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Hot in Journal CHEST April 2018

By: Dr. Chris Carroll

Dr. Chris CarrollEach month, we ask Drs. Chris Carroll and Deep Ramachandran, Social Media Co-Editors of CHEST, to weigh in on the hot topics in CHEST. It's April, so let's hear from Dr. Carroll as he outlines his highlights. After reviewing the issue, be sure to share your hot list on our Facebook wall, tweet with the hashtag #journalCHEST, or discuss in the CHEST LinkedIn group.

They say that March comes in like a lion! Similarly, a new issue of CHEST® roars into publication this week! Lots of great articles this month, and here are three of my favorites!

A Multicenter Randomized Trial of a Checklist for Endotracheal Intubation of Critically Ill Adults

Intubations are a high-risk event in the ICU and just the sort of intervention that you would expect would be amenable to a checklist. However, a study in this month’s CHEST, a randomized prospective multicenter trial of 267 critically ill adults had a surprising finding. A preintubation checklist did not reduce complications in this cohort. Specifically, the authors looked at incidence of hypotension and desaturation and found no differences in rates of complications between the two groups nor differences in procedure duration and number of attempts.

I’ll be honest, this result surprised me. And at the risk of rationalizing a study result that doesn’t agree with my preconceptions, I’m going to do just that. There are a couple of reasons this study might have been negative. First, the outcomes were really, really good in both groups. There were relatively little changes in saturations and blood pressures during intubations, and the tubes were placed easily and quickly. It may be that with low incidences of complications, it’s hard to show differences.

Additionally, this study excluded patients with “emergent” intubations. In my experience, emergent events are when checklists are needed most, since they are low frequency and even higher risk. It may be that checklists continue to be an important tool in more emergent events. So personally, I’m going to keep my checklists for now.

Patient Engagement Using New Technology to Improve Adherence to Positive Airway Pressure Therapy by @AtulMalhotra13

Adherence to CPAP therapy can be challenging, but improving adherence can significantly improve the health of patients with obstructive sleep apnea. Web-based feedback and gamification systems are widely used in the nonmedical setting to improve engagement. In a study in this month’s CHEST, providers used a web-based engagement tool to attempt to improve adherence in this population.

This tool provided real-time feedback and coaching, provided usage-based messages of praise, and “badges” for usage. In this retrospective trial, the authors found that adherence increased to 87% in the cohort that used this web-based tool compared with 70% in the usual care group. This is a promising development and suggests that technology and gamification may be used to improve adherence in sleep medicine and perhaps other fields as well.

Noninvasive Blood Pressure Monitoring in the Critically Ill: Time to Abandon the Arterial Catheter?

And finally, in a Contemporary Review in Critical Care, Drs. Karim Lakhal, Stephan Ehrmann, and Thierry Boulain make the case for abandoning the arterial line in favor of noninvasive positive pressure monitoring. Advances in technology may soon allow for noninvasive monitoring that provides beat-to-beat measurements of a patient’s blood pressure. Check out this piece in this month’s CHEST for a thorough review of the technology and the literature and physiologic rationale behind it!

April CHEST Lakhal et al

Source: Lakhal K, Ehrmann S, Boulain T. Noninvasive BP Monitoring in the Critically Ill: Time to Abandon the Arterial Catheter? Chest. 2017;153(4):1023.