PRISM Rounds: Pulmonary Critical Care & Sleep Podcast

When a patient with septic shock requires escalating norepinephrine, should we continue increasing the dose, or introduce multiple vasopressors earlier?In this episode of PRISM Rounds, we examine the TRICYCLE randomized controlled trial, published in Critical Care in 2026, which evaluated early multimodal vasopressor therapy combining norepinephrine, vasopressin, and angiotensin II versus conventional stepwise escalation.The 79-patient trial found faster reductions in plasma renin and lactate, earlier reductions in vasopressor requirements, improved organ dysfunction scores, and fewer tachyarrhythmias. However, a survival benefit was not established, and the trial was not powered to detect differences in mortality.We explore several important questions:Why target three vasoconstrictor pathways instead of one?Is renin a useful biomarker or simply a reflection of angiotensin II activity?Does earlier catecholamine sparing translate into meaningful clinical benefit?Was TRICYCLE truly an early-intervention trial, or were patients already receiving substantial vasopressor support?Should these findings change how we manage septic shock today?We also examine the methodological debate surrounding the trial and place its findings in the context of prior vasopressor research.The bedside bottom line: TRICYCLE offers promising physiological evidence for multimodal vasopressor therapy, but larger trials are needed before routine early triple therapy can be recommended.Featured publication:Kalamar et al. Early multimodal vasopressor strategy in septic shock: results of the TRICYCLE randomized controlled trial. Critical Care. 2026;30:508.https://doi.org/10.1186/s13054-026-06323-zPRISM Rounds uses AI-generated voices, with content curated for clinical accuracy and educational value. Episodes are intended for education and discussion, not individual medical advice.#PRISMRounds #TRICYCLETrial #SepticShock #Sepsis #CriticalCare #IntensiveCare #Vasopressors #Norepinephrine #Vasopressin #AngiotensinII #Hemodynamics #ClinicalTrials #EvidenceBasedMedicine #ICUResearch #PulmonaryCriticalCare

When should we add vasopressin in septic shock? At a norepinephrine dose of 0.1 mcg/kg/min, or should we wait until 0.4?In this episode of PRISM Rounds, we examine the VASSPR trial, published in JAMA in October 2026. This pragmatic, cluster-randomized crossover trial enrolled 3,959 patients across 13 hospitals and compared earlier versus later vasopressin initiation strategies.Earlier initiation increased vasopressin use and reduced the norepinephrine dose at which it was started. However, 28-day mortality was similar between groups (31.8% vs 33.0%), with no significant improvement in kidney replacement therapy-free days.We explore the trial's strengths, imperfect adherence, implications for current sepsis guidelines, and why a fixed norepinephrine threshold may not capture the complexity of septic shock.The central question: Should vasopressor management be guided by a number, or by the patient's evolving physiology?A practical, evidence-based discussion for intensivists, emergency physicians, hospitalists, fellows, nurses, and ICU pharmacists.Primary article: Peltan ID, et al. Effect of Vasopressin Initiation Threshold on Septic Shock Mortality: The VASSPR Cluster Crossover Randomized Strategy Trial. JAMA. October 14, 2026.https://doi.org/10.1001/jama.2026.21333Tags: Septic Shock, VASSPR Trial, Vasopressin, Norepinephrine, Critical Care, Intensive Care, Sepsis, Vasopressors, Hemodynamics, JAMA, Clinical Trials, Evidence-Based Medicine, PRISM RoundsAt PRISM Rounds, we use AI-generated voices to bring you thoughtfully curated medical research in an engaging, conversational format. While we do our best to keep things accurate, occasional errors or mispronunciations may slip through. We hope these episodes spark curiosity and encourage you to explore the original research.

Can stimulating the orexin receptor improve both sleepiness and cataplexy in narcolepsy type 1? In this episode of PRISM Rounds, we examine the First Light and Radiant Light phase 3 trials of oveporexton.Across two 12-week trials, oveporexton produced substantial improvements in objective wakefulness, patient-reported sleepiness, and cataplexy compared with placebo. We discuss what those changes could mean for patients, why urinary frequency and insomnia matter, and what remains uncertain about long-term safety and comparisons with existing treatments.Read the trial: https://www.nejm.org/doi/full/10.1056/NEJMoa2601598Find more episodes at https://www.prismrounds.com and follow PRISM Rounds on Spotify or Apple Podcasts.Tags narcolepsy type 1, oveporexton, orexin, hypocretin, cataplexy, excessive daytime sleepiness, sleep medicine, clinical trials, First Light trial, Radiant Light trial, NEJM, PRISM Rounds

Choosing between high-flow nasal cannula, noninvasive ventilation (NIV), CPAP, and conventional oxygen is one of the most common decisions in critical care. The new 2026 American Thoracic Society (ATS) Clinical Practice Guideline provides updated, evidence-based recommendations across the spectrum of acute respiratory failure.In Season 1, Episode 62 of PRISM Rounds, we examine the guideline published in the American Journal of Respiratory and Critical Care Medicine and explore what its recommendations mean for bedside practice.We discuss four critical clinical questions:Acute hypoxemic respiratory failure: Why is high-flow nasal cannula strongly recommended over conventional oxygen, and when should clinicians consider NIV or CPAP?Acute hypercapnic respiratory failure: Why does NIV remain first-line therapy, and when might high-flow oxygen be a reasonable alternative?Preoxygenation before intubation: How can HFNC and NIV reduce peri-intubation hypoxemia?Postextubation respiratory support: Which patients benefit from preventive NIV or HFNC, and how can we reduce reintubation?We also examine the strength and certainty of the evidence, important limitations of network meta-analyses, and the distinction between reducing intubation and improving survival.The central clinical question: Are we choosing the right respiratory support strategy for the right patient, and recognizing early enough when that strategy is failing?This episode is designed for intensivists, pulmonologists, emergency physicians, respiratory therapists, critical care fellows, and other clinicians managing acute respiratory failure.Primary Reference:Goel NN, Ferreyro BL, et al. Noninvasive respiratory support for adult patients with acute respiratory failure: An official American Thoracic Society Clinical Practice Guideline. American Journal of Respiratory and Critical Care Medicine. 2026;212(9):2135–2158.https://doi.org/10.1093/ajrccm/aamag302Listen and subscribe to PRISM Rounds on Apple Podcasts, Spotify, Youtube or visit https://www.prismrounds.com.Evidence reviewed. Clinical decisions informed.Tagsritical CarePulmonary MedicineATS GuidelinesNoninvasive VentilationNIVHigh-Flow Nasal CannulaHFNCCPAPAcute Respiratory FailureHypoxemic Respiratory FailureHypercapnic Respiratory FailureCOPD ExacerbationMechanical VentilationPreoxygenationExtubationIntensive Care MedicineEvidence-Based MedicineClinical Practice GuidelinesRespiratory TherapyPRISM Rounds

Can therapeutic plasma exchange save lives in acute-on-chronic liver failure, or does it simply delay the inevitable?In Season 1, Episode 61 of PRISM Rounds, we examine a 2026 randomized controlled trial published in Hepatology evaluating therapeutic plasma exchange in 194 patients with acute-on-chronic liver failure (ACLF).The findings are striking. Plasma exchange reduced 28-day mortality from 63.9% to 44.3%, an absolute difference of nearly 20 percentage points. However, by 90 days, mortality was similar between groups, and more than 40% of patients could not complete the planned treatment.We examine the trial's methodology, treatment complications, and clinical implications alongside the 2023 EASL guidelines and a 2025 meta-analysis of plasma exchange in ACLF.The central question: Does plasma exchange meaningfully alter the course of liver failure, or does it provide a temporary bridge to hepatic recovery or transplantation?Join us as we explore what this trial should, and should not, change in ICU practice.Read the primary study:https://doi.org/10.1097/HEP.0000000000001755Subscribe to PRISM Rounds on Apple Podcasts, Spotify, or YouTube.Visit https://www.prismrounds.com for more episodes.TagsCritical Care, Intensive Care, Hepatology, Acute-on-Chronic Liver Failure, ACLF, Therapeutic Plasma Exchange, Plasmapheresis, Liver Failure, Liver Transplantation, Randomized Controlled Trial, Evidence-Based Medicine, ICU Research, PRISM Rounds