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Pulmonary Medicine Update: Bariatric surgery for COPD exacerbations & The Mortality Indicator that Won’t Die.

Study Shows That Bariatric Surgery Reduced COPD Exacerbations by More Than Half

I often tell my patients with COPD that quitting smoking can have a greater effect on their respiratory health than any inhaler that I could prescribe them. Should I now also extend that advice to include weight loss for obese patients with COPD? In this journal CHEST® study, researchers used registry data to look at COPD exacerbations for patients both before and after bariatric surgery. In the year before bariatric surgery, risk of COPD exacerbations was 31%. Looking at the rate of COPD exacerbations during the year after bariatric surgery, that rate dropped to 12%, an astounding change.

The accompanying editorial proposes mechanisms explaining why this might be so and postulates whether obesity could be a modifiable risk factor in COPD. While these results are certainly exciting, we look forward to future investigation into whether bariatric surgery, or other weight loss means, could further help reduce risk of COPD exacerbation.

Pneumonia: If You Can’t See It, Does It Still Exist?

The diagnosis of pneumonia requires the radiographic presence of infiltrates on imaging. However, with its greater resolution, CT scanning can often demonstrate infiltrates when none are seen on chest roentgenogram. Do we treat these the same as a regular pneumonia? This study sought to quantify differences between patients with pneumonia as seen on a chest radiograph vs CT scanning. The differences between the two groups appeared to be minor, with procalcitonin levels appearing to be lower in the CT group. Otherwise, it would appear that patients with pneumonia seen only on CT scanning should be managed like other groups.

The accompanying editorial raises the question of what to do with patients who are suspected of pneumonia but have negative chest radiographs. Certainly, exposing them all to CT scanning can’t be the right answer. Perhaps we should err on the side of caution and treat these patients for pneumonia when clinical suspicion is high. Conversely, we should consider CT scanning in this group only if suspicion is low and the presence of an infiltrate would change management. Continue reading “Pulmonary Medicine Update: Bariatric surgery for COPD exacerbations & The Mortality Indicator that Won’t Die.”

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Devastation in Puerto Rico leads to hospital shortages in U.S.

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Hospitals run short of critical medications after loss of production in Puerto Rico facilities. 

“Doc, you mind switching that to an oral preparation?”, our clinical pharmacist inquired during multi-disciplinary rounds as intravenous infusion devices beeped annoyingly in the background.  Taking care of ICU patients can be extraordinarily complicated, so doing it as part of a team helps make sure that all bases are covered. ICU’s like ours have a BEEP BEEP BEEP. Excuse me, for a moment,  Staci, can you get that thing to stop, please? BEEP, BEEP, BEE– Thanks, Staci!. As I was saying, like many hospitals, ours uses a multidisciplinary model which makes rounds on all patients in the ICU.  An ICU nurse, clinical pharmacist, dietitian,  social worker, pastoral care, respiratory therapist, each provides important insight and perspective that guides patient care in the right direction.

As a pulmonary, critical care doc, I’m lucky to have a great team, so my ears perked up when I heard the suggestion. This was now the third patient he had made a suggestion to switch a medication to the oral route from the intravenous route. “What gives, Scott?” Over the past few years, we’ve been experiencing alot of spot medication shortages either because of inadequate supply, or because of precipitous price increases;  we can usually change to an alternative. But today was different. Today we were switching a number of different medications, all of which were intravenous to oral formulations of the same or similar medicines.

“It’s not the medicines,” he replied, “It’s the bags they’re in”. Continue reading “Devastation in Puerto Rico leads to hospital shortages in U.S.”

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The PROCESS Trial: End of the Line for Central Lines?

A lot of things change for doctors once we’re done with training. Most of us leave behind the ivory tower that is the academic medical center to plow the common fields of private practice. We no longer have the weekly journal clubs, the Grand Rounds, the CME lectures. But what we gain is practical hands-on experience with what works, and what doesn’t. A nuanced knowledge of what’s accepted vs. what’s acceptable.

One such area has been the approach to sepsis. Manny Rivers et al published  their game changing study on early goal directed therapy (EGDT) in the treatment of septic shock in 2001, and the result became scripture in the field of Critical Care Medicine. The knowledge that tying sepsis resuscitation to the measurement of central venous oxygen saturation (ScvO2) and central venous pressure (CVP) using a central venous catheter, lead to a surge of recommendations.

The brain trust spewed forth these recommendations in various forms;  Surviving Sepsis Campaign, Sepsis guidelines, Sepsis bundles, Sepsis video games and Sepsis action figures. Somewhere in that sentence I may have transitioned to hyperbole.

Those of us in clinical practice didn’t always follow the drumbeat. Many of our patients with sepsis it seemed, did just fine without a routine central line or blood transfusions, or dobutamine drips. Why use invasive measures when we don’t really need them, and we’re not really sure that they’re helping? Still, when I talked to my ivory tower friends, the response was same, “We always use central lines and follow the EGDT”, they would say.

In case you’re thinking that I’m a maverick, well, it wasn’t just me. Surveys/studies that have looked at compliance with EGDT show compliance anywhere from as low as 0.1% to just above 50%. Clearly people were pushing back against the guidelines, and many began to publicly question whether results of EGDT could be generalized to the general population with sepsis. Continue reading “The PROCESS Trial: End of the Line for Central Lines?”