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

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This large multicenter study of 24,643 hospitalized patients found that starting phenobarbital versus diazepam for alcohol withdrawal led to essentially no difference in hospital length of stay, invasive mechanical ventilation, or most other outcomes, suggesting the two are close to therapeutically equivalent. The one notable difference was more self-directed discharge among patients started on diazepam, though that finding deserves cautious interpretation. This is useful pragmatic evidence against assuming phenobarbital automatically improves throughput or safety, and it reinforces the need for a real comparative clinical trial before changing standardized withdrawal pathways.

This KFF Health News investigation follows Kenney Blewett, whose worsening COPD and a delayed nebulized medication—amid confusion between Walgreens, his pulmonologist’s office, Medicare Part B, and his drug plan—left his family wondering whether the flare-up preceding his suicide might have been preventable. It also shows how voluntary insurer reforms and increasingly complex, potentially AI-driven prior authorization can leave patients and clinicians navigating a maze. This is a painful example of how fragmented medication-access workflows can become a clinical safety issue, so PCCM practices need clearer ownership, escalation pathways, and closed-loop follow-up when an urgent respiratory prescription is delayed.

This Global Burden of Disease 2023 analysis shows that chronic respiratory disease affected about 54.5 million people in the US in 2023—up from 33.3 million in 1990—with rising age-standardized prevalence, modestly higher mortality, and major state-level disparities, especially for COPD and pneumoconiosis in Appalachia and asthma and ILD in the South and Great Plains. Modifiable risks accounted for about 44.5% of DALYs, and models project 45.7 million people with asthma and 19.6 million with COPD by 2050.

This international prospective cohort of 2,454 mechanically ventilated adults across 41 countries found that fluid input peaked around 3.0 L/day after intubation, with maintenance/replacement and “creep” fluids making up most of the volume—not resuscitation—and substantial practice variation persisting across ICUs. The practical takeaway is that fluid stewardship has to include medication carriers, line keep-open fluids, and routine maintenance, because those process-driven inputs may be a bigger and more standardizable target than the resuscitation bolus itself.

In this pragmatic, open-label randomized trial of 780 mechanically ventilated adults with acute hypoxemic respiratory failure across 14 Canadian ICUs, an isoflurane-based inhaled sedation strategy did not reduce hospital mortality compared with usual IV sedation (42.5% vs 43.8%), and ICU-, ventilator-, hospital-free days plus 3-month quality of life and disability were similar; the inhaled group did use more hypoxemia rescue therapies and had slightly fewer delirium- and coma-free days. Inhaled sedation doesn’t earn a routine role based on these outcomes, especially given the added equipment and training burden, so implementation should stay selective and driven by specific clinical or operational needs rather than an expectation of better recovery.

JAMA’s VASSPR pragmatic cluster-randomized crossover trial across 13 US hospitals compared starting vasopressin at a lower vs higher norepinephrine-equivalent threshold in more than 3,900 patients with septic shock; earlier initiation did not improve 28-day mortality (31.8% vs 33.0%; adjusted risk difference, −0.4 percentage points; 95% CI, −2.7 to 1.3), kidney-replacement-therapy–free days, or other major outcomes. Simply pushing vasopressin earlier should not be treated as a mortality strategy, and the trial is a useful reminder that a protocol can reliably change bedside behavior without necessarily improving patient-centered outcomes—so we still need better phenotyping and implementation workflows to identify who actually benefits.

In this multicenter open-label noninferiority trial of 535 critically ill adults with acute kidney injury who needed renal-replacement therapy, starting with intermittent hemodialysis did not meet noninferiority for 90-day major adverse kidney events and was associated with higher 90-day mortality than continuous therapy (63.1% vs. 53.5%; hazard ratio, 1.30), so the trial was stopped early. This is likely a pretty practice-shifting ICU result: continuous therapy may be the safer default when renal-replacement therapy is needed, though the resource burden and which patients truly benefit still need to be worked into a practical, non-one-size-fits-all protocol.

This NEJM perspective summarizes the IARC’s 21st Handbook, which weighs the benefits and harms of lung-cancer screening with low-dose CT or chest radiography and reviews strategies for improving screening delivery. The big practical point for me is that screening only works when evidence-based eligibility, follow-up, and equitable implementation are built into a reliable workflow—not just when scans are ordered.

This Belgian nationwide cohort of 283,760 adults with asthma or COPD found that increasing use of SAMA or SABA+SAMA inhalers was associated with more cardiovascular events and higher all-cause mortality; collecting ≥3 SABA canisters per year was linked to about a 1.1-fold higher risk of heart failure and mortality, while 1–2 canisters were not associated with increased risk. Clinically, the ≥3-canister threshold is a useful workflow trigger to reassess control, maintenance therapy, adherence, and cardiovascular risk, although the observational design means residual confounding by disease severity cannot be ruled out.

This prospective study found that the Samsung Galaxy Watch could identify moderate-to-severe obstructive sleep apnea pretty well compared with in-lab polysomnography in 152 adults, with an AUROC of 0.94; it also performed especially well at flagging patients with high hypoxic burden, a group with greater cardiometabolic risk. A smartwatch could make OSA screening and triage much more scalable, although it should support—not replace—definitive testing, and the enriched cohort, industry support, and lack of public data mean we still need broader real-world validation. From a workflow standpoint, this is promising because better front-end screening could reduce delays and focus sleep-lab resources on the patients most likely to benefit.

CRITICAL CARE
A patient with ARDS is intubated, has a functional GI tract, is receiving stable norepinephrine at 0.12 mcg/kg/min, and has a clearing lactate without abdominal findings.

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Keeping it simple,

Jared