James

I pretend I'm not surprised when it works out like that.

I hear you. I hobble around until I get my orthotic indoor sandals on so my flat feet and plantar fasciitis don't keep me from packing lunches every morning.

Super interesting paper and study. Did we need the placebo group? Would pre-post have been enough? Just wondering since I would feel bad about keeping my IPF patient off of nintedanib for three months.

I love changing to odd numbers and seeing how long until the RT can't resist the urge to change back to evens

Great story!

Apixaban compared with warfarin to prevent thrombosis in thrombotic antiphospholipid syndrome: a randomized trial Key Points. The primary outcome, stroke, occurred in 6 of 23 patients randomized to apixaban compared with 0 of 25 patients randomized to warfarin.This stu

ashpublications.org/bloodadvance...

this is the study about eliquis and APS

I would think that PRVC is more problematic if used in a non-invasive setting. The awake patient with leaking around the mask could throw off the algorithm and result in too much variation in volume wouldn't it?

This comes up in pulm clinic as part of the work up in dyspnea consults as well, and I still don't know if non anemic iron deficiency can be a cause for dyspnea. I think it probably can, but I'm reminded that I don't understand the human body on a daily basis. It seems impossible to study

I've never seen a noninvasive vent that can do PRVC. Do you know what device you have at your place?

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I feel like you and I would bore everyone on rounds. For just hypoxia, there's no role for inhaled vasodilators for me. either overcome with the vent or they go on ecmo.

I'd also add that I'm not sold on a benefit from matching intrinsic peep. Doesn't seem to help. You also risk increasing end expiratory volume, which will worsen hyperinflation.

I'm a pulmonologist, and you did an amazing job here. To look like a boss when bipap is failing, just say change to AVAPS and walk away.

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That's awesome. I was thinking of doing that with this little dwarf pomegranate I have, but it looks like an intense hobby

CT progression of a patient with GPA. Discussed in ILD conference that centrilobular nodules aren't just bronchiolitis. Can sometimes be early vasculitis. This patient needed ecmo,steroids, cytoxan,PLEX, ivig 2g/kg. #pccmsky #emimccm #ctchest #ecmo #ILD

Would be interesting to see a similar study on patients who have had pericardiotomy

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That's what I was taught as a reason to push for rhythm control in PAH patients in Afib. Also explains why these patients can crash so quickly when they flip into a fib and the dangers of inotropes. This is more pulmonary hypertension than critical care, but I think the concept remains.

I have a lot of veterans in pulm clinic. They don't get nearly enough benefits. This article is garbage

So agreed. Multicenter randomized control trial looks like it's in the works with our institutions. I'll get the protocol drafted and send it to you both.
First obstacle will just be to get people to care about the poor right ventricle

Totally reasonable and I recognize that some folks will look at you cross eyed when ordering treprostinil. I think the key is having an objective way to measure if there was an improvement. If not, do something different.

Assessment of the physiologic contribution of right atrial function to total right heart function in patients with and without pulmonary arterial hypertension - PubMed Total right heart function requires normal function of both the right ventricle and the right atrium. However, the degree to which right atrial (RA) function and right ventricular (RV) function each c...

A stunned RV with normal pulmonary vascular compliance maybe. But not enough after load reduction to help when after load is the main problem.
I often cite this paper to highlight the dangers of Afib in RV failure. They're much more reliant on atrial kick. pubmed.ncbi.nlm.nih.gov/27683609/

I know a lot of people like milrinone in RV failure, but it doesn't work when the PVR is high. And the risk of arrhythmia is particularly dangerous with a weak RV

I've given up on inhaled because I've never seen objective evidence of improvement like this when ARDS is this bad. I think there isn't enough ventilation

Also highlights the pitfalls of PAC. A little RV afterload helped us move more quickly to decannulate the arterial cannula and later impella. PAC does not help you fine tune the differences between the right and the left function as accurately.

Great point. This low dose shouldn't cause systemic dilation. PVR should improve as the ARDS improves and peep decreases as well. That will allow you to titrate off. Importance of daily pocus. VQ mismatch is another concern, but irrelevant when their lungs are this bad. just enough to offload RV.

I agree. A lot depends on the biologic. Benra is superfast acting.
For patients with very high eos, they feel better within minutes after the injection.

Ards on VVA #ecmo with an impella for venting. #pocus shows reduced RVOT vti with notching. Repeat later same day after 2ng/kg/min treprostinil shows notching resolved and VTI increased 3 cm. No other changes were made in between. So many chances to nerd out on one case. #pccmsky #emimccm

I find pocus more beneficial. With lvot and RVOT VTI as well as close assent if what the ventricles actually look like, I think you get more accurate info than with PAC.