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CICM 2021 ASM: Respiratory
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Session 2: The lungs: Not so sterile

Session Description

SESSION CHAIR: A/Professor Shailesh Bihari
Session Sponsor: baxter

Session Chairs

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Shailesh Bihari

Session Program

Remember back to a time 18 months ago when COVID was not a word you were familiar with.

When severe acute respiratory infection (SARI) meant influenza, community acquired pneumonia or perhaps if you were lucky, some really unusual type of pneumonia! We didn’t know about lockdowns, bubbles, flattening the curve or Zoom. 

What do we know about SARI incidence and treatment innovations in the last year? How may SARI therapies perhaps change given our pandemic experience? What will the world post-COVID look like in terms of management of SARI and how are we studying this now?

Pneumonia remains a global healthcare challenge associated with substantial morbidity and mortality. Antimicrobial therapy is the primary intervention used by clinicians, but variable effectiveness exists which in part can be related sub-optimal dosing. To be maximally effective, antimicrobial dosing should ensure therapeutic concentrations at the site of infection, which in the context of pneumonia, is measured in the epithelial lining fluid (ELF). Of course, defining which concentration is ‘therapeutic’ is affected by the susceptibility of the pathogen to the antimicrobial (pharmacodynamics). Concentrations in the ELF for most antimicrobial are affected by typical factors like renal function and body size, as well as sickness severity, lung inflammation and presence of fibrosis from chronic pathologies like chronic obstructive airways disease. Careful interpretation of data is also important as concentration-time profiles in the lung do not match plasma and so singular time-point comparisons can provided misleading estimates of drug penetration. Available data demonstrates highly variable antimicrobial exposures in ELF, both between antimicrobials and between patients receiving the same antimicrobial. Antimicrobials considered to have consistently adequate penetration into the lung include linezolid and macrolides like azithromycin. Beta-lactams have variable penetration (e.g. meropenem ELF exposure is <5% to >200% in ventilator associated pneumonia patients). Other drugs have low and variable penetration including glycopeptides, whilst the aminoglycosides have such low penetration that they are considered not a clinical option in monotherapy. The importance of antimicrobial penetration into the lung is being recognized by pharmaceutical industry, with some drugs like ceftolozane-tazobactam now having a pneumonia-specific dose which is twice the urinary tract and intra-abdominal infection doses to account for ~50% lung penetration.

Described a mere 25 years ago, our understanding of lung ultrasound and how it can be used to inform rapid, bedside diagnosis and management of the critically ill is growing rapidly.  From basic B lines to advanced techniques – this education-focused talk will, in addition to providing examples of all key lung ultrasound findings, will discuss integrating these findings, practical tips and future directions.

Interventional pulmonology techniques and procedures have become more complex over the past decade.  There are a multitude of procedures for both diagnostic and therapeutic purposes available to the clinician.  These range from Endobronchial Ultrasound (EBUS) for accurate diagnosis of malignant and non-malignant conditions, to Bronchial Thermoplasty for therapy in moderate to severe asthma, to stent insertion for airway obstruction or tracheo-oesophageal fistula.  Not all procedures are relevant to current Intensive Care Medicine practice.  
This presentation will focus on three procedures relevant to Intensive Care Medicine.   Firstly, the use of endobronchial valves in the management of persistent air leaks from broncho/alveolar-pleural fistulae.  This technique allows resolution of air leaks in patients on mechanical ventilation, who may not be fit for surgical intervention.   This is a novel use of these devices, which were originally designed for endoscopic lung volume reduction in COPD. Secondly, the technique of cryobiopsy for diagnosis of parenchymal lung disease and the risk of pneumothorax and significant haemorrhage with this procedure.  Significant haemorrhage has been described after cryobiopsy and may need ICU admission, if life threatening.  The use of a bronchial blocker at the time of the procedure reduces bleeding risk.  Lastly, the therapeutic modality of bronchial thermoplasty (BT) for moderate to severe asthma and the risk of exacerbation post procedure.  BT requires three separate bronchoscopic procedures, three weeks apart.  Patients are at risk of exacerbations of asthma up until six weeks after the last procedure.  A lower FEV1 predicts the risk for post procedure hospitalisation.

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