Bhupinder S Natt

Interests

Teaching

Airway Management,Interstitial Lung Disease,Extracorporeal Membrane OxygenationMechanical Ventilation

Research

Airway ManagementInterstitial Lung DiseaseExtracorporeal Membrane Oxygenation

Courses

No activities entered.

Scholarly Contributions

Chapters

• Natt, B. (2024). Applied Aiirway Ultrasound. In Airway Management in Critical Care(pp 70-75). Wolters Kluwer.
• Natt, B. (2024). Combination Techniques. In Airway Management in Critically Ill(pp 271-278). Wolters Kluwer.
• Natt, B. (2024). Percutaneous Tracheostomy. In Airway Management in Critically Ill(pp 309-312). Wolters Kluwer.
• Natt, B. (2024). The Medical Patient. In Airway Management in Critically Ill(pp 329-350). Wolters Kluwer.
• Natt, B. (2024). The Neurological Patient. In Airway Management in Critically Ill(pp 321-328). Wolters Kluwer.
• Natt, B., & Mosier, J. M. (2024). Applied Ultrasonogrpahy. In Manual of Airway Management in Critical care(pp 76-86). Wolters Kluwer.

Journals/Publications

• Soin, S., Ibrahim, R., Kusupati, V., Sainbayar, E., Pham, H. N., Natt, B., Ferreira, J. P., Ussavarungsi, K., & Low, S. W. (2024). Interstitial Lung Disease Mortality Disparities Along the US-Mexico Border, 1999-2020. Chest.
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  Optimal diagnosis and management of interstitial lung diseases (ILDs) needs access to specialized centers, frequent monitoring, and complex therapeutic options. In underprivileged areas, these necessities can often lead to barriers in delivering care.
• , N. H., Shapiro, N. I., Douglas, I. S., Brower, R. G., Brown, S. M., Exline, M. C., Ginde, A. A., Gong, M. N., Grissom, C. K., Hayden, D., Hough, C. L., Huang, W., Iwashyna, T. J., Jones, A. E., Khan, A., Lai, P., Liu, K. D., Miller, C. D., Oldmixon, K., , Park, P. K., et al. (2023). Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. The New England journal of medicine, 388(6), 499-510.
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  Intravenous fluids and vasopressor agents are commonly used in early resuscitation of patients with sepsis, but comparative data for prioritizing their delivery are limited.
• Malo, J., Natt, B., Chaudhary, S., & Knox, K. S. (2023). Prophylaxis in Lung Transplant Recipients. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 76(2), 368-369.
• Chaudhary, S., Knox, K. S., Malo, J., & Natt, B. (2022). Prophylaxis in Lung Transplant Recipients. Clinical Infectious Diseases, 76(2), 368-369. doi:10.1093/cid/ciac706
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  To theEditor—We read the article by Truong and colleagues with great interest [1]. Our lung transplant program in Arizona has also adopted a universal lifelong fungal prophylaxis protocol with similarly excellent results in reducing incident coccidioidomycosis among lung transplant recipients. Despite the excellent tolerance reported by Truong et al, challenges may arise for patients who need to stop prophylaxis due to side effects or financial concerns or for patients who leave the endemic area and wish to discontinue prophylaxis. Moreover, many patients who receive transplants at centers elsewhere and relocate to regions endemic for coccidioidomycosis will not be on a fungal prophylaxis regimen as recommendations regarding prophylaxis vary based on local epidemiology and time post-transplant [2, 3]. Current American Society of Transplantation guidelines recommend 6–12 months of Coccidioides prophylaxis for recipients living in endemic regions. Risk stratification for these patient populations may be helpful in determining the safety of withholding prophylaxis. Unfortunately, current commonly used diagnostic testing (Coccidioides serology) is not sensitive for remote infection [4, 5], which may reactivate and disseminate in the setting of immunosuppression. Skin testing is an attractive alternative but is cumbersome, insensitive, and infrequently used [6].
• Kazui, T., Hsu, C. H., Lick, S. D., Hypes, C. D., Natt, B., Malo, J., Mosier, J. M., & Bull, D. A. (2022). Outcomes of Venovenous Extracorporeal Membrane Oxygenation in Viral Acute Respiratory Distress Syndrome. ASAIO journal (American Society for Artificial Internal Organs : 1992), 68(11), 1399-1406.
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  Our study assessed the relationship between the duration of venovenous extracorporeal membrane oxygenation (V-V ECMO) and patient outcomes. We studied patients undergoing V-V ECMO support for acute respiratory distress syndrome (ARDS) between 2009 and 2017 who were reported to the Extracorporeal Life Support Organization registry. We evaluated survival, major bleeding, renal failure, pulmonary complications, mechanical complications, neurologic complications, infection, and duration of V-V ECMO support. Multivariable regression modeling assessed risk factors for adverse events. Of the 4,636 patients studied, the mean support duration was 12.2 ± 13.7 days. There was a progressive increase in survival after the initiation of V-VECMO, peaking at a survival rate of 73% at 10 days of support. However, a single-day increase in V-V ECMO duration was associated with increased bleeding events (odds ratio [OR] 1.038; 95% confidence interval [CI]: 1.029-1.047; p < 0.0001), renal failure (OR 1.018; 95% CI: 1.010-1.027; p < 0.0001), mechanical complications (OR 1.065; 95% CI: 1.053-1.076; p < 0.0001), pulmonary complications (OR 1.04; 95% CI: 1.03-1.05; p < 0.0001), and infection (OR 1.04; 95% CI: 1.03-1.05; p < 0.0001). V-V ECMO progressively increases survival for ARDS over the first 10 days of support. Thereafter, rising complications associated with prolonged durations of support result in a progressive decline in survival.
• Lee, J., White, E. A., Freiheit, E., Patel, N., Bascom, R., Belloli, E. A., Bhatt, N., Bhorade, S., Case, A. H., Castriotta, R. J., Criner, G. J., Danoff, S. K., Andrade, J. d., Desai, A., Glassberg, M. K., Glazer, C. S., Gulati, M., Gupta, N., Hamblin, M. J., , Huie, T. J., et al. (2022). Cough-Specific Quality of Life Predicts Disease Progression Among Patients With Interstitial Lung Disease. CHEST. doi:10.1016/j.chest.2022.03.025
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  Cough is a common symptom of interstitial lung disease (ILD) and negatively impacts health-related quality of life (QOL). Previous studies have shown that among patients with idiopathic pulmonary fibrosis, cough may predict progression of lung disease and perhaps even respiratory hospitalizations and mortality.Does cough-specific QOL predict disease progression, respiratory hospitalization, lung transplantation, and death among patients with ILD?We analyzed data from the Pulmonary Fibrosis Foundation Registry, which comprises a multicenter population of well-characterized patients with ILD. We first examined associations between patient factors and baseline scores on the Leicester Cough Questionnaire (LCQ), a cough-specific QOL tool, using a proportional odds model. Next, we examined associations between baseline LCQ scores and patient-centered clinical outcomes, as well as pulmonary function parameters, using a univariable and multivariable proportional hazards model that was adjusted for clinically relevant variables, including measures of disease severity.One thousand four hundred forty-seven patients with ILD were included in our study. In the multivariable proportional odds model, we found that the following patient factors were associated with worse cough-specific QOL: younger age, diagnosis of "other ILD," gastroesophageal reflux disease, and lower FVC % predicted. Multivariable Cox regression models, adjusting for several variables including baseline disease severity, showed that a 1-point decrease in LCQ score (indicating lower cough-specific QOL) was associated with a 6.5% higher risk of respiratory-related hospitalization (hazard ratio [HR], 1.065; 95% CI, 1.025-1.107), a 7.4% higher risk of death (HR, 1.074; 95% CI, 1.020-1.130), and an 8.7% higher risk of lung transplantation (HR, 1.087; 95% CI, 1.022-1.156).Among a large population of well-characterized patients with ILD, cough-specific QOL was associated independently with respiratory hospitalization, death, and lung transplantation.
• Lee, J., White, E., Freiheit, E., Scholand, M. B., Strek, M. E., Podolanczuk, A. J., Patel, N. M., & , P. F. (2022). Cough-Specific Quality of Life Predicts Disease Progression Among Patients With Interstitial Lung Disease: Data From the Pulmonary Fibrosis Foundation Patient Registry. Chest, 162(3), 603-613.
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  Cough is a common symptom of interstitial lung disease (ILD) and negatively impacts health-related quality of life (QOL). Previous studies have shown that among patients with idiopathic pulmonary fibrosis, cough may predict progression of lung disease and perhaps even respiratory hospitalizations and mortality.
• Blackstone, N., Olson, A., Gibbs, A., Natt, B., & Campion, J. (2021). March 2021 Pulmonary Case of the Month: Transfer for ECMO Evaluation. SWJPCC. doi:10.13175/swjpcc069-20
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  No abstract available. Article truncated after 150 words. A 31-year-old male fire fighter with a history of recurrent “atypical pneumonia,” environmental and drug allergies, nasal polyps, asthma, and Crohn's disease (not on immunosuppressants) was transferred from an outside hospital for management of acute hypoxic respiratory failure with peripheral eosinophilia. Prior to admission he reported a 2-week history of worsening dyspnea, productive cough and wheezing, prompting an urgent care visit where he was prescribed amoxicillin-clavulanate for suspected community acquired pneumonia. Despite multiple days on this medication, his symptoms significantly worsened until he was unable to lie flat without coughing or wheezing. He was ultimately admitted to an outside hospital where his labs were notable for a leukocytosis to 22,000 and peripheral eosinophilia with an absolute eosinophil count of 9700 cells/microL. His blood cultures and urine cultures were negative, and a radiograph of the chest demonstrated bilateral nodular infiltrates. With these imaging findings combined with the peripheral eosinophilia there was …
• Chaudhary, S., Natt, B., Bime, C., Knox, K. S., & Glassberg, M. K. (2021). Corrigendum: Antifibrotics in COVID-19 Lung Disease: Let Us Stay Focused. Frontiers in Medicine. doi:10.3389/fmed.2020.604640
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  Incorrect AffiliationIn the published article, there was an error in affiliation. Instead of “Sachin Chaudhary*, Bhupinder Natt, Christian Bime, Kenneth S. Knox, Marilyn K. Glassberg, Interstitial Lung Disease Program, University of Arizona Colleges of Medicine, Banner-University Medicine Division, Phoenix, AZ, United States”, it should be “Sachin Chaudhary 1*, Bhupinder Natt1, Christian Bime1, Interstitial Lung Disease Program, University of Arizona College of Medicine, Tucson, AZ, United States and Kenneth S. Knox2, Marilyn K Glassberg2, Immunologic Lung Disease Program, Banner-University Medical Center, Phoenix, AZ, United States.” The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.
• Chaudhary, S., Natt, B., Bime, C., Knox, K., & Glassberg, M. (2021). Corrigendum: Antifibrotics in COVID-19 Lung Disease: Let Us Stay Focused (Front. Med., (2020), 7, (539), 10.3389/fmed.2020.00539). Frontiers in Medicine, 7. doi:10.3389/fmed.2020.604640
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  In the published article, there was an error in affiliations for Kenneth S. Knox. Instead of having affiliations 1 and 2, Kenneth S. Knox should only have affiliation 2. The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.
• Harris, D. T., Badowski, M., Jernigan, B., Sprissler, R., Edwards, T., Cohen, R., Paul, S., Merchant, N., Weinkauf, C. C., Bime, C., Erickson, H. E., Bixby, B., Parthasarathy, S., Chaudhary, S., Natt, B., Cristan, E., El Aini, T., Rischard, F., Campion, J., , Chopra, M., et al. (2021). SARS-CoV-2 Rapid Antigen Testing of Symptomatic and Asymptomatic Individuals on the University of Arizona Campus. Biomedicines, 9(5).
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  SARS-CoV-2, the cause of COVID19, has caused a pandemic that has infected more than 80 M and killed more than 1.6 M persons worldwide. In the US as of December 2020, it has infected more than 32 M people while causing more than 570,000 deaths. As the pandemic persists, there has been a public demand to reopen schools and university campuses. To consider these demands, it is necessary to rapidly identify those individuals infected with the virus and isolate them so that disease transmission can be stopped. In the present study, we examined the sensitivity of the Quidel Rapid Antigen test for use in screening both symptomatic and asymptomatic individuals at the University of Arizona from June to August 2020. A total of 885 symptomatic and 1551 asymptomatic subjects were assessed by antigen testing and real-time PCR testing. The sensitivity of the test for both symptomatic and asymptomatic persons was between 82 and 90%, with some caveats.
• Martinez, F. J., Yow, E., Flaherty, K. R., Snyder, L. D., Durheim, M. T., Wisniewski, S. R., Sciurba, F. C., Raghu, G., Brooks, M. M., Kim, D. Y., Dilling, D. F., Criner, G. J., Kim, H., Belloli, E. A., Nambiar, A. M., Scholand, M. B., Anstrom, K. J., Noth, I., & , C. I. (2021). Effect of Antimicrobial Therapy on Respiratory Hospitalization or Death in Adults With Idiopathic Pulmonary Fibrosis: The CleanUP-IPF Randomized Clinical Trial. JAMA, 325(18), 1841-1851.
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  Alteration in lung microbes is associated with disease progression in idiopathic pulmonary fibrosis.
• Mosier, J., Natt, B., & Malo, J. (2021). ARDS in COVID-19 and beyond: Let's keep our eyes on the goal instead of the straw man. Journal of the Intensive Care Society, 22(4), 267-269.
• Natt, B., & Mosier, J. (2021). Airway Management in the Critically Ill Patient. Current anesthesiology reports, 1-12.
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  This paper will evaluate the recent literature and best practices in airway management in critically ill patients.
• Natt, B., Mosier, J., & Malo, J. (2021). ARDS in COVID-19 and beyond: Let's keep our eyes on the goal instead of the straw man.. Journal of the Intensive Care Society, 22(4), 267-269. doi:10.1177/1751143720973527
• Nyquist, A., & Natt, B. (2021). IS CRITICAL CARE MYOPATHY A CONTRAINDICATION FOR SUCCINYLCHOLINE?. Chest, 160(4), A641. doi:10.1016/j.chest.2021.07.611
• Qadir, N., Bartz, R. R., Cooter, M. L., Hough, C. L., Lanspa, M. J., Banner-Goodspeed, V. M., Chen, J. T., Giovanni, S., Gomaa, D., Sjoding, M. W., Hajizadeh, N., Komisarow, J., Duggal, A., Khanna, A. K., Kashyap, R., Khan, A., Chang, S. Y., Tonna, J. E., Anderson, H. L., , Liebler, J. M., et al. (2021). Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study. Chest, 160(4), 1304-1315.
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  Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown.
• Qadir, N., Bartz, R. R., Cooter, M., Hough, C. L., Lanspa, M. J., Banner‐Goodspeed, V., Chen, J., Giovanni, S. P., Gomaa, D., Sjoding, M. W., Hajizadeh, N., Duggal, A., Khanna, A. K., Kashyap, R., Khan, A., Chang, S. Y., Tonna, J. E., Anderson, H. L., Liebler, J. M., , Mosier, J., et al. (2021). Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States. CHEST. doi:10.1016/j.chest.2021.05.047
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  BackgroundAlthough specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown.Research QuestionWhat is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States?Study Design and MethodsWe conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and Pao2 to Fio2 ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H2O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed.ResultsA total of 2,466 patients were enrolled. Median baseline Pao2 to Fio2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H2O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR.InterpretationSubstantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes.Trial RegistryClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and Pao2 to Fio2 ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H2O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed. A total of 2,466 patients were enrolled. Median baseline Pao2 to Fio2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H2O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR. Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes. ClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov FOR EDITORIAL COMMENT, SEE PAGE 1167ARDS is a potentially fatal condition characterized by acute hypoxemia and bilateral radiographic infiltrates, with a reported mortality of 36% to 47%.1Bellani G. Laffey J.G. Pham T. et al.Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries.JAMA. 2016; 315: 788-800Crossref PubMed Scopus (2949) Google Scholar, 2Ferguson N.D. Fan E. Camporota L. et al.The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material.Intensive Care Med. 2012; 38: 1573-1582Crossref PubMed Scopus (978) Google Scholar, 3Rubenfeld G.D. Caldwell E. Peabody E. et al.Incidence and outcomes of acute lung injury.N Engl J Med. 2005; 353: 1685-1693Crossref PubMed Scopus (2937) Google Scholar, 4Villar J. Blanco J. Añón J.M. et al.The ALIEN study: incidence and outcome of acute respiratory distress syndrome in the era of lung protective ventilation.Intensive Care Med. 2011; 37: 1932-1941Crossref PubMed Scopus (434) Google Scholar, 5Ike J.D. Kempker J.A. Kramer M.R. Martin G.S. The association between acute respiratory distress syndrome hospital case volume and mortality in a U.S. cohort, 2002-2011.Crit Care Med. 2018; 46: 764-773Crossref PubMed Scopus (23) Google Scholar Specific interventions in ARDS, including lung protective ventilation (LPV)6Brower R.G. Matthay M.A. et al.Acute Respiratory Distress Syndrome NetworkVentilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.N Engl J Med. 2000; 342: 1301-1308Crossref PubMed Scopus (10449) Google Scholar and prone positioning,7Guerin C. Reignier J. Richard J.C. et al.Prone positioning in severe acute respiratory distress syndrome.N Engl J Med. 2013; 368: 2159-2168Crossref PubMed Scopus (2514) Google Scholar previously were demonstrated to improve survival in clinical trials, but remain underused.1Bellani G. Laffey J.G. Pham T. et al.Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries.JAMA. 2016; 315: 788-800Crossref PubMed Scopus (2949) Google Scholar,8Duan E.H. Adhikari N.K.J. D’Aragon F. et al.Management of acute respiratory distress syndrome and refractory hypoxemia. A multicenter observational study.Ann Am Thorac Soc. 2017; 14: 1818-1826Crossref PubMed Scopus (47) Google Scholar, 9Li X. Scales D.C. Kavanagh B.P. Unproven and expensive before proven and cheap: extracorporeal membrane oxygenation versus prone position in acute respiratory distress syndrome.Am J Respir Crit Care Med. 2018; 197: 991-993Crossref PubMed Scopus (41) Google Scholar, 10Guerin C. Beuret P. Constantin J.M. et al.A prospective international observational prevalence study on prone positioning of ARDS patients: the APRONET (ARDS Prone Position Network) study.Intensive Care Med. 2018; 44: 22-37Crossref PubMed Scopus (178) Google Scholar, 11Weiss C.H. Baker D.W. Weiner S. et al.Low tidal volume ventilation use in acute respiratory distress syndrome.Crit Care Med. 2016; 44: 1515-1522Crossref PubMed Scopus (75) Google Scholar Simultaneously, treatment methods with unclear benefit and potential, including neuromuscular blockade,12Moss M. Huang D.T. et al.National Heart, Lung, and Blood Institute PETALS Clinical Trials NetworkEarly neuromuscular blockade in the acute respiratory distress syndrome.N Engl J Med. 2019; 380: 1997-2008Crossref PubMed Scopus (475) Google Scholar extracorporeal membrane oxygenation,13Combes A. Hajage D. Capellier G. et al.Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome.N Engl J Med. 2018; 378: 1965-1975Crossref PubMed Scopus (1258) Google Scholar steroids,14Villar J. Ferrando C. Martinez D. et al.Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial.Lancet Respir Med. 2020; 8: 267-276Abstract Full Text Full Text PDF PubMed Scopus (641) Google Scholar and pulmonary vasodilators,15Gebistorf F. Karam O. Wetterslev J. Afshari A. Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) in children and adults.Cochrane Database Syst Rev. 2016; : CD002787PubMed Google Scholar,16Afshari A. Bastholm Bille A. Allingstrup M. Aerosolized prostacyclins for acute respiratory distress syndrome (ARDS).Cochrane Database Syst Rev. 2017; 7: CD007733PubMed Google Scholar continue to be used in the management of ARDS. Regional variation in adoption of different practices for treating patients with ARDS was described previously.17Laffey J.G. Madotto F. Bellani G. et al.Geo-economic variations in epidemiology, patterns of care, and outcomes in patients with acute respiratory distress syndrome: insights from the LUNG SAFE prospective cohort study.Lancet Respir Med. 2017; 5: 627-638Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar,18Duggal A. Rezoagli E. Pham T. et al.Patterns of use of adjunctive therapies in patients with early moderate to severe ARDS: insights from the LUNG SAFE Study.Chest. 2020; 157: 1497-1505Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar More recently, reports of widely variable treatments for COVID-19-related ARDS have emerged.19Gupta S. Hayek S.S. Wang W. et al.Factors associated with death in critically ill patients with coronavirus disease 2019 in the US.JAMA Intern Med. 2020; 180: 1436-1447Crossref PubMed Scopus (597) Google Scholar Because of the complexity of ARDS epidemiologic reporting, it is unclear if ARDS mortality has changed over time,5Ike J.D. Kempker J.A. Kramer M.R. Martin G.S. The association between acute respiratory distress syndrome hospital case volume and mortality in a U.S. cohort, 2002-2011.Crit Care Med. 2018; 46: 764-773Crossref PubMed Scopus (23) Google Scholar,20Bhatraju P.K. Ghassemieh B.J. Nichols M. et al.Covid-19 in critically ill patients in the Seattle region—case series.N Engl J Med. 2020; 382: 2012-2022Crossref PubMed Scopus (1738) Google Scholar, 21Grasselli G. Zangrillo A. Zanella A. et al.Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy.JAMA. 2020; 323: 1574-1581Crossref PubMed Scopus (3634) Google Scholar, 22Richardson S. Hirsch J.S. Narasimhan M. et al.Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.JAMA. 2020; 323: 2052-2059Crossref PubMed Scopus (6061) Google Scholar, 23Cochi S.E. Kempker J.A. Annangi S. Kramer M.R. Martin G.S. Mortality trends of acute respiratory distress syndrome in the United States from 1999-2013.10th. 13(10). Ann Am Thorac Soc., 2016: 1742-1751Google Scholar, 24Maca J. Jor O. Holub M. et al.Past and present ARDS mortality rates: a systematic review.Respir Care. 2017; 62: 113-122Crossref PubMed Scopus (202) Google Scholar, 25Pham T. Rubenfeld G.D. Fifty years of research in ARDS. The epidemiology of acute respiratory distress syndrome. A 50th birthday review.Am J Respir Crit Care Med. 2017; 195: 860-870Crossref PubMed Scopus (156) Google Scholar and the impact of potential heterogeneity in ARDS management on patient outcomes remains unknown. FOR EDITORIAL COMMENT, SEE PAGE 1167 To understand the patient- and center-level treatment factors associated with mortality in moderate to severe ARDS in the United States, we conducted a multicenter observational study across US institutions. Center variability in management practices was examined, as well as the association of this variability with patient outcomes. We hypothesized that center management practices would be associated with risk-adjusted 28-day in-hospital mortality. The Severe ARDS: Generating Evidence Study was a multicenter observational cohort study (ClinicalTrials.gov Identifier: NCT 03021824) conducted in 125 ICUs at 29 academic and community hospital centers across the United States from October 1, 2016, through April 30, 2017. Institutional review board approval was obtained at each center, and the requirement for informed consent was waived. Study principal investigators were responsible for ensuring data integrity and validity and for reviewing that patients met study criteria. A list of collaborating centers can be viewed in e-Appendix 1. All consecutive patients 18 years of age or older who were receiving invasive mechanical ventilation at participating ICUs were followed up for 5 days for the development of ARDS by Berlin criteria and a Pao2 to Fio2 ratio of ≤ 150.2Ferguson N.D. Fan E. Camporota L. et al.The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material.Intensive Care Med. 2012; 38: 1573-1582Crossref PubMed Scopus (978) Google Scholar Data subsequently were collected for 3 days from the time of inclusion, and patients were followed up for 28 days or until hospital discharge, whichever occurred first. No exclusion criteria were applied. Study day 1 was defined as the first day that patients met enrollment criteria. Inclusion criteria could be met at either the study hospital, if the patient was a direct admission, or at a referring hospital, if the patient was transferred to the study hospital. The initial 6-month study period was extended for 1 additional month to capture ongoing presentation of seasonal respiratory illness at the clinical sites. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed. Baseline demographic variables, ARDS risk factors, arterial blood gas (ABG) analysis, mechanical ventilator settings, and sequential organ failure assessment (SOFA) scores were collected. Ventilator data and respiratory parameters also were collected for the first 3 days of invasive mechanical ventilation and on days when any adjunctive therapy was initiated. Determination of day 1 adherence to LPV required both documented tidal volume (VT) ventilation of ≤ 6.5 mL/kg predicted body weight (PBW) and plateau pressure of ≤ 30 cm H2O. In cases where plateau pressure was not recorded, the combination of VT < 6.5 mL/kg PBW and peak inspiratory pressure of ≤ 30 cm H2O was considered LPV. For instances in which an adjunctive therapy was initiated at a transferring hospital, the first known date of adjunctive therapy was collected. Outcomes data that were collected included hospital mortality, liberation from mechanical ventilation, discharge from the ICU, discharge from the hospital at 28 days, and SOFA score at day 7. Patients who were discharged from the hospital alive before study day 28 were assumed to be alive at that time point. Additionally, whether evidence was present in the chart of active withdrawal of life-sustaining measures was documented. The full case report form can be viewed in e-Appendixes 2 and 3. Data sources came from the electronic health record at each institution. In some cases (four centers), data variables were extracted electronically when feasible. Data were entered into a Research Electronic Data Capture database housed behind the Duke University School of Medicine firewall. Site investigators were required to respond to any queries raised by the electronic case report form before finalizing individual entries. Additionally, all entries were screened for outliers, potentially erroneous data, or missing outcomes. Data that could not be verified or corrected by site investigators were not included in the final data set. We summarized the baseline characteristics, day 1 ventilator settings, and 28-day outcomes for the study cohort overall using numbers and percentages for categorical variables and mean ± SD or median (interquartile range) for continuous variables. We then explored the use patterns of various adjunctive therapies by summarizing therapies used in isolation and in combination as well as timing of treatment initiation. We explored the univariate relationships between early LPV adherence and the primary outcome of 28-day in-hospital mortality via Kaplan-Meier curves and log-rank tests. We used a multivariate generalized mixed-effect model for 28-day in-hospital mortality, with fixed terms for baseline variables and random effects for center to investigate which baseline factors were associated with our primary outcome. Model adjustment terms were fixed a priori and included the following: inclusion Pao2 to Fio2 ratio, day 1 SOFA score, age, sex, day 1 VT > 6.5 mL/kg, risk factor for ARDS, and comorbidities. To further explore the variability in mortality rate across centers while accounting for patient-level factors, we derived and compared standardized mortality ratios (SMRs). The SMR for a given center was calculated as the ratio between the observed mortality rate and the expected mortality rate. Because no appropriate standard population exists for this type of patient population, we used the center-wise average of predicted mortality probabilities from a multivariate logistic regression model, adjusting for the baseline patient-level characteristics listed above, as the best approximation. The 95% CI for SMR was calculated using the Byar approximation. We described center variability visually and descriptively by summarizing ventilator settings, adjunctive therapy use, and SMR by center. We then explored the relationship between SMR and center median day 1 VT, rate of adherence to LPV, PEEP, and rate of adjunctive therapy use visually and via Pearson correlation. Statistical analysis was performed using SAS version 9.4 software (SAS, Inc.). All P values were two-sided, and P < .05 was considered statistically significant. Of 27,656 patients screened, 2,466 (8.9%) were identified as having moderate to severe ARDS (Fig 1). Baseline characteristics are summarized in Table 1. The mean age was 56.9 ± 16.3 years, with 58.6% being men. The median day 1 Pao2 to Fio2 ratio was 105 (interquartile range, 78-129), and the most common risk factors for ARDS development were sepsis (62.3%) and pneumonia (62.5%). Shock, as defined by the use of vasopressors, was present in 64.5% of patients. Only 7.1% of patients were enrolled in concurrent ARDS clinical trials. Center characteristics are presented in e-Table 1.Table 1Baseline Characteristics (N = 2,466 Patients)Baseline CharacteristicDataAge, y57 ± 16.3Sex, male1,445 (58.6)Height, m1.70 ± 0.11Weight, kg88.15 ± 30.1BMI, kg/m230.46 ± 9.6Race or ethnicity American Indian/Alaskan Native32 (1.5) Asian96 (4.4) Hispanic or Latino241 (9.8) Black338 (15.4) Native Hawaiian/Pacific Islander12 (0.6) White1,712 (77.9) Multiracial9 (0.4) Unknown/not reported267 (10.8)Transferred from outside hospital621 (25.2)Comorbidities Cirrhosis240 (9.7) Hepatic failure156 (6.3) ESRD requiring hemodialysis140 (5.7) Metastatic carcinoma142 (5.8) Lymphoma56 (2.3) Leukemia84 (3.431) Myeloma16 (0.7) AIDS44 (1.8) Immunosuppression454 (18.4) Chronic lung disease572 (23.2) Diabetes mellitus724 (29.4) Congestive heart failure402 (16.3)Risk factors for ARDS Sepsis1,537 (62.3) Pneumonia1,541 (62.5) Shock1,429 (58) Aspiration658 (26.7) Blood product transfusion545 (22.1) Trauma240 (9.7) Drug overdose127 (5.2) Pancreatitis82 (3.3) OtheraIncludes smoke inhalation, near drowning, burn, or other known risk factors not listed above.226 (9.2) Unknown26 (1.1)Data are presented as No. (%) or mean ± SD. ESRD = end-stage renal disease.a Includes smoke inhalation, near drowning, burn, or other known risk factors not listed above. Open table in a new tab Data are presented as No. (%) or mean ± SD. ESRD = end-stage renal disease. For the overall cohort, mean day 1 VT was 7 mL/kg PBW (SD, 1.5 mL/kg PBW), with 56.3% of patients receiving a VT of > 6.5 mL/kg PBW and 21.7% receiving > 8 mL/kg PBW (Table 2). Substantial variation among centers was noted in mean Vt (6.2-7.9 mL/kg PBW) as well as initial rate of adherence to LPV (0-65%) (Fig 2A). Mean day 1 PEEP was 9.2 cm H2O (SD, 3.9 cm H2O). The overall rate of measurement of the plateau pressure on day 1 was 49.6%, with 85% of recorded values being ≤ 30 mm H2O. When plateau pressure was not recorded, peak inspiratory pressure of ≤ 30 cm H2O was used to permit classifying LPV adherence in > 90% of the remaining cohort. Overall adherence to LPV in this group was 31.4%, with more than half of the nonadherence to LPV the result of use of Vt values of > 6.5 mL/kg PBW. Characteristics of patients who received LPV on day 1 and those who did not were similar, with the exception of day 1 VT (7.6 mL/kg PBW vs 5.9 mL/kg PBW; Cohen’s d, –1.49), day 1 peak pressure (32 cm H2O vs 26 cm H2O; Cohen’s d, –0.76), day 1 plateau pressure (24 cm H2O vs 23 cm H2O; Cohen’s d, –0.35), and height (1.68 cm vs 1.73 cm; Cohen’s d, 0.42) (e-Table 2). Additional physiologic characteristics are presented in e-Table 3.Table 2Clinical Characteristics, Ventilator Management, and Outcomes (N = 2,466 Patients)VariableDataDay 1 clinical characteristics Pao2 to Fio2 ratio105 (78-129) Fio280 (60-100) SOFA score12 ± 4 Vasopressors (infusion lasting > 1 h)1,572 (64.5)Missing28 PEEP, mm H2O9 ± 4Missing92 Plateau pressure, mm H2O24 (20-28)Missing1,223 Peak pressure, mm H2O29 (24-35)Missing243 Vt, mL/kg PBW7 ± 1.5Missing154 Vt > 6.5 mL/kg PBW1301 (56.3) Vt > 8 mL/kg PBW502 (21.7) LPV adherenceaDefined as Vt ≤ 6.5 mL/kg PBW and plateau pressure ≤ 30 mm H2O. If plateau pressure was missing, peak pressure was used. Either Vt or plateau pressure and peak pressure were missing for 197 patients.712 (31.4)Outcomes Ventilator-free days to day 28bIf the patient died during the study period, ventilator- and hospital-free days were set to 0, or else ventilator- or hospital-free days were the difference between 28 and the duration of invasive mechanical ventilation or hospitalization.1 (0-22) Mechanical ventilation duration (d)cStudy follow-up truncated at 28 days after inclusion (durations range, 0-28 d). Length of stay for patients who died was defined as days from study inclusion to day of death.6 (3-13)Missing28 Duration of initial ICU stay, dcStudy follow-up truncated at 28 days after inclusion (durations range, 0-28 d). Length of stay for patients who died was defined as days from study inclusion to day of death.9 (4-16)Missing38 Alive day 71,890 (76.7) SOFA score day 7dOnly among those alive and data available on day 7 (n = 1,890).9 ± 4 Alive and with UAB day 281,166 (47.9)Missing34 Hospital-free days to day 28bIf the patient died during the study period, ventilator- and hospital-free days were set to 0, or else ventilator- or hospital-free days were the difference between 28 and the duration of invasive mechanical ventilation or hospitalization.0 (0-12) Hospital length of stay, dcStudy follow-up truncated at 28 days after inclusion (durations range, 0-28 d). Length of stay for patients who died was defined as days from study inclusion to day of death.13 (6-25)Missing16 28-day hospital mortality1,003 (40.7)Data are presented as No. (%), mean ± SD or median (interquartile range). If data are missing present, this is listed below the specific variable. LPV = lung protective ventilation; PBW = predicted body weight; PEEP = positive end-expiratory pressure; SOFA = Sequential Organ Failure Assessment; UAB = unassisted breathing; Vt = tidal volume.a Defined as Vt ≤ 6.5 mL/kg PBW and plateau pressure ≤ 30 mm H2O. If plateau pressure was missing, peak pressure was used. Either Vt or plateau pressure and peak pressure were missing for 197 patients.b If the patient died during the study period, ventilator- and hospital-free days were set to 0, or else ventilator- or hospital-free days were the difference between 28 and the duration of invasive mechanical ventilation or hospitalization.c Study follow-up truncated at 28 days after inclusion (durations range, 0-28 d). Length of stay for patients who died was defined as days from study inclusion to day of death.d Only among those alive and data available on day 7 (n = 1,890). Open table in a new tab Data are presented as No. (%), mean ± SD or median (interquartile range). If data are missing present, this is listed below the specific variable. LPV = lung protective ventilation; PBW = predicted body weight; PEEP = positive end-expiratory pressure; SOFA = Sequential Organ Failure Assessment; UAB = unassisted breathing; Vt = tidal volume. Adjunctive therapies were used in 57.5% of patients. Among those receiving adjunctive therapy, systemic steroids were the most commonly used (41.5%), followed by neuromuscular blockade (27.4%), pulmonary vasodilators (11.7%), prone positioning (5.8%), and extracorporeal membrane oxygenation (4.5%) (Table 3). Adjunctive therapies were used most often in combination, and most were initiated before or within 1 day of ARDS development. Although the indication for steroid use was not recorded, 71.8% of patients who received steroids also were noted to have shock requiring vasopressors, and 30.9% had immunosuppression listed as a comorbidity. Substantial center-to-center variation was found in the specific type and rate of adjunctive therapy use (27.1%-96.4%) (Fig 2B). Twenty-nine different combinations of therapy were administered during the study period, with different frequencies at each center.Table 3Adjunctive Therapy UseVariableNMB (n = 675 [27.4%])Prone Positioning (n = 143 [5.8%])Steroid (n = 1,015 [41.2%])PVD (n = 289 [11.7%])ECMO (n = 110 [4.5%])Individual therapy is the only one given215 (31.9)10 (7)591 (58.2)36 (12.5)16 (14.6)Individual therapy is first used503 (75.5)28 (20.4)751 (74.8)81 (28.3)43 (39.1)No. receiving therapy with known start date6661371004286110Study day of therapy start1 (1-2)2 (1-3)1 (0-2)1 (1-2)1 (1-2)Therapy started before study day 190 (13.5)12 (8.8)283 (28.2)54 (18.9)25 (22.7)Therapy started by study day 1429 (64.4)61 (44.5)652 (64.9)175 (61.2)72 (65.5)Therapy started by study day 3572 (85.9)112 (81.8)844 (84.1)238 (83.2)92 (83.6)Therapy started by study day 7629 (94.4)127 (92.7)943 (93.9)257 (89.9)105 (95.5)Data are presented as No. (%) or median (interquartile range). ECMO = extracorporeal membrane oxygenation; NMB = neuromuscular blockage; PVD = pulmonary vasodilator. Open table in a new tab Data are presented as No. (%) or median (interquartile range). ECMO = extracorporeal membrane oxygenation; NMB = neuromuscular blockage; PVD = pulmonary vasodilator. Overall 28-day in-hospital mortality was 40.7%, with higher mortality in patients with severe ARDS compared with those with moderate ARDS (44.4% vs 36.0%; P < .001, log-rank test). One thousand one hundred eleven patients (45.1%) were discharged alive from the hospital, and 352 patients (14.3%) remained hospitalized at day 28 (Table 2). Of those discharged alive from the hospital, 10.4% continued receiving mechanical ventilation, whereas 89.6% were breathing unassisted at discharge. Among the patients still hospitalized, 43.3% continued receiving mechanical ventilation. Life-sustaining measures were known to be withdrawn or limited for 24.7% of patients. In the multivariate generalized mixed-effect model, baseline factors found to be associated with 28-day in-hospital mortality were baseline Pao2 to Fio2 ratio, day 1 SOFA score, age, and the following comorbidities: cirrhosis, hepatic failure, metastatic carcinoma, and leukemia (Fig 3). Mortality varied widely across centers, ranging from 16.7% to 73.3% (Fig 4A). Evaluation of SMRs across centers showed that significant variation persisted (0.33-1.98) after adjustment for baseline factors (Fig 4B). At the center level, higher SMR correlated with nonadherence with day 1 LPV (Pearson r = 0.52; 95% CI, 0.19-0.74; P = .016, adjusted for multiple comparisons), but not with any other individual treatment-level factor, including mean day 1 VT (r = 0.27), mean day 1 PEEP (r = 0.08), or rate of adjunctive therapy use (r = –0.09) (Fig 5). The use of any specific adjunctive therapy also did not correlate strongly with SMR (neuromuscular blockade, r = 0.09; prone positioning, r = 0.28; steroids, r = –0.28; PVD, r = 0.21; extracorporeal membrane oxygenation, r = 0.16) (e-Fig 1).Figure 5A-D, Scatterplots showing SMR vs center metrics. A, SMR vs day 1 VT. B, SMR vs rate of day 1 nonadherence to LPV (VT < 6.5 mL/kg predicted body weight, plateau pressure plateau pressure or peak inspiratory pressure ≤ 30 cm H2O). C, SMR vs day 1 PEEP. D, SMR vs rate of use of any adjunctive therapy. LPV = lung protective ventilation; PEEP = positive end-expiratory pressure; SMR = standardized mortality ratio; VT = tidal volume.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The primary comparison of center-level adherence with day 1 LPV and SMR assumes that LPV adherence was similar for patients with known or unknown adherence status at the same site. As a sensitivity analysis, we examined two extreme scenarios, one in which all patients missing LPV adherence status were assumed to be adherent and another in which all were assumed to be nonadherent. We found the association between day 1 LPV adherence and SMR remained significant whether all patients with unknown status were assumed to be adherent (r = 0.38; 95% CI, 0.02-0.65; P = .042) or nonadherent (r = 0.49; 95% CI, 0.16-0.73; P = .006). Hence, under all scenarios examined, an association s
• Casanova, N. G., Gonzalez-Garay, M. L., Sun, B., Bime, C., Sun, X., Knox, K. S., Crouser, E. D., Sammani, N., Gonzales, T., Natt, B., Chaudhary, S., Lussier, Y., & Garcia, J. G. (2020). Differential transcriptomics in sarcoidosis lung and lymph node granulomas with comparisons to pathogen-specific granulomas. Respiratory research, 21(1), 321.
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  Despite the availability of multi-"omics" strategies, insights into the etiology and pathogenesis of sarcoidosis have been elusive. This is partly due to the lack of reliable preclinical models and a paucity of validated biomarkers. As granulomas are a key feature of sarcoidosis, we speculate that direct genomic interrogation of sarcoid tissues, may lead to identification of dysregulated gene pathways or biomarker signatures.
• Chaudhary, S., Natt, B., Bime, C., Knox, K. S., & Glassberg, M. K. (2020). Antifibrotics in COVID-19 Lung Disease: Let Us Stay Focused. Frontiers in medicine, 7, 539.
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  After decades of research, two therapies for chronic fibrotic lung disease are now approved by the FDA, with dozens more anti-fibrotic therapies in the pipeline. A great deal of enthusiasm has been generated for the use of these drugs, which are by no means curative but clearly have a favorable impact on lung function decline over time. Amidst a flurry of newly developed and repurposed drugs to treat the coronavirus disease 2019 (COVID-19) and its accompanying acute respiratory distress syndrome (ARDS), few have emerged as effective. Historically, survivors of severe viral pneumonia and related acute lung injury with ARDS often have near full recovery of lung function. While the pathological findings of the lungs of patients with COVID-19 can be diverse, current reports have shown significant lung fibrosis predominantly in autopsy studies. There is growing enthusiasm to study anti-fibrotic therapy for inevitable lung fibrosis, and clinical trials are underway using currently FDA-approved anti-fibrotic therapies. Given the relatively favorable outcomes of survivors of virus-mediated ARDS and the low prevalence of clinically meaningful lung fibrosis in survivors, this perspective examines if there is a rationale for testing these repurposed antifibrotic agents in COVID-19-associated lung disease.
• Chaudhary, S., Natt, B., Bime, C., Knox, K. S., & Glassberg, M. K. (2020). Corrigendum: Antifibrotics in COVID-19 Lung Disease: Let Us Stay Focused. Frontiers in medicine, 7, 604640.
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  [This corrects the article DOI: 10.3389/fmed.2020.00539.].
• Kazui, T., Hypes, C., Natt, B., Malo, J., Hsu, C. H., Lick, S. D., Bull, D. A., Smith, R. G., Natt, B., Mosier, J., Mogan, C., Malo, J., Lick, S. D., Kazui, T., Hypes, C., Hsu, C. H., & Bull, D. A. (2020). Interfacility Transfer via a Mobile Intensive Care Unit Following a Double Lumen Catheter Cannulation at the Referring Facility for Veno-Venous Extracorporeal Membrane Oxygenation.. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation, 39(4S), S419. doi:10.1016/j.healun.2020.01.194
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  Assess the feasibility of interfacility transfer via a mobile intensive care unit (MOBI) after a double lumen catheter cannulation at a referring facility for veno-venous extracorporeal membrane oxygenation (VV-ECMO)..This single center retrospective data analysis utilized our institutional data from January 2015-September 2019. We divided patients into 2 groups: Group A had a double lumen cannulation for in-hospital VV-ECMO; Group B had the same procedure for interfacility transfer via an MOBI. Cannulation was performed with fluoroscopic guidance at the referring facility by either one of its surgeons or the MOBI team. The MOBI consisted of an ECMO physician (either a surgeon or an intensivist), a respiratory therapist, an ECMO nurse, and a transport nurse. The 2 groups were compared in terms of pre support, complications during the ECMO support, and survival..There were no complications related to cannulation at the referring facility nor transfer. Group A had 33 patients (average age was 45.1 ± 18.0). Group B had 20 patients (average age was 48.4 ± 13.5). Pre ECMO pH, PCO2, PO2, and SaO2 were 7.2 ± 0.2, 7.3 ± 0.2 (p=0.08), 65.0 ± 21.6mmHg, 59.3 ± 24.2mmHg (p=0.27), 69.8 ± 26.3mmHg, 66.6 ± 45.0mmHg (p=0.18), 85.7 ± 9.7%, 82.5 ± 14.4% (p=0.61) in Group A and B, respectively. During ECMO support, Group A had 18 complications; Group B had 13 (p=0.57), including circuit component clots [5 and 4 (p=0.72)], circuit exchange [3 and 2 (p=1.00)], creatinine 1.5 - 3.0 [5 and 1 (p=0.39)], creatinine >3.0 [2 and 3 (p=0.35)], and renal replacement therapy [6 and 4 (p=1.00)]. Respectively, 69.7% and 50.0% of patients came off ECMO support, and 45.4% and 50.0% of patients survived to discharge (p=0.18)..Double lumen catheter cannulation at the referring facility with MOBI demonstrated equivalent results to in-house cannulation.
• Nikolich-Zugich, J., Knox, K. S., Rios, C. T., Natt, B., Bhattacharya, D., & Fain, M. J. (2020). Correction to: SARS-CoV-2 and COVID-19 in older adults: what we may expect regarding pathogenesis, immune responses, and outcomes. GeroScience, 42(3), 1013.
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  The affiliation of the second author (Kenneth S. Knox) should have been Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ 85004, USA instead of Department of Medicine, University of Arizona-Phoenix, Phoenix, AZ 85004, USA.
• Nikolich-Zugich, J., Knox, K. S., Rios, C. T., Natt, B., Bhattacharya, D., & Fain, M. J. (2020). SARS-CoV-2 and COVID-19 in older adults: what we may expect regarding pathogenesis, immune responses, and outcomes. GeroScience, 42(2), 505-514.
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  SARS-CoV-2 virus, the causative agent of the coronavirus infectious disease-19 (COVID-19), is taking the globe by storm, approaching 500,000 confirmed cases and over 21,000 deaths as of March 25, 2020. While under control in some affected Asian countries (Taiwan, Singapore, Vietnam), the virus demonstrated an exponential phase of infectivity in several large countries (China in late January and February and many European countries and the USA in March), with cases exploding by 30-50,000/day in the third and fourth weeks of March, 2020. SARS-CoV-2 has proven to be particularly deadly to older adults and those with certain underlying medical conditions, many of whom are of advanced age. Here, we briefly review the virus, its structure and evolution, epidemiology and pathogenesis, immunogenicity and immune, and clinical response in older adults, using available knowledge on SARS-CoV-2 and its highly pathogenic relatives MERS-CoV and SARS-CoV-1. We conclude by discussing clinical and basic science approaches to protect older adults against this disease.
• Ripperger, T. J., Uhrlaub, J. L., Watanabe, M., Wong, R., Castaneda, Y., Pizzato, H. A., Thompson, M. R., Bradshaw, C., Weinkauf, C. C., Bime, C., Erickson, H. L., Knox, K., Bixby, B., Parthasarathy, S., Chaudhary, S., Natt, B., Cristan, E., Aini, T. E., Rischard, F., , Campion, J., et al. (2020). Detection, prevalence, and duration of humoral responses to SARS-CoV-2 under conditions of limited population exposure. medRxiv : the preprint server for health sciences.
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  We conducted an extensive serological study to quantify population-level exposure and define correlates of immunity against SARS-CoV-2. We found that relative to mild COVID-19 cases, individuals with severe disease exhibited elevated authentic virus-neutralizing titers and antibody levels against nucleocapsid (N) and the receptor binding domain (RBD) and the S2 region of spike protein. Unlike disease severity, age and sex played lesser roles in serological responses. All cases, including asymptomatic individuals, seroconverted by 2 weeks post-PCR confirmation. RBD- and S2-specific and neutralizing antibody titers remained elevated and stable for at least 2-3 months post-onset, whereas those against N were more variable with rapid declines in many samples. Testing of 5882 self-recruited members of the local community demonstrated that 1.24% of individuals showed antibody reactivity to RBD. However, 18% (13/73) of these putative seropositive samples failed to neutralize authentic SARS-CoV-2 virus. Each of the neutralizing, but only 1 of the non-neutralizing samples, also displayed potent reactivity to S2. Thus, inclusion of multiple independent assays markedly improved the accuracy of antibody tests in low seroprevalence communities and revealed differences in antibody kinetics depending on the viral antigen. In contrast to other reports, we conclude that immunity is durable for at least several months after SARS-CoV-2 infection.
• Ripperger, T. J., Uhrlaub, J. L., Watanabe, M., Wong, R., Castaneda, Y., Pizzato, H. A., Thompson, M. R., Bradshaw, C., Weinkauf, C. C., Bime, C., Erickson, H. L., Knox, K., Bixby, B., Parthasarathy, S., Chaudhary, S., Natt, B., Cristan, E., El Aini, T., Rischard, F., , Campion, J., et al. (2020). Orthogonal SARS-CoV-2 Serological Assays Enable Surveillance of Low-Prevalence Communities and Reveal Durable Humoral Immunity. Immunity, 53(5), 925-933.e4.
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  We conducted a serological study to define correlates of immunity against SARS-CoV-2. Compared to those with mild coronavirus disease 2019 (COVID-19) cases, individuals with severe disease exhibited elevated virus-neutralizing titers and antibodies against the nucleocapsid (N) and the receptor binding domain (RBD) of the spike protein. Age and sex played lesser roles. All cases, including asymptomatic individuals, seroconverted by 2 weeks after PCR confirmation. Spike RBD and S2 and neutralizing antibodies remained detectable through 5-7 months after onset, whereas α-N titers diminished. Testing 5,882 members of the local community revealed only 1 sample with seroreactivity to both RBD and S2 that lacked neutralizing antibodies. This fidelity could not be achieved with either RBD or S2 alone. Thus, inclusion of multiple independent assays improved the accuracy of antibody tests in low-seroprevalence communities and revealed differences in antibody kinetics depending on the antigen. We conclude that neutralizing antibodies are stably produced for at least 5-7 months after SARS-CoV-2 infection.
• Self, W. H., Semler, M. W., Leither, L. M., Casey, J. D., Angus, D. C., Brower, R. G., Chang, S. Y., Collins, S. P., Eppensteiner, J. C., Filbin, M. R., Files, D. C., Gibbs, K. W., Ginde, A. A., Gong, M. N., Harrell, F. E., Hayden, D. L., Hough, C. L., Johnson, N. J., Khan, A., , Lindsell, C. J., et al. (2020). Effect of Hydroxychloroquine on Clinical Status at 14 Days in Hospitalized Patients With COVID-19: A Randomized Clinical Trial. JAMA, 324(21), 2165-2176.
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  Data on the efficacy of hydroxychloroquine for the treatment of coronavirus disease 2019 (COVID-19) are needed.
• Bailey, M., Berry, C. E., Bime, C., Borgstrom, M., Goel, K., Natt, B., & Parthasarathy, S. (2019). Trends in Chronic Obstructive Pulmonary Disease Hospitalization and In-Hospital Deaths in the United States by Sex: 2005 to 2014.. Annals of the American Thoracic Society, 16(3), 391-393. doi:10.1513/annalsats.201807-488rl
• Goel, K., Bailey, M., Borgstrom, M., Parthasarathy, S., Natt, B., Berry, C., & Bime, C. (2019). Trends in chronic obstructive pulmonary disease hospitalization and in-hospital deaths in the United States by sex: 2005 to 2014. Annals of the American Thoracic Society, 16(3). doi:10.1513/AnnalsATS.201807-488RL
• Insel, M., Bime, C., Malo, J., Mosier, J., & Natt, B. (2019). The Association of Non-Cardiac ECMO With Influenza Incidence: A Time Series Analysis.. Respiratory care, 64(3), 279-284. doi:10.4187/respcare.06145
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  The 2009 H1N1 influenza epidemic saw a rise in the use of extracorporeal membrane oxygenation (ECMO) as a supportive therapy for refractory ARDS. We sought to determine whether ECMO utilization follows a seasonal pattern that matches the influenza season, and whether it can further be explained by the incidence of each influenza subtype..We performed a longitudinal analysis of non-cardiac and cardiac-associated ECMO cases from the National In-patient Sample from 2005 to 2014, using overdispersed Poisson regression to evaluate associations with influenza incidence categorized by influenza-like illness and total positive influenza tests divided by subtype from the Centers for Disease Control and Prevention..Non-cardiac ECMO use was positively associated with influenza-like illness incidence in the current month (incidence risk ratio [IRR] 1.11, 95% confidence interval [CI] 1.07-1.15, P < .001) and with influenza-like illness in the previous month (IRR 1.09, 95% CI 1.05-1.14, P < .001). The 2009 H1N1 subtype had the strongest association with non-cardiac ECMO (IRR 1.19, 95% CI 1.09-1.31, P < .001). Cardiac ECMO was also positively associated with the incidence of influenza-like illness (IRR 1.05, 95% CI 1.01-1.09, P = .02)..Non-cardiac and cardiac ECMO use in the United States were significantly associated with influenza incidence. The influenza A, H1N1 2009, subtype had the strongest association.
• Insel, M., Natt, B., Mosier, J., Malo, J., & Bime, C. (2019). The association of non-cardiac ECMO with influenza incidence: A time series analysis. Respiratory Care, 64(3). doi:10.4187/respcare.06145
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  BACKGROUND: The 2009 H1N1 influenza epidemic saw a rise in the use of extracorporeal membrane oxygenation (ECMO) as a supportive therapy for refractory ARDS. We sought to determine whether ECMO utilization follows a seasonal pattern that matches the influenza season, and whether it can further be explained by the incidence of each influenza subtype. METHODS: We performed a longitudinal analysis of non-cardiac and cardiac-associated ECMO cases from the National In-patient Sample from 2005 to 2014, using overdispersed Poisson regression to evaluate associations with influenza incidence categorized by influenza-like illness and total positive influenza tests divided by subtype from the Centers for Disease Control and Prevention. RESULTS: Non-cardiac ECMO use was positively associated with influenza-like illness incidence in the current month (incidence risk ratio [IRR] 1.11, 95% confidence interval [CI] 1.07–1.15, P < .001) and with influenza-like illness in the previous month (IRR 1.09, 95% CI 1.05–1.14, P < .001). The 2009 H1N1 subtype had the strongest association with non-cardiac ECMO (IRR 1.19, 95% CI 1.09–1.31, P < .001). Cardiac ECMO was also positively associated with the incidence of influenza-like illness (IRR 1.05, 95% CI 1.01–1.09, P = .02). CONCLUSION: Non-cardiac and cardiac ECMO use in the United States were significantly associated with influenza incidence. The influenza A, H1N1 2009, subtype had the strongest association.
• Nyquist, A., Natt, B., & Bardwell, J. (2019). LIGHTNING STRIKE: RECOGNITION AND MANAGEMENT. Chest, 156(4), A1242. doi:10.1016/j.chest.2019.08.1120
• Sears, S., Palacio, D., & Natt, B. (2019). Medical image of the week: diffuse pulmonary ossification. Southwest Journal of Pulmonary and Critical Care, 19(2), 65-67. doi:10.13175/swjpcc028-19
• Ali, H., Cairns, C. B., Hypes, C., Kazui, T., Khalpey, Z., Mosier, J., Natt, B., & Rao, P. (2018). 168: RIGHT VENTRICULAR DYSFUNCTION IN ACUTE RESPIRATORY DISTRESS SYNDROME. Critical Care Medicine, 46(1), 67-67. doi:10.1097/01.ccm.0000528188.73359.0b
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  Rao, Prashant; Ali, Hasan; Hypes, Cameron; Natt, Bhupinder; Kazui, Toshinobu; Khalpey, Zain; Cairns, Charles; Mosier, Jarrod Author Information
• Bime, C., Malo, J., Mosier, J. M., Natt, B., & Insel, M. (2018). The Association of Non-Cardiac ECMO With Influenza Incidence: A Time Series Analysis.. Respiratory Care.
• Goel, K., Bailey, M., Borgstrom, M., Parthasarathy, S., Natt, B., Berry, C., & Bime, C. (2018). Trends in COPD Hospitalization and In-Hospital Deaths in the United States by Sex: 2005-2014. Annals of the American Thoracic Society.
• Insel, M., Natt, B., Mosier, J., Malo, J., & Bime, C. (2018). The Association of Non-Cardiac ECMO With Influenza Incidence: A Time Series Analysis. Respiratory care.
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  The 2009 H1N1 influenza epidemic saw a rise in the use of extracorporeal membrane oxygenation (ECMO) as a supportive therapy for refractory ARDS. We sought to determine whether ECMO utilization follows a seasonal pattern that matches the influenza season, and whether it can further be explained by the incidence of each influenza subtype.
• Malo, J., Chaudhury, A. R., Crabbe, S., Hypes, C., Kazui, T., Khalpey, Z., Mosier, J., & Natt, B. (2018). 1061: DURATION OF MECHANICAL VENTILATION AND PATIENT OUTCOMES FOR EXTRACORPOREAL MEMBRANE OXYGENATION. Critical Care Medicine, 46(1), 514-514. doi:10.1097/01.ccm.0000529067.98515.04
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  Crabbe, Stephen; Malo, Josh; Natt, Bhupinder; Kazui, Toshinobu; Khalpey, Zain; Roy- Chaudhury, Akshay; Mosier, Jarrod; Hypes, Cameron Author Information
• Malo, J., Chaudhury, A. R., Crabbe, S., Hypes, C., Kazui, T., Khalpey, Z., Mosier, J., & Natt, B. (2018). 1097: EVALUATION OF THE RESP SCORE FOR SURVIVAL PREDICTION IN VENOVENOUS ECMO. Critical Care Medicine, 46(1), 532-532. doi:10.1097/01.ccm.0000529102.89106.1e
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  Crabbe, Stephen; Malo, Josh; Natt, Bhupinder; Khalpey, Zain; Kazui, Toshinobu; Roy- Chaudhury, Akshay; Mosier, Jarrod; Hypes, Cameron Author Information
• Malo, J., Hypes, C., Natt, B., Cristan, E., Greenberg, J., Morrissette, K., Snyder, L. A., Knepler, J., Sakles, J. C., Knox, K. S., & Mosier, J. (2018). Airway registry and training curriculum improve intubation outcomes in the intensive care unit. SWJPCC. doi:10.13175/swjpcc037-18
• Natt, B. (2018). Medical image of the week: plastic bronchitis. Southwest Journal of Pulmonary and Critical Care, 16(1), 28-28. doi:10.13175/swjpcc005-18
• Natt, B., Chaudhary, S., Ateeli, H., & Ali, H. (2018). Medical image of the week: Dobhoff tube placement with Roux-en-Y gastric bypass. Southwest Journal of Pulmonary and Critical Care, 16(4), 226-227. doi:10.13175/swjpcc045-18
• Natt, B., Elaini, T., & El-aini, T. (2018). Medical image of the week: neuromyelitis optica and sarcoidosis. Southwest Journal of Pulmonary and Critical Care, 16(6), 341-342. doi:10.13175/swjpcc081-18
• Robbins, R., Pulmonary, P., & Natt, B. (2018). Medical Image of the Week: Medical Administrative Growth. Southwest Journal of Pulmonary and Critical Care, 17(1), 35-35. doi:10.13175/swjpcc087-18
• Bime, C., Natt, B., Desai, H., Poongkunran, C., & Borgstrom, M. (2017). Reply: Racial Disparities in Acute Respiratory Distress Syndrome Mortality. Annals of the American Thoracic Society, 14(2), 300-301.
• Hypes, C., Sakles, J., Joshi, R., Greenberg, J., Natt, B., Malo, J., Bloom, J., Chopra, H., & Mosier, J. (2017). Failure to achieve first attempt success at intubation using video laryngoscopy is associated with increased complications. Internal and Emergency Medicine, 12(8). doi:10.1007/s11739-016-1549-9
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  The purpose of this investigation was to investigate the association between first attempt success and intubation-related complications in the Intensive Care Unit after the widespread adoption of video laryngoscopy. We further sought to characterize and identify the predictors of complications that occur despite first attempt success. This was a prospective observational study of consecutive intubations performed with video laryngoscopy at an academic medical Intensive Care Unit. Operator, procedural, and complication data were collected. Multivariable logistic regression was used to examine the relationship between the intubation attempts and the occurrence of one or more complications. A total of 905 patients were intubated using a video laryngoscope. First attempt success occurred in 739 (81.7 %), whereas >1 attempt was needed in 166 (18.3 %). One or more complications occurred in 146 (19.8 %) of those intubated on the first attempt versus 107 (64.5 %, p < 0.001) of those requiring more than one attempt. Logistic regression analysis shows that >1 attempt is associated with 6.4 (95 % CI 4.4–9.3) times the adjusted odds of at least one complication. Pre-intubation predictors of at least one complication despite first attempt success include vomit or edema in the airway as well as the presence of hypoxemia or hypotension. There are increased odds of complications with even a second attempt at intubation in the Intensive Care Unit. Complications occur frequently despite a successful first attempt, and as such, the goal of airway management should not be simply first attempt success, but instead first attempt success without complications.
• Malo, J., Bloom, J. W., Chopra, H., Greenberg, J., Hypes, C., Joshi, R., Mosier, J., Natt, B., & Sakles, J. C. (2017). Failure to achieve first attempt success at intubation using video laryngoscopy is associated with increased complications.. Internal and emergency medicine, 12(8), 1235-1243. doi:10.1007/s11739-016-1549-9
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  The purpose of this investigation was to investigate the association between first attempt success and intubation-related complications in the Intensive Care Unit after the widespread adoption of video laryngoscopy. We further sought to characterize and identify the predictors of complications that occur despite first attempt success. This was a prospective observational study of consecutive intubations performed with video laryngoscopy at an academic medical Intensive Care Unit. Operator, procedural, and complication data were collected. Multivariable logistic regression was used to examine the relationship between the intubation attempts and the occurrence of one or more complications. A total of 905 patients were intubated using a video laryngoscope. First attempt success occurred in 739 (81.7 %), whereas >1 attempt was needed in 166 (18.3 %). One or more complications occurred in 146 (19.8 %) of those intubated on the first attempt versus 107 (64.5 %, p < 0.001) of those requiring more than one attempt. Logistic regression analysis shows that >1 attempt is associated with 6.4 (95 % CI 4.4-9.3) times the adjusted odds of at least one complication. Pre-intubation predictors of at least one complication despite first attempt success include vomit or edema in the airway as well as the presence of hypoxemia or hypotension. There are increased odds of complications with even a second attempt at intubation in the Intensive Care Unit. Complications occur frequently despite a successful first attempt, and as such, the goal of airway management should not be simply first attempt success, but instead first attempt success without complications.
• Mosier, J. M., Kazui, T., Malo, J., Basken, R., Hypes, C., & Natt, B. (2017). Suspected Heparin Induced Thrombocytopenia in patients receiving Extracorporeal Membrane Oxygenation: a case series.. Journal of ExtraCorporeal Technology.
• Natt, B. (2017). Medical image of the week: barium aspiration. Southwest Journal of Pulmonary and Critical Care, 15(6), 267-268. doi:10.13175/swjpcc146-17
• Natt, B. (2017). Medical image of the week: central venous access with dextrocardia. Southwest Journal of Pulmonary and Critical Care, 15(6), 296-296. doi:10.13175/swjpcc148-17
• Natt, B., Desai, H., Bime, C., Dill, J., Dalen, J. E., & Alpert, J. S. (2017). The Reply. The American journal of medicine, 130(4), e165.
• Natt, B., Hypes, C., Basekn, R., Malo, J., Kazui, T., & Mosier, J. M. (2017). The use of extracorporeal membrane oxygenation in the bronchoscopic management of critical upper airway obstruction. Journal of Extra Corporeal Technology, 49(1), 54-58.
• Natt, B., Hypes, C., Basken, R., Malo, J., Kazui, T., & Mosier, J. (2017). Suspected Heparin-Induced Thrombocytopenia in Patients Receiving Extracorporeal Membrane Oxygenation. The journal of extra-corporeal technology, 49(1), 54-58.
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  Heparin-induced thrombocytopenia (HIT) is an immune reaction usually secondary to unfractionated heparin. Anticoagulation management is critical in patients while on extracorporeal membrane oxygenation (ECMO) to prevent thromboembolism and for the optimal functioning of the circuit. We identified five patients with respiratory failure at our hospital managed with ECMO in the last 2 years that were treated for HIT. A brief clinical course and their management are discussed. We also briefly review the literature for best evidence for management of such patients.
• Natt, B., Knepler, J. L., Kazui, T., Mosier, J. M., Natt, B., Knepler, J. L., Kazui, T., & Mosier, J. M. (2017). The use of extracorporeal membrane oxygenation in the bronchoscopic management of critical upper airway obstruction. J Bronchology Interv Pulmonol, 24(1), e12-e14.
• Ateeli, H., Goel, K., Jaffer, F., Low, S., & Natt, B. (2016). 1402: CURB-65 SCORE CORRELATES WITH ICU ADMISSION AND IN-HOSPITAL MORTALITY IN PATIENTS WITH SEPSIS.. Critical Care Medicine, 44(12), 426-426. doi:10.1097/01.ccm.0000510076.20420.2b
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  Copyright © 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
• Bime, C., Desai, H., & Natt, B. (2016). Outcome of Patients With Pulmonary Hypertension Undergoing Elective, Non-Cardiac Surgery: A Propensity-Matched Study. Chest, 150(4), 37A. doi:10.1016/j.chest.2016.08.044
• Bime, C., Poongkunran, C., Borgstrom, M., Natt, B., Desai, H., Parthasarathy, S., & Garcia, J. G. (2016). Racial Differences in Mortality from Severe Acute Respiratory Failure in the United States, 2008-2012. Annals of the American Thoracic Society, 13(12), 2184-2189.
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  Racial disparities in health and healthcare in the United States are well documented and are increasingly recognized in acute critical illnesses such as sepsis and acute respiratory failure.
• Cristan, E., Greenberg, J., Hypes, C., Milligan, R., Morrissette, K., Mosier, J., Natt, B., & Sakles, J. C. (2016). 1180: FLEXIBLE FIBEROPTIC VERSUS VIDEO LARYGOSCOPY. Critical Care Medicine, 44(12), 370-370. doi:10.1097/01.ccm.0000509854.00689.42
• Cristan, E., Greenberg, J., Hypes, C., Milligan, R., Morrissette, K., Mosier, J., Natt, B., & Sakles, J. C. (2016). 278: RETHINKING NIV. Critical Care Medicine, 44(12), 146-146. doi:10.1097/01.ccm.0000508958.82084.d5
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  Greenberg, Jeremy; Mosier, Jarrod; Natt, Bhupinder; Morrissette, Katelin; Cristan, Elaine; Sakles, John; Milligan, Rebecca; Hypes, Cameron
• Cristan, E., Greenberg, J., Hypes, C., Milligan, R., Morrissette, K., Mosier, J., Natt, B., & Sakles, J. C. (2016). 320: A COMPARISON OF C-MAC AND GLIDESCOPE VIDEO LARYNGOSCOPES FOR INTUBATION IN THE INTENSIVE CARE UNIT.. Critical Care Medicine, 44(12), 157-157. doi:10.1097/01.ccm.0000508999.03766.c2
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  Milligan, Rebecca; Mosier, Jarrod; Greenberg, Jeremy; Morrissette, Katelin; Cristan, Elaine; Natt, Bhupinder; Sakles, John; Hypes, Cameron
• Desai, H., Natt, B., Kim, S. S., Bime, C., Desai, H., Natt, B., Kim, S. S., & Bime, C. (2016). Decreased In-hospital Mortality after Lobectomy Using Video-Assisted Thoracoscopic Surgery Compared to Open Thoracotomy.. Annals of American Thoracic Society.
• Desai, H., Natt, B., Kim, S., & Bime, C. (2016). Decreased In-hospital Mortality after Lobectomy Using Video-Assisted Thoracoscopic Surgery Compared to Open Thoracotomy. Annals of the American Thoracic Society.
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  There is a paucity of data regarding the optimal surgical approach for lung lobectomy. Lobectomy performed by video-assisted thoracoscopic surgery (VATS) has been associated with lower morbidity as compared to thoracotomy. However, no multicenter studies have shown improved mortality with VATS lobectomy compared to open surgical lobectomy.
• Hypes, C. D., Stolz, U., Sakles, J. C., Joshi, R. R., Natt, B., Malo, J., Bloom, J. W., & Mosier, J. M. (2016). Video Laryngoscopy Improves Odds of First-Attempt Success at Intubation in the Intensive Care Unit. A Propensity-matched Analysis. Annals of the American Thoracic Society, 13(3), 382-90.
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  Urgent tracheal intubation is performed frequently in intensive care units and incurs higher risk than when intubation is performed under more controlled circumstances. Video laryngoscopy may improve the chances of successful tracheal intubation on the first attempt; however, existing comparative data on outcomes are limited.
• Hypes, C., Sakles, J., Joshi, R., Greenberg, J., Natt, B., Malo, J., Bloom, J., Chopra, H., & Mosier, J. (2016). Failure to achieve first attempt success at intubation using video laryngoscopy is associated with increased complications. Internal and emergency medicine.
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  The purpose of this investigation was to investigate the association between first attempt success and intubation-related complications in the Intensive Care Unit after the widespread adoption of video laryngoscopy. We further sought to characterize and identify the predictors of complications that occur despite first attempt success. This was a prospective observational study of consecutive intubations performed with video laryngoscopy at an academic medical Intensive Care Unit. Operator, procedural, and complication data were collected. Multivariable logistic regression was used to examine the relationship between the intubation attempts and the occurrence of one or more complications. A total of 905 patients were intubated using a video laryngoscope. First attempt success occurred in 739 (81.7 %), whereas >1 attempt was needed in 166 (18.3 %). One or more complications occurred in 146 (19.8 %) of those intubated on the first attempt versus 107 (64.5 %, p 1 attempt is associated with 6.4 (95 % CI 4.4-9.3) times the adjusted odds of at least one complication. Pre-intubation predictors of at least one complication despite first attempt success include vomit or edema in the airway as well as the presence of hypoxemia or hypotension. There are increased odds of complications with even a second attempt at intubation in the Intensive Care Unit. Complications occur frequently despite a successful first attempt, and as such, the goal of airway management should not be simply first attempt success, but instead first attempt success without complications.
• Lutrick, K., Malo, J., Cairns, C. B., Hypes, C., Kazui, T., Mosier, J., & Natt, B. (2016). 993: DEMOGRAPHICS OF SEVERE INFLUENZA DURING THE 2016 SEASON: A TERTIARY CARE HOSPITAL EXPERIENCE.. Critical Care Medicine, 44(12), 324-324. doi:10.1097/01.ccm.0000509669.58415.c6
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  Natt, Bhupinder; Mosier, Jarrod; Lutrick, Karen; Hypes, Cameron; Malo, Josh; Kazui, Toshinobu; Cairns, Charles
• Natt, B. (2016). Medical image of the week: endobronchial valves. Medical image of the week: endobronchial valves, 13(1), 34-35.
• Natt, B. (2016). Medical image of the week: subcutaneous calcification in dermatomyositis. SWJPCC. doi:10.13175/swjpcc130-16
• Natt, B. S., Desai, H., Singh, N., Poongkunran, C., Parthasarathy, S., & Bime, C. (2016). Extracorporeal Membrane Oxygenation for ARDS: National Trends in the United States 2008-2012. Respiratory care, 61(10), 1293-8.
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  Recent advances in technology and protocols have made the use of extracorporeal membrane oxygenation (ECMO) a viable rescue therapy for patients with ARDS who present with refractory hypoxemia. Despite the lack of strong evidence supporting the use of ECMO in ARDS, its use seems to be increasing. We sought to determine recent trends in the use of ECMO for ARDS. We also assessed trends in mortality among patients with ARDS in whom ECMO was used.
• Natt, B. S., Malo, J., Hypes, C. D., Sakles, J. C., & Mosier, J. M. (2016). Strategies to improve first attempt success at intubation in critically ill patients. British journal of anaesthesia, 117 Suppl 1, i60-i68.
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  Tracheal intubation in critically ill patients is a high-risk procedure. The risk of complications increases with repeated or prolonged attempts, making expedient first attempt success the goal for airway management in these patients. Patient-related factors often make visualization of the airway and placement of the tracheal tube difficult. Physiologic derangements reduce the patient's tolerance for repeated or prolonged attempts at laryngoscopy and, as a result, hypoxaemia and haemodynamic deterioration are common complications. Operator-related factors such as experience, device selection, and pharmacologic choices affect the odds of a successful intubation on the first attempt. This review will discuss the 'difficult airway' in critically ill patients and highlight recent advances in airway management that have been shown to improve first attempt success and decrease adverse events associated with the intubation of critically ill patients.
• Natt, B., & Knepler, J. L. (2016). Medical image of the week: endobronchial valves. Southwest Journal of Pulmonary and Critical Care, 13(1), 34-35.
• Natt, B., & Knepler, J. L. (2016). Medical image of the week: lung entrapment. Southwest Journal of Pulmonary and Critical Care, 13(1), 36-37.
• Natt, B., Power, E., & Beatty, N. (2016). Medical image of the week: purpura fulminans. Southwest Journal of Pulmonary and Critical Care, 13(6), 307-308.
• Tey, K. R., & Natt, B. (2016). Medical image of the week: mediastinal metastases causing right ventricular outflow obstruction. Southwest Journal of Pulmonary and Critical Care, 12(1), 22-23.
• Baalachandran, R., Hypes, C., Natt, B., & Snyder, L. (2015). Pipe Dreams: Concealed Methamphetamine Causing Severe Toxicity. The American Journal of Medical Sciences. doi:10.1097/maj.0000000000000428
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  Methamphetamine is a highly addictive and toxic drug of abuse. Hospital visits related to methamphetamine abuse have increased dramatically since 2007, with nearly 103,000 visits recorded in 2011. Methamphetamine is absorbed rapidly after delivery. The various routes of administration and their times of onset being oral (20–30 minutes), nasal (3–5 minutes), intravenous (15–30 seconds), inhaled (7–10 seconds), rectal (3–5 minutes) and vaginal routes (3–5 minutes). 1. Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality The DAWN Report: Emergency Department Visits Involving Methamphetamine: 2007 to 2011. 2014 Google Scholar , 2. Carvalho M. Carmo H. Costa V.M. et al. Toxicity of amphetamines: an update. Arch Toxicol. 2012; 86: 1167-1231 Crossref PubMed Scopus (285) Google Scholar We report a case of toxicity from rectal absorption of methamphetamine secondary to concealed drug paraphernalia.
• Baalachandran, R., Hypes, C., Natt, B., & Snyder, L. (2015). Pipe dreams: concealed methamphetamine causing severe toxicity. The American journal of the medical sciences, 349(6), 548-9.
• Bime, C., Desai, H., Natt, B., Poongkunran, C., & Singh, N. (2015). ARDS Prevalence and Survival Trends in the United States; 2008-2012. Chest, 148(4), 1-7. doi:10.1378/chest.2278583
• Bime, C., Desai, H., Natt, B., Poongkunran, C., Raz, Y., & Singh, N. (2015). Extracorporeal Membrane Oxygenator Use in ARDS; Trends From 2008-2012. Chest, 148(4), 292A. doi:10.1378/chest.2278195
• Bull, D. A., Lick, S. D., Hypes, C., Natt, B., Mosier, J. M., Malo, J., Hsu, C., & Kazui, T. (2019). DURATION OF VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION SUPPORT AND ADVERSE OUTCOMES IN ACUTE RESPIRATORY DISTRESS SYNDROME: AN ANALYSIS FROM THE EXTRACORPOREAL LIFE SUPPORT ORGANIZATION REGISTRY. Journal of heart and lung transplantation.
• Bull, D. A., Lick, S. D., Hypes, C., Natt, B., Mosier, J. M., Malo, J., Hsu, C., & Kazui, T. (2021). Outcomes of venovenous extracorporeal membrane oxygenation support in acute respiratory distress syndrome. Annals of Thoracic Surgery.
• Desai, H., Bajaj, A., Hanamaikai, K., & Natt, B. (2015). Medical image of the week: acute aortic dissection. Southwest Journal of Pulmonary and Critical Care, 10(6), 348-349.
• Desai, H., Natt, B., Bime, C., Dill, J., Dalen, J. E., & Alpert, J. S. (2017). Pulmonary Embolism with Right Ventricular Dysfunction: Who Should Receive Thrombolytic Agents?. The American journal of medicine, 130(1), 93.e29-93.e32.
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  Appropriate management of pulmonary embolism patients with right ventricular dysfunction is uncertain. Recent guidelines have stressed the need for more data on the use of thrombolytic agents in the stable pulmonary embolism patient with right ventricular dysfunction. The objective of this study is to investigate the hypothesis that thrombolytic therapy in hemodynamically stable pulmonary embolism patients with right ventricular dysfunction is not associated with improved mortality.
• El Aini, T., Omar, M., & Natt, B. (2015). Medical image of the week: bilateral symmetrical nephromegaly. Southwest Journal of Pulmonary and Critical Care, 10(2), 93-94.
• Habibi, S., Natt, B., & Jenkins, C. (2015). Medical image of the week: ‘CSFoma’. Southwest Journal of Pulmonary and Critical Care, 11(4), 192.
• Mosier, J. M., Malo, J., Sakles, J. C., Hypes, C. D., Natt, B., Snyder, L., Knepler, J., Bloom, J. W., Joshi, R., & Knox, K. (2015). The impact of a comprehensive airway management training program for pulmonary and critical care medicine fellows. A three-year experience. Annals of the American Thoracic Society, 12(4), 539-48.
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  Airway management in the intensive care unit (ICU) is challenging, as many patients have limited physiologic reserve and are at risk for clinical deterioration if the airway is not quickly secured. In academic medical centers, ICU intubations are often performed by trainees, making airway management education paramount for pulmonary and critical care trainees.
• Natt, B., & Raz, Y. (2015). Air Bronchogram. NEJM. doi:10.1056/nejmicm1503806
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  A 26-year-old woman with ESRD presented with fever, cough, and shortness of breath. The acute respiratory distress syndrome developed. Anterior–posterior chest radiography showed dense airspace disease with bilateral hemithorax opacification and air bronchograms.
• Natt, B., & Raz, Y. (2015). Air bronchogram. NEJM, 373(27). doi:10.1056/NEJMicm1503806
• Natt, B., & Raz, Y. (2015). IMAGES IN CLINICAL MEDICINE. Air Bronchogram. The New England journal of medicine, 373(27), 2663.
• Natt, B., Knepler, J., Kazui, T., & Mosier, J. M. (2017). The Use of Extracorporeal Membrane Oxygenation in the Bronchoscopic Management of Critical Upper Airway Obstruction. Journal of bronchology & interventional pulmonology, 24(1), e12-e14.
• Natt, B., Mazursky, K., & Meinke, L. E. (2015). Medical image of the week: acute amiodarone pulmonary toxicity. Southwest Journal of Pulmonary and Critical Care, 11(4), 189-190.
• Natt, B., Mosier, J. M., Hypes, C., Kazui, T., Basken, R., Malo, J., Basken, R., Malo, J., Kazui, T., Hypes, C., Mosier, J. M., & Natt, B. (2017). Suspected Heparin Induced Thrombocytopenia in patients receiving Extracorporeal Membrane Oxygenation: a case series.. Journal of ExtraCorporeal Technology.
• Omar, M., El Aini, T., & Natt, B. (2015). Medical image of the week: Westermark sign. Southwest Journal of Pulmonary and Critical Care, 10(3), 125-126.
• Poongkunran, C., Natt, B., Singh, N., Poongkunran, C., Natt, B., Desai, H., Borgstrom, M., & Bime, C. (2015). 679: INCREASED MORTALITY IN ARDS PATIENTS REQUIRING CONTINUOUS RENAL REPLACEMENT THERAPY. Critical Care Medicine, 43, 171. doi:10.1097/01.ccm.0000474507.38895.79
• Tey, K. R., & Natt, B. (2015). Medical image of the week: empyema necessitans. Southwest Journal of Pulmonary and Critical Care, 11(6), 271-272.
• Berry, C., Gerald, J. K., & Natt, B. (2014). September 2014 Tucson pulmonary journal club: PANTHEON study. Southwest Journal of Pulmonary and Critical Care, 9(4), 249-250. doi:10.13175/swjpcc144-14
• Bloom, J. W., Hypes, C., Joshi, R., Malo, J., Mosier, J., Natt, B., Sakles, J. C., & Stolz, U. (2014). 14: VIDEO LARYNGOSCOPY IMPROVES ODDS OF FIRST ATTEMPT SUCCESS AT INTUBATION IN THE INTENSIVE CARE UNIT. Critical Care Medicine, 42, A1372. doi:10.1097/01.ccm.0000457547.64511.59
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  Rationale: Urgent tracheal intubation is performed frequently in intensive care units and incurs higher risk than when intubation is performed under more controlled circumstances. Video laryngoscopy may improve the chances of successful tracheal intubation on the first attempt; however, existing comparative data on outcomes are limited. Objectives: To compare first-attempt success and complication rates during intubation when using video laryngoscopy compared with traditional direct laryngoscopy in a tertiary academic medical intensive care unit. Methods: We prospectively collected and analyzed data from a continuous quality improvement database of all intubations in one medical intensive care unit between January 1, 2012, and December 31, 2014. Propensity matching and multivariable logistic regression were used to reduce the risk of bias and control for confounding. Measurements and Main Results: A total of 809 intubations took place over the study period. Of these, 673 (83.2%) were performed using video laryngoscopy and 136 (16.8%) using direct laryngoscopy. First-attempt success with video laryngoscopy was 80.4% (95% confidence interval [CI], 77.2–83.3%) compared with 65.4% (95% CI, 56.8–73.4%) for intubations performed with direct laryngoscopy (P ,0.001). In a propensity-matched analysis, the odds ratio for first-attempt success with video laryngoscopy versus direct laryngoscopy was 2.81 (95% CI, 2.27–3.59). The rate of arterial oxygen desaturation events during the first intubation attempt was significantly lower for video laryngoscopy than for direct laryngoscopy (18.3% vs. 25.9%; P = 0.04). The rate of esophageal intubation during any attempt wasalso significantly lowerforvideolaryngoscopy(2.1%vs.6.6%; P = 0.008).
• Campion, J., Koleilat, S., & Natt, B. (2014). December 2014 critical care case of the month: weak for weeks. Southwest Journal of Pulmonary and Critical Care, 9(6), 302-308. doi:10.13175/swjpcc141-14
• Natt, B. S., Campion, J. M., & Knox, K. S. (2014). Acute eosinophilic pneumonia associated with ingestion of Ulomoides dermestoides larvae ("Chinese beetles"). Annals of the American Thoracic Society, 11(10), 1667-8.
• Natt, B., & Arteaga, V. (2014). Medical image of the week: pneumatocele. Southwest Journal of Pulmonary and Critical Care, 9(2), 126-127. doi:10.13175/swjpcc102-14
• Natt, B., & Szerlip, H. M. (2014). The lost art of the history and physical. The American journal of the medical sciences, 348(5), 423-5.
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  The important contribution of the history and physical in making a correct medical diagnosis has been known for centuries. Despite this, these skills are being undermined by technology that many physicians mistakenly believe to be the new gold standard. The authors report 2 cases in which the history and physical trumped technology in making the correct diagnosis. Medical educators need to reemphasize the importance of the history and physical. This will require changes in curriculum and intense faculty development.
• Natt, B., Berry, C. E., Bime, C., & Gerald, J. E. (2014). April 2014 Tucson critical care journal club: early goal-directed therapy. SWJPCC. doi:10.13175/swjpcc058-14
• Natt, B., Berry, C. E., Bime, C., & Gerald, J. K. (2014). Tucson critical care journal club: early goal-directed therapy. Southwest Journal of Pulmonary and Critical Care.
• Natt, B., Campion, J., & Knox, K. S. (2014). Acute Eosinophilic Pneumonia Associated with Ingestion ofUlomoides dermestoidesLarvae (“Chinese Beetles”). Annals of American Thoracic Society. doi:10.1513/annalsats.201410-483le
• Natt, B., Snyder, L. A., & Lax, D. (2014). Ultrasound for critical care physicians: where did the bubbles go?. SWJPCC. doi:10.13175/swjpcc100-14
• Natt, B., Snyder, L., & Campion, J. (2014). January critical care case of the month: bad cough. SWJPCC. doi:10.13175/swjpcc161-13
• Natt, B., Szerlip, H. M., & Hamm, L. L. (2014). The Lost Art of the History and Physical. The American Journal of Medical Sciences. doi:10.1097/maj.0000000000000326
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  The important contribution of the history and physical in making a correct medical diagnosis has been known for centuries. Despite this, these skills are being undermined by technology that many physicians mistakenly believe to be the new gold standard. The authors report 2 cases in which the history and physical trumped technology in making the correct diagnosis. Medical educators need to reemphasize the importance of the history and physical. This will require changes in curriculum and intense faculty development.
• Zaid, L., Natt, B., & Enakpene, E. (2014). Medical image of the week: paradoxical stroke. Southwest Journal of Pulmonary and Critical Care, 9(5), 278-280. doi:10.13175/swjpcc135-14
• Mosier, J., Natt, B., Raz, Y., & Siddiqi, T. (2013). Refractory cardiogenic shock. Southwest Journal of Pulmonary and Critical Care, 7(4), 246-250. doi:10.13175/swjpcc098-13
• Sandoval-gonzalez, J., Natt, B., Luraschi-monjagatta, C., Franco, R., Campion, J., & Arteaga, V. (2013). Medical image of the week: accessory cardiac bronchus. Southwest Journal of Pulmonary and Critical Care, 7(3), 193-193. doi:10.13175/swjpcc126-13

Proceedings Publications

• Kumar, S., Natt, B., & Srinivasan, S. (2020). Vasoplegic Shock: Throwing the Kitchen Sink. In American Thoracic Society.
• Bailey, M., Chaudhary, S., Kato, K., Knox, K. S., & Natt, B. (2019). CA 15-3: A Novel Biomarker for the Diagnosis and Progression of Interstitial Lung Disease. In A38. IDIOPATHIC INTERSTITIAL PNEUMONIA: DIAGNOSIS AND NATURAL HISTORY.
• Miller, D., Natt, B., & Sazgar, S. (2019). The Hamman Rich Syndrome: A Case of Recurrent Acute Interstitial Pneumonia. In American Thoracic Society.

Presentations

• Bull, D. A., Lick, S. D., Hypes, C., Natt, B., Mosier, J. M., Malo, J., & Hsu, C. (2019, May/). Duration and Outcomes of Veno-Venous Extracorporeal Membrane Oxygenation Support in Acute Respiratory Distress Syndrome: Results from ELSO database. American association for thoracic surgery 99th annual meeting. Toronto: American association for thoracic surgery.

Poster Presentations

• Bull, D. A., Kazui, T., Kazui, T., Bull, D. A., Lick, S. D., Hsu, C., Lick, S. D., Hsu, C., Hypes, C., Malo, J., Hypes, C., Malo, J., Natt, B., Mosier, J. M., Natt, B., Mosier, J. M., Mosier, J. M., Natt, B., Mosier, J. M., , Natt, B., et al. (2020, April). Interfacility transfer via a mobile intensive care unit following a double lumen catheter cannulation at the referring facility for veno-venous extracorporeal membrane oxygenation. THE INTERNATIONAL SOCIETY FOR HEART AND LUNG TRANSPLANTATION 2020 Scientific Program. Montreal, Canada: THE INTERNATIONAL SOCIETY FOR HEART AND LUNG TRANSPLANTATION.
• Kazui, T., Bull, D. A., Hsu, C., Lick, S. D., Malo, J., Hypes, C., Mosier, J. M., Natt, B., Natt, B., Mosier, J. M., Hypes, C., Malo, J., Lick, S. D., Hsu, C., Bull, D. A., & Kazui, T. (2020, April). Interfacility transfer via a mobile intensive care unit following a double lumen catheter cannulation at the referring facility for veno-venous extracorporeal membrane oxygenation. THE INTERNATIONAL SOCIETY FOR HEART AND LUNG TRANSPLANTATION 2020 Scientific Program. Montreal, Canada: THE INTERNATIONAL SOCIETY FOR HEART AND LUNG TRANSPLANTATION.
• Natt, B. (2018, February). Right ventricular dysfunction in acute respiratory distress syndrome. SCCM. San Antonio, TX: SCCM.
• Hypes, C., Sakles, J. C., Mosier, J. M., Natt, B., Greenberg, J., Morrissette, K., & Cristan, E. (2017, Feb). Rethinking NIV: when it works, it works. When it doesn't, it really doesn't. Society of Critical Care Medicine Annual Congress. Honolulu, HI.: Society of Critical Care Medicine.
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  22. Greenberg J, Mosier J, Natt B, Morrissette K, Cristan C, Sakles J, Hypes C; Rethinking NIV: when it works, it works. When it doesn't, it really doesn't [Poster]; Society of Critical Care Medicine Annual Congress; February 2017; Honolulu, HI.
• Desai, H., Natt, B., & Bime, C. (2016, May/Spring). Decreased in-hospital mortality after lobectomy using video-assisted thoracoscopic surgery compared to open thoracotomy. ATS International Conference. San Francisco, CA.
• Hypes, C., Sakles, J. C., Nararro, T., Greenberg, J., Natt, B., Chopra, H., & Mosier, J. M. (2016, Sept). Failure to achieve first attempt success is associated with a higher odds of adverse events during intubation in the Intensive Care Unit using a video laryngoscope. Society for Airway Management. Atlanta.
• Nararro, T., Mosier, J. M., Sakles, J. C., Greenberg, J., Natt, B., Chopra, H., & Hypes, C. (2016, Sept). Predictors of complications of Intensive Care Unit airway management despite first attempt success using video laryngoscopy. Society for Airway Management.
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  This submission won the SAM travel award for Dr. Navarro to present it at the conference. I mentored Dr. Navarro in this activity.
• Natt, B., Malo, J., Hypes, C., Kazui, T., Basken, R., & Mosier, J. M. (2016, August). Outcomes of Patients with Severe Influenza Treated at the Banner-University Medical Center During the 2015-16 Influenza Season. Options IX for the Control of Influenza. Chicago.
• Natt, B., Malo, J., Hypes, C., Kazui, T., Basken, R., & Mosier, J. M. (2016, August/Summer). Outcomes of Patients with Severe Influenza Treated at the Banner-University Medical Center During the 2015-16 Influenza Season. Options IX for the Control of Influenza. Chicago, IL.
• Natt, B., Malo, J., Hypes, C., Kazui, T., Basken, R., & Mosier, J. M. (2016, Summer). Outcomes of Patients with Severe Influenza Treated at the Banner-University Medical Center During the 2015-16 Influenza Season. Options IX for the Control of Influenza. Chicago, IL.
• Natt, B., Rodriguez, ., Knox, K. S., & Carr, G. E. (2016, May/Spring). Concurrent Myasthenia Gravis and autoimmune featured interstitial lung disease: a case report. ATS International Conference. San Francisco, CA.
• Bull, D. A., Lick, S. D., Hypes, C., Natt, B., Mosier, J. M., Malo, J., Hsu, C., & Kazui, T. (2020, April). Interfacility transfer via a mobile intensive care unit following a double lumen catheter cannulation at the referring facility for veno-venous extracorporeal membrane oxygenation. THE INTERNATIONAL SOCIETY FOR HEART AND LUNG TRANSPLANTATION 2020 Scientific Program. Montreal, Canada: THE INTERNATIONAL SOCIETY FOR HEART AND LUNG TRANSPLANTATION.
• Crabbe, S., Malo, J., Natt, B., Kazui, T., Khalpey, Z. I., Roy-Chaudhury, A., Mosier, J. M., & Hypes, C. (2018, February). Duration of Mechanical Ventilation and Patient Outcomes for Extracorporeal Membrane Oxygenation. SCCM Annual Meeting 2018.
• Crabbe, S., Malo, J., Natt, B., Khalpey, Z. I., Kazui, T., Roy-Chaudhury, A., Mosier, J. M., & Hypes, C. (2018, February). EVALUATION OF THE RESP SCORE FOR SURVIVAL PREDICTION IN VENOVENOUS ECMO. SCCM Annual Meeting.
• Key, T., Natt, B., Pederson, K. R., Meinel, M. K., & Carr, G. E. (2015, May/Spring). Implementing an Inpatient Chain of Survival at an Academic Medical Center. American College of Physicians National Meeting. Washington, DC.
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  (National winner)
• Key, T., Natt, B., Pederson, K. R., Meinel, M. K., & Carr, G. E. (2015, November/Fall). Implementing an Inpatient Chain of Survival at an Academic Medical Center. American College of Physicians Arizona Meet. Tucson, AZ.
• Natt, B., Desai, H., Poongkunran, C., & Bime, C. (2015, October/Fall). Extracorporeal Membrane Oxygenator Use in ARDS. CHEST Annual Meeting. Montreal, Québec, Canada.
• Natt, B., Desai, H., Singh, N., Poongkunran, C., & Bime, C. (2015, October/Fall). ARDS Prevalence and Survival Trends in the United States; 2008-2012. CHEST Annual Meeting. Montreal, Québec, Canada.
• Natt, B., Malo, J., Snyder, L. S., Knepler, J. L., Knox, K. S., & Mosier, J. M. (2015, May/Spring). Advanced Airway Management in Critical Care Fellowship Training. ATS International Conference. Denver, CO.
• Natt, B., Mosier, J. M., Lutrick, K., Hypes, C., Malo, J., Kazui, T., & Cairns, C. B. (2017, Spring). Demographics of severe influenza during the 2016 season: A tertiary care hospital experience. SCCM Annual Congress. Honolulu, HI.
• Singh, N., Natt, B., Ainapurapu, B. B., & Trowers, E. A. (2015, November/Fall). Hereditary Spherocytosis Leading to Pulmonary Hypertension. American College of Physicians Arizona Meet. Tucson, AZ.

Case Studies

• Campion, J. M., & Natt, B. (2017. ICU CXR(p. 1).
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  Image of the week