Daily Archives: December 2, 2022

Bilateral pneumonectomies and ECMO support

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I read with fascination these case reports about bilateral pneumonectomies with ECMO support – came up during Lung Rescue discussion.

From Cypel et al

https://www.sciencedirect.com/science/article/pii/S0022522316316233 – Cypel et al, a CF patient who had shock from Pseudomonas bacteremia who had this done to get source control, after pneumonectomies, she had dramatic improvement. Had this configuration:

https://www.sciencedirect.com/science/article/pii/S1053249819316298?via%3Dihub – Barac et al, another young CF patient with Bulkholderia, with bilateral pneumonectomies to clear his infection prior to transplant. With this layout:

Figure 1

Really interesting to read about these cases. A more recent case: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8780122/ – severe COVID respiratory failure on ECMO with persistent COVID and Stenotrophomonas, interestingly had a PFO that was used for shunting to offload the left ventricle (they suggest atrial septostomy could be performed in those who don’t have a PFO).

Azithromycin for acute exacerbations of asthma: The AZALEA randomized clinical trial

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“Azithromycin for acute exacerbations of asthma: The AZALEA randomized clinical trial,” JAMA IM, 2016, United Kingdom

Question: Does azithromycin improve outcomes for patients with acute asthma exacerbations?

Study Type: Multicenter, double-blind, placebo-controlled randomized trial

Study Population: Adults with a documented history of asthma who required IV or oral steroids for an acute asthma exacerbation were eligible.  Notable exclusion criteria included the use of oral or intravenous corticosteroids within the previous 28 days and need for intensive care unit admission.

Study Groups: Patients were randomized to receive azithromycin 500mg daily or placebo for 3 days.

Primary Outcome: Diary card summary symptom score at day 10

Results: Of the 4,500 patients screened, 45% were excluded because they had already received antibiotics.  199 patients were randomized.  Asthma symptom scores measured at day 10 did not differ between the two groups. Similarly, the addition of azithromycin did not improve quality-of-life scores, lung function measurements, or time to 50% reduction in symptom score.

Caveats: Study did not meet enrollment goal and was underpowered, investigators enrolled a select group of patients that treating clinicians felt would not benefit from antibiotic therapy (the 55% of patients not excluded for already receiving abx) perhaps skewing the trial toward a negative result.

 Take-home Point: Azithromycin does not improve outcomes for patients with acute asthma exacerbations.  The trial also shows that abx are still widely prescribed for asthma exacerbations despite not being supported by guidelines or evidence.