The Year in Critical Care: Mechanical Ventilation and ARDS
Part 4 of the 2025 year-end roundup
Too many posts here to fit inside one email! Click the title link to see what your email client cut off from the bottom. Happy holidays! —Matt
UK-ROX Proves the U.K. Rocks, But
High oxygen doses are toxic to the mammalian respiratory system, as noted at least as far back as 1927 in animal testing. In the 1980s, healthy human test subjects breathing 100% oxygen for 24 hours at sea level were observed to develop substernal discomfort, airway erythema and leakage of protein into the alveoli on bronchoscopy
Is higher or lower oxygenation better in critical illness? Let's settle this (Review)
This post is long with multiple forest plots and tables. If you’re reading this in an email, click the title to view it on pulmccm.org or in the Substack app for a better experience. —Ed.
Clonidine sedates as well as dex or propofol in vented patients? (Part 1)
An earlier version of this post contained an error, saying clonidine mediates peripheral vasodilation via alpha-1 receptors rather than alpha-2 receptors. It has been corrected. -Ed.
Clonidine sedates as well as dex or propofol in vented patients? (Part 2)
Thanks to the astute readers who noticed our error in part 1: clonidine mediates peripheral vasodilation via stimulation of alpha-2 receptors, not alpha-1. The post has been corrected. -Ed.
Sedation and Analgesia Guideline Update: Dex vs Propofol
Virtually all critically ill patients experience pain, anxiety, sleep disturbance, agitation, or a combination of these bothersome symptoms. Relieving these burdens should be considered a fundamental aspect of caring for the most seriously ill.
High-flow nasal oxygen vs. noninvasive ventilation for acute hypoxemic respiratory failure (RENOVATE)
Severe acute hypoxemic respiratory failure (AHRF) is today treated with high-flow nasal cannula oxygen or noninvasive ventilation, in an attempt to forestall the need for intubation and mechanical ventilation.
Pulse oximeters overestimate O2 saturations in darker-skin patients; FDA acts (kind of)
Pulse oximeters for healthcare and consumer use are calibrated on patients with lighter skin. Manufacturers have recognized the devices’ suboptimal performance in darker-skinned patients for decades, but they have faced no serious regulatory or legal pressure to act.
The Real-World Boards: Question #23
These are the Real-World Boards. As in the real world, there may be no single “right” answer, and you are only competing against yourself. Upgrade to the Lifelong Learner level for full access to all the questions and unlimited CME credits with an included Learner+ account.
"Advanced Practice Respiratory Therapists": coming to your ICU soon?
Intensivists should take notice of an emerging accreditation in the alphabet soup of accolades: advanced practice respiratory therapists (APRTs). Respiratory therapist societies have so far failed to move the new role forward meaningfully, but now they’re getting a boost from one of the major US critical care societies.
Can Lungpacer® wean your patient off the vent?
About 2.5 million people each year go on a mechanical ventilator, and some do not easily come off. Estimates vary, but in the U.S., tens of thousands of people annually require ventilation for ≥14 days, and hundreds of thousands remain persistently ventilator dependent at any given time.
The STAMINA trial was ironically named, it turns out
The STAMINA trial enrolled patients in Brazil with severe pneumonia and acute hypoxemic respiratory failure (aka ARDS), randomizing them to a dynamic strategy limiting the driving pressure (= plateau pressure minus PEEP, representing the distending pressure on the lung with each breath) or a strategy limiting PEEP.
Can new smart vents beat intensivists in the MICU? (ACTIVE trial)
New “intelligent” ventilator modes purport to wean patients faster (and safely), with minimal hands-on adjustment by clinicians. These go by a variety of names and have under-the-hood differences, but conceptually speaking, they dynamically and algorithmically hybridize
Does ventilator mode matter?
Modern ventilators are complicated machines, but at its most basic level, a ventilator is simply a pump that generates pressure to push air (a mixture of gases) through a closed circuit at regular intervals.
Guideline Update: Early mobilization advised for all ICU patients
In a March 2025 guideline update, the major U.S. critical care society advised that all critically ill patients should receive “enhanced mobilization” or rehabilitation, over and above usual physical therapy.
Does prophylactic noninvasive ventilation prevent reintubation in obese patients?
After liberation from mechanical ventilation, obese patients may be at increased risk for recurrent respiratory failure and reintubation.
Sedation, Analgesia, and Sleep Guideline Update: Melatonin
Normal sleep patterns aren’t just altered in critically ill, mechanically ventilated patients—often, they’re virtually wiped out by the use of heavy sedatives around the clock.