Author Archives: Cathy

MICU studies: KOURAGE

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CMZ-207: ‘KOURAGE’

🔹 Key Info:

  • 💉 Drug: Auxora (zegocractin)
  • Mechanism: a calcium release-activated calcium (CRAC) channel inhibitor with potent anti-inflammatory and pulmonary endothelial protective properties (https://pubmed.ncbi.nlm.nih.gov/40489964/)
  • 👥 Eligibility: adult patients with AKI who are hypoxemic: P/F<300 (can be imputed from SpO2/FiO2) on HFNC, NIV, or vent
  • Multicenter, phase 2, randomized, double blind, placebo-controlled
  • Randomized 1:1 to receive five daily IV doses vs placebo
  • 🎯Objectives: safety, efficacy; days alive, ventilator-free, kidney replacement therapy-free
  • 👩‍🔬PIs/SIs: Drs. Pickens, Wunderink, Jose & Russell
  • Link: https://clinicaltrials.gov/study/NCT06374797

📟 Have a patient or questions? Page the MICU Research Team at 59285

ETT blockages

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🫁 Recently bronched a patient with a gunked up ETT and wonder how often this happens?
369 ETTs cut and measured degree of blockage (see pic)
📊 Moderate blockage common (CICU 28%, MICU 17%)
🔑 Risks: coagulopathy, longer ventilation, closed suction
⚠️ Ppeak ↑ but not clinically useful as many blocked tubes did not have this elevation!
Full paper: https://lnkd.in/gKjXsmsj

What does ‘purulent sputum’ even mean?

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Just how reliable are bedside sputum assessments anyway? 📄 Schuiteman et al in journal_CHESTCritCare American College of Chest Physicians Hayley Gershengorn https://lnkd.in/gD4BQUJu

📍 10 ventilated pts, videos/photos shown to 383 ICU staff
📍 Gold standard = gram stain PMNs

Results: ✅ Accuracy: 69% 🔍 Sensitivity: 58% 🔍 Specificity: 92% No difference by role.

Agreement was poor: 🎨 Color α=0.40 💧 Viscosity α=0.21 📦 Volume α=0.17

Take-home: Bedside purulence checks = low accuracy + low consistency → risk of VAP overdiagnosis & unnecessary antibiotics!

 

More proning variation

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Does it ever feel like some attendings prone everyone and some attendings prone no one? You’re not imaging things! From #CLIFconsortium rockstar Anna Barker and #UMichMed:

1) 514 ICU pts eligible for proning (P/F ≤150, FiO₂ ≥60%, PEEP ≥5): only 17% were actually proned. (why are we still so bad at this?)

2) 48 attendings analyzed → huge variation: 📊 Adjusted rates: 14.9%–74.2% 📈 Median OR for being proned by one attending vs another = 2.6 Greater effect than a 30 mmHg drop in P/F ratio.

3) Variation persisted even with ARDS documented. Predictors of proning: COVID status, code status, lower P/F ratio.

Take-home: Who your attending is may matter more than your oxygen level. #journal_CHESTCritCare https://www.chestcc.org/article/S2949-7884(25)00031-0/fulltext

OpenAI+Penda study

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http://cdn.openai.com/pdf/a794887b-5a77-4207-bb62-e52c900463f1/penda_paper.pdf

🚨 New preprint from OpenAI + Penda Health, a large network of primary care clinics in Nairobi, Kenya.

Unlike most LLM research that lives in theory or simulation (for example, testing on NEJM Challenge Cases or benchmarking questions), this was tested live across nearly 40,000 real patient visits.

They deployed AI Consult, an LLM that reviews clinician notes and flags potential issues (see example in screenshot). It uses traffic-light colors to indicate level of concern.

Half of the clinicians were randomly given access, half were not.

Key Results:

  • 🩺 32% reduction in history-taking errors
  • 🔍 16% reduction in diagnostic errors
  • 💊 14% reduction in treatment errors
  • ✅ 100% of surveyed clinicians who responded (only 67% completed it) said it was helpful
  • ⚠️ No safety harms identified

The “left in red” rate (visits where the final AI Consult call was red) in the AI group dropped to 20% from 35-40% (similar to non-AI group at start), while the non-AI group’s rate remained ~40%. This indicates clinicians were acting on the most severe alerts.

This is one of the clearest real-world wins for LLMs in healthcare to date. Yes, OpenAI funded and helped analyze the study—so read with a grain of salt—but the results are promising and cool!

 

New ATS CAP guidelines

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🚨 The new ATS CAP guidelines just dropped, featuring our very own Dr. Pickens! https://www.atsjournals.org/doi/epdf/10.1164/rccm.202507-1692ST?role=tab

Highlights:

Lung Ultrasound is now an acceptable alternative to CXR for diagnosis.
📍Evidence-based, bedside, radiation-free — a win for POCUS!

Outpatients w/ no comorbidities and positive viral test?
🚫 No antibiotics needed.

Severe CAP:
✅ Empiric antibiotics recommended
⏱️ Duration: ≥5 days (Compare to outpatients: as few as 3 days may be enough)

Systemic corticosteroids are suggested for severe CAP (🛑 but NOT if flu-related).
💬 Still a debated area with mixed RCTs – low quality evidence acknowledged
Consider more if ICU, severe respiratory failure (P/F<300), elevated inflammatory markers like CRP, and soon after symptom onset!~
#FOAMed

Proportional-Assist Ventilation for Minimizing the Duration of Mechanical Ventilation (Bosma et al, NEJM, 2025. The PROMIZING Trial) 

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Thanks to Luisa for this paper summary!

Proportional-Assist Ventilation for Minimizing the Duration of Mechanical Ventilation (Bosma et al, NEJM, 2025. The PROMIZING Trial)

Study objective: To determine whether proportional-assist ventilation with load-adjustable gains (PAV+) reduces the time to successful liberation from mechanical ventilation (MV) compared to the standard pressure-support ventilation (PSV) in critically ill adults.
Type: randomized, open-label, multicenter.
Participants: 573 critically ill adults on MV >24 hours
Intervention: PAV+ vs PSV
Primary Outcome: time from randomization to successful liberation from MV (defined as 7+ days off MV).
Results: non statistically significant difference on 1) Time to liberation from MV, 2) Mortality, 3) VDFs, 4) ICU/hospital discharge, 5) Rates of reintubation, trach and adverse events. Slight benefit for PAV+ mode on sedation use and delirium.
Comment: The CCCTG reintroduces proportional modes of ventilation—such as NAVA and PAV+—as alternatives to pressure support ventilation (PSV) for facilitating liberation from MV. These modes are grounded in core physiological principles and aim to optimize patient–ventilator interaction while preserving both lung and respiratory muscle function. Specifically, PAV+ continuously adapts ventilatory support based on real-time assessments of respiratory mechanics, using brief end-inspiratory occlusion maneuvers every 10–15 breaths to calculate resistance and elastance via the equation of motion. This allows the ventilator to deliver pressure assistance proportional to the patient’s instantaneous inspiratory flow and volume (i.e., to patient-generated muscular pressure, Pmus). The authors highlight a key limitation of PSV: it can deliver substantial tidal volumes even when respiratory drive is minimal, potentially resulting in over-assistance and misleading clinicians about a patient’s readiness for extubation. While the approach has a solid physiological basis, smaller trials for the past ~30 years have not shown a significant benefit to PAV+ for liberation from MV. I think this larger trial should put this approach to rest.

Inhalation injury and pneumonia

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How much does inhalation injury severity increase the risk of pneumonia? A decade of data gives us answers. 🔥🫁

This retrospective cohort study looked at 245 patients admitted to a regional burn center from 2011–2022 with suspected inhalation injury. All had diagnostic bronchoscopy within 48h of arrival. Patients were categorized based on injury severity using the Abbreviated Injury Scale.

Among patients hospitalized ≥48h: 48% with high-grade injury developed NP 31% with low-grade injury developed NP 14% with no injury developed NP So… the worse the inhalation injury, the higher the pneumonia risk. 📈

Why does this matter? Pneumonia is a major driver of morbidity and mortality in burn patients. This study emphasizes the need for early identification and tailored prevention strategies for those with more severe inhalation injuries.

📄 Published in CHEST, Vol 166(6)

✍️ Coston et al.

https://journal.chestnet.org/article/S0012-3692(24)04572-0/fulltext 

Upcoming deadlines!

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Reminder for CHEST Conference Sign Up: Early bird registration for CHEST ends on July 14th!
CHEST will be in Chicago this year, so a great opportunity to not have to spend travel money! https://www.chestnet.org/learning-and-events/events/chest-annual-meeting

Also, friendly reminder that SCCM 2026 will be in Chicago, deadline coming up August 6th! https://www.sccm.org/annual-congress/abstracts-and-case-reports