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MICU Milestones

Date: October 27, 2014

Roy Brower’s research on acute respiratory distress syndrome aims to improve outcomes.
Roy Brower’s research on acute respiratory distress syndrome aims to improve outcomes.

For more than 30 years, physicians with Johns Hopkins’ medical intensive care unit (MICU) have conducted groundbreaking clinical research in the challenging critical care arena. 

“Our efforts have resulted in greater survival and lower costs for our patients,” says pulmonologist Roy Brower, MICU medical director. The MICU opened in 1971 on the seventh floor of the Osler Building and remained in its original location for 41 years before moving to the Sheikh Zayed Tower in 2012. 

A major research focus has been on acute respiratory distress syndrome, (ARDS) the severe, life-threatening illness that prevents enough oxygen from getting to the lungs and into the blood. Often caused by pneumonia, infections or trauma, ARDS has mortality rates as high as 39 percent, Brower says. The number of deaths from ARDS in the United States each year exceeds the number of deaths from breast cancer. Many survivors have lasting neuropsychiatric or neuromuscular issues.

Brower has led or contributed to a dozen clinical trials looking at management of the condition. A modified ventilator strategy designed to prevent ventilator-induced lung injury piloted in the Johns Hopkins MICU was then modified and adopted nationwide by hospitals participating in the National Heart, Lung and Blood Institute’s ARDS Network. This substantially reduced mortality from ARDS. Other studies have improved the use of intravenous fluids and diuretics. Most recently, the group disproved a theory that statin medications can decrease ARDS complications.

Now Brower is looking to study oxygen toxicity, a problem that occurs when lung injury patients receive too much supplemental oxygen. “Oxygen toxicity looks just like pneumonia or other inflammatory diseases in the lung and is not clearly recognizable,” Brower says. With a gift from Sheila Pakula, a grateful patient treated at the MICU for ARDS, and her husband, Lawrence Pakula, Brower and Neil Aggarwal are planning a clinical trial in which patients who come in with early acute lung injury, like pneumonia, will be randomized to receive usual care or a more oxygen-conservative tactic.

“We’re hoping to find an approach to using oxygen that allows us to give less while promoting faster recovery,” he says.

Brower and colleagues continue to investigate other issues affecting the critically ill, like how to manage rehabilitation. With his support, intensivist Dale Needham in 2006 introduced a pilot program in which patients were given less sedation so they could begin rehabilitation sooner. It was so successful, it became usual practice. Today, says Brower, “we have patients who are wide awake and get up and go for a walk even while receiving mechanical ventilation.” And work published last spring in Critical Care Medicine shows that the program decreased the average MICU length of stay by 23 percent and saved the hospital an estimated $818,000 per year.

They’re also studying sleep in the intensive care unit, which Brower says is disastrous for patients: “They never get a good night’s sleep—they take catnaps 24 hours a day. Sleep deprivation can cause delirium and depressed immune function, and sedatives given to promote sleep make things worse.” A 2013 study demonstrated that simple measures, like turning off televisions and room lights, reducing overhead pages and stopping insomnia medications, reduced patient delirium and improved their perceptions about sleep quality. 

Research has accelerated since the new MICU opened in 2012, says Brower: “We continue to take ideas from the laboratories and test them in the clinical environment to see what really works and what doesn’t. Critically ill patients are very complicated, and somebody always has an interesting idea for how to improve their care.”

Articles in this Issue

Director's Column

Intensive Care Insights

Pulmonology Research

Recognizing Clinical Excellence