Pulmonology & Critical Care Clinical Practice Updates
We summarize recent practice-changing research in pulmonary and critical care medicine from peer-reviewed journals. Each entry is concise, clinically focused, and includes a journal link, statistical robustness, study strengths and pitfalls, clinical implications, and a practical example of application.
Phase 3 trials in NEJM (BOREAS, NOTUS) show dupilumab reduces moderate/severe exacerbations and improves lung function in COPD with eosinophilic/type-2 inflammation.
Statistical Robustness
Large, multicenter RCTs with prespecified endpoints and significant reductions in exacerbation rates; lung-function and symptom benefits maintained through 52 weeks.
Strengths
Targeted endotype; consistent efficacy across confirmatory trials.
Pitfalls
Indicated for patients with elevated eosinophils; cost/access and injection adverse events to consider.
Clinical Implication
Consider dupilumab in COPD with blood eosinophils ≥300/µL and frequent exacerbations despite triple therapy.
Practical Example
A 65-year-old with 3+ exacerbations/year on LABA/LAMA/ICS and eosinophils 350/µL: refer for biologic eligibility and payer review.
Reference: Bhatt SP, et al. Dupilumab for COPD with type 2 inflammation. N Engl J Med. 2023. Confirmatory: NOTUS trial. N Engl J Med. 2024.
2. Early Mobilization in Mechanically Ventilated ICU Patients
In the TEAM RCT (NEJM 2022), increased early mobilization did not improve the primary outcome (days alive and out of hospital at 180 days) versus usual care and was associated with more mobilization-related adverse events.
Statistical Robustness
Multicenter RCT (n=750) with prespecified primary endpoint; neutral primary result; safety events higher with aggressive mobilization.
4. High-Flow Nasal Oxygen for Acute Hypoxemic Respiratory Failure
In the landmark RCT by Frat et al. (NEJM 2015), high-flow nasal oxygen reduced intubation rates and improved survival versus standard oxygen in acute hypoxemic respiratory failure.
Statistical Robustness
Randomized, three-arm trial (HFNO vs standard O2 vs NIV); significant survival advantage and lower intubation with HFNO in predefined analyses.
5. ECMO for Severe ARDS: ELSO Guidance & Key Trial
ELSO’s VV-ECMO consensus guideline (2021) outlines indications, management, and weaning; the EOLIA RCT (NEJM 2018) showed no significant 60-day mortality benefit for early ECMO versus conventional strategies with rescue ECMO, informing referral/timing decisions.
Statistical Robustness
Guideline synthesizes RCTs/observational data; EOLIA underpowered for modest effects but pivotal for practice.
Strengths
Standardized criteria and circuit management; supports regional referral pathways.
Pitfalls
Resource-intensive; outcomes vary with center experience and patient selection.
Clinical Implication
For refractory hypoxemia (e.g., PaO2/FiO2 <80 despite optimal care), initiate rapid ECMO center consultation; consider transport on high-flow/prone as appropriate.
Practical Example
Young ARDS patient failing proning/paralysis: notify ECMO hub early, share ventilator/ABG data and contraindications checklist.
Reference: ELSO VV-ECMO adult management guideline. 2021. | Combes A, et al. EOLIA trial. NEJM. 2018.
6. Corticosteroids in Severe Community-Acquired Pneumonia
CAPE COD (NEJM 2023) found that early hydrocortisone reduced 28-day mortality in ICU patients with severe CAP versus placebo.
Statistical Robustness
Multicenter, double-blind RCT with significant mortality reduction; subsequent reviews suggest hydrocortisone drives the mortality benefit in severe CAP.
Strengths
Hard outcomes; protocolized steroid dosing; early initiation.
Pitfalls
Monitor for hyperglycemia/secondary infection; applicability to non-ICU CAP limited.
Clinical Implication
For severe CAP in ICU, consider hydrocortisone per CAPE COD protocol alongside guideline-directed antibiotics and source control.
Practical Example
Shock with lobar CAP on admission: start hydrocortisone 200 mg/day (continuous or divided), titrate vasopressors, monitor glucose and cultures.
Reference: Dequin PF, et al. Hydrocortisone in severe CAP (CAPE COD). N Engl J Med. 2023.
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