American Journal of Respiratory and Critical Care Medicine

Treatment

1. Curtis JR, Treece PD, Nielsen EL et al. Randomized Trial of Communication Facilitators to Reduce Family Distress and Intensity of End-of-life Care. Am J Respir Crit Care Med. 2015 Sep 17. [Epub ahead of print]

CONCLUSIONS: Communication facilitators may be associated with decreased family depressive symptoms at 6-months, but we found no significant difference at 3-months nor in anxiety or PTSD. The intervention reduced costs and length of stay, especially among decedents. This is the first study to find a reduction in intensity of end-of-life care with similar or improved family distress. PMID:26378963

Comments: Of course, having a dedicated ED communicator is not feasible, clear communication adapted to the family's needs makes a big difference in their emotional state.  Compassionate but realistic conversation with family starts with us in the ED.  And families who understood what was going on ended up spending much less on healthcare with no change in outcome, especially among patient who ultimately died.  Instead of a month in the ICU before dying, the LOS was a week.  Instead of spending almost $100,000 before dying, the expenditures were $23,000.  Again, overall mortality was the same in each group.  Finding a sensitive way to communicate that we are ultimately not helping their loved one live longer and are prolonging suffering makes a big difference not only in cost but in helping family cope better.

 

2. Semler MW, Janz DR, Lentz RJ et al for the FELLOW Investigators and the Pragmatic Critical Care Research Group. Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill. Am J Respir Crit Care Med. 2015 Oct 1. [Epub ahead of print]

CONCLUSIONS: Apneic oxygenation does not appear to increase lowest arterial oxygen saturation during endotracheal intubation of critically ill patients compared to usual care. These findings do not support routine use of apneic oxygenation during endotracheal intubation of critically ill adults. PMID: 26426458

Comments: Smaller RCTs have shown benefit for apneic oxygenation.  This Vanderbilt study is the largest RCT to tackle this topic, and it showed no difference.  Many of these patients had severe problems with oxygenation already, as opposed to prior RCTs with healthy patients in the OR.  Possibly a higher flow rate, such as 60mL/min as in other studies, may have added benefit.  The authors also note, "High compliance with pre-oxygenation (including non-invasive ventilation for patients with hypoxemia), patient positioning, and equipment preparation best practices may have reduced the potential additive impact of apneic oxygenation. Had we used a standardized intubation protocol or a highly-uniform group of operators, we might have reduced practice-related variation in lowest arterial oxygen saturation, making any effect of apneic oxygenation easier to detect."  I plan to continue using HFNC + NRB mask to preoxygenate prior to intubation.  I see no downside, and the benefit is clearer in patients without severe preexisting pulmonary disease and in obese patients.  Here is what the EMCrit podcast, EMCrit blog and EMLitofNote had to say.


3. Philippart F, Gaudry S, Quinquis L et al for the TOP-Cuff Study Group. Randomized intubation with polyurethane or conical cuffs to prevent pneumonia in ventilated patients. Am J Respir Crit Care Med. 2015 Mar 15;191(6):637-45. doi:
10.1164/rccm.201408-1398OC.

CONCLUSIONS: Among patients requiring mechanical ventilation, polyurethane and/or conically shaped cuffs were not superior to conventional cuffs in preventing tracheal colonization and VAP. PMID: 25584431

Comments: Usual ETTs are made of PVC and a cylindrical cuff.  Neither polyurethane conical or cylindrical cuffs nor PVC conical cuffs prevented VAP.  Since it's not the shape or substance of the ETT that seems to matter, attention can be directed to other best practices to prevent VAP.

Diagnostic

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Review

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Clinical Prediction Rules

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