1/2 First paper from my PhD ✅ We found that spontaneous breathing's effects on gas exchange, lung injury, haemodynamics, and diaphragm function are highly context-dependent, influenced by disease severity, effort, ventilator settings, and adjunctive therapies. www.chestcc.org/article/S294...

The Biological and Physiologic Effects of Spontaneous Breathing in Acute Hypoxemic Respiratory Failure Requiring Invasive Ventilation

Our results show that SB during invasive ventilation in AHRF has variable context-dependent physiologic effects, with potential benefits, but possible harm, in severe disease or high respiratory drive...

chestcc.org

This month's #ISHLTJournalWatch features studies in critical care and transplant anesthesiology. Brigitte Hollander of Auckland City Hospital is the guest editor for the issue. #medsky #pulmsky #transplantsky www.ishlt.org/about/news-d...

Anesthesiology and Critical Care Transplant Topics on Journal Watch

Presented by the ISHLT Early Career and Trainee Committee, this month's ISHLT Journal Watch explores topics in critical care and transplant-related topics in anesthesiology.

ishlt.org

FCICM ✅️

On the note of VAP, we've written a review article. More specifically, focusing on the evidence behind strategies to prevent and manage VAP. This link gives 50 days of free access. Hope you all find it useful. #emimcc authors.elsevier.com/a/1lbEr7K3e2...

@IM_Crit_@imcrit.bsky.social · last yr.

I am reading this editorial on ventilator-associated pneumonia (VAP) from ⁦‪Chest in June 2025. It states that VAP affects up to 40% of patients on the vent. However, if you walk in any ICU in 🇺🇸 & ask, they will tell you that they rarely see a VAP. This is false

Insulin gtt + usual management. Oral triglyceride meds going forward.

Nice thread. Well summarised. Thank you. Imho- prone ventilation helps homogenise distribution of mechanical power. If on VV and on “rest” ventilation (whatever that is since no consensus on what rest is whilst ELSo guidelines allude to) then the benefit from proning is v minimal

I think, given that it took many trials with different sample sizes and durations of proning for us to realise its effectiveness in ARDS without ECMO, it would be even harder to prove in patients on ECMO for several reasons. COI: I love to prone 🧵 #emimcc

josh farkas 💊@pulmcrit.bsky.social · last yr.

interesting editorial on proning during VV-ECMO the sequence of [#1] VV-ECMO without a prone trial, and then [#2] proning while on VV-ECMO seems 🍑 backwards and proning while on VV-ECMO doesn't seem awesome (c/w the largest RCT) (but there may be situations where this makes sense 🤷‍♂️) #EMIMCC

I don't have strong opinions about APRV, but I think the utility and effectiveness of certain strategies depend heavily on the system within which they work. #EMIMCC

Segun Olusanya (He/Him)@drfreeze.bsky.social · last yr.

Should APRV remain part of the recommendations in severe ARDS, and should a trial be considered before VV ECMO referral? Discuss. #emimcc @pulmcrit.bsky.social @icmtim.bsky.social Open DOI: our ECMO centre doesn’t recommend APRV…

A well written argument cautioning against misinterpreting evidence from clinical trials on angiotensin II. Currently, A-II is not available outside a clinical trial where I work. However, there are efforts to evaluate A-II in other populations (not sepsis). pmc.ncbi.nlm.nih.gov/articles/PMC...

A Prospective double-blind, randomised controlled trial comparing angiotensin II to norepinephrine to reduce length of hospital stay in cardiac surgery patients (the PORTHOS study protocol)

Cardiac surgery is frequently associated with vasoplegia and vasopressor treatment. Both may be associated with postoperative complications and prolonged length of stay. The most frequently used vasop...

pmc.ncbi.nlm.nih.gov

josh farkas 💊@pulmcrit.bsky.social · last yr.

💯 Angiotensin II may also increase the risk of thromboembolic events. This is why real trials with clinically-oriented endpoints are needed. this blog is surely dated but most of the points are still accurate: emcrit.org/pulmcrit/ang...

I rather think it’s action bias, easier to do something than to wait and see. People overestimate the risk of deterioration and underestimate bleeding risk.

interesting thread with some great points here 👇 IMHO the key is having an institutional pathway about classification & management that everybody agrees on for patients in whom the treatment pathway is clear, there is no need to involve everybody (eg, if clearly not an IR candidate, why call IR?)

Dilip Jayasimhan@dilipj1.bsky.social · last yr.

My unpopular opinion is that I'm skeptical about the effectiveness of PERT. 🧵 #EMIMCC

Similar arguments could be made perhaps for “shock” teams 🤔

Could not agree more! The problem with pulmonary embolism is the lack of clear ownership (at least in my part of the world). #emimcc #cardiosky

Dilip Jayasimhan@dilipj1.bsky.social · last yr.

Cardiologists don't congregate when a STEMI comes through the door, nor do neurologists when a stroke is admitted. Partly because there is ownership by one specialty, and because there is high quality evidence to guide management. Evidence rather than eminence based medicine.

My unpopular opinion is that I'm skeptical about the effectiveness of PERT. 🧵 #EMIMCC

josh farkas 💊@pulmcrit.bsky.social · last yr.

it's largely impossible to handle a PERT (PE response team) call *without* a CT angiogram even if the RV looks horrible on POCUS, this doesn't differentiate between acute PE vs chronic pulm HTN (which is common in older, multimorbid pts) unless pt is in extremis, start with a CT angio. #EMIMCC

An interesting issue of ICU Management & Practice. From Sepsis to ARDS. #EMIMCC healthmanagement.org/c/icu/issue/...

Volume 25 - Issue 2, 2025

Change content default value...

healthmanagement.org

#emimcc

Paul Young@dogicuma.bsky.social · 2y ago

The final interim analysis for the #MegaROX trial, including the first 32000 patients enrolled, is happening soon.

Let’s try something different. Does anyone have any questions about acute and critical care echocardiography? If I can’t answer I’ll try to bring in someone who can. #emimcc #cccsky #pocus

I disagree with the conclusion reached here. I have previously written a thread on this, which I have linked below. #emimcc

Anand Swaminathan@emswami.bsky.social · 2y ago

Clinical Conundrum: Should We Always Treat Fever in Sepsis?: bit.ly/3BwUEbq TL;DR: No. No incr mortality/morbidity + possible protective effects #MedSky #EMIMCC

What I love about echocardiography in critical care is how you can see physiology unfolding before your eyes. This is a case that has stayed with me and shaped how I think about treating acute LVOT obstruction #cccsky #echofirst #pocus #emimcc

Lars Mølgaard Saxhaug@load-dependent.eurosky.social · 6y ago

A case both for not forgetting basic physical examination including auscultation and for echo in shock. Shared with patients consent. 🧵 #foamcc #foamed

Are you interested in #Sustainability in #Anesthesiology and how reusing TIVA lines could help reduce greenhouse gas emissions? Per Werner Moller, originally an expert in #AppliedPhysiology and #VenousReturn, discusses their environmental paper on the #EJA podcast. open.spotify.com/episode/2RCa...

Bacterial contamination and greenhouse gas emissions: A... : European Journal of Anaesthesiology | EJA

roorganisms, and eliminating the risk for patient-to-patient cross-contamination. However, infusion-set contamination from compromised aseptic handling could affect quality of care. INTERVENTIONS T...

journals.lww.com

Kaspar Bachmann@kasparbachmann.bsky.social · 2y ago

So the author Per Werner Moller, who is an amazing researcher and extremely insightful person, has answered these questions and talks about the paper in a podcast for #EJA, which is absolutely worth a listen: #Sustainability #Anesthesiology open.spotify.com/episode/2RCa...

Had a similar case of someone with disproportionate hypoxaemia in the context of an intermediate risk PE. Pt was also hypertensive. #emimcc #pulmsky #medsky

Emily Fridenmaker@emilyfri.bsky.social · 2y ago

An older but very functional patient presented from another facility to the neuro ICU with a brain abscess after a dental procedure. The abscess was being treated conservatively and was improving. Pulm was consulted for hypoxia. #emimcc

This trial always fascinated me. It's extremely informative and with other evidence (ASTER), makes you wonder about the benefit of PCM/APAP in sepsis. Primary outcome was neutral, but PCM/APAP ⬇️ ICU LOS in survivors and ⬆️ ICU LOS in non-survivors. This can mean one of 2 things (1/7)🧵 #emimcc #medsky

Patrick Bafuma PA-C@pbafuma.bsky.social · 2y ago

Might be something to this for peds, but for adult sepsis, we have pretty good data: www.nejm.org/doi/full/10....

It's unethical not to adjust for a priori important baseline characteristics predictive of the outcome! #stats #medsky #metascience

Dilip Jayasimhan@dilipj1.bsky.social · 2y ago

When interpreting this trial, it is also important to consider the pre-specified adjusted analysis [OR 0.89 (95%CI 0.79 to 0.99)] as adjustment improves statistical efficiency. This article explains the benefits of adjustment quite well. #emimcc jamanetwork.com/journals/jam...

When interpreting this trial, it is also important to consider the pre-specified adjusted analysis [OR 0.89 (95%CI 0.79 to 0.99)] as adjustment improves statistical efficiency. This article explains the benefits of adjustment quite well. #emimcc jamanetwork.com/journals/jam...

Adjustment for Baseline Characteristics in Randomized Clinical Trials

This Guide to Statistics and Methods provides an overview of the use of adjustment for baseline characteristics in the analysis of randomized clinical trials and emphasizes several important considera...

jamanetwork.com

Brian Elliott@brianelliottmd.bsky.social · 2y ago

The BLING III Trial. Do cont vs intermittent beta lactams improve mortality in sepsis? Maybe? The primary outcome (90d mortality) resulted in a 2% ARR with p=0.08, causing substantial debate about the conclusions that could be drawn and how to interpret p values jamanetwork.com/journals/jam...

I agree, in a Vt range of 6-8 ml, the main component is dP. However, if you target low/very low dP (12-15) in a patient with poor compliance (very low tidal ventilation) and the increase in respiratory rate becomes relevant, I think. The figure is from the excellent paper you referenced (thanks).

This trial evaluating a driving pressure limiting strategy to standard care in patients with pneumonia and ARDS showed no difference in ventilator-free days. However, I have a few thoughts on it. 🧵

Steven Mathern@stevenmathern.bsky.social · 2y ago

'In patients with moderate to severe ARDS secondary to community-acquired pneumonia, a driving pressure-limiting strategy did not increase the number of ventilator-free days compared with a standard low PEEP strategy' #critcaresky #emimcc pubmed.ncbi.nlm.nih.gov/39592365/

A treasure trove of important trials for ICM trainees to sink their teeth into Nice work @dilipj1.bsky.social 🙌

Dilip Jayasimhan@dilipj1.bsky.social · 2y ago

A thread 🧵 on trials I think have changed or will change ICU practice (at least my own). #emimcc

We are gearing up to offer our online course on Reimagining Global Health in summer 2025 For now, you can access last year's slides & readings here www.teachepi.org/courses/reim...

A thread 🧵 on trials I think have changed or will change ICU practice (at least my own). #emimcc

I think that’s right, but it’s being made worse by a monomanic focus on sepsis through campaigns etc. People are more scared of missing sepsis than misclassifying other kinds of shock as sepsis.