Annals of the American Thoracic Society
-
Rationale: Sleep-disordered breathing (SDB) occurring primarily during rapid eye movement (REM) sleep is a common clinical problem. The natural history of REM-related SDB and the associated cardiovascular sequelae of disease progression remain to be determined. Objectives: The objective of the current study was to describe the natural history of REM-related SDB, ascertain predictors of progression, and determine whether the evolution of REM-related SDB into non-REM (NREM) sleep is associated with incident cardiovascular events. ⋯ Progression of SDB into NREM sleep is associated with sex, weight, and age. SDB during REM and NREM sleep tends to develop concurrently. Finally, the development of SDB during NREM sleep is associated with incident cardiovascular events, but only in women with REM-related SDB at baseline.
-
Intensive care units (ICUs) are an appropriate focus of antibiotic stewardship program efforts because a large proportion of any hospital's use of parenteral antibiotics, especially broad-spectrum, occurs in the ICU. Given the importance of antibiotic stewardship for critically ill patients and the importance of critical care practitioners as the front line for antibiotic stewardship, a workshop was convened to specifically address barriers to antibiotic stewardship in the ICU and discuss tactics to overcome these. The working definition of antibiotic stewardship is "the right drug at the right time and the right dose for the right bug for the right duration." A major emphasis was that antibiotic stewardship should be a core competency of critical care clinicians. ⋯ Instead, it should enhance care both for individual patients (by improving and individualizing their choice of antibiotic) and for the ICU population as a whole. Opportunities for antibiotic stewardship in common ICU infections, including community- and hospital-acquired pneumonia and sepsis, are discussed. Intensivists can partner with antibiotic stewardship programs to address barriers and improve patient care.
-
Rationale: Interpretation of spirometry is influenced by inherent limitations and by the normal or predicted reference values used. For example, traditional spirometric parameters such as "distal" airflows do not provide sufficient differentiating capacity, especially for mixed patterns or small airway disease. Objectives: We assessed the utility of an alternative spirometric parameter (area under the expiratory flow-volume curve [AEX]) in differentiating between normal, obstruction, restriction, and mixed patterns, as well as in severity stratification of traditional functional impairments. ⋯ Using forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and FEV1/FVC z-scores plus the square root of AEX in a machine learning algorithm, diagnostic categorization of ventilatory impairments was accomplished with very low rates of misclassification (<9%). Especially for mixed ventilatory patterns, the neural network model performed best in improving the rates of diagnostic misclassification. Conclusions: Using a novel approach to lung function assessment in combination with traditional spirometric measurements, AEX differentiates well between normal, obstruction, restriction and mixed impairments, potentially obviating the need for more complex lung volume-based determinations.
-
Amid efforts to care for the large number of patients with COVID-19, there has been considerable speculation about whether the lung injury seen in these patients is different than ARDS from other causes. One idea that has garnered considerable attention, particularly on social media and in free open access medicine is the notion that lung injury due to COVID-19 is more similar to high altitude pulmonary edema (HAPE). ⋯ Despite some similarities in clinical features between the two entities, such as hypoxemia, radiographic opacities and altered lung compliance, the pathophysiological mechanisms of HAPE and lung injury due to COVID-19 are fundamentally different and the entities cannot be viewed as equivalent. While of high utility in the management of HAPE and acute mountain sickness, systemically delivered pulmonary vasodilators and acetazolamide should not be used in the treatment of COVID-19, as they carry the risk of multiple adverse consequences including worsened ventilation-perfusion matching, impaired carbon dioxide transport, systemic hypotension and increased work of breathing.