Prevalence and Impact on Mechanical Ventilation Weaning of Pleural Effusion in ICU Patients Pleural effusion is frequently encountered in patients who are mechanically ventilated in the intensive care unit and may be logically suspected in case of difficult weaning from mechanical ventilation. Through several mechanisms, pleural effusion may impair gas exchange, respiratory mechanics, and ventilation/perfusion matching. However, data exploring the respective contribution of pleural effusion on weaning failure are scarce. This review discusses the most recent findings pertaining to the potential role of pleural effusion in weaning outcome.

Time-limited Trials in the Intensive Care Unit to Promote Goal-Concordant Patient Care Consider the hypothetical case of a 75-year-old patient admitted to the intensive care unit (ICU) for acute hypoxemic respiratory failure due to pneumonia and systolic heart failure. Although she suffers from a potentially treatable infection, her advanced age and chronic illness increase her risk of experiencing a poor outcome. Her family feels conflicted about whether the use of mechanical ventilation would be acceptable given what they understand about her values and preferences. In the ICU setting, clinicians, patients, and surrogate decision-makers frequently face challenges of prognostic uncertainty and uncertainty with regard to patients’ goals and values. Time-limited trials (TLTs) of life-sustaining treatments in the ICU have been proposed as one strategy to help facilitate goal-concordant care in the midst of a complex and high-stakes decision-making environment. TLTs represent an agreement between clinicians and patients or surrogate decision-makers to use a therapy for an agreed-upon time period, with a plan for subsequent reassessment of the patient’s progress according to previously established criteria for improvement or decline. Herein, we review the concept of TLTs in intensive care, and explore their potential benefits, barriers, and challenges. Research demonstrates that, in practice, TLTs are conducted infrequently, and often incompletely, and are challenged by system-level factors that diminish their effectiveness. The promise of TLTs in intensive care warrants continued research efforts, including implementation studies to improve adoption and fidelity, observational research to determine optimal time frames for TLTs, and interventional trials to determine whether TLTs ultimately improve the delivery of goal-concordant care in the ICU.

Providing an Antibiotic Allergy Service Approximately 10% of patients report an allergy to ≥1 antibiotics, most commonly penicillins. Having a label of penicillin allergy has important health consequences for the individual, as well as health and economic impact at the population level. Despite this, only a minority of patients have the opportunity to have suspected antibiotic allergies confirmed. Busy clinicians seldom have time to explore the history of suspected antibiotic allergies in detail; an important role of the antibiotic allergy service is to do just this, including gathering contemporaneous notes, charts, and correspondence where necessary. The likelihood of true allergy, the mechanisms of immune hypersensitivity, the approach to testing, and the risk of reexposure to the same or related antibiotics can then be considered. Skin testing remains the mainstay of investigation, with challenge testing generally used to confirm tolerance. A basic knowledge of the frequency with which different drugs cause different hypersensitivity responses and that of the patterns of cross-reactivity between related drugs is very useful to a wide range of clinicians.

Acute Respiratory Failure Due to Acute Exacerbation of Chronic Obstructive Pulmonary Disease: The Spectrum of Ventilator Strategies Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States. Acute exacerbation of COPD is associated with a faster decline in lung function, lower quality of life, and increased mortality. Management of acute exacerbation of COPD in the intensive care unit includes pharmacotherapy and mechanical ventilatory support. Noninvasive mechanical ventilation has led to significant improvement in outcomes of COPD and reduced morbidity and mortality compared with invasive mechanical ventilation. An emerging modality, extracorporeal carbon dioxide removal is now being studied to reduce the need for ventilatory assistance in acute ventilatory failure due to COPD exacerbation.

A Case of Vanishing Lung Cysts Pulmonary cysts are frequently encountered at thoracic computed tomography, often incidentally detected. For patients older than 40 years of age, a few pulmonary cysts found at thoracic computed tomography can be a normal finding. The etiologies of pulmonary cysts are numerous, and cysts should be distinguished from other focal lucent lung lesions, such as the numerous causes of cavitary lung disease, bronchiectasis, honeycombing, and emphysema. When pulmonary cysts are encountered in older children or adult patients, a number of specific disorders, collectively referred to as diffuse cystic lung diseases, merit consideration. These conditions include Langerhans cell histiocytosis, lymphangioleiomyomatosis, Birt-Hogg-Dubé syndrome, follicular bronchiolitis, and lymphocytic interstitial pneumonia, and even light-chain deposition disease and amyloidosis. More recently, etiologies of small airway obstruction, including asthma, hypersensitivity pneumonitis, and bronchiolitis obliterans, have been reported to cause diffuse cystic lung disease. When diffuse cystic pulmonary disorders are encountered, the combination of the clinical history, presentation, and the imaging appearance of the pulmonary cysts may be sufficiently characteristic to offer a specific diagnosis. However, not infrequently, tissue sampling procedures are required to establish the correct diagnosis because the imaging features of diffuse cystic pulmonary disorders may overlap. Distinguishing among the various etiologies of diffuse pulmonary cysts is important because the treatment approaches to these conditions differ substantially.

Are We Using the Correct Inhaled Medication to Treat Mild Asthma With Low Sputum Eosinophilia? Synopsis: This crossover trial evaluated the efficacy of inhaled corticosteroids and long-acting muscarinic antagonists compared with placebo in asthmatic patients in relation to sputum eosinophil counts. No statistical significance was found between the Mometasone versus placebo or the Tiotropium versus placebo groups, and the responses to the active drugs were not greater than the responses to the placebo medications in those with a low sputum eosinophil count. Source: Lazarus SC, Krishnan JA, King TS, et al. Mometasone or Tiotropium in mild asthma with a low sputum eosinophil level. NEJM. 2019;380:2009–2019.

Is This the End of Albuterol? Synopsis: In patients with mild asthma, a strategy of budesonide-formoterol as needed was superior to albuterol as needed to prevent asthma exacerbations. Source: Beasley R, Holiday M, Reddel HK, et al. Controlled trial of budesonide-formoterol as needed for mild asthma. N Engl J Med. 2019;380:2020–2030.

Pity The Fool Who Extubates Too Soon: Does T-Piece Weaning Have Better Outcomes Compared With Standard Pressure Support Weaning? Synopsis: A spontaneous breathing trial consisting of 30 minutes of pressure support ventilation, compared with 2 hours of T-piece ventilation, led to significantly higher rates of successful extubation. Source: Subirá C, Hernández G, Vázquez A, et al. Effect of pressure support versus T-piece ventilation strategies during spontaneous breathing trials on successful extubation among patients receiving mechanical ventilation: a randomized clinical trial. JAMA. 2019;321:2175–2182.

Does Aspirin Use Influence Exacerbations and Morbidity of Chronic Obstructive Pulmonary Disease? Synopsis: Aspirin use has led to an improvement in mortality rate in coronary artery disease (CAD) patients, but there are not many studies showing mortality benefit in chronic obstructive pulmonary disease (COPD) patients. A recent observational cohort study assessed its influence on acute exacerbation of COPD, respiratory morbidity, and quality of life. The results showed a promising therapeutic use for aspirin, but further randomized controlled trials are necessary for a more definitive answer. Source: Fawzy A, Putcha N, Aaron CP, et al. Aspirin use and respiratory morbidity in COPD: a propensity score-matched analysis in subpopulations and intermediate outcome measures in COPD study. Chest. 2018.

Inhaled Tranexamic Acid: A Therapeutic Option For Hemoptysis Synopsis: A prospective randomized, double-blinded, placebo-controlled trial in patients with nonmassive hemoptysis demonstrated that inhaled tranexamic acid significantly reduced the volume of expectorated blood with a higher rate of hemoptysis resolution, decreased the need for invasive procedures, shortened the length of hospital stay, and reduced the recurrence rate at 1-year follow-up, compared with placebo. However, its role in patients with massive hemoptysis remains an open question. Source: Wand O, Guber E, Guber A, et al. Inhaled tranexamic acid for hemoptysis treatment, a randomized controlled trial. Chest. 2018;154:1379–1384.