Since we’re entering the last month of 2024, here is a non-systematic review of #pulmcrit trials published this year that I found particularly noteworthy. Not comprehensive, so please include any that I may have missed! (🧵1/11) #emimcc #critcare #pulmsky #medsky - ThreadSky

brianelliottmd.bsky.social • 90 days ago

Since we’re entering the last month of 2024, here is a non-systematic review of #pulmcrit trials published this year that I found particularly noteworthy. Not comprehensive, so please include any that I may have missed!

(🧵1/11)

#emimcc #critcare #pulmsky #medsky

Comments

mollybillings.bsky.social•89 days ago

Excellent thread 🧵 with key articles. Might add the surmount trial which has potential big implications for OSA treatment: https://www.nejm.org/doi/full/10.1056/NEJMoa2404881

economicexile.bsky.social•89 days ago

Great list! I would add the PREOXI trial to the list of practice-changing papers in PCCM.

brianelliottmd.bsky.social•89 days ago

Can’t believe I missed that one! Definitely noteworthy. We use a lot of HHFNC so unclear how that compares to the mostly NRB control arm, but the BiPAP reduction in arrest rates vs NRB make me avoid NRB for sure

https://www.nejm.org/doi/full/10.1056/NEJMoa2313680

economicexile.bsky.social•89 days ago

Yeah, it was practice changing for me. I'm biased because the first author, Kevin Gibbs, is at my institution.(Wake Forest). HHFNC vs BiPAP would be very interesting.

galaxygirl.bsky.social•89 days ago

📌

brianelliottmd.bsky.social•90 days ago

The TRAIN trial was one of the few that will directly change my practice. In patients with acute brain injury, a liberal transfusion strategy (<9) vs a restrictive (<7) resulted in an ARR of 10% for unfavorable neurologic outcome.
https://jamanetwork.com/journals/jama/article-abstract/2824930

brianelliottmd.bsky.social•90 days ago

The BLING III Trial. Do cont vs intermittent beta lactams improve mortality in sepsis? Maybe? The primary outcome (90d mortality) resulted in a 2% ARR with p=0.08, causing substantial debate about the conclusions that could be drawn and how to interpret p values
https://jamanetwork.com/journals/jama/article-abstract/2819971

andymoz78.bsky.social•89 days ago

Mortality is not the only important outcome, and pre-specified significance thresholds set by Fisher in 1925 not only arbiter of significance. There is good PK/PD rationale for continuous infusion, clinical cure is an important outcome and meta-analysis supportive.

andymoz78.bsky.social•89 days ago

IMHO this should be practice changing, with all drugs with time above MIC killing given as infusions assuming stability data supportive. I think there remains questions around CNS penetrance and high peak concentrations - but for everything else CI (with loading dose!) is way forward.

brianelliottmd.bsky.social•89 days ago

I agree there is good rationale. The outcome just didn’t seem to be strong enough to overturn the status quo. I haven’t worked for a shop that has the training, order sets, etc to do it. Did see one bad patient outcome when a Dr. tried to do it without these institutional changes in place.

andymoz78.bsky.social•89 days ago

It definitely needs to be planned and implemented properly with everyone (intensivists, pharmacists, nurses) on board
Systematic review is, IMHO, pretty convincing and direction of effect is inline with underpinning pharmacology

https://jamanetwork.com/journals/jama/article-abstract/2819970

matdesgro.bsky.social•89 days ago

💯💯 but there’s a gap in research to be filled with extensive IV compatibilities. This would simplify use & adoption for a lot of people

brianelliottmd.bsky.social•90 days ago

PARAMEDIC3 was an RCT of IO access vs IV access in out of hospital cardiac arrest. The primary outcome of favorable neuro status was not different, but higher ROSC rates with IV access.

https://www.nejm.org/doi/abs/10.1056/NEJMoa2407780

brianelliottmd.bsky.social•90 days ago

The REDOX trial. There was no mortality or hospitalization benefit to using 24hr oxygen vs 15hr. Very important point when counseling patients on something that immensely impacts quality of life.

https://www.nejm.org/doi/full/10.1056/NEJMoa2402638

brianelliottmd.bsky.social•90 days ago

The HAPPEN trial
Go hard or go home because high intensity NIPPV (10-15ml/kg IBW TVs) vs low intensity (6-10) in COPD exacerbations reduced the rate of patients meeting predefined criteria for intubation by 9% (ARR).

https://jamanetwork.com/journals/jama/article-abstract/2823763

brianelliottmd.bsky.social•90 days ago

The NODUS study
Dupilumab reduced the rates of exacerbations, improved FEV1s, but did not significantly improve symptoms in patients with COPD and eos >/=300. Biologics may be on the horizon for COPD patients with the right phenotype
https://www.nejm.org/doi/full/10.1056/NEJMoa2401304

amyattawaymd.bsky.social•88 days ago

The REDOX trial was only for one year. The NOTT and MRC trials showed mortality benefit of oxygen therapy at two years and five years, respectively. I was really surprised the editorial didn't mention this.

karijerge.bsky.social•90 days ago

📌

sleepy3er1doc.bsky.social•89 days ago

Fantastic thread. Thank you for sharing 👍

cnemehmd.bsky.social•89 days ago

Great thread, thank you for assembling these!

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