Faculty Bibliography

BACKGROUND:Despite a high incidence of tracheostomy-related airway complications with potentially life-threatening implications, nonsurgical tracheostomy first-responders receive limited formal education on the management of tracheostomy emergencies. While the U.K. has developed multidisciplinary guidelines and education for tracheostomy emergencies, such programs have not been widely implemented in the United States. OBJECTIVE:We evaluated the feasibility and effectiveness of an immersive virtual reality (VR) simulation training as a potential generalizable and scalable approach to tracheostomy-related emergency training. METHODS:Over the academic year 2023-2024, critical care fellows were randomized to participate in tracheostomy emergency training either via immersive VR simulation or via small group discussion sessions facilitated by expert faculty. After each case-based educational intervention, participants were asked to manage four simulated tracheostomy-related emergencies involving common tracheostomy complications. Fellow performance was evaluated using a purpose-built task trainer. Three independent and blinded graders completed fellow scoring using a checklist assessment for which validation evidence was also collected. Fellows received pre- and post-intervention surveys to measure attitudes towards VR training. RESULTS:Nineteen out of 27 eligible fellows participated in the study, managing a total of 76 simulated tracheostomy emergencies. There were 10 fellows in the VR arm and 9 fellows in the Small Group arm. Out of a total possible 26 points on the checklist assessment, fellows in the VR group scored an average of 18.03 ± 3.39 compared to the Small Group score of 16.96 ± 4.41 (P = .558). Surveys indicated improvements in fellow confidence after the training and high levels of acceptance of the VR curriculum. CONCLUSIONS:An immersive VR educational intervention for the management of tracheostomy-related emergencies was feasible and well-received by learners. There was no significant difference in post-training checklist assessment scores between the VR and Small Group participants, suggesting non-inferiority of the VR intervention, and contributing validation evidence to our task trainer simulation assessment. FUNDING/BACKGROUND:This study was funded via the APCCMPD, CHEST, and ATS Education Research Award.

Background: Various weight-based strategies using actual, ideal, adjusted, and lean body weights (LBWs) have been studied for propofol dosing finding that propofol is better related to LBW as opposed to actual body weight (ABW). However, the most common dosing strategy is based on ABW due to its high lipophilicity and large volume of distribution. It is not known whether ideal body weight (IBW)-based dosing would have similar efficacy and safety as ABW-based dosing in all patient populations. This study compares efficacy and safety of ABW- versus IBW-based dosing of continuous propofol infusion in mechanically ventilated adults. Methods: This is a retrospective, multicenter cohort study of mechanically ventilated adults in intensive care units at a large academic health system. The two cohorts were patients receiving continuous propofol infusion based on ABW from January to December 2019 or IBW from June 2020 to November 2020. The primary efficacy endpoint is time to target sedation score based on the Richmond Agitation and Sedation Scale (RASS). The safety endpoints are based on adverse effects of propofol. Results: Data from 50 patients were analyzed: 25 in the IBW and 25 in the ABW group. Upon evaluation, the IBW group targeted a deeper initial RASS goal (−2 vs. −1, P=0.004), and there was no difference in median body mass index between groups (27.5 vs. 29.2 kg/m², P=0.938). Despite the difference between groups, there was no difference in time to target RASS when propofol was dosed based on IBW versus ABW (6 vs. 7 hours, P=0.714) nor in absolute total dose (1.91 vs. 1.94 mcg/min, P=0.883). Patients with initial RASS goal targeting light sedation had no difference in time to goal RASS (6 vs. 7 hours, P=0.910). Outcomes including descriptive information of propofol, duration of mechanical ventilation, intensive care unit (ICU) and hospital length of stay, re-intubations and mortality were not statistically significant. Adverse events were similar between groups. Conclusions: Compared to ABW-based dosing, IBW-based dosing may be an alternative dosing strategy of continuous propofol infusion with similar efficacy and safety profiles. Larger studies with matched cohorts are required to confirm these findings and form a conclusion.

INTRODUCTION: Various weight-based strategies using actual, ideal, adjusted, and lean body weights have been studied for propofol dosing finding that propofol is better related to lean body weight as opposed to actual body weight (ABW). However, the most commonly used dosing strategy is based on ABW due to its high lipophilicity and large volume of distribution. It is not known whether ideal body weight (IBW)-based dosing would have similar efficacy and safety as ABW-based dosing in all patient populations. This study compares the efficacy and safety of ABW- versus IBWbased dosing of continuous propofol infusion in mechanically ventilated adult patients.
METHOD(S): This is a retrospective, multicenter cohort study of mechanically ventilated adult patients in the intensive care units at a large academic health system. The two cohorts were patients receiving continuous propofol infusion based on ABW from January to December 2019 or IBW from June 2020 to November 2020. The primary efficacy endpoint is time to target sedation score based on the Richmond Agitation and Sedation Scale (RASS). The safety endpoints are based on adverse effects of propofol.
RESULT(S): Data from 50 patients were analyzed: 25 in the IBW and 25 in the ABW group. Upon evaluation, the IBW group targeted a deeper initial RASS goal (-2 vs. -1, p=0.004), and there was no difference in median body mass index between groups (27.5 vs. 29.2 kg/m2, p=0.938). Despite the difference between groups, there was no difference in time to target RASS when propofol was dosed based on IBW versus ABW (6 vs. 7 hours, p= 0.714) nor in absolute total dose (1.91 vs 1.94 mcg/min, p=0.883). Patients with initial RASS goal targeting light sedation had no difference in time to goal RASS (6 vs. 7 hours, p= 0.910). Outcomes including descriptive information of propofol, duration of mechanical ventilation, ICU and hospital length of stay, re-intubations and mortality were not statistically significant. Adverse events were similar between groups.
CONCLUSION(S): Compared to ABW-based dosing, IBWbased dosing may be an alternative dosing strategy of continuous propofol infusion with similar efficacy and safety profiles. Larger studies with matched cohorts are required to confirm these findings and form a conclusion

BACKGROUND:The prevalence of burnout and depressive symptoms is high among physician trainees. RESEARCH QUESTION/OBJECTIVE:What is the burden of burnout and depressive symptoms among fellows training in pulmonary and critical care medicine (PCCM) and what are associated individual fellow, program, and institutional characteristics? STUDY DESIGN AND METHODS/METHODS:We conducted a cross-sectional electronic survey of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States to assess burnout and depressive symptoms. Burnout symptoms were measured using the Maslach Burnout Index two-item measure. The two-item Primary Care Evaluation of Mental Disorders Procedure was used to screen for depressive symptoms. For each of the two outcomes (burnout and depressive symptoms), we constructed three multivariate logistic regression models to assess individual fellow characteristics, program structure, and institutional polices associated with either burnout or depressive symptoms. RESULTS:Five hundred two of the 976 fellows who received the survey completed it-including both outcome measures-giving a response rate of 51%. Fifty percent of fellows showed positive results for either burnout or depressive symptoms, with 41% showing positive results for depressive symptoms, 32% showing positive results for burnout, and 23% showing positive results for both. Reporting a coverage system in the case of personal illness or emergency (adjusted OR [aOR], 0.44; 95% CI, 0.26-0.73) and access to mental health services (aOR, 0.14; 95% CI, 0.04-0.47) were associated with lower odds of burnout. Financial concern was associated with higher odds of depressive symptoms (aOR, 1.13; 95% CI, 1.05-1.22). Working more than 70 hours in an average clinical week and the burdens of electronic health record (EHR) documentation were associated with a higher odds of both burnout and depressive symptoms. INTERPRETATION/CONCLUSIONS:Given the high prevalence of burnout and depressive symptoms among fellows training in PCCM, an urgent need exists to identify solutions that address this public health crisis. Strategies such as providing an easily accessible coverage system, access to mental health resources, reducing EHR burden, addressing work hours, and addressing financial concerns among trainees may help to reduce burnout or depressive symptoms and should be studied further by the graduate medical education community.

PURPOSE OF REVIEW/OBJECTIVE:To highlight recent original research and specialty society guidelines regarding the diagnosis and treatment of nontuberculous mycobacterial (NTM) pulmonary disease. RECENT FINDINGS/RESULTS:The prevalence of NTM pulmonary disease has risen in recent years. The prevalence of individual NTM species varies geographically, although Mycobacterium avium complex (MAC) and Mycobacterium abscessus complex (MABC) remain among the most commonly encountered in many regions. Diagnosis and treatment of NTM pulmonary disease can be complex but guideline-based recommendations have been published. However, adherence to guideline recommendations is poor. Drug susceptibility testing plays a role with important caveats for treatment. Alternative therapies are being explored with older antimycobacterial drugs like clofazimine, which has demonstrated efficacy and tolerability for treatment-refractory NTM infections, and a novel formulation of amikacin for inhalation which may be better tolerated than parenteral administration. Several studies have shown that patients will have recurrences as high as 48%, and that these are not solely relapses but many cases are reinfections with a new organism. United States and European research registries of patients with non-cystic fibrosis bronchiectasis are expected to provide needed data on clinical characteristics of patients at risk for NTM pulmonary disease. SUMMARY/CONCLUSIONS:The evidence base for optimal management of NTM pulmonary disease is expanding but notable gaps in the literature remain.

INTRODUCTION: Vancomycin has been implicated uncommonly in the development of immune-mediated thrombocytopenia. We present the case of a patient who developed severe thrombocytopenia after receiving vancomycin that was refractory to several therapies. CASE PRESENTATION: A 69-year-old woman with metastatic breast cancer, atrial fibrillation (on coumadin) and CKD stage III was admitted after a fall. She was treated for pneumonia with ceftriaxone and azithromycin. On hospital day 2, the patient became encephalopathic, hypotensive and required endotracheal intubation for hypercapneic respiratory failure. Antibiotics were broadened to vancomycin and piperacillin/tazobactam. On hospital day 3, the platelet count abruptly dropped from 168x103/mL to 1x103/mL with initially stable hemoglobin and WBC count. Labs and peripheral smear did not suggest a microangiopathic hemolytic process or worsening coagulopathy. The patient developed small-volume hemoptysis and extensive ecchymoses. Druginduced thrombocytopenia was suspected and vancomycin was discontinued. Notably, the patient was not exposed to any heparin products as her INR was therapeutic. She received prothrombin complex concentrate and plasma to reverse her coagulopathy, along with a total of 8 units of platelets and 2 units of pRBCs. Intravenous immunoglobulin was given but the platelet count never recovered. The patient developed worsening hypoxic respiratory failure and died in hospice on hospital day 7. Labs subsequently confirmed the presence of vancomycin-dependent anti-platelet IgM and IgG antibodies. DISCUSSION: Thrombocytopenia induced by vancomycin exposure is thought to be due to the synthesis of IgG and IgM antibodies that interact with the glycoprotein IIb/IIIa receptor on the platelet surface in a vancomycin dependent manner, with subsequent platelet activation and destruction. Thrombocytopenia typically occurs after several days of exposure to vancomycin but platelet counts can drop precipitously in patients who have been previously exposed. We suspect this patient had prior vancomycin exposure given the rapid drop in platelet count. The degree of thrombocytopenia induced by vancomycin can be very severe and platelet transfusion is often ineffective. Cessation of vancomycin is essential, which results in normalization of the platelet count in most patients. Intravenous immunoglobulin and plasmapheresis have been used to neutralize or remove the vancomycin-dependent antibodies. Delayed clearance of vancomycin from renal failure can delay the recovery of platelet counts, which was likely a factor for our patient. CONCLUSIONS: Our case highlights drug-induced thrombocytopenia as a rare but life-threatening complication of vancomycin administration. Immediate discontinuation of vancomycin is paramount; however, platelet destruction may be so rapid and refractory to treatment that clinical consequences can be dire