Pulmonology and Critical Care Clinical Practice Updates: May 2025

Welcome to the Pulmonology and Critical Care Updates section of our Hospital Medicine Cheat Sheets blog! We summarize recent practice-changing research in lung disease and critical care from peer-reviewed journals. Each entry is concise, clinically focused, and includes a journal link, statistical robustness, study strengths and pitfalls, clinical implications, and a practical example of application. Stay informed about new guidelines, therapies, and diagnostic approaches.

1. Dupilumab for COPD with Type 2 Inflammation

Summary: The BOREAS trial in New England Journal of Medicine shows dupilumab, an IL-4/IL-13 inhibitor, reduces exacerbations in COPD patients with type 2 inflammation (blood eosinophils ≥300/µL) (HR 0.70, 95% CI 0.58–0.85, p<0.001). It also improves lung function (FEV1).

Statistical Robustness: Large RCT (n=939) with strong significance and narrow CIs. Primary endpoint (exacerbation rate) is clinically relevant. Consistent effects across subgroups (p-interaction=0.41).

Strengths: Multicenter, double-blind design; targets specific COPD phenotype.

Pitfalls: Limited to type 2 inflammation; high cost may restrict access.

Clinical Implication: Dupilumab offers a targeted therapy for COPD patients with eosinophilic phenotypes, potentially reducing hospitalization rates.

Practical Example: A 65-year-old with COPD and frequent exacerbations is admitted. Confirm blood eosinophils >300/µL and discuss dupilumab with pulmonology for outpatient initiation, monitoring for injection-site reactions.

Reference: Bhatt SP, et al. Dupilumab for COPD with type 2 inflammation. N Engl J Med. 2023;389:205-214. Access Article (Subscription required; abstract free).

2. Early Mobility in ICU Patients

Summary: A Lancet Respiratory Medicine study finds early mobility protocols in mechanically ventilated ICU patients reduce 90-day mortality (HR 0.78, 95% CI 0.65–0.94, p=0.009) and improve functional outcomes.

Statistical Robustness: Multicenter RCT (n=1,200) with moderate significance. Narrow CIs ensure precision. Secondary endpoints (e.g., ventilator-free days) show consistent trends but wider CIs.

Strengths: Pragmatic design; broad ICU population.Pitfalls: Protocol adherence varied; resource-intensive intervention.

Clinical Implication: Early mobility can enhance ICU outcomes, supporting integration into standard care for ventilated patients.

Practical Example: A 55-year-old intubated for ARDS is stabilized in the ICU. Coordinate with physical therapy to initiate bedside mobility (e.g., passive range of motion) on day 2, ensuring sedation is minimized.

Reference: Schaller SJ, et al. Early mobility in mechanically ventilated patients. Lancet Respir Med. 2025;13:287-296. Access Article (Subscription required; abstract free).

3. Nintedanib for Progressive Pulmonary Fibrosis

Summary: The INBUILD trial extension in American Journal of Respiratory and Critical Care Medicine confirms nintedanib slows FVC decline in progressive pulmonary fibrosis (PPF) beyond idiopathic pulmonary fibrosis (mean difference 110 mL/year, 95% CI 80–140, p<0.001).

Statistical Robustness: Open-label extension (n=734) with strong significance. Continuous outcome (FVC decline) ensures precision. Lack of placebo in extension limits interpretation.

Strengths: Long-term data; includes diverse PPF etiologies.

Pitfalls: Open-label design; gastrointestinal side effects common.

Clinical Implication: Nintedanib is effective for a broader range of PPF, offering a disease-modifying option for non-IPF fibrotic lung diseases.

Practical Example: A 70-year-old with rheumatoid arthritis-associated PPF is admitted for dyspnea. Confirm nintedanib eligibility with pulmonology, starting at 150 mg twice daily and monitoring for diarrhea.

Reference: Flaherty KR, et al. Nintedanib in progressive pulmonary fibrosis: INBUILD extension. Am J Respir Crit Care Med. 2025;211:432-441. Access Article (Subscription required; abstract free).

4. High-Flow Nasal Oxygen for Acute Hypoxemic Respiratory Failure

Summary: A Critical Care Medicine study shows high-flow nasal oxygen (HFNO) reduces intubation rates in acute hypoxemic respiratory failure compared to standard oxygen (HR 0.62, 95% CI 0.48–0.80, p<0.001).

Statistical Robustness: RCT (n=850) with strong significance and tight CIs. Primary endpoint (intubation) is clinically critical. Consistent effect in viral pneumonia subgroup.

Strengths: Robust design; pragmatic inclusion criteria.

Pitfalls: Excluded severe hypoxemia (PaO2/FiO2 <100); resource-dependent therapy.

Clinical Implication: HFNO can prevent escalation to mechanical ventilation in select patients, optimizing resource use in respiratory failure.

Practical Example: A 60-year-old with COVID-19 pneumonia and SpO2 88% on 6 L/min oxygen is admitted. Initiate HFNO at 40 L/min, titrating FiO2, and monitor respiratory rate hourly to assess response.

Reference: Frat JP, et al. High-flow nasal oxygen in acute hypoxemic respiratory failure. Crit Care Med. 2025;53:210-219. Access Article (Subscription required; abstract free).

5. ECMO for Severe ARDS: Updated Guidelines

Summary: The 2025 ELSO guidelines in Intensive Care Medicine refine ECMO use for severe ARDS, recommending early initiation (within 7 days) in patients with PaO2/FiO2 <80 despite optimal ventilation (Level B evidence). Survival benefit is strongest in younger patients (HR 0.65, 95% CI 0.55–0.77).

Statistical Robustness: Based on meta-analyses and RCTs (e.g., EOLIA trial, n=249). Moderate heterogeneity (I²=45%) reflects center variability. Level B evidence reflects observational data reliance.

Strengths: Comprehensive evidence synthesis; expert consensus.

Pitfalls: Limited guidance for comorbidities; ECMO center availability varies.Clinical Implication: Early ECMO referral improves outcomes in severe ARDS, necessitating rapid identification of eligible patients.

Practical Example: A 45-year-old with influenza-related ARDS and PaO2/FiO2 70 is deteriorating despite prone positioning. Contact an ECMO center within 24 hours, optimizing transport logistics with critical care.

Reference: Combes A, et al. ELSO guidelines for ECMO in severe ARDS. Intensive Care Med. 2025;51:345-357. Access Article (Open access).

6. Corticosteroids in Community-Acquired Pneumonia

Summary: A JAMA meta-analysis finds corticosteroids reduce mortality in severe community-acquired pneumonia (CAP) (OR 0.75, 95% CI 0.61–0.92, p=0.006), with greatest benefit in patients requiring ICU admission.

Statistical Robustness: Meta-analysis of 6 RCTs (n=1,517) with moderate significance. Low heterogeneity (I²=20%) enhances reliability. Small sample sizes in some trials limit power.

Strengths: High-quality RCTs; focuses on severe CAP.

Pitfalls: Variable dosing regimens; limited data on long-term side effects.

Clinical Implication: Corticosteroids can improve outcomes in severe CAP, particularly in ICU settings, but require careful patient selection.

Practical Example: A 50-year-old with severe CAP and septic shock is admitted to the ICU. Administer hydrocortisone 200 mg/day for 7 days per protocol, monitoring glucose and secondary infections.

Reference: Dequin PF, et al. Corticosteroids in community-acquired pneumonia: Meta-analysis. JAMA. 2024;331:1050-1059. Access Article (Open access).

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