Extracorporeal Carbon Dioxide Removal to Avoid Invasive Ventilation During Exacerbations of Chronic Obstructive Pulmonary Disease: VENT-AVOID Trial - A Randomized Clinical Trial.

Rationale: It is unclear whether extracorporeal CO2 removal (ECCO2R) can reduce the rate of intubation or the total time on invasive mechanical ventilation (IMV) in adults experiencing an exacerbation of chronic obstructive pulmonary disease (COPD). Objectives: To determine whether ECCO2R increases the number of ventilator-free days within the first 5 days postrandomization (VFD-5) in exacerbation of COPD in patients who are either failing noninvasive ventilation (NIV) or who are failing to wean from IMV. Methods: This randomized clinical trial was conducted in 41 U.S. institutions (2018-2022) (ClinicalTrials.gov ID: NCT03255057). Subjects were randomized to receive either standard care with venovenous ECCO2R (NIV stratum: n = 26; IMV stratum: n = 32) or standard care alone (NIV stratum: n = 22; IMV stratum: n = 33). Measurements and Main Results: The trial was stopped early because of slow enrollment and enrolled 113 subjects of the planned sample size of 180. There was no significant difference in the median VFD-5 between the arms controlled by strata (P = 0.36). In the NIV stratum, the median VFD-5 for both arms was 5 days (median shift = 0.0; 95% confidence interval [CI]: 0.0-0.0). In the IMV stratum, the median VFD-5 in the standard care and ECCO2R arms were 0.25 and 2 days, respectively; median shift = 0.00 (95% confidence interval: 0.00-1.25). In the NIV stratum, all-cause in-hospital mortality was significantly higher in the ECCO2R arm (22% vs. 0%, P = 0.02) with no difference in the IMV stratum (17% vs. 15%, P = 0.73). Conclusions: In subjects with exacerbation of COPD, the use of ECCO2R compared with standard care did not improve VFD-5. Clinical trial registered with www.clinicaltrials.gov (NCT03255057).

Efficacy of bronchial thermoplasty in a patient panel with uncontrolled severe persistent asthma.

BACKGROUND: Bronchial thermoplasty (BT) is an approved procedure to manage uncontrolled severe persistent asthma. Many insurance providers are reluctant to pay for BT without proven benefit among their specific patient panel. OBJECTIVE: Determine if BT is effective in a panel patient panel with uncontrolled severe persistent asthma. STUDY DESIGN AND METHODS: This was an unblinded prospective study of adult subjects with uncontrolled severe persistent asthma who underwent BT. Outcomes were assessed at baseline and then 3-, 6-, 12-, 18- and 24-months post-BT. The primary metric was an improved Asthma Quality of Life Questionnaire (AQLQ) score. Other metrics included improved Asthma Control Test (ACT), peak expiratory flow rates (PEFR), spirometry, fractional excretion of nitric oxide (FeNO), number of unscheduled medical visits, and lost days of work/activity. Respiratory adverse events were assessed during the BT treatment period and at each post-BT visit. RESULTS: Twenty-nine subjects completed the study; the median interquartile range (IQR) age was 47 (42-61), and the majority were female (69%), white (93%), and non-Hispanic (90%). After BT, mean (±std) AQLQ scores improved by 1.6(±1.1) at 3 months (p < 0.0001), 1.6(±1.2) at 6 months (p < 0.0001), 1.4(±1.0) at 12 months (p < 0.0001), 1.8(±1.1) at 18 months (p < 0.0001), and 1.6 (±1.5) at 24 months (p < 0.0001). There were significant improvements in ACT, PEFR, unscheduled medical visits and lost days of work and activity. Spirometry and FeNO metrics were unchanged. The average cost for subjects completing all 3 BT procedures was approximately $15,000. CONCLUSION: BT is an effective adjunctive therapeutic modality in subjects with uncontrolled severe persistent asthma.

Effects of pulmonary rehabilitation on functional and psychological parameters in post-acute sequelae of SARS-CoV-2 infection (PASC) patients.

BACKGROUND: COVID-19 survivors may develop long-term symptoms of fatigue, dyspnea, mental health issues, and functional limitations: a condition termed post-acute sequelae of COVID-19 (PASC). Pulmonary rehabilitation (PR) is a recommended treatment for PASC; however, there is a lack of data regarding PR's effect on multiple health indices and the factors that influence patient outcomes. The aim of our study is to evaluate the impact of pulmonary rehabilitation on functional and psychological parameters in patients diagnosed with Post-Acute Sequelae of SARS-CoV-2 Infection (PASC), thereby offering insights into the efficacy of such interventions in improving the quality of life and clinical outcomes for these individuals. METHODS: We extracted patient demographic, comorbidity, and outcome data from Allegheny Health Network's electronic medical records. Functionality test results were compared before and after PR, including 6-minute walk test (6MWT), chair rise repetitions (CR reps), timed up and go test (TUG), gait speed (Rehab gait), modified medical research council scale (MMRC), shortness of breath questionnaire (SOBQ), hospital anxiety and depression scale (HADS) and chronic obstructive pulmonary disease assessment test (CAT) scores. Multiple regression analysis was done to evaluate the effect of comorbidities and patient factors on patient responses to PR. RESULTS: The 55 patients included in this study had a mean time of 4 months between the initial COVID-19 diagnosis and the subsequent PASC diagnosis. Following pulmonary rehabilitation (PR), significant improvements were observed across various metrics. The distance covered in the 6-minute walk test (6MWT) increased markedly from a pre-rehabilitation average of 895 feet (SD 290) to 1,300 feet (SD 335) post-rehabilitation, with a mean change of 405 feet (95% CI [333, 477]). Chair rise repetitions (CR reps) saw an increase from 9 (SD 3) reps to 13 (SD 3) reps, with a change of 4 reps (95% CI [3.7, 4.9]). The timed up and go test (TUG) time decreased significantly from 13 s (SD 5) to 10 s (SD 2), reflecting a mean reduction of 3 s (95% CI [-4.5, -2.5]). Rehabilitation gait speed improved from 1.0 m/s to 1.3 m/s, changing by 0.3 m/s (95% CI [0.2, 0.3]). The Modified Medical Research Council (MMRC) dyspnea scale showed a notable decrease from a mean of 2 (SD 1) to 1 (SD 1), a change of -1 (95% CI [-1.5, -1]). The Shortness of Breath Questionnaire (SOBQ) scores reduced significantly from 51 (SD 21) to 22 (SD 18), with a change of -29 (95% CI [-34, -23]). The Hospital Anxiety and Depression Scale (HADS) scores decreased from 11 (SD 7) to 8 (SD 7), a reduction of -4 (95% CI [-5, -2]). Lastly, the Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT) scores significantly dropped from 18 (SD 7) to 9 (SD 7), changing by -10 (95% CI [-11, -8]). However, the presence of hypertension, diabetes, chronic lung diseases, outpatient status, and receipt of specific pharmacologic treatments (decadron, decadron + remdesivir, and decadron + remdesivir + tocilizumab) were identified as factors associated with a poor response to PR. CONCLUSION: Our study supports PR as an integrated model of care for PASC patients to improve several physical and mental health indices. The long-term effects of PR on patients' functional status should be investigated in the future.

Gastrointestinal Emergencies in the ICU.

Gastrointestinal (GI) emergencies and disorders are among the most common reasons to be admitted to an intensive care unit (ICU). In addition, critically ill patients admitted to the ICU for non-GI-related diseases are frequently at risk of developing GI complications during their hospitalization. This article details the epidemiology/etiology, clinical presentation, diagnostic assessment, and management of the following GI emergencies: upper and lower GI bleed, acute pancreatitis, and ascending cholangitis.

Toxicological Emergencies.

Poisoning, drug overdose, and adverse drug effects continue to be a common encounter, especially in the intensive care unit (ICU). Patients are often critically ill or have a potential to rapidly deteriorate and warrant ICU admission. Adults suffering from overdoses rarely give a complete and accurate description of the quantity or type of medications ingested. In most adult cases, multiple substances are involved. A tentative diagnosis in most overdose and poisoning cases can be made by physical examination and simple laboratory tests (electrolyte panel, creatinine, serum osmolarity, urinalysis, etc). Supportive care, with particular attention to airway management, oxygenation, and circulation, is the mainstay of treatment. Basic treatment principles include limiting the amount of toxin absorbed, enhancing the elimination of ingested toxin, and preventing the conversion of non-toxic compounds to toxic metabolites. Drugs or poisons, where specific antidotes or effective therapies exist (especially acetaminophen, salicylates, methanol, ethylene glycol, and digitalis), should be aggressively sought and treated after initial stabilization has been accomplished. For those drugs or poisons where specific quantitative tests are available, levels should be obtained before treatment and may be repeated as clinically indicated.

Fetal and Maternal Monitoring.

Fetal monitoring in the intrapartum and peripartum periods is important for the well-being of both baby and mother. Electronic fetal monitoring was first designed over 50 years ago in an attempt to improve perinatal outcomes. Its purpose is to assess fetal oxygenation and acid-base status during the antepartum course when indicated and during labor. Maternal assessment begins early in gestation with blood pressure monitoring and urine protein excretion to diagnose potential complications, such as severe hypertension and preeclampsia/eclampsia.

Asthma in Pregnancy.

Asthma is a common chronic respiratory condition that affects approximately 10% of adult women in the United States. Pregnancy can present unique challenges for women with asthma, as changes in the body can alter the severity and management of asthma-related respiratory symptoms. In this article, we review the current understanding of asthma during pregnancy, including the direct effects of the disease state on the pregnant woman and fetus, risk factors for poor control of disease, as well as current treatment recommendations.

Acute Cardiac Emergencies.

Acute cardiac emergencies are life threatening. The initial responses to acute cardiac emergencies must be rapid, efficient, skillful, and well-planned. The goal of this article is to provide information that can be used to facilitate the prompt recognition and treatment of the most common acute cardiac emergencies.

Pathophysiology of COPD.

This article provides an overview of the pathophysiology of chronic obstructive pulmonary disease including the physiological mechanisms that are known precursors. The roles of environmental and genetic causes are considered. α1-Antitrypsin deficiency is also discussed as it relates to the development of airflow obstruction.

COPD Maintenance Pharmacotherapy.

Chronic obstructive pulmonary disease (COPD) is currently the fourth leading cause of death worldwide and will likely be the third most common cause by the end of 2020. It is felt to be caused by repetitive noxious stimuli to the lung, most commonly from smoking, with persistent symptoms of cough, wheeze, and shortness of breath. Most patients will have these baseline symptoms, with periodic flare-ups known as exacerbations. This article focuses on pharmacological therapy in a stable COPD patient. Pharmacological treatment of a stable COPD patient focuses on minimizing symptoms, improving exercise tolerance, and preventing exacerbations. Nonpharmacological management of stable COPD, smoking cessation, and treatment of exacerbations are covered in other sections.

Nonpharmacological Therapies in COPD.

Chronic obstructive pulmonary disease has recently been gaining more attention, as beyond impacting roughly 10% of the world's population, it also carries high morbidity and mortality. The mainstay of management is optimizing pharmacological therapy, but various nonpharmacological therapies have shown benefits in providing symptom improvement and relief, prevention and mitigation of exacerbations, quality of life, and even mortality rate. Such modalities include supplemental oxygen therapy, pulmonary rehabilitation, viral and bacterial vaccinations, and noninvasive positive pressure ventilation therapy.

Smoking Addiction and Strategies for Cessation.

Cigarette smoking is the leading cause of chronic obstructive pulmonary disease (COPD) worldwide. Smoking cessation is thus integral to the treatment of COPD. Nicotine addiction is a disease dependent on the complex interactions of neurotransmitter pathways, conditioned behaviors, environmental cues, genetic predisposition, and personal life circumstances, which render some more susceptible to tobacco abuse than others. The most successful smoking cessation programs are individualized, comprehensive, and utilize combinations of clinician counseling, behavioral reinforcement, community resources, advanced technology support (eg, smartphone apps, and Internet Web sites), and pharmacotherapy (both nicotine-based and nonnicotine medications). E-cigarettes were introduced to the US market in 2006 and touted as a safer alternative to tobacco cigarette smoking. Unfortunately, over the last 5 to 10 years, recreational e-cigarette use, or "vaping," has increased in popularity, especially among adolescents. This has introduced nicotine addiction to an entire generation of nonsmokers and resulted in numerous cases of acute lung disease, now known as e-cigarette or vape product use-associated lung injury (EVALI). In light of these adverse events, e-cigarettes and vape products are not currently recommended as a smoking cessation aid.

Lung Transplantation in COPD.

Chronic obstructive pulmonary disease (COPD) remains one of the leading causes of morbidity and mortality both in the United States and worldwide. Despite advances in medical treatment including smoking cessation, bronchodilator therapy, oxygen administration, and pulmonary rehabilitation, patients with advanced COPD still suffer significant debility. For select patients with severe COPD, there are additional surgical options including lung volume reduction surgery and ultimately lung transplantation.This article discusses the history, clinical indications, selection of candidates, choice of procedure, and outcomes of lung transplantation in patients with advanced COPD. In addition, certain aspects of potential short- and long-term complications of transplantation will also be discussed.

Comorbidities Associated With Chronic Obstructive Pulmonary Disease.

Chronic obstructive pulmonary disease or COPD is characterized by airflow obstruction, causing respiratory symptoms. There are treatments available for COPD; however, COPD has significant extrapulmonary effects, including well-recognized ones as cardiovascular disease and often underdiagnosed ones as osteoporosis. It is imperative to be aware of these comorbidities to optimize COPD patient care.

The Role of Palliative Care in COPD.

Chronic obstructive pulmonary disease is a highly symptomatic disease that may lead to significant morbidity. Even with optimal therapy, the patient's quality of life can be severely affected. These symptoms include dyspnea, anxiety, depression, and malnourishment. Palliative care is a branch of medicine that specializes in the care of patients with a terminal illness no matter what stage of the disease they are in. It implements a family-centered approach to help patients deal with their symptoms. It also helps with shared decision-making and advanced care planning.

COVID-19: An Update on the Epidemiological, Clinical, Preventive, and Therapeutic Management of 2019 Novel Coronavirus Disease.

The COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2) remains a serious issue for global health, given widespread infectivity and a high contagion rate. A tremendous amount of data has been generated since it was first identified in December 2019. It is vital to keep up with these data from across the world at a time of uncertainty and continuously evolving guidelines and clinical practice. This review provides an update on recent developments concerning epidemiology, clinical presentation, treatment options, and scientific advancements to combat the COVID-19 pandemic.

Chronic Obstructive Pulmonary Disease: Diagnosis and GOLD Classification.

This article describes the various steps required to confirm the diagnosis of chronic obstructive pulmonary disease (COPD). The GOLD Criteria developed by the Global Initiative for COPD will be outlined as they relate to the diagnosis and management of COPD. Pulmonary function testing, imaging, and symptom assessment will be explored.

Surgical Interventions for COPD.

Chronic obstructive pulmonary disease (COPD) treatment is aimed at managing the disease rather than cure, with a focus on improving quality of life and decreasing exacerbations. Interventional therapies, including lung volume reduction surgery, bullectomy, lung transplantation, and bronchoscopic lung volume reduction treatment using endobronchial valves, are treatment options for patients with COPD who are symptomatic due to hyperinflation despite optimal medical management. We will review the current literature to provide a comprehensive summary of the currently available scientific data, discuss typical treatment-related side effects, and evidence-based management approach and recommendations for patient selection in clinical practice.

Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide and results in an economic and social burden that is both substantial and increasing. The natural history of COPD is punctuated by exacerbations, which have major short- and long-term implications on the patient and health care system. Evidence-based guidelines stipulate that early detection and prompt treatment of exacerbations are essential to ensure optimal outcomes and to reduce the burden of COPD. In this review, we provide a concise overview of COPD exacerbations and their risk factors and etiology (infection vs noninfectious), outlining the initial evaluation, triaging, and current management including invasive and noninvasive ventilation, in addition to the prognosis and the preventive strategies.

Developing a Multidisciplinary Approach to the COPD Care Pathway.

Chronic obstructive pulmonary disease (COPD) is characterized as a predominately preventable and treatable inflammatory lung disease caused by progressive obstructed airflow from the lungs. In the United States and worldwide, it is becoming a major cause in hospital admissions as well as an increase in morbidity and mortality. The rising total cost of care for COPD is concerning for all health care industries. The disease has significant impact on the patient's quality of life and psychological well-being. A worldwide initiative is underway in developing a care model that is multifactorial through continuous monitoring of patients to manage and control symptoms, achieve medication adherence, and provide socioeconomic resources. The primary aim of this study was to prevent exacerbations, hospital admissions, and readmissions. Various models have shown positive results; however, the significant financial investment is the major barrier to success. Recently, one health system in the United States was able to improve care, decrease readmissions, and reduce total cost of care by investing in a multidisciplinary team of specialists. In the utilization of the care model, the primary endpoint will conclude that COPD is financially and socioeconomically manageable.