Category Archives: Cathy’s Crit Care Corner

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

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 

Developing ICU Clinical Behavioral Atlas Using Ambient Intelligence and Computer Vision | NEJM AI

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Developing ICU Clinical Behavioral Atlas Using Ambient Intelligence and Computer Vision | NEJM AI
Dai et al., NEJM AI 2025 (Paper also attached)
TL;DR – shiny new computer vision model from Stanford ICU video data that annotates 40 clinical activities and 55 object categories of ICU care, ranging from whether the patient is wearing SCDs (very good performance at 98% sensitive and 98% specific) to patient oral care (not very good performance at sensitivity 13% specificity 100%). They started with 140,000 hours of ICU daytime video, and annotated over 70,000 people and 650,000 objects! Good at identifying big things like ventilator, CRRT, but more trouble with HFNC and urinary catheters.  Average Precision is a common score used in computer vision tasks (closer to 1 is better), and the model ranged from 0.23-0.95 depending on the item/task.
My take: this is a nice start, but we are still far behind surgical computer vision, where AP scores are in the >98 range; and miles behind self-driving cars, which are near-perfect. I think this could be helpful for tracking care for some aspects, and could help quantify care automatically in quality improvement projects, rather than someone manually recording things.

CAPE-COD: steroids in severe CAP

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Thanks to Jose for presenting this today! CAPE-COD (paper here)

  • 800 patients with severe CAP randomized (excluded those who were on pressors, influenza, aspiration)
  • Balanced baseline groups
  • Hydrocortisone infusion 200mg/day, duration could be extended based on criteria + taper vs placebo with same protocol; median duration 5 days
  • Fewer death by day 28 in those given hydrocortisone 6.2% vs 11.9%
  • Fewer intubation by day 28 19.5% vs 27.7%
  • More insulin in steroid group
  • Especially helpful in women and age>65 by subgroup analysis
  • strengths included fast onset to medication dosage ~15 hours, and high adherence to protocol, reasonable 21% VAP rate (compared to many studies with low rates)
  • limitations: surprisingly low mortality, unstandardized microbiology (45% without identified pathogen)

Discussion points brought up included the variety of pathogens and heterogeneous groups and the syndrome of CAP, unclear exactly which subpopulation would be most benefitted (compared with COVID, where things were more clear and homogeneous), unusual population where a large number of patients had high CRP (based on a prior Spanish study that showed benefit in this population that took years to enroll a certain number of patients); steroids are a blunt instrument, choice of specific steroid (hydrocortisone vs dexametahsone). Of note – immediate meta-analysis incorporating this data – slight benefit?

Recent VA study showing no benefit (mostly men so maybe one explanation for the difference): https://link.springer.com/article/10.1007/s00134-022-06684-3

Of note – new guidelines for severe CAP including our very own Dr. Wunderink: https://link.springer.com/article/10.1007/s00134-023-07033-8

Future thoughts: designing trials better phenotyping to target specific pathways!

ISICEM and steroids in severe pneumonia

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ISICEM has begun – lots of interesting papers being presented, can follow on Twitter with #ISICEM23 [https://twitter.com/hashtag/ISICEM23?src=hashtag_click].

Some studies of high interest: anticoagulation for COVID, ravulizumab for COVID, feeding in shock, and more:  https://twitter.com/tscquizzato/status/1638128616713101313

And of special interest – CAPE COD – are steroids back in for severe pneumonia? Out in NEJM today: https://www.nejm.org/doi/full/10.1056/NEJMoa2215145?query=featured_home

TL;DR – 800 patients with severe pneumonia admitted to the ICU randomized to 200mg daily hydrocortisone vs placebo; reduced mortality (6.2% vs 11.9%), higher ICU discharge, less intubation (18% vs 29.5%)! Note those with septic shock were excluded (probably because they would receive hydrocort 50q6 anyway?).

Especially beneficial in subgroup with high CRP (makes sense)

Farkas already has his take up here: https://emcrit.org/pulmcrit/cape-cod/