97% (on pulse oximetry without an ABG)

That’s while receiving either mechanical ventilation, or (this is new):

• High flow nasal oxygen ≥30 L/min, or

• Noninvasive ventilation/CPAP with at least 5 cm H2O end-expiratory pressure

Bilateral opacities are still part of the definition, but can now be identified by ultrasound (this is new), as well as CT or radiography.

The prior requirement for mechanical ventilation excluded patients on high-flow oxygen, whose use has expanded dramatically.

A more expansive definition also enlarges the eligible population for studies, including in low-resource environments, formerly called developing countries.

A prominent blogger argues that as a syndrome, not a diagnosis, ARDS isn’t “real”, as it lumps together unrelated etiologies for respiratory failure (e.g., pneumonia or vasculitis), severely limiting its clinical utility. Making the “diagnosis” of ARDS could lead clinicians to truncate workups without identifying the true cause for respiratory failure, resulting in missed diagnoses and suboptimal treatment.

ARDS is “real” at least some of the time, representing the histopathologic process of diffuse alveolar damage, distinct from the initial disease process (pneumonia, vasculitis, inhalational injury etc.) that set it into motion.

Adding “with ARDS” to those primary disease diagnoses in progress notes still reminds everyone to use the lowest possible tidal volumes, target low plateau pressures, follow PaO2:FiO2 ratios, consider prone positioning, watch out for barotrauma, etc. It also helps physicians counsel families and set expectations (“if the pneumonia’s been treated, why isn’t Mom better?”) All that remains worthwhile. Read at ATS Abstracts

Haldol is safe and appropriate to use for selected patients with hyperactive delirium in the ICU.

Antipsychotics have been overused in hospitalized patients, in and out of ICUs. After the 2018 MIND-USA trial found neither haloperidol nor ziprasidone reduced delirium in the ICU, critical care guidelines advised against their wide use. But about 90% of the MIND-USA patients had hypoactive delirium, without agitation. The recommendations had the effect of discouraging antipsychotic use in agitated delirious patients, without strong evidence.

The AID-ICU trial showed that among 1000 patients at 16 European ICUs, among patients with agitated (hyperactive) delirium who received haloperidol (in 2.5 mg doses, up to 20 mg/day) or placebo, there was no difference in survival out of the hospital at 90 days. There was even an intriguing 7% absolute risk reduction in 90-day mortality in the haldol group. No outcomes regarding the delirium itself were reported (i.e., whether haloperidol actually reduced delirium).

Intensivists generally treat patients with haloperidol in the ICU when they are unsafe to themselves or others. Antipsychotics shouldn’t be used thoughtlessly, but AID-ICU’s reassuring safety signal makes me much more comfortable giving escalating doses of haloperidol when needed to help calm an agitated, delirious patient. Read in NEJM

In The News

America’s doctors are in ‘moral crisis’. The capitalistic capture of U.S. healthcare has evolved from consolidation of health systems and giant corporate conglomerates into its next, more malignant phase: exerting direct control over physicians as the revenue- and cost-generating units of production. Private equity-backed firms are buying and expanding physician practices and squeezing them for profit, with little regard for patient outcomes, professional standards, or ethics. Insurers continue to grind down docs through pre-authorization and denials. All this is causing moral distress and burnout, and challenging the idea of what it means to be a physician. Professional societies and the AMA aren’t meaningfully pushing back. Residents are unionizing, but laws prevent most physicians from doing so. You know this; you live it. The trends feel unsustainable and undesirable to everyone except the profit-takers, and yet we all keep going along, lamenting that “healthcare is broken.” But we are healthcare. What will be the catalyst igniting the fire for change—and how and when will it manifest? Read in NYT

Deadly fungal infections are on the rise, and are often diagnosed late, leading to worse outcomes. A one-day delay in diagnosis of invasive candidiasis can double the risk of death, but such delays are typical when cultures are inconclusive and empiric treatments center on covering the far more common bacterial infections. “In medicine, fungi are an afterthought,” said ID doc Andrej Spec at Washington University in St. Louis. “We need a paradigm shift.” They published a paper making the case that in patients at high risk for fungemia, earlier use of empiric antifungals without waiting for positive fungal blood cultures would save lives. Better diagnostics are also needed, as blood cultures have low sensitivity for fungus, and take too long to result. Read in WSJ

Less can be more in cancer treatment, according to new research presented at the American Society of Clinical Oncology conference in Chicago. Cervical and pancreatic cancer patients often do as well with less invasive surgery, and some patients with rectal cancer or Hodgkin lymphoma can safely get less radiation.  “It’s time to look at less toxic approaches,” said Dr. Julie Gralow, executive vice president of the American Society of Clinical Oncology. The findings add to the previous recognition that early palliative care can result in increased survival in advanced lung cancer and observing prostate cancer can improve quality of life with no reduction in survival. Read at WSJ