The preliminary report of the Adaptive COVID-19 Treatment Trial (ACTT-1), a multi-center, placebo-controlled RCT on remdesivir is here!1 The one we’ve all been waiting for! Patients Patients were recruited from 60 sites in several countries. Inclusion criteria were patients who were hospitalized due to COVID-19 with evidence of lower respiratory tract infection, defined in terms […]
PulmCrit – Sodium Zirconium Cyclosilicate for urgent treatment of hyperkalemia?
Sodium Zirconium Cyclosilicate (SZC) is a potassium-exchange resin similar in concept to sodium polystyrene sulfonate (Kayexalate). It’s not particularly new, as the original studies were performed around 2015. Accumulating evidence over the last five years supports the drug’s safety. The real question is how effective it may be. Efficacy data for short-term improvement in potassium […]
IBCC chapter & cast – COPD exacerbation
COPD exacerbation is bread and butter critical care. However, familiarity can breed concept. Thus, it’s important to always approach patients labeled with “COPD exacerbation” with fresh eyes, because they can present with other pulmonary pathologies as well. The primary challenge among these patients is usually utilizing noninvasive support devices to avoid intubation, whenever possible. The […]
PulmCrit – Before/after study of short-course steroid in COVID-19
One of the most notable controversies in COVID is when steroid might be beneficial. Since steroid is widely available and inexpensive, this issue has escaped the attention of pharmaceutical companies. Consequently, evidence surrounding this is extremely sparse. Available evidence consists largely of retrospective studies which relate steroid administration to outcome. Such studies are inherently flawed, […]
PulmCrit – Lupus Anticoagulant in COVID-19: Culprit or correlate?
An emerging body of evidence relates lupus anticoagulant to COVID-19. Both of these topics are enormously confusing on their own, so let’s try to ease into this… background on lupus anticoagulant what is lupus anticoagulant? Lupus anticoagulant isn’t any single thing, but instead it refers to a variety of different antibodies which may behave […]
PulmCrit- Virus Wars: Return of Lopinavir/Ritonavir (along with ribavirin and interferon)
Background Where were we with the Lopinavir/Ritonavir story? Let’s backtrack for a moment. Lopinavir/Ritonavir showed some efficacy against SARS, but as triple therapy in combination with ribavirin. A while ago, some studies tested lopinavir/ritonavir alone against COVID-19 and this didn’t work. Consequently, that was set aside for a while. However, there were lingering questions about […]
PulmCrit – High-dose anakinra for COVID-19: The anti-inflammatory trials begin
Over the last several weeks, we have seen a flurry of studies on various anti-viral therapies (lopinavir-ritonavir, hydroxychloroquine, chloroquine, and remdesivir). On the whole, these studies were consistently unimpressive. Perhaps remdesivir works a bit, but overall these studies simplified management by allowing us to ignore several drugs. I’m expecting the anti-inflammatory trials to be the […]
PulmCrit – Thrombosis update in COVID-19: Data from the Mount Sinai system in NYC
One of the most controversial issues regarding management of COVID-19 is the appropriate dosing of anticoagulation. It’s universally agreed upon that patients with COVID-19 should receive some dose of anticoagulation (at least prophylaxis), barring contraindications. However, the optimal dose is unclear. Numerous reports indicate that patients with COVID-19 have high rates of venous thromboembolic disease, […]
PulmCrit – Awake Proning for COVID-19
Recently, many on twitter have been engaged in a furious debate about how to ventilate patients with COVID-19. Is it ARDS or not? High PEEP or low PEEP?… As an intensivist, these issues are near and dear to my heart. However, the truth is that humble methods to keep patients off invasive ventilation altogether are […]
PulmCrit – Is COVID-19 ARDS, pseudoARDS, L, or H? Physiology data from Boston
There has been considerable speculation in the literature regarding the physiology of intubated patients with COVID, but little actual data. A fresh study describing the physiology of intubated patients at Massachusetts General Hospital and Beth Israel offers to finally answer some questions. This is a retrospective case series involving 66 patients intubated during March 11-30. […]
PulmCrit- First placebo-controlled RCT on remdesivir for COVID-19
Remdesivir is being promoted as an anti-viral agent for the treatment of COVID-19. The first randomized, blinded, placebo-controlled trial of remdesivir was just released (Wang et al.). But before we dig into this trial, a little background… Background: Animal studies on Remdesivir Remdesivir is an anti-viral agent with strong efficacy against COVID-19 both in vitro […]
PulmCrit- American research infrastructure is killing us: The misbegotten battle between the ivory tower academics and the rogue cowboys
the battle between the ivory tower academics vs. the rogue cowboys An internecine war is brewing about the treatment of COVID-19. You can hardly open up a journal or look at social media without getting caught in the cross-fire. The cause of the schism is pretty simple. There are no proven treatments for COVID-19. Based […]
PulmCrit Wee: Lung pathology of COVID-19: is AFOP in play?
We’re beginning to start to see some information about lung pathology due to COVID-19. But before jumping into that, a little background… background: lung pathology, DAD, and AFOP Lung pathology & treatment: the bigger picture In an ideal world, different insults to the lung would cause specific histologic patterns. These patterns would be related to […]
PulmCrit Wee – Some take-home messages about the COVID experience in New York
Currently, three publications are available describing coronavirus outcomes among hospitalized patients in New York: Goyal et al: 393 patients at Cornell. Cummings et al: described 257 patients who were critically ill (among a total of 1,150 patients at Columbia and a community affiliate). Richardson et al: 5700 patients at Northwell Health System (including North Shore […]
PulmCrit- Timed & titrated use of steroid in COVID-19?
Guideline recommendations on steroid use in COVID are contradictory. For example, the Surviving Sepsis Campaign recommends steroid for intubated patients with COVID and ARDS,1 whereas the IDSA guidelines recommend that steroid should be restricted to randomized controlled trials. Reviewing these documents shows that they often lean on data from influenza and MERS, which may not […]
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