Good morning! Welcome to another edition of Pressure Support, a weekly newsletter simplifying pulmonary and critical care medicine—and the systems that shape it.

Spent the last week in the MICU and found a prior article I wrote on the “GOC” experience relevant again! Enjoy this article on ICU Terms and Conditions.

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January 9th, 2025

I’m wrapping up a week in ICU. I found myself reflecting on the unique challenges of critical care. One thought, in particular, stuck with me: ICU Terms and Conditions.

The ICU is the last stop in the hospital for the sickest patients. It’s where we deploy our most advanced tools and interventions to combat life-threatening conditions. When you’re admitted to the ICU, there are really only two potential outcomes: you stabilize and transfer back to a lower level of care, or… you don’t.

We understand the gravity of the ICU as physicians. It’s where medicine meets its limits, where we’re not always aiming to cure or fix but to keep patients alive long enough to give their bodies a fighting chance.

But many patients and their families don’t know this.

To most people, hospitals are mysterious and intimidating places. The ICU is an even deeper mystery—a place they’ve only seen in TV dramas or imagined in stories. And because they don’t fully understand what being in the ICU truly means, they come in with expectations that may not align with reality. That disconnect can lead to confusion, frustration, and, in the worst cases, broken trust.

When I admit a patient to the ICU, I make it a point to address this gap. I tell patients and families something along these lines:

“I don’t like surprises, and I don’t want you to be surprised either if something happens. You (or your loved one) is critically ill and at high risk of death. We will do everything within our control to avoid that, but I want you to understand the seriousness of the situation.”

This is not an easy conversation to have. But it’s necessary. It’s my way of managing expectations while reassuring them that, yes, we will fight with every tool at our disposal—but there are limits to what medicine can do.

This led me to an idea: What if we had ICU Terms and Conditions?

Here’s what I’m picturing: when a patient is admitted to the ICU, they—or their family—are handed a straightforward document or given a brief explanation that outlines exactly what being in the ICU means. This is what it might cover:

I’m not saying we should have patients sign a literal document like they would for an iPhone update (which we knowingly just accept without reading). Instead, this could be as simple as a structured conversation with a visual handout to guide the discussion. Something short, digestible, and respectful of the fact that families are often processing a lot of information all at once.

A few key points, delivered in plain language, could go a long way toward bridging the gap between what we know as ICU providers and what families understand as they walk through those doors.

When families come to the ICU, they’re in crisis mode. Their loved one is fighting for their life, and they’re often overwhelmed, sleep-deprived, and desperate for good news. In that state, it’s easy to misinterpret what the ICU is capable of. Some may see it as a guarantee of survival—“They’re in the ICU now, so they’ll be fine.” Others may underestimate the intensity of interventions required.

The goal of this ICU “terms and conditions” wouldn’t be to scare patients and families but to level with them. It’s about transparency, setting expectations, and ensuring everyone understands the critical nature of the ICU. By giving families a clear, honest explanation upfront, we can prevent many of the misunderstandings that lead to frustration or disappointment later.

This JACI: In Practice study compared large language model AI recommendations vs a severe asthma multidisciplinary team (MDT) when deciding on biologic therapy, and found the AI’s suggestions frequently didn’t line up with the MDT. In 114 patients, agreement between MDT decisions and AI was poor (κ ~0.14–0.21), leading the authors to conclude current AI models aren’t suitable as standalone or even adjunct decision-makers for biologic selection. This feels like a good reminder that “clinical AI” still needs tight guardrails and real workflow-aware validation—because getting biologic decisions wrong creates a lot of downstream inefficiency (and risk) for patients and teams.

NEJM reports two replicate phase 3 trials (OBERON and TITANIA) testing add‑on tozorakimab (an anti–IL‑33 monoclonal antibody) every 4 weeks for 52 weeks in COPD patients with prior exacerbations despite maintenance inhalers. It significantly lowered the annualized rate of moderate/severe exacerbations versus placebo in former smokers (rate ratios 0.71 and 0.66) and in the overall population (rate ratios ~0.70–0.71), with adverse events that were similar to or a bit lower than placebo. It’s exciting to see a biologic signal this clean in COPD without eosinophil-based selection—if the safety/cost profile holds up, this could become a pragmatic add-on option for the “still exacerbating” crowd we see all the time.

This NEJM clinical review walks through a practical approach to incidental pulmonary nodules — start with pretest cancer risk (patient factors + nodule size/appearance), then decide between short-interval CT surveillance, PET/CT, or tissue diagnosis, with special attention to subsolid nodules and when to involve a multidisciplinary nodule clinic. It basically gives you an “if this, then that” roadmap for avoiding both over-testing low-risk nodules and missing early lung cancer.

This pragmatic RCT in medically underserved adults referred for CT lung cancer screening compared usual ask-advise-refer vs adding free cessation meds, vs adding up to $600 in financial incentives (± a mobile future-self tool). Financial incentives meaningfully improved biochemically verified sustained abstinence through 6 months (about 8.8% vs 4.3%), while free pharmacotherapy alone didn’t outperform usual care. It’s a nice reminder that in real-world LCS workflows, reducing friction isn’t enough—patients often need tangible support, and incentive-based programs may be the highest-yield lever if a system can implement them equitably.

OncLive reports the FDA granted breakthrough therapy designation to telisotuzumab adizutecan (Temab‑A; ABBV‑400), a c‑Met–targeted ADC, for previously treated c‑Met–expressing, EGFR–wild type nonsquamous NSCLC after platinum chemo and anti–PD-(L)1 therapy, based largely on phase 1 M21-404 data (overall ORR ~48% with higher responses at higher c‑Met expression). They also highlight encouraging activity in an EGFR-mutated cohort (confirmed ORR ~63% and median PFS ~10.9 months). I’m going to want to see durability, safety/tolerability, and how cleanly “c‑Met–expressing” can be operationalized in real-world practice before getting too excited.

CRITICAL CARE
A patient with severe ARDS remains profoundly hypoxemic despite optimized lung-protective ventilation, appropriate PEEP titration, and 2 cycles of proning.

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Keeping it simple,

Jared