Publications by authors named "Andrew M Luks"

82 Publications

Return to High Altitude after Recovery from Coronavirus Disease 2019.

High Alt Med Biol 2021 May 11. Epub 2021 May 11.

Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City, Utah, USA.

Luks, Andrew M. and Colin K. Grissom. Return to high altitude after recovery from coronavirus disease 2019. 00:000-000, 2021.-With the increasing availability of coronavirus disease 2019 (COVID-19) vaccines and the eventual decline in the burden of the disease, it is anticipated that all forms of tourism, including travel to high altitude, will rebound in the near future. Given the physiologic challenges posed by hypobaric hypoxia at high altitude, it is useful to consider whether high-altitude travel will pose risks to those previously infected with severe acute respiratory syndrome coronavirus 2, particularly those with persistent symptoms after resolution of their infection. Although no studies have specifically examined this question as of yet, available data on the cardiopulmonary sequelae of COVID-19 provide some sense of the problems people may face at high altitude and who warrants evaluation before such endeavors. On average, most individuals who have recovered from COVID-19 have normal or near normal gas exchange, pulmonary function testing, cardiovascular function, and exercise capacity, although a subset of individuals have persistent functional deficits in some or all of these domains when examined up to 5 months after infection. Evaluation is warranted before planned high-altitude travel in individuals with persistent symptoms at least 2 weeks after a positive test or hospital discharge as well as in those who required care in an intensive care unit or suffered from myocarditis or arterial or venous thromboembolism. Depending on the results of this testing, planned high-altitude travel may need to be modified or even deferred pending resolution of the identified abnormalities. As more people travel to high altitude after the pandemic and further studies are conducted, additional data should become available to provide further guidance on these issues.
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http://dx.doi.org/10.1089/ham.2021.0049DOI Listing
May 2021

Just-In-Time Tools for Training Non-Critical Care Providers. Troubleshooting Problems in the Ventilated Patient.

ATS Sch 2020 Jun 29;1(2):178-185. Epub 2020 Jun 29.

Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine.

Due to the limited number of critical care providers in the United States, even well-staffed hospitals are at risk of exhausting both physical and human resources during the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). One potential response to this problem is redeployment of non-critical care providers to increase the supply of available clinicians. To support efforts to increase capacity as part of surge preparation for the coronavirus disease (COVID-19) outbreak, we created an online educational resource for non-intensivist providers to learn basic critical care content. Among those materials, we created a series of one-page learning guides for the management of common problems encountered in the intensive care unit (ICU). These guides were meant to be used as just-in-time tools to guide problem-solving during the provision of ICU care. This article presents five guides related to managing complications that can arise in patients receiving invasive mechanical ventilation.
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http://dx.doi.org/10.34197/ats-scholar.2020-0038INDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043298PMC
June 2020

Just-In-Time Tools for Training Non-Critical Care Providers. Basics of Respiratory Failure.

ATS Sch 2020 Jun 29;1(2):170-177. Epub 2020 Jun 29.

Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine.

Due to the limited number of critical care providers in the United States, even well-staffed hospitals are at risk of exhausting both physical and human resources during the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). One potential response to this problem is redeployment of non-critical care providers to increase the supply of available clinicians. To support efforts to increase capacity as part of surge preparation for the coronavirus disease (COVID-19) outbreak, we created an online educational resource for nonintensivist providers to learn basic critical care content. Among those materials, we created a series of one-page learning guides for the management of common problems encountered in the intensive care unit (ICU). These guides were meant to be used as just-in-time tools to guide problem-solving during the provision of ICU care. This article presents five guides related to the evaluation and management of patients with hypoxemic respiratory failure and the basics of invasive mechanical ventilation.
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http://dx.doi.org/10.34197/ats-scholar.2020-0039INDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043299PMC
June 2020

Reply: Portable, Consumer-grade Pulse Oximeters are Accurate for Home and Medical Use: Implications for their Use in COVID-19 Patients.

Ann Am Thorac Soc 2021 Feb 22. Epub 2021 Feb 22.

University of Washington, 7284, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, Washington, United States.

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http://dx.doi.org/10.1513/AnnalsATS.202101-070LEDOI Listing
February 2021

Altered Mental Status After Esophagogastroduodenoscopy.

Chest 2021 Feb;159(2):e75-e79

Department of Pathology, University of Washington, Seattle, WA.

Case Presentation: A 79-year-old man with medical history of atrial fibrillation and esophageal cancer status post trans-hiatal esophageal resection and chemotherapy presented with altered mental status after outpatient esophagogastroduodenoscopy (EGD). One month before presentation, the patient was seen at another hospital with severe anemia and melena requiring transfusion of multiple units of RBCs. No endoscopy was performed during that admission, but his anticoagulation was held. After follow-up with his oncologist, he was referred for outpatient endoscopy. His esophagogastroduodenoscopy demonstrated an intact esophagogastric anastomosis as well as two gastric ulcers with no stigmata of recent bleeding. The patient was discharged to home in good condition with normal mental status. Several hours later, he developed a deteriorating level of consciousness, prompting presentation to the hospital.
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http://dx.doi.org/10.1016/j.chest.2020.08.2098DOI Listing
February 2021

Face Masks and the Cardiorespiratory Response to Physical Activity in Health and Disease.

Ann Am Thorac Soc 2021 03;18(3):399-407

Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; and.

To minimize transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel coronavirus responsible for coronavirus disease (COVID-19), the U.S. Centers for Disease Control and Prevention and the World Health Organization recommend wearing face masks in public. Some have expressed concern that these may affect the cardiopulmonary system by increasing the work of breathing, altering pulmonary gas exchange and increasing dyspnea, especially during physical activity. These concerns have been derived largely from studies evaluating devices intentionally designed to severely affect respiratory mechanics and gas exchange. We review the literature on the effects of various face masks and respirators on the respiratory system during physical activity using data from several models: cloth face coverings and surgical masks, N95 respirators, industrial respirators, and applied highly resistive or high-dead space respiratory loads. Overall, the available data suggest that although dyspnea may be increased and alter perceived effort with activity, the effects on work of breathing, blood gases, and other physiological parameters imposed by face masks during physical activity are small, often too small to be detected, even during very heavy exercise. There is no current evidence to support sex-based or age-based differences in the physiological responses to exercise while wearing a face mask. Although the available data suggest that negative effects of using cloth or surgical face masks during physical activity in healthy individuals are negligible and unlikely to impact exercise tolerance significantly, for some individuals with severe cardiopulmonary disease, any added resistance and/or minor changes in blood gases may evoke considerably more dyspnea and, thus, affect exercise capacity.
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http://dx.doi.org/10.1513/AnnalsATS.202008-990CMEDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7919154PMC
March 2021

Comparison of Clinical Features and Outcomes in Critically Ill Patients Hospitalized with COVID-19 versus Influenza.

Ann Am Thorac Soc 2021 04;18(4):632-640

Division of Pulmonary, Critical Care, and Sleep Medicine.

No direct comparisons of clinical features, laboratory values, and outcomes between critically ill patients with coronavirus disease (COVID-19) and patients with influenza in the United States have been reported. To evaluate the risk of mortality comparing critically ill patients with COVID-19 with patients with seasonal influenza. We retrospectively identified patients admitted to the intensive care units (ICUs) at two academic medical centers with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or influenza A or B infections between January 1, 2019, and April 15, 2020. The clinical data were obtained by medical record review. All patients except one had follow-up to hospital discharge or death. We used relative risk regression adjusting for age, sex, number of comorbidities, and maximum sequential organ failure scores on Day 1 in the ICU to determine the risk of hospital mortality and organ dysfunction in patients with COVID-19 compared with patients with influenza. We identified 65 critically ill patients with COVID-19 and 74 patients with influenza. The mean (±standard deviation) age in each group was 60.4 ± 15.7 and 56.8 ± 17.6 years, respectively. Patients with COVID-19 were more likely to be male, have a higher body mass index, and have higher rates of chronic kidney disease and diabetes. Of the patients with COVID-19, 37% identified as Hispanic, whereas 10% of the patients with influenza identified as Hispanic. A similar proportion of patients had fevers (∼40%) and lymphopenia (∼80%) on hospital presentation. The rates of acute kidney injury and shock requiring vasopressors were similar between the groups. Although the need for invasive mechanical ventilation was also similar in both groups, patients with COVID-19 had slower improvements in oxygenation, longer durations of mechanical ventilation, and lower rates of extubation than patients with influenza. The hospital mortality was 40% in patients with COVID-19 and 19% in patients with influenza (adjusted relative risk, 2.13; 95% confidence interval, 1.24-3.63;  = 0.006). The need for invasive mechanical ventilation was common in patients in the ICU for COVID-19 and influenza. Compared with those with influenza, patients in the ICU with COVID-19 had worse respiratory outcomes, including longer duration of mechanical ventilation. In addition, patients with COVID-19 were at greater risk for in-hospital mortality, independent of age, sex, comorbidities, and ICU severity of illness.
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http://dx.doi.org/10.1513/AnnalsATS.202007-805OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009008PMC
April 2021

Watch Your Language!-Misusage and Neologisms in Clinical Communication.

JAMA Intern Med 2021 Jan;181(1):5-6

Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin-Madison, Madison.

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http://dx.doi.org/10.1001/jamainternmed.2020.5679DOI Listing
January 2021

Effects of surgical and FFP2/N95 face masks on cardiopulmonary exercise capacity: the numbers do not add up.

Clin Res Cardiol 2020 12 9;109(12):1605-1606. Epub 2020 Oct 9.

Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, USA.

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http://dx.doi.org/10.1007/s00392-020-01748-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7688504PMC
December 2020

COVID-19 Lung Injury and High-Altitude Pulmonary Edema. A False Equation with Dangerous Implications.

Ann Am Thorac Soc 2020 08;17(8):918-921

Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington; and.

Amid efforts to care for the large number of patients with coronavirus disease (COVID-19), there has been considerable speculation about whether the lung injury seen in these patients is different than acute respiratory distress syndrome from other causes. One idea that has garnered considerable attention, particularly on social media and in free open-access medicine, is the notion that lung injury due to COVID-19 is more similar to high-altitude pulmonary edema (HAPE). Drawing on this concept, it has also been proposed that treatments typically employed in the management of HAPE and other forms of acute altitude illness-pulmonary vasodilators and acetazolamide-should be considered for COVID-19. Despite some similarities in clinical features between the two entities, such as hypoxemia, radiographic opacities, and altered lung compliance, the pathophysiological mechanisms of HAPE and lung injury due to COVID-19 are fundamentally different, and the entities cannot be viewed as equivalent. Although of high utility in the management of HAPE and acute mountain sickness, systemically delivered pulmonary vasodilators and acetazolamide should not be used in the treatment of COVID-19, as they carry the risk of multiple adverse consequences, including worsened ventilation-perfusion matching, impaired carbon dioxide transport, systemic hypotension, and increased work of breathing.
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http://dx.doi.org/10.1513/AnnalsATS.202004-327CMEDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7393782PMC
August 2020

Comorbid Medical Conditions in Young Athletes: Considerations for Preparticipation Guidance During the COVID-19 Pandemic.

Sports Health 2020 Sep/Oct;12(5):456-458. Epub 2020 Jun 24.

Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah.

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http://dx.doi.org/10.1177/1941738120939079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315380PMC
September 2020

Unattended Hoist Extraction of an Intubated Patient From Mountainous Terrain.

Air Med J 2020 May - Jun;39(3):214-217. Epub 2020 Feb 12.

Department of Emergency Medicine, University of Washington, Seattle, WA.

Airway management and maintenance of adequate ventilation during a patient's unattended helicopter rescue hoist extraction present unique challenges to the air medical provider. We present the case of a critically injured patient requiring emergent airway management and subsequent extrication via hoist from challenging, near-vertical terrain, which illustrates the logistical challenges of providing high-quality, neuroprotective mechanical ventilation in an austere air medical scenario.
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http://dx.doi.org/10.1016/j.amj.2020.01.006DOI Listing
February 2020

Pulse Oximetry for Monitoring Patients with COVID-19 at Home. Potential Pitfalls and Practical Guidance.

Ann Am Thorac Soc 2020 09;17(9):1040-1046

Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington; and.

During the ongoing coronavirus disease (COVID-19) pandemic, reports in social media and the lay press indicate that a subset of patients are presenting with severe hypoxemia in the absence of dyspnea, a problem unofficially referred to as "silent hypoxemia." To decrease the risk of complications in such patients, one proposed solution has been to have those diagnosed with COVID-19 but not sick enough to warrant admission monitor their arterial oxygenation by pulse oximetry at home and present for care when they show evidence of hypoxemia. Though the ease of use and low cost of pulse oximetry makes this an attractive option for identifying problems at an early stage, there are important considerations with pulse oximetry about which patients and providers may not be aware that can interfere with successful implementation of such monitoring programs. Only a few independent studies have examined the performance of pocket oximeters and smart phone-based systems, but the limited available data raise questions about their accuracy, particularly as saturation falls below 90%. There are also multiple sources of error in pulse oximetry that must be accounted for, including rapid fluctuations in measurements when the arterial oxygen pressure/tension falls on the steep portion of the dissociation curve, data acquisition problems when pulsatile blood flow is diminished, accuracy in the setting of severe hypoxemia, dyshemoglobinemias, and other problems. Recognition of these issues and careful counseling of patients about the proper means for measuring their oxygen saturation and when to seek assistance can help ensure successful implementation of needed monitoring programs.
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http://dx.doi.org/10.1513/AnnalsATS.202005-418FRDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7462317PMC
September 2020

COVID-19 Lung Injury and High Altitude Pulmonary Edema: A False Equation with Dangerous Implications.

Ann Am Thorac Soc 2020 Apr 24. Epub 2020 Apr 24.

University of Washington, Medicine, Seattle, Washington, United States.

Amid efforts to care for the large number of patients with COVID-19, there has been considerable speculation about whether the lung injury seen in these patients is different than ARDS from other causes. One idea that has garnered considerable attention, particularly on social media and in free open access medicine is the notion that lung injury due to COVID-19 is more similar to high altitude pulmonary edema (HAPE). Drawing on this concept, it has also been proposed that treatments typically employed in the management of HAPE and other forms of acute altitude illness, pulmonary vasodilators and acetazolamide, should be considered for COVID-19. Despite some similarities in clinical features between the two entities, such as hypoxemia, radiographic opacities and altered lung compliance, the pathophysiological mechanisms of HAPE and lung injury due to COVID-19 are fundamentally different and the entities cannot be viewed as equivalent. While of high utility in the management of HAPE and acute mountain sickness, systemically delivered pulmonary vasodilators and acetazolamide should not be used in the treatment of COVID-19, as they carry the risk of multiple adverse consequences including worsened ventilation-perfusion matching, impaired carbon dioxide transport, systemic hypotension and increased work of breathing.
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http://dx.doi.org/10.1513/AnnalsATS.202004-327FRDOI Listing
April 2020

COVID-19 Lung Injury is Not High Altitude Pulmonary Edema.

High Alt Med Biol 2020 06 13;21(2):192-193. Epub 2020 Apr 13.

Altitude Research Center, Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

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http://dx.doi.org/10.1089/ham.2020.0055DOI Listing
June 2020

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update.

Wilderness Environ Med 2019 Dec 24;30(4S):S3-S18. Epub 2019 Jun 24.

Altitude Research Center, Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.

To provide guidance to clinicians about best preventive and therapeutic practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for prevention and treatment of acute mountain sickness, high altitude cerebral edema, and high altitude pulmonary edema. Recommendations are graded based on the quality of supporting evidence and the balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches to prevention and management of each form of acute altitude illness that incorporate these recommendations. This is an updated version of the original WMS Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness published in 2010 and subsequently updated as the WMS Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness in 2014.
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http://dx.doi.org/10.1016/j.wem.2019.04.006DOI Listing
December 2019

Preventing Dogma from Driving Practice.

N Engl J Med 2019 02 18;380(9):870-871. Epub 2019 Feb 18.

From the Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle.

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http://dx.doi.org/10.1056/NEJMe1900708DOI Listing
February 2019

When One Door Closes, Another Opens.

Ann Am Thorac Soc 2018 11;15(11):1349-1353

Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington.

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http://dx.doi.org/10.1513/AnnalsATS.201805-314CCDOI Listing
November 2018

The 2018 Lake Louise Acute Mountain Sickness Score.

High Alt Med Biol 2018 03 13;19(1):4-6. Epub 2018 Mar 13.

6 Roslin Institute, University of Edinburgh , Easter Bush, Midlothian, United Kingdom .

Roach, Robert C., Peter H. Hackett, Oswald Oelz, Peter Bärtsch, Andrew M. Luks, Martin J. MacInnis, J. Kenneth Baillie, and The Lake Louise AMS Score Consensus Committee. The 2018 Lake Louise Acute Mountain Sickness Score. High Alt Med Biol 19:1-4, 2018.- The Lake Louise Acute Mountain Sickness (AMS) scoring system has been a useful research tool since first published in 1991. Recent studies have shown that disturbed sleep at altitude, one of the five symptoms scored for AMS, is more likely due to altitude hypoxia per se, and is not closely related to AMS. To address this issue, and also to evaluate the Lake Louise AMS score in light of decades of experience, experts in high altitude research undertook to revise the score. We here present an international consensus statement resulting from online discussions and meetings at the International Society of Mountain Medicine World Congress in Bolzano, Italy, in May 2014 and at the International Hypoxia Symposium in Lake Louise, Canada, in February 2015. The consensus group has revised the score to eliminate disturbed sleep as a questionnaire item, and has updated instructions for use of the score.
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http://dx.doi.org/10.1089/ham.2017.0164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6191821PMC
March 2018

Clinical recommendations for high altitude exposure of individuals with pre-existing cardiovascular conditions: A joint statement by the European Society of Cardiology, the Council on Hypertension of the European Society of Cardiology, the European Society of Hypertension, the International Society of Mountain Medicine, the Italian Society of Hypertension and the Italian Society of Mountain Medicine.

Eur Heart J 2018 05;39(17):1546-1554

Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia, 20, 20149 Milan, Italy.

Take home figureAdapted from Bärtsch and Gibbs2 Physiological response to hypoxia. Life-sustaining oxygen delivery, in spite of a reduction in the partial pressure of inhaled oxygen between 25% and 60% (respectively at 2500 m and 8000 m), is ensured by an increase in pulmonary ventilation, an increase in cardiac output by increasing heart rate, changes in vascular tone, as well as an increase in haemoglobin concentration. BP, blood pressure; HR, heart rate; PaCO2, partial pressure of arterial carbon dioxide.
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http://dx.doi.org/10.1093/eurheartj/ehx720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5930248PMC
May 2018

Reply.

Exp Physiol 2017 11;102(11):1562

University of Washington, Seattle, WA, 98104, USA.

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http://dx.doi.org/10.1113/EP086664DOI Listing
November 2017

Gas Exchange in the Prone Posture.

Respir Care 2017 Aug 30;62(8):1097-1110. Epub 2017 May 30.

Department of Medicine.

The prone posture is known to have numerous effects on gas exchange, both under normal conditions and in patients with ARDS. Clinical studies have consistently demonstrated improvements in oxygenation, and a multi-center randomized trial found that, when implemented within 48 h of moderate-to-severe ARDS, placing subjects in the prone posture decreased mortality. Improvements in gas exchange occur via several mechanisms: alterations in the distribution of alveolar ventilation, redistribution of blood flow, improved matching of local ventilation and perfusion, and reduction in regions of low ventilation/perfusion ratios. Ventilation heterogeneity is reduced in the prone posture due to more uniform alveolar size secondary to a more uniform vertical pleural pressure gradient. The prone posture results in more uniform pulmonary blood flow when compared with the supine posture, due to an anatomical bias for greater blood flow to dorsal lung regions. Because both ventilation and perfusion heterogeneity decrease in the prone posture, gas exchange improves. Other benefits include a more uniform distribution of alveolar stress, relief of left-lower-lobe lung compression by the heart, enhanced secretion clearance, and favorable right-ventricular and systemic hemodynamics.
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http://dx.doi.org/10.4187/respcare.05512DOI Listing
August 2017

Changes in acute pulmonary vascular responsiveness to hypoxia during a progressive ascent to high altitude (5300 m).

Exp Physiol 2017 06 21;102(6):711-724. Epub 2017 May 21.

Department of Medicine, University of Washington, Seattle, WA, USA.

New Findings: What is the central question of this study? Do the pulmonary vascular responses to hypoxia change during progressive exposure to high altitude and can alterations in these responses be related to changes in concentrations of circulating biomarkers that affect the pulmonary circulation? What is the main finding and its importance? In our field study with healthy volunteers, we demonstrate changes in pulmonary artery pressure suggestive of remodelling in the pulmonary circulation, but find no changes in the acute responsiveness of the pulmonary circulation to changes in oxygenation during 2 weeks of exposure to progressive hypoxia. Pulmonary artery pressure changes were associated with changes in erythropoietin, 8-isoprostane, nitrite and guanosine 3',5'-cyclic monophosphate. We sought to determine whether changes in pulmonary artery pressure responses to hypoxia suggestive of vascular remodelling occur during progressive exposure to high altitude and whether such alterations are related to changes in concentrations of circulating biomarkers with known or suspected actions on the pulmonary vasculature during ascent. We measured tricuspid valve transvalvular pressure gradients (TVPG) in healthy volunteers breathing air at sea level (London, UK) and in hypoxic conditions simulating the inspired O partial pressures at two locations in Nepal, Namche Bazaar (NB, elevation 3500 m) and Everest Base Camp (EBC, elevation 5300 m). During a subsequent 13 day trek, TVPG was measured at NB and EBC while volunteers breathed air and hyperoxic or hypoxic mixtures simulating the inspired O partial pressures at the other locations. For each location, we determined the slope of the relationship between TVPG and arterial oxygen saturation (SaO2) to estimate the pulmonary vascular response to hypoxia. Mean TVPG breathing air was higher at any SaO2 at EBC than at sea level or NB, but there was no change in the slope of the relationship between SaO2 and TVPG between locations. Nitric oxide availability remained unchanged despite increases in oxidative stress (elevated 8-isoprostane). Erythropoietin, pro-atrial natriuretic peptide and interleukin-18 levels progressively increased on ascent. Associations with TVPG were observed only with erythropoietin, 8-isoprostane, nitrite and guanosine 3',5'-cyclic monophosphate. Although the increased TVPG for any given SaO2 at EBC suggests that pulmonary vascular remodelling might occur during 2 weeks of progressive hypoxia, the lack of change in the slope of the relationship between TVPG and SaO2 indicates that the acute pulmonary vascular responsiveness to changes in oxygenation does not vary within this time frame.
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http://dx.doi.org/10.1113/EP086083DOI Listing
June 2017

The Transition From Emergency Medicine Resident to Critical Care Fellow: A Road Map.

AEM Educ Train 2017 Apr 22;1(2):116-123. Epub 2017 Mar 22.

Division of Pulmonary and Critical Care Medicine University of Washington/Harborview Medical Center Seattle WA.

Emergency medicine (EM) residents now have a number of opportunities for fellowship training in critical care medicine (CCM). The aim of this review is to help EM residents navigate the application process, transition to fellowship, and start planning their careers beyond fellowship. Pathways to advanced training in CCM available for EM residents include internal medicine-CCM, anesthesiology-CCM, surgical critical care, and neurocritical care. Each has unique prerequisites, application timelines, and training requirements. EM residency graduates generally already have well-developed crisis management and team leadership skills and excel with procedures such as airway management, vascular access, and bedside ultrasound. Potential areas for growth for EM trainees include critical care physiology, end-of-life care, longitudinal inpatient care, and perioperative medicine. Career opportunities for physicians trained in EM and CCM are diverse and include options in community or academic settings. Some choose EM or CCM exclusively or engage in a mix of both. Academic positions with joint opportunities in EM and CCM are desirable, but can be challenging to negotiate. Many EM-CCM physicians serve as topic experts in their respective groups for clinical care, quality improvement, education, or research involving the interface between the ED and intensive care unit. As career paths in critical care continue to grow in popularity, EM residents, as well as CCM faculty and program directors, should be aware of the available fellowship options, as well as training and career development needs specific to EM residents.
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http://dx.doi.org/10.1002/aet2.10023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6001715PMC
April 2017

Acute high-altitude sickness.

Eur Respir Rev 2017 Jan 31;26(143). Epub 2017 Jan 31.

Dept of Internal Medicine, University Clinic Heidelberg, Heidelberg, Germany.

At any point 1-5 days following ascent to altitudes ≥2500 m, individuals are at risk of developing one of three forms of acute altitude illness: acute mountain sickness, a syndrome of nonspecific symptoms including headache, lassitude, dizziness and nausea; high-altitude cerebral oedema, a potentially fatal illness characterised by ataxia, decreased consciousness and characteristic changes on magnetic resonance imaging; and high-altitude pulmonary oedema, a noncardiogenic form of pulmonary oedema resulting from excessive hypoxic pulmonary vasoconstriction which can be fatal if not recognised and treated promptly. This review provides detailed information about each of these important clinical entities. After reviewing the clinical features, epidemiology and current understanding of the pathophysiology of each disorder, we describe the current pharmacological and nonpharmacological approaches to the prevention and treatment of these diseases.
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http://dx.doi.org/10.1183/16000617.0096-2016DOI Listing
January 2017

Implementation of a Professional Society Core Curriculum and Integrated Maintenance of Certification Program.

Ann Am Thorac Soc 2017 Apr;14(4):495-499

13 Division of Pulmonary and Critical Care, Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Boston, Massachusetts.

Medical professional societies exist to foster collaboration, guide career development, and provide continuing medical education opportunities. Maintenance of certification is a process by which physicians complete formal educational activities approved by certifying organizations. The American Thoracic Society (ATS) established an innovative maintenance of certification program in 2012 as a means to formalize and expand continuing medical education offerings. This program is unique as it includes explicit opportunities for collaboration and career development in addition to providing continuing medical education and maintenance of certification credit to society members. In describing the development of this program referred to as the "Core Curriculum," the authors highlight the ATS process for content design, stages of curriculum development, and outcomes data with an eye toward assisting other societies that seek to program similar content. The curriculum development process described is generalizable and positively influences individual practitioners and professional societies in general, and as a result, provides a useful model for other professional societies to follow.
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http://dx.doi.org/10.1513/AnnalsATS.201612-1001PSDOI Listing
April 2017

An Insidious Cause of Low Oxygen Saturation after Stem Cell Transplantation.

Ann Am Thorac Soc 2016 Nov;13(11):2082-2086

Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington.

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http://dx.doi.org/10.1513/AnnalsATS.201604-283CCDOI Listing
November 2016

Medication Use Among Mount Everest Climbers: Practice and Attitudes.

High Alt Med Biol 2016 Dec 20;17(4):315-322. Epub 2016 Oct 20.

5 Department of Emergency Medicine, University of Colorado , Denver, Colorado.

Luks, Andrew M., Colin Grissom, Luanne Freer, and Peter Hackett. Medication use among mount Everest climbers: practice and attitudes. High Alt Med Biol. 17:315-322, 2016.-The lay public, media, and medical experts have expressed concern about the ethics of climbers using medications to improve performance and increase the odds of summit success while climbing at high altitude, but the true incidence of this practice remains unclear. We conducted an anonymous survey of climbers who have attempted to climb Mt. Everest to gather information about medication use and attitudes toward medication and supplemental oxygen use while climbing the mountain. One hundred eighty-seven individuals completed the survey, providing information about medication and oxygen use for 262 expeditions to Mt. Everest between 1963 and 2015, the majority of which occurred after the year 2000. The majority of respondents were male (82%) and from English-speaking countries (75%). Medications were used on 43% of climbs, with acetazolamide being the most commonly used medication. Reported use of dexamethasone, nifedipine, sildenafil, or tadalafil was uncommon as was use of multiple medications at the same time. The majority of respondents indicated that it was acceptable for climbers to use medications and supplemental oxygen to prevent altitude illness while climbing Mt. Everest. Opinions were more mixed regarding whether summiting without the use of medications or oxygen carried the same value as reaching the summit using those interventions. Our data suggest that less than one-half of Mt. Everest climbers use medications during their expedition, with the primary medication used being acetazolamide, for prevention of altitude illness. Given the limitations of the study design and preliminary nature of these data, further research is warranted to further clarify these issues.
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http://dx.doi.org/10.1089/ham.2016.0077DOI Listing
December 2016