Faculty Bibliography

This ahead-of-print article has been temporarily removed from the AnnalsATS journal website in anticipation of the publication of a forthcoming official ATS/ ERS/JRS/ALAT clinical practice guideline on patient-centered outcomes research in interstitial lung disease, to be published in a future issue of the American Journal of Respiratory and Critical Care Medicine (AJRCCM). This article was posted prematurely and will be published in the Annals of the American Thoracic Society after the official clinical practice guideline has been published in AJRCCM.

BACKGROUND:After the publication of a 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic. Gaps in prior pandemic planning were identified and require modification in the midst of ongoing surges throughout the world. METHODS:The Task Force for Mass Critical Care (TFMCC) adopted a modified version of established rapid guideline methodologies from the World Health Organization and the Guidelines International Network-McMaster Guideline Development Checklist. With a consensus development process incorporating expert opinion to define important questions and extract evidence, the TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, "gray" evidence from lay media sources, and anecdotal experiential evidence. RESULTS:Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. ICU surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and to avoid crisis triage, with early transfer strategies to further load-balance care. We suggest that intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in ICUs. CONCLUSIONS:A subcommittee from the TFMCC offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands resulting from COVID-19.

BACKGROUND:Early in the COVID-19 pandemic, there was serious concern that the United States (US) would encounter a short fall of mechanical ventilators. In response, the US government, utilizing the Defense Production Act ordered the development of 200,000 ventilators from 11 different manufacturers. These ventilators have different capabilities and it is not evident whether all are able to support COVID-19 patients. RESEARCH QUESTION/OBJECTIVE:Evaluate ventilator requirements for affected COVID-19 patients, assess the clinical performance of current SNS ventilators employed during the pandemic, and finally compare ordered ventilators functionality based on COVID-19 patient needs. STUDY DESIGN AND METHODS/METHODS:Current published literature, publicly available documents, and lay press articles were reviewed by a diverse team of disaster experts. Data was assembled into tabular format which formed the basis for analysis and future recommendations. RESULTS:COVID-19 patients often develop severe hypoxemic acute respiratory failure and ARDS requiring high levels of ventilator support. Current SNS ventilators were unable to fully support all COVID-19 patients, and only about half of newly ordered ventilators have the capacity to support the most severely affected patients; ventilators with less capacity for providing high level support are still of significant value in caring for many patients. INTERPRETATION/CONCLUSIONS:Current SNS ventilators and those on order are capable of supporting most but not all COVID-19 patients. Technologic, logistic, and educational challenges encountered from current SNS ventilators are summarized, with potential next generation SNS ventilator updates offered. CLINICAL TRIAL REGISTRATION/BACKGROUND:N/A.

BACKGROUND: New York City became the epicenter of the COVID-19 pandemic in the US, reporting its first case of SARS-CoV-2 on March 1, 2020. Patients with co-morbid conditions such as hypertension and diabetes are disproportionately impacted by COVID-19. Hospital systems have been burdened nationwide, including community and safety-net hospitals who serve medically underserved populations, placing them at risk from a resource-needs standpoint. Our study aim is to describe the clinical presentation and outcomes of hospitalized patients with COVID-19, and to highlight the burden on community hospitals, in order to guide health policy and resource allocation in future crises.
METHOD(S): We conducted a retrospective case series of patients admitted to NYU Langone Hospital - Brooklyn between March 13th and April 4th, 2020. Reverse-transcriptase polymerase chain reaction nasopharyngeal swab confirmed infection with the SARS-CoV-2 virus. Clinical demographics were obtained from the electronic health record (Epic Hyperspace, Madison, WI). The primary outcome was time-to-event, defined as transfer to an intensive care unit, mechanical ventilation or death from time of admission. Statistical analysis was performed using Stata SE 16 (StataCorp, College Station, TX).
RESULT(S): There were 561 patients admitted with a median age of 61 years(IQR 48-74). See Table 1. The median time to composite event was 4.13 days(IQR: 2.23-7.97).
CONCLUSION(S): Our results show that the impact of COVID-19 on a community hospital is similar to what has been reported in the literature for tertiary centers, implying that safety-net hospitals can play an integral role in future impact mitigation. These implications hold true as the pandemic continues to disproportionately affect those with chronic diseases. As cases of COVID-19 near 20 million, our experience positions us as harbingers who can provide insight for resource allocation across the US. LEARNING OBJECTIVE #1: Patient Care: Identify the characteristics in patients with COVID-19 associated with increased risk for hospitalization LEARNING OBJECTIVE #2: Medical Knowledge: Understand the outcomes related to COVID-19 in a diverse population

Background: Evidence-based guidelines are needed for effective delivery of home oxygen therapy to appropriate patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD).Methods: The multidisciplinary panel created six research questions using a modified Delphi approach. A systematic review of the literature was completed, and the Grading of Recommendations Assessment, Development and Evaluation approach was used to formulate clinical recommendations.Recommendations: The panel found varying quality and availability of evidence and made the following judgments: 1) strong recommendations for long-term oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe chronic resting hypoxemia, 2) a conditional recommendation against long-term oxygen use in patients with COPD with moderate chronic resting hypoxemia, 3) conditional recommendations for ambulatory oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe exertional hypoxemia, 4) a conditional recommendation for ambulatory liquid-oxygen use in patients who are mobile outside the home and require >3 L/min of continuous-flow oxygen during exertion (very-low-quality evidence), and 5) a recommendation that patients and their caregivers receive education on oxygen equipment and safety (best-practice statement).Conclusions: These guidelines provide the basis for evidence-based use of home oxygen therapy in adults with COPD or ILD but also highlight the need for additional research to guide clinical practice.

The "daily disasters" within the ebb and flow of routine critical care provide a foundation of preparedness for the less-frequent, larger events that affect most health care organizations at some time. Although large disasters can overwhelm, those who strengthen processes and habits through daily practice will be the best prepared to manage them.

Background/UNASSIGNED:Management of mechanical ventilation (MV) is an important and complex aspect of caring for critically ill patients. Management strategies and technical operation of the ventilator are key skills for physicians in training, as lack of expertise can lead to substantial patient harm. Objective/UNASSIGNED:We performed a narrative review of the literature describing MV education in graduate medical education (GME) and identified best practices for training and assessment methods. Methods/UNASSIGNED:We searched MEDLINE, PubMed, and Google Scholar for English-language, peer-reviewed articles describing MV education and assessment. We included articles from 2000 through July 2018 pertaining to MV education or training in GME. Results/UNASSIGNED:Fifteen articles met inclusion criteria. Studies related to MV training in anesthesiology, emergency medicine, general surgery, and internal medicine residency programs, as well as subspecialty training in critical care medicine, pediatric critical care medicine, and pulmonary and critical care medicine. Nearly half of trainees assessed were dissatisfied with their MV education. Six studies evaluated educational interventions, all employing simulation as an educational strategy, although there was considerable heterogeneity in content. Most outcomes were assessed with multiple-choice knowledge testing; only 2 studies evaluated the care of actual patients after an educational intervention. Conclusions/UNASSIGNED:There is a paucity of information describing MV education in GME. The available literature demonstrates that trainees are generally dissatisfied with MV training. Best practices include establishing MV-specific learning objectives and incorporating simulation. Next research steps include developing competency standards and validity evidence for assessment tools that can be utilized across MV educational curricula.

Desmopressin, a synthetic vasopressin analog, is used to treat central diabetes insipidus, hemostatic disorders such as von Willebrand's disease, and nocturnal enuresis. We present the case of a 69-year-old man who developed severe hyponatremia during treatment with intranasal desmopressin at 10 µg twice daily for chronic polyuria and nocturia thought to be due to central diabetes insipidus. After 5 months of therapy, the patient noticed progressive fatigue, anorexia, dizziness, weakness, light-headedness, decreased concentration, and new-onset falls. At 6 months of therapy, the patient was brought to the emergency department for altered mental status and was found to be severely hyponatremic with a serum sodium level of 96 mmol/L, down from a value of 134 mmol/L at the initiation of therapy. The intranasal desmopressin was discontinued and the patient was admitted to the intensive care unit where the hyponatremia was slowly corrected over the next week to 132 mmol/L, never increasing by more than 8 mmol/L a day, with careful fluid management. This included infusion of over 11 L of 5% dextrose to account for a high urine output, which peaked at 7.4 L in 1 day. However, while the recommended rate for sodium correction was followed, the patient's magnetic resonance imaging of the brain obtained after discharge displayed evidence of central pontine myelinolysis. Despite this finding, the patient eventually returned to his baseline mental status with no permanent neurologic deficits.