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Affiliation(s)
- Manuel Tisminetzky
- Department of Medicine, Division of Respirology, Sinai Health System and University Health Network, 585 University Avenue, 9-MaRS-9013, Toronto, Ontario M5G2G2, Canada
| | - Bruno L Ferreyro
- Department of Medicine, Division of Respirology, Sinai Health System and University Health Network, 585 University Avenue, 9-MaRS-9013, Toronto, Ontario M5G2G2, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 4th Floor, Toronto, ON M5T 3M6, Canada
| | - Eddy Fan
- Department of Medicine, Division of Respirology, Sinai Health System and University Health Network, 585 University Avenue, 9-MaRS-9013, Toronto, Ontario M5G2G2, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 4th Floor, Toronto, ON M5T 3M6, Canada; Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, 204 Victoria Street, 4th Floor, Room 411, Toronto, Ontario M5B 1T8, Canada.
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52
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Subudhi S, Voutouri C, Hardin CC, Nikmaneshi MR, Patel AB, Verma A, Khandekar MJ, Dutta S, Stylianopoulos T, Jain RK, Munn LL. Strategies to minimize heterogeneity and optimize clinical trials in Acute Respiratory Distress Syndrome (ARDS): Insights from mathematical modelling. EBioMedicine 2022; 75:103809. [PMID: 35033853 PMCID: PMC8757652 DOI: 10.1016/j.ebiom.2021.103809] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 12/20/2021] [Accepted: 12/27/2021] [Indexed: 12/15/2022] Open
Abstract
Background Mathematical modelling may aid in understanding the complex interactions between injury and immune response in critical illness. Methods We utilize a system biology model of COVID-19 to analyze the effect of altering baseline patient characteristics on the outcome of immunomodulatory therapies. We create example parameter sets meant to mimic diverse patient types. For each patient type, we define the optimal treatment, identify biologic programs responsible for clinical responses, and predict biomarkers of those programs. Findings Model states representing older and hyperinflamed patients respond better to immunomodulation than those representing obese and diabetic patients. The disparate clinical responses are driven by distinct biologic programs. Optimal treatment initiation time is determined by neutrophil recruitment, systemic cytokine expression, systemic microthrombosis and the renin-angiotensin system (RAS) in older patients, and by RAS, systemic microthrombosis and trans IL6 signalling for hyperinflamed patients. For older and hyperinflamed patients, IL6 modulating therapy is predicted to be optimal when initiated very early (<4th day of infection) and broad immunosuppression therapy (corticosteroids) is predicted to be optimally initiated later in the disease (7th – 9th day of infection). We show that markers of biologic programs identified by the model correspond to clinically identified markers of disease severity. Interpretation We demonstrate that modelling of COVID-19 pathobiology can suggest biomarkers that predict optimal response to a given immunomodulatory treatment. Mathematical modelling thus constitutes a novel adjunct to predictive enrichment and may aid in the reduction of heterogeneity in critical care trials. Funding C.V. received a Marie Skłodowska Curie Actions Individual Fellowship (MSCA-IF-GF-2020-101028945). R.K.J.'s research is supported by R01-CA208205, and U01-CA 224348, R35-CA197743 and grants from the National Foundation for Cancer Research, Jane's Trust Foundation, Advanced Medical Research Foundation and Harvard Ludwig Cancer Center. No funder had a role in production or approval of this manuscript.
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Hashem MD, Hopkins RO, Colantuoni E, Dinglas VD, Sinha P, Aronson Friedman L, Morris PE, Jackson JC, Hough CL, Calfee CS, Needham DM. Six-month and 12-month patient outcomes based on inflammatory subphenotypes in sepsis-associated ARDS: secondary analysis of SAILS-ALTOS trial. Thorax 2022; 77:22-30. [PMID: 34112703 PMCID: PMC8660939 DOI: 10.1136/thoraxjnl-2020-216613] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/28/2021] [Accepted: 03/15/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Prior acute respiratory distress syndrome (ARDS) trials have identified hypoinflammatory and hyperinflammatory subphenotypes, with distinct differences in short-term outcomes. It is unknown if such differences extend beyond 90 days or are associated with physical, mental health or cognitive outcomes. METHODS 568 patients in the multicentre Statins for Acutely Injured Lungs from Sepsis trial of rosuvastatin versus placebo were included and assigned a subphenotype. Among 6-month and 12-month survivors (N=232 and 219, respectively, representing 243 unique survivors), subphenotype status was evaluated for association with a range of patient-reported outcomes (eg, mental health symptoms, quality of life). Patient subsets also were evaluated with performance-based tests of physical function (eg, 6 min walk test) and cognition. FINDINGS The hyperinflammatory versus hypoinflammatory subphenotype had lower overall 12-month cumulative survival (58% vs 72%, p<0.01); however, there was no significant difference in survival beyond 90 days (86% vs 89%, p=0.70). Most survivors had impairment across the range of outcomes, with little difference between subphenotypes at 6-month and 12-month assessments. For instance, at 6 months, in comparing the hypoinflammatory versus hyperinflammatory subphenotypes, respectively, the median (IQR) patient-reported SF-36 mental health domain score was 47 (33-56) vs 44 (35-56) (p=0.99), and the per cent predicted 6 min walk distance was 66% (48%, 80%) vs 66% (49%, 79%) (p=0.76). INTERPRETATION Comparing the hyperinflammatory versus hypoinflammatory ARDS subphenotype, there was no significant difference in survival beyond 90 days and no consistent findings of important differences in 6-month or 12-month physical, cognitive and mental health outcomes. These findings, when considered with prior results, suggest that inflammatory subphenotypes largely reflect the acute phase of illness and its short-term impact.
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Affiliation(s)
- Mohamed D Hashem
- Department of Medicine, Marshfield Clinic Health System, Marshfield, Wisconsin, USA
| | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Medical Center, Murray, Utah, USA
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah, USA
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins University - Bloomberg School of Public Health, Baltimore, Maryland, USA
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pratik Sinha
- Division of Critical Care, Department of Anesthesia, Washington University in St Louis, Saint Louis, Missouri, USA
| | - Lisa Aronson Friedman
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter E Morris
- Division of Pulmonary, Critical Care & Sleep Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - James C Jackson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS Center), Nashville, Tennessee, USA
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco Department of Medicine, San Francisco, California, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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54
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Sinha P, Furfaro D, Cummings MJ, Abrams D, Delucchi K, Maddali MV, He J, Thompson A, Murn M, Fountain J, Rosen A, Robbins-Juarez SY, Adan MA, Satish T, Madhavan M, Gupta A, Lyashchenko AK, Agerstrand C, Yip NH, Burkart KM, Beitler JR, Baldwin MR, Calfee CS, Brodie D, O'Donnell MR. Latent Class Analysis Reveals COVID-19-related Acute Respiratory Distress Syndrome Subgroups with Differential Responses to Corticosteroids. Am J Respir Crit Care Med 2021; 204:1274-1285. [PMID: 34543591 PMCID: PMC8786071 DOI: 10.1164/rccm.202105-1302oc] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Rationale Two distinct subphenotypes have been identified in acute respiratory distress syndrome (ARDS), but the presence of subgroups in ARDS associated with coronavirus disease (COVID-19) is unknown. Objectives To identify clinically relevant, novel subgroups in COVID-19–related ARDS and compare them with previously described ARDS subphenotypes. Methods Eligible participants were adults with COVID-19 and ARDS at Columbia University Irving Medical Center. Latent class analysis was used to identify subgroups with baseline clinical, respiratory, and laboratory data serving as partitioning variables. A previously developed machine learning model was used to classify patients as the hypoinflammatory and hyperinflammatory subphenotypes. Baseline characteristics and clinical outcomes were compared between subgroups. Heterogeneity of treatment effect for corticosteroid use in subgroups was tested. Measurements and Main Results From March 2, 2020, to April 30, 2020, 483 patients with COVID-19–related ARDS met study criteria. A two-class latent class analysis model best fit the population (P = 0.0075). Class 2 (23%) had higher proinflammatory markers, troponin, creatinine, and lactate, lower bicarbonate, and lower blood pressure than class 1 (77%). Ninety-day mortality was higher in class 2 versus class 1 (75% vs. 48%; P < 0.0001). Considerable overlap was observed between these subgroups and ARDS subphenotypes. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RT-PCR cycle threshold was associated with mortality in the hypoinflammatory but not the hyperinflammatory phenotype. Heterogeneity of treatment effect to corticosteroids was observed (P = 0.0295), with improved mortality in the hyperinflammatory phenotype and worse mortality in the hypoinflammatory phenotype, with the caveat that corticosteroid treatment was not randomized. Conclusions We identified two COVID-19–related ARDS subgroups with differential outcomes, similar to previously described ARDS subphenotypes. SARS-CoV-2 PCR cycle threshold had differential value for predicting mortality in the subphenotypes. The subphenotypes had differential treatment responses to corticosteroids.
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Affiliation(s)
- Pratik Sinha
- Department of Anesthesiology, Washington University Medical School, Saint Louis, Missouri
| | - David Furfaro
- Division of Pulmonary, Allergy, and Critical Care Medicine
| | | | - Darryl Abrams
- Division of Pulmonary, Allergy, and Critical Care Medicine
| | | | | | - June He
- Department of Anesthesiology, Washington University Medical School, Saint Louis, Missouri
| | | | - Michael Murn
- Division of Pulmonary, Allergy, and Critical Care Medicine
| | | | | | | | - Matthew A Adan
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Tejus Satish
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | | | | | - Alexander K Lyashchenko
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York
| | | | - Natalie H Yip
- Division of Pulmonary, Allergy, and Critical Care Medicine
| | | | | | | | - Carolyn S Calfee
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine.,Cardiovascular Research Institute, and.,Department of Anesthesia, University of California, San Francisco, San Francisco, California; and
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine
| | - Max R O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine.,Department of Epidemiology, Mailman School of Public Health, and
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55
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Dunbar H, Weiss DJ, Rolandsson Enes S, Laffey JG, English K. The Inflammatory Lung Microenvironment; a Key Mediator in MSC Licensing. Cells 2021; 10:cells10112982. [PMID: 34831203 PMCID: PMC8616504 DOI: 10.3390/cells10112982] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 12/12/2022] Open
Abstract
Recent clinical trials of mesenchymal stromal cell (MSC) therapy for various inflammatory conditions have highlighted the significant benefit to patients who respond to MSC administration. Thus, there is strong interest in investigating MSC therapy in acute inflammatory lung conditions, such as acute respiratory distress syndrome (ARDS). Unfortunately, not all patients respond, and evidence now suggests that the differential disease microenvironment present across patients and sub-phenotypes of disease or across disease severities influences MSC licensing, function and therapeutic efficacy. Here, we discuss the importance of licensing MSCs and the need to better understand how the disease microenvironment influences MSC activation and therapeutic actions, in addition to the need for a patient-stratification approach.
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Affiliation(s)
- Hazel Dunbar
- Department of Biology, Maynooth University, W23 F2H6 Maynooth, Ireland;
- Kathleen Lonsdale Institute for Human Health Research, Maynooth University, W23 F2H6 Maynooth, Ireland
| | - Daniel J Weiss
- Department of Medicine, 226 Health Science Research Facility, Larner College of Medicine, University of Vermont, Burlington, VT 05405, USA;
| | - Sara Rolandsson Enes
- Department of Experimental Medical Science, Faculty of Medicine, Lund University, 22100 Lund, Sweden;
| | - John G Laffey
- Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, H91 W2TY Galway, Ireland;
- Department of Anaesthesia, Galway University Hospitals, SAOLTA University Health Group, H91 YR71 Galway, Ireland
| | - Karen English
- Department of Biology, Maynooth University, W23 F2H6 Maynooth, Ireland;
- Kathleen Lonsdale Institute for Human Health Research, Maynooth University, W23 F2H6 Maynooth, Ireland
- Correspondence: ; Tel.: +353-1-7086290
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Wang Q, Xie T, Gao R, Long X, Wei J, Ye L, Jiang J, Kang L, Wang J, Jun C, Lyu J. Neutrophil-to-lymphocyte ratio is a powerful predictor of adult patients with acute respiratory distress syndrome who might benefit from corticosteroid therapy. Am J Transl Res 2021; 13:11556-11570. [PMID: 34786082 PMCID: PMC8581852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 08/11/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND There is no convincing pharmacological treatment for patients withacute respiratory distress syndrome (ARDS). The efficacy of corticosteroids in ARDS patients remains controversial. Neutrophil-to-Lymphocyte Ratio (NLR) has displayed as a good biomarker for inflammation and immune status, and thus a prognostic marker in some critical patients of ARDS. In this study, we hypothesized that NLR could also serve as an indicator for the efficacy of corticosteroid therapy in ARDS patients. METHODS Subjects included in this retrospective cohort study with ARDS patients who were admitted to an academic hospital in Wuhan, China, from May 1st, 2020 to April 20th, 2021. Multivariable logisitic regression model was used to evaluate risk factors of 30-day in-hospital mortality and ventilator-free days. Multi-Cox regression model was used to assess the efficacy of corticosteroid treatment in terms of NLR cutoff value. RESULTS Among the 357 patients in our study, 89 (24.9%) had NLR≥14.35 and 268 (75.1%) had NLR<14.35. Among them, 53 patients with NLR≥14.35 (58.9%) received corticosteroids and 99 patients with NLR<14.35 (37.1%) received corticosteroids. Post-adjustment analysis (by APACHE II score and age) revealed that corticosteroid treatment was associated with a decreased risk of 30-day mortality in the NLR≥14.35 group but with an increased risk of death in the NLR<14.35 group. Use of corticosteroid in NLR≥14.35 group significantly increased ventilator-free days (7.0 vs. 13.0, P<0.001). CONCLUSION NLR may be used to help identify ARDS patients who may benefit from corticosteroid treatment. Large-sized randomized controlled trials are warranted to determine the optimal cutoff value of NLR.
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Affiliation(s)
- Qingyuan Wang
- Department of Emergency (The Center of Emergency and Critical Care Medicine), Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Tuxiu Xie
- Department of General Practice, Guanggu Zone, Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Rukai Gao
- Wuhan Britain-China SchoolWuhan, Hubei Province, China
| | - Xiaobing Long
- Department of Emergency (The Center of Emergency and Critical Care Medicine), Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Jie Wei
- Department of Emergency (The Center of Emergency and Critical Care Medicine), Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Lu Ye
- Department of Emergency (The Center of Emergency and Critical Care Medicine), Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Jie Jiang
- Department of Emergency, Guanggu Zone, Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Lulu Kang
- Department of Emergency (The Center of Emergency and Critical Care Medicine), Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Jing Wang
- Department of Emergency (The Center of Emergency and Critical Care Medicine), Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Chen Jun
- Department of Radiology, Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Jingjun Lyu
- Department of Emergency (The Center of Emergency and Critical Care Medicine), Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
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57
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Pierrakos C, Smit MR, Pisani L, Paulus F, Schultz MJ, Constantin JM, Chiumello D, Mojoli F, Mongodi S, Bos LDJ. Lung Ultrasound Assessment of Focal and Non-focal Lung Morphology in Patients With Acute Respiratory Distress Syndrome. Front Physiol 2021; 12:730857. [PMID: 34594240 PMCID: PMC8476947 DOI: 10.3389/fphys.2021.730857] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/17/2021] [Indexed: 12/04/2022] Open
Abstract
Background: The identification of phenotypes based on lung morphology can be helpful to better target mechanical ventilation of individual patients with acute respiratory distress syndrome (ARDS). We aimed to assess the accuracy of lung ultrasound (LUS) methods for classification of lung morphology in critically ill ARDS patients under mechanical ventilation. Methods: This was a post hoc analysis on two prospective studies that performed LUS and chest computed tomography (CT) scanning at the same time. Expert panels from the two participating centers separately developed two LUS methods for classifying lung morphology based on LUS aeration scores from a 12-region exam (Amsterdam and Lombardy method). Moreover, a previously developed LUS method based on anterior LUS scores was tested (Piedmont method). Sensitivity and specificity of all three LUS methods was assessed in the cohort of the other center(s) by using CT as the gold standard for classification of lung morphology. Results: The Amsterdam and Lombardy cohorts consisted of 32 and 19 ARDS patients, respectively. From these patients, 23 (45%) had focal lung morphology while others had non-focal lung morphology. The Amsterdam method could classify focal lung morphology with a sensitivity of 77% and a specificity of 100%, while the Lombardy method had a sensitivity and specificity of 100 and 61%. The Piedmont method had a sensitivity and specificity of 91 and 75% when tested on both cohorts. With both the Amsterdam and Lombardy method, most patients could be classified based on the anterior regions alone. Conclusion: LUS-based methods can accurately classify lung morphology in invasively ventilated ARDS patients compared to gold standard chest CT. The anterior LUS regions showed to be the most discriminant between focal and non-focal lung morphology, although accuracy increased moderately when lateral and posterior LUS regions were integrated in the method.
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Affiliation(s)
- Charalampos Pierrakos
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Marry R Smit
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Luigi Pisani
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Anesthesia and Intensive Care, Miulli Regional Hospital, Acquaviva delle Fonti, Italy.,Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands.,Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Jean-Michel Constantin
- Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Davide Chiumello
- Dipartimento di Emergenza Urgenza, SC Anestesia e Rianimazione, ASST Santi Paolo e Carlo, Milan, Italy.,Centro di Ricerca Coordinata di Insufficienza Respiratoria, University of Milan, Milan, Italy
| | - Francesco Mojoli
- Anaesthesia and Intensive Care, San Matteo Hospital, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Silvia Mongodi
- Anaesthesia and Intensive Care, San Matteo Hospital, Pavia, Italy
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands
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58
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Millar JE, Wildi K, Bartnikowski N, Bouquet M, Hyslop K, Passmore MR, Ki KK, See Hoe LE, Obonyo NG, Neyton L, Pedersen S, Rozencwajg S, Baillie JK, Li Bassi G, Suen JY, McAuley DF, Fraser JF. Characterizing preclinical sub-phenotypic models of acute respiratory distress syndrome: An experimental ovine study. Physiol Rep 2021; 9:e15048. [PMID: 34617676 PMCID: PMC8495778 DOI: 10.14814/phy2.15048] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/13/2021] [Accepted: 08/15/2021] [Indexed: 12/15/2022] Open
Abstract
The acute respiratory distress syndrome (ARDS) describes a heterogenous population of patients with acute severe respiratory failure. However, contemporary advances have begun to identify distinct sub-phenotypes that exist within its broader envelope. These sub-phenotypes have varied outcomes and respond differently to several previously studied interventions. A more precise understanding of their pathobiology and an ability to prospectively identify them, may allow for the development of precision therapies in ARDS. Historically, animal models have played a key role in translational research, although few studies have so far assessed either the ability of animal models to replicate these sub-phenotypes or investigated the presence of sub-phenotypes within animal models. Here, in three ovine models of ARDS, using combinations of oleic acid and intravenous, or intratracheal lipopolysaccharide, we investigated the presence of sub-phenotypes which qualitatively resemble those found in clinical cohorts. Principal Component Analysis and partitional clustering identified two clusters, differentiated by markers of shock, inflammation, and lung injury. This study provides a first exploration of ARDS phenotypes in preclinical models and suggests a methodology for investigating this phenomenon in future studies.
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Affiliation(s)
- Jonathan E. Millar
- Critical Care Research GroupThe Prince Charles HospitalBrisbaneAustralia
- Faculty of MedicineUniversity of QueenslandBrisbaneAustralia
- Roslin InstituteUniversity of EdinburghEdinburghUK
| | - Karin Wildi
- Critical Care Research GroupThe Prince Charles HospitalBrisbaneAustralia
- Faculty of MedicineUniversity of QueenslandBrisbaneAustralia
- Cardiovascular Research Institute BaselBaselSwitzerland
| | - Nicole Bartnikowski
- Critical Care Research GroupThe Prince Charles HospitalBrisbaneAustralia
- Institute of Health and Biomedical InnovationQueensland University of TechnologyAustralia
| | - Mahe Bouquet
- Critical Care Research GroupThe Prince Charles HospitalBrisbaneAustralia
- Faculty of MedicineUniversity of QueenslandBrisbaneAustralia
| | - Kieran Hyslop
- Critical Care Research GroupThe Prince Charles HospitalBrisbaneAustralia
- Faculty of MedicineUniversity of QueenslandBrisbaneAustralia
| | - Margaret R. Passmore
- Critical Care Research GroupThe Prince Charles HospitalBrisbaneAustralia
- Faculty of MedicineUniversity of QueenslandBrisbaneAustralia
| | - Katrina K. Ki
- Critical Care Research GroupThe Prince Charles HospitalBrisbaneAustralia
- Faculty of MedicineUniversity of QueenslandBrisbaneAustralia
| | - Louise E. See Hoe
- Critical Care Research GroupThe Prince Charles HospitalBrisbaneAustralia
- Faculty of MedicineUniversity of QueenslandBrisbaneAustralia
| | - Nchafatso G. Obonyo
- Critical Care Research GroupThe Prince Charles HospitalBrisbaneAustralia
- Wellcome Trust Centre for Global Health ResearchImperial College LondonUK
| | | | - Sanne Pedersen
- Critical Care Research GroupThe Prince Charles HospitalBrisbaneAustralia
| | - Sacha Rozencwajg
- Critical Care Research GroupThe Prince Charles HospitalBrisbaneAustralia
- Sorbonne UniversitésUPMC Université Paris 06INSERMUMRS‐1166ICAN Institute of Cardiometabolism and Nutrition, Medical ICUPitié‐Salpêtrière University HospitalParisFrance
| | | | - Gianluigi Li Bassi
- Critical Care Research GroupThe Prince Charles HospitalBrisbaneAustralia
- Faculty of MedicineUniversity of QueenslandBrisbaneAustralia
| | - Jacky Y. Suen
- Critical Care Research GroupThe Prince Charles HospitalBrisbaneAustralia
- Faculty of MedicineUniversity of QueenslandBrisbaneAustralia
| | - Daniel F. McAuley
- Wellcome‐Wolfson Institute for Experimental MedicineQueen’s University BelfastBelfastUK
| | - John F. Fraser
- Critical Care Research GroupThe Prince Charles HospitalBrisbaneAustralia
- Faculty of MedicineUniversity of QueenslandBrisbaneAustralia
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59
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Abstract
Acute respiratory distress syndrome is a heterogenous syndrome with many etiologies for which there are no definitive pharmacologic treatments, despite decades of research. We explore some adjunctive pharmacologic therapies, including neuromuscular blockade, corticosteroids, and inhaled pulmonary vasodilators. Additionally, we explore some investigative therapies, including Vitamin C, beta-agonists, statins, mesenchymal stromal cells, and granulocyte-macrophage colony stimulating factor. We do discuss the potential role of steroids in acute respiratory distress syndrome with severe acute respiratory syndrome coronavirus 2 as a trigger. The standard of care, however, remains supportive care.
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Affiliation(s)
- Nida Qadir
- David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Room 43-229 CHS, Los Angeles, CA 90095, USA.
| | - Steven Y Chang
- David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Room 43-229 CHS, Los Angeles, CA 90095, USA
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60
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Sinha P, Bos LD. Pathophysiology of the Acute Respiratory Distress Syndrome: Insights from Clinical Studies. Crit Care Clin 2021; 37:795-815. [PMID: 34548134 PMCID: PMC8149201 DOI: 10.1016/j.ccc.2021.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Pratik Sinha
- Division of Clinical and Translational Research, Department of Anesthesia, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8054, St Louis, MO 63110, USA.
| | - Lieuwe D Bos
- Department of Respiratory Medicine, Infection and Immunity, Amsterdam University Medical Center, AMC, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands
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61
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Maciejewski D, Putowski Z, Czok M, Krzych ŁJ. Electrical impedance tomography as a tool for monitoring mechanical ventilation. An introduction to the technique. Adv Med Sci 2021; 66:388-395. [PMID: 34371248 DOI: 10.1016/j.advms.2021.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/27/2021] [Accepted: 07/28/2021] [Indexed: 02/02/2023]
Abstract
Electrical impedance tomography (EIT) is a non-invasive, radiation-free method of diagnostics imaging, allowing for a bedside, real-time dynamic assessment of lung function. It stands as an alternative for other imagining methods, such as computed tomography (CT) or ultrasound. Even though the technique is rather novel, it has a wide variety of possible applications. In the era of modern mechanical ventilation, a dynamic assessment of patient's respiratory condition appears to fulfil the idea of personalized treatment. Additionally, an increasing frequency of respiratory failure among intensive care populations raises demand for improved monitoring tools. This review aims to raise awareness and presents possible implications for the use of EIT in the intensive care setting.
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Affiliation(s)
- Dariusz Maciejewski
- Department of Anesthesiology and Intensive Therapy, Regional Hospital in Bielsko-Biala, Bielsko-Biala, Poland
| | - Zbigniew Putowski
- Students' Scientific Society, Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.
| | - Marcelina Czok
- Students' Scientific Society, Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Łukasz J Krzych
- Students' Scientific Society, Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
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Liu X, Jiang Y, Jia X, Ma X, Han C, Guo N, Peng Y, Liu H, Ju Y, Luo X, Li X, Bu Y, Zhang J, Liu Y, Gao Y, Zhao M, Wang H, Luo L, Yu K, Wang C. Identification of distinct clinical phenotypes of acute respiratory distress syndrome with differential responses to treatment. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:320. [PMID: 34461969 PMCID: PMC8404019 DOI: 10.1186/s13054-021-03734-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/18/2021] [Indexed: 02/05/2023]
Abstract
Background Acute respiratory distress syndrome (ARDS) is a heterogeneous syndrome, and the identification of homogeneous subgroups and phenotypes is the first step toward precision critical care. We aimed to explore whether ARDS phenotypes can be identified using clinical data, are reproducible and are associated with clinical outcomes and treatment response. Methods This study is based on a retrospective analysis of data from the telehealth intensive care unit (eICU) collaborative research database and three ARDS randomized controlled trials (RCTs) (ALVEOLI, FACTT and SAILS trials). We derived phenotypes in the eICU by cluster analysis based on clinical data and compared the clinical characteristics and outcomes of each phenotype. The reproducibility of the derived phenotypes was tested using the data from three RCTs, and treatment effects were evaluated. Results Three clinical phenotypes were identified in the training cohort of 3875 ARDS patients. Of the three phenotypes identified, phenotype I (n = 1565; 40%) was associated with fewer laboratory abnormalities, less organ dysfunction and the lowest in-hospital mortality rate (8%). Phenotype II (n = 1232; 32%) was correlated with more inflammation and shock and had a higher mortality rate (18%). Phenotype III (n = 1078; 28%) was strongly correlated with renal dysfunction and acidosis and had the highest mortality rate (22%). These results were validated using the data from the validation cohort (n = 3670) and three RCTs (n = 2289) and had reproducibility. Patients with these ARDS phenotypes had different treatment responses to randomized interventions. Specifically, in the ALVEOLI cohort, the effects of ventilation strategy (high PEEP vs low PEEP) on ventilator-free days differed by phenotype (p = 0.001); in the FACTT cohort, there was a significant interaction between phenotype and fluid-management strategy for 60-day mortality (p = 0.01). The fluid-conservative strategy was associated with improved mortality in phenotype II but had the opposite effect in phenotype III. Conclusion Three clinical phenotypes of ARDS were identified and had different clinical characteristics and outcomes. The analysis shows evidence of a phenotype-specific treatment benefit in the ALVEOLI and FACTT trials. These findings may improve the identification of distinct subsets of ARDS patients for exploration in future RCTs. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03734-y.
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Affiliation(s)
- Xiaowei Liu
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Yusheng Jiang
- LinkDoc AI Lab, LinkDoc Technology, Floor 11, Sinosteel Plaza, 8 Haidian Street, Haidian District, Beijing, 100080, China
| | - Xiaonan Jia
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Xiaohui Ma
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Ci Han
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Nana Guo
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, 150 Haping Road, Nangang District, Harbin, 150081, Heilongjiang, China
| | - Yahui Peng
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Haitao Liu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, 150 Haping Road, Nangang District, Harbin, 150081, Heilongjiang, China
| | - Yingnan Ju
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, 150 Haping Road, Nangang District, Harbin, 150081, Heilongjiang, China
| | - Xiangfeng Luo
- LinkDoc AI Lab, LinkDoc Technology, Floor 11, Sinosteel Plaza, 8 Haidian Street, Haidian District, Beijing, 100080, China
| | - Xueting Li
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, 150 Haping Road, Nangang District, Harbin, 150081, Heilongjiang, China
| | - Yue Bu
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Jin Zhang
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Yansong Liu
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Yan Gao
- Department of Critical Care Medicine, Forth Affiliated Hospital of Harbin Medical University, 37 Yiyuan Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Mingyan Zhao
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Hongliang Wang
- Department of Critical Care Medicine, Second Affiliated Hospital of Harbin Medical University, 246 Xuefu Road, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Ligang Luo
- LinkDoc AI Lab, LinkDoc Technology, Floor 11, Sinosteel Plaza, 8 Haidian Street, Haidian District, Beijing, 100080, China
| | - Kaijiang Yu
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China.
| | - Changsong Wang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, 150 Haping Road, Nangang District, Harbin, 150081, Heilongjiang, China.
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Chiu LC, Chuang LP, Lin SW, Li HH, Leu SW, Chang KW, Huang CH, Chiu TH, Wu HP, Tsai FC, Huang CC, Hu HC, Kao KC. Comparisons of Outcomes between Patients with Direct and Indirect Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation. MEMBRANES 2021; 11:membranes11080644. [PMID: 34436407 PMCID: PMC8397979 DOI: 10.3390/membranes11080644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/10/2021] [Accepted: 08/18/2021] [Indexed: 11/20/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a heterogeneous syndrome caused by direct (local damage to lung parenchyma) or indirect lung injury (insults from extrapulmonary sites with acute systemic inflammatory response), the clinical and biological complexity can have a profound effect on clinical outcomes. We performed a retrospective analysis of 152 severe ARDS patients receiving extracorporeal membrane oxygenation (ECMO). Our objective was to assess the differences in clinical characteristics and outcomes of direct and indirect ARDS patients receiving ECMO. Overall hospital mortality was 53.3%. A total of 118 patients were assigned to the direct ARDS group, and 34 patients were assigned to the indirect ARDS group. The 28-, 60-, and 90-day hospital mortality rates were significantly higher among indirect ARDS patients (all p < 0.05). Cox regression models demonstrated that among direct ARDS patients, diabetes mellitus, immunocompromised status, ARDS duration before ECMO, and SOFA score during the first 3 days of ECMO were independently associated with mortality. In indirect ARDS patients, SOFA score and dynamic compliance during the first 3 days of ECMO were independently associated with mortality. Our findings revealed that among patients receiving ECMO, direct and indirect subphenotypes of ARDS have distinct clinical outcomes and different predictors for mortality.
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Affiliation(s)
- Li-Chung Chiu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Thoracic Medicine, New Taipei Municipal TuCheng Hospital and Chang Gung University, Taoyuan 33302, Taiwan
| | - Li-Pang Chuang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
| | - Shih-Wei Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
| | - Hsin-Hsien Li
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan;
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan 33302, Taiwan
| | - Shaw-Woei Leu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
| | - Ko-Wei Chang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
| | - Chi-Hsien Huang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
| | - Tzu-Hsuan Chiu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
| | - Huang-Pin Wu
- Division of Pulmonary, Critical Care and Sleep Medicine, Chang Gung Memorial Hospital, Keelung 20401, Taiwan;
| | - Feng-Chun Tsai
- Division of Cardiovascular Surgery, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan;
| | - Chung-Chi Huang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan 33302, Taiwan
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
| | - Han-Chung Hu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan 33302, Taiwan
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
- Correspondence: ; Tel.: +886-3-3281200 (ext. 8467)
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan 33302, Taiwan
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
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De Luca D, Autilio C. Strategies to protect surfactant and enhance its activity. Biomed J 2021; 44:654-662. [PMID: 34365021 PMCID: PMC8847817 DOI: 10.1016/j.bj.2021.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/21/2021] [Accepted: 07/29/2021] [Indexed: 11/22/2022] Open
Abstract
The knowledge about surfactant biology is now deeper and recent research has allowed to clarify its role in several human lung disorders. The balance between surfactant production and consumption is better known and the same applies to their regulatory mechanisms. This has allowed to hypothesize and investigate several new and original strategies to protect surfactant and enhance its activity. These interventions are potentially useful for several disorders and particularly for acute respiratory distress syndrome. We here highlight the mechanisms regulating surfactant consumption, encompassing surfactant catabolism but also surfactant injury due to other mechanisms, in a physiopathology-driven fashion. We then analyze each corresponding strategy to protect surfactant and enhance its activity. Some of these strategies are more advanced in terms of research & development pathway, some others are still investigational, but all are promising and deserve a joint effort from clinical-academic researchers and the industry.
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Affiliation(s)
- Daniele De Luca
- Division of Paediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France; Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France.
| | - Chiara Autilio
- Dpt. of Biochemistry and Molecular Biology and Research Institute "Hospital 12 de Octubre", Complutense University, Madrid, Spain
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65
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Heijnen NFL, Hagens LA, Smit MR, Cremer OL, Ong DSY, van der Poll T, van Vught LA, Scicluna BP, Schnabel RM, van der Horst ICC, Schultz MJ, Bergmans DCJJ, Bos LDJ. Biological Subphenotypes of Acute Respiratory Distress Syndrome Show Prognostic Enrichment in Mechanically Ventilated Patients without Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2021; 203:1503-1511. [PMID: 33465019 DOI: 10.1164/rccm.202006-2522oc] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rationale: Recent studies showed that biological subphenotypes in acute respiratory distress syndrome (ARDS) provide prognostic enrichment and show potential for predictive enrichment. Objectives: To determine whether these subphenotypes and their prognostic and potential for predictive enrichment could be extended to other patients in the ICU, irrespective of fulfilling the definition of ARDS. Methods: This is a secondary analysis of a prospective observational study of adult patients admitted to the ICU. We tested the prognostic enrichment of both cluster-derived and latent-class analysis (LCA)-derived biological ARDS subphenotypes by evaluating the association with clinical outcome (ICU-day, 30-day mortality, and ventilator-free days) using logistic regression and Cox regression analysis. We performed a principal component analysis to compare blood leukocyte gene expression profiles between subphenotypes and the presence of ARDS. Measurements and Main Results: We included 2,499 mechanically ventilated patients (674 with and 1,825 without ARDS). The cluster-derived "reactive" subphenotype was, independently of ARDS, significantly associated with a higher probability of ICU mortality, higher 30-day mortality, and a lower probability of successful extubation while alive compared with the "uninflamed" subphenotype. The blood leukocyte gene expression profiles of individual subphenotypes were similar for patients with and without ARDS. LCA-derived subphenotypes also showed similar profiles. Conclusions: The prognostic and potential for predictive enrichment of biological ARDS subphenotypes may be extended to mechanically ventilated critically ill patients without ARDS. Using the concept of biological subphenotypes for splitting cohorts of critically ill patients could add to improving future precision-based trial strategies and lead to identifying treatable traits for all critically ill patients.
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Affiliation(s)
- Nanon F L Heijnen
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | | | | | | | - David S Y Ong
- Division of Infectious Diseases.,Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Infection and Immunity
| | - Tom van der Poll
- Laboratory of Experimental Intensive Care and Anesthesiology, and.,Department of Respiratory Medicine, Amsterdam University Medical Centers, location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Brendon P Scicluna
- Laboratory of Experimental Intensive Care and Anesthesiology, and.,Department of Intensive Care Medicine and
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care Medicine.,Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Medical Microbiology and Infection Control, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; and
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care Medicine.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: Unbiased global metabolomic profiling has not been used to identify distinct subclasses in patients with early sepsis and sepsis-associated acute respiratory distress syndrome. In this study, we examined whether the plasma metabolome reflects systemic illness in early sepsis and in acute respiratory distress syndrome. DESIGN: Plasma metabolites were measured in subjects with early sepsis. SETTING: Patients were admitted from the emergency department to the ICU in a plasma sample collected within 24 hours of ICU admission. Metabolic profiling of 970 metabolites was performed by Metabolon (Durham, NC). Hierarchical clustering and partial least squares discriminant clustering were used to identify distinct clusters among patients with early sepsis and sepsis-associated acute respiratory distress syndrome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among critically ill patients with early sepsis (n = 197), three metabolically distinct subgroups were identified, with metabolic subtype driven by plasma lipids. Group 1, with 45 subjects (23% of cohort), had increased 60-day mortality (odds ratio, 2; 95% CI, 0.99–4.0; p = 0.04 for group 1 vs all others). This group also had higher rates of vasopressor-dependent shock, acute kidney injury, and met Berlin acute respiratory distress syndrome criteria more often (all p < 0.05). Conversely, metabolic group 3, with 76 subjects (39% of cohort), had the lowest risk of 60-day mortality (odds ratio, 0.44; 95% CI, 0.22–0.86; p = 0.01) and lower rates of organ dysfunction as reflected in a lower Simplified Acute Physiology Score II (p < 0.001). In contrast, global metabolomic profiling did not separate patient with early sepsis with moderate-to-severe acute respiratory distress syndrome (n = 78) from those with sepsis without acute respiratory distress syndrome (n = 75). CONCLUSIONS: Plasma metabolomic profiling in patients with early sepsis identified three metabolically distinct groups that were characterized by different plasma lipid profiles, distinct clinical phenotypes, and 60-day mortality. Plasma metabolites did not distinguish patients with early sepsis who developed acute respiratory distress syndrome from those who did not.
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Khan YA, Fan E, Ferguson ND. Precision Medicine and Heterogeneity of Treatment Effect in Therapies for Acute Respiratory Distress Syndrome. Chest 2021; 160:1729-1738. [PMID: 34270967 PMCID: PMC8277554 DOI: 10.1016/j.chest.2021.07.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/28/2021] [Accepted: 07/05/2021] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a clinically heterogenous syndrome, rather than a distinct disease. This heterogeneity at least partially explains the difficulty in studying treatments for these patients and contributes to the numerous trials of therapies for the syndrome that have not shown benefit. Recent studies have identified different subphenotypes within the heterogenous patient population. These different subphenotypes likely have variable clinical responses to specific therapies, a concept known as heterogeneity of treatment effect (HTE). Recognizing different subphenotypes and HTE has important implications for the clinical management of patients with ARDS. In this review, we will present studies that have identified different subphenotypes and discuss how they can modify the effects of therapies evaluated in trials that are commonly considered to have demonstrated no overall benefit in patients with ARDS.
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Affiliation(s)
- Yasin A Khan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Toronto General Hospital Research Institute, Toronto, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Toronto General Hospital Research Institute, Toronto, Canada; Department of Physiology, University of Toronto, Toronto, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada.
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68
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Bihari S, Bersten A, Paul E, McGuinness S, Dixon D, Sinha P, Calfee CS, Nichol A, Hodgson C. Acute respiratory distress syndrome phenotypes with distinct clinical outcomes in PHARLAP trial cohort. CRIT CARE RESUSC 2021; 23:163-170. [PMID: 38045528 PMCID: PMC10692525 DOI: 10.51893/2021.2.oa3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The Permissive Hypercapnia, Alveolar Recruitment and Low Airway Pressure (PHARLAP) randomised controlled trial compared an open lung ventilation strategy with control ventilation, and found that open lung ventilation did not reduce the number of ventilatorfree days (VFDs) or mortality in patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Parsimonious models can identify distinct phenotypes of ARDS (hypo-inflammatory and hyperinflammatory) which are associated with different outcomes and treatment responses. Objective: To test the hypothesis that a parsimonious model would identify patients with distinctly different clinical outcomes in the PHARLAP study. Design, setting and participants: Blood and lung lavage samples were collected in a subset of PHARLAP patients who were recruited in Australian and New Zealand centres. A previously validated parsimonious model (interleukin-8, soluble tumour necrosis factor receptor-1 and bicarbonate) was used to classify patients with blood samples into hypo-inflammatory and hyperinflammatory groups. Generalised linear modelling was used to examine the interaction between inflammatory phenotype and treatment group (intervention or control). Main outcome measure: The primary outcome was number of VFDs at Day 28. Results: Data for the parsimonious model were available for 56 of 115 patients (49%). Within this subset, 38 patients (68%) and 18 patients (32%) were classified as having hypo-inflammatory and hyperinflammatory phenotypes, respectively. Patients with the hypo- inflammatory phenotype had more VFDs at Day 28 when compared with those with the hyperinflammatory phenotype (median [IQR], 19.5[11-24] versus 8[0-21];P= 0.03). Patients with the hyperinflammatory phenotype had numerically fewer VFDs when managed with an open lung strategy than when managed with control "protective" ventilation (median [IQR], 0 [0-19] versus 16 [8-22]). Conclusion: In the PHARLAP trial, ARDS patients classified as having a hyperinflammatory phenotype, with a parsimonious three-variable model, had fewer VFDs at Day 28 compared with patients classified as having a hypo-inflammatory phenotype. Future clinical studies of ventilatory strategies should consider incorporating distinct ARDS phenotypes into their trial design.
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Affiliation(s)
- Shailesh Bihari
- College of Medicine and Public Health- Flinders University-, Adelaide, - SA-, Australia
- Intensive and Critical Care Unit- Flinders Medical Centre-, Adelaide, - SA-, Australia
| | - Andrew Bersten
- College of Medicine and Public Health- Flinders University-, Adelaide, - SA-, Australia
- Intensive and Critical Care Unit- Flinders Medical Centre-, Adelaide, - SA-, Australia
| | - Eldho Paul
- Australian and New Zealand Intensive Care Research Centre, Monash University-, Melbourne, - VIC-, Australia
| | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, Monash University-, Melbourne, - VIC-, Australia
- Cardiothoracic and Vascular Intensive Care Unit-, Auckland, City Hospital- Auckland- New Zealand
- Medical Research Institute of New Zealand-, Wellington- New Zealand
| | - Dani Dixon
- College of Medicine and Public Health- Flinders University-, Adelaide, - SA-, Australia
- Intensive and Critical Care Unit- Flinders Medical Centre-, Adelaide, - SA-, Australia
| | - Pratik Sinha
- Division of Pulmonary- Critical Care- Allergy and Sleep Medicine Department of Medicine- University of California San Francisco-, San Francisco, - Calif-, USA
| | - Carolyn S. Calfee
- Division of Pulmonary- Critical Care- Allergy and Sleep Medicine Department of Medicine- University of California San Francisco-, San Francisco, - Calif-, USA
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, Monash University-, Melbourne, - VIC-, Australia
- Intensive Care Unit- The Alfred-, Melbourne, - VIC-, Australia
- University College Dublin Clinical Research Centre- St Vincent's University Hospital-, Dublin- Ireland
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University-, Melbourne, - VIC-, Australia
- Intensive Care Unit- The Alfred-, Melbourne, - VIC-, Australia
- Contributed equally to the manuscript
| | - for the PHARLAP Study Investigators
- College of Medicine and Public Health- Flinders University-, Adelaide, - SA-, Australia
- Intensive and Critical Care Unit- Flinders Medical Centre-, Adelaide, - SA-, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University-, Melbourne, - VIC-, Australia
- Cardiothoracic and Vascular Intensive Care Unit-, Auckland, City Hospital- Auckland- New Zealand
- Medical Research Institute of New Zealand-, Wellington- New Zealand
- Division of Pulmonary- Critical Care- Allergy and Sleep Medicine Department of Medicine- University of California San Francisco-, San Francisco, - Calif-, USA
- Intensive Care Unit- The Alfred-, Melbourne, - VIC-, Australia
- University College Dublin Clinical Research Centre- St Vincent's University Hospital-, Dublin- Ireland
- Contributed equally to the manuscript
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Ramos-Casals M, Brito-Zerón P, Mariette X. Systemic and organ-specific immune-related manifestations of COVID-19. Nat Rev Rheumatol 2021; 17:315-332. [PMID: 33903743 PMCID: PMC8072739 DOI: 10.1038/s41584-021-00608-z] [Citation(s) in RCA: 173] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 01/08/2023]
Abstract
Immune-related manifestations are increasingly recognized conditions in patients with COVID-19, with around 3,000 cases reported worldwide comprising more than 70 different systemic and organ-specific disorders. Although the inflammation caused by SARS-CoV-2 infection is predominantly centred on the respiratory system, some patients can develop an abnormal inflammatory reaction involving extrapulmonary tissues. The signs and symptoms associated with this excessive immune response are very diverse and can resemble some autoimmune or inflammatory diseases, with the clinical phenotype that is seemingly influenced by epidemiological factors such as age, sex or ethnicity. The severity of the manifestations is also very varied, ranging from benign and self-limiting features to life-threatening systemic syndromes. Little is known about the pathogenesis of these manifestations, and some tend to emerge within the first 2 weeks of SARS-CoV-2 infection, whereas others tend to appear in a late post-infectious stage or even in asymptomatic patients. As the body of evidence comprises predominantly case series and uncontrolled studies, diagnostic and therapeutic decision-making is unsurprisingly often based on the scarcely reported experience and expert opinion. Additional studies are required to learn about the mechanisms involved in the development of these manifestations and apply that knowledge to achieve early diagnosis and the most suitable therapy.
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Affiliation(s)
- Manuel Ramos-Casals
- Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.
- Department of Medicine, University of Barcelona, Barcelona, Spain.
| | - Pilar Brito-Zerón
- Department of Internal Medicine, Hospital CIMA-Sanitas, Barcelona, Spain
| | - Xavier Mariette
- Department of Rheumatology, Center for Immunology of Viral Infections and Autoimmune Diseases, Université Paris-Saclay, INSERM, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France
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70
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Ruan SY, Huang CT, Chien YC, Huang CK, Chien JY, Kuo LC, Kuo PH, Ku SC, Wu HD. Etiology-associated heterogeneity in acute respiratory distress syndrome: a retrospective cohort study. BMC Pulm Med 2021; 21:183. [PMID: 34059024 PMCID: PMC8168042 DOI: 10.1186/s12890-021-01557-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/26/2021] [Indexed: 12/16/2022] Open
Abstract
Background Heterogeneity in acute respiratory distress syndrome (ARDS) has led to many statistically negative clinical trials. Etiology is considered an important source of pathogenesis heterogeneity in ARDS but previous studies have usually adopted a dichotomous classification, such as pulmonary versus extrapulmonary ARDS, to evaluate it. Etiology-associated heterogeneity in ARDS remains poorly described. Methods In this retrospective cohort study, we described etiology-associated heterogeneity in gas exchange abnormality (PaO2/FiO2 [P/F] and ventilatory ratios), hemodynamic instability, non-pulmonary organ dysfunction as measured by the Sequential Organ Failure Assessment (SOFA) score, biomarkers of inflammation and coagulation, and 30-day mortality. Linear regression was used to model the trajectory of P/F ratios over time. Wilcoxon rank-sum tests, Kruskal–Wallis rank tests and Chi-squared tests were used to compare between-etiology differences. Results From 1725 mechanically ventilated patients in the ICU, we identified 258 (15%) with ARDS. Pneumonia (48.4%) and non-pulmonary sepsis (11.6%) were the two leading causes of ARDS. Compared with pneumonia associated ARDS, extra-pulmonary sepsis associated ARDS had a greater P/F ratio recovery rate (difference = 13 mmHg/day, p = 0.01), more shock (48% versus 73%, p = 0.01), higher non-pulmonary SOFA scores (6 versus 9 points, p < 0.001), higher d-dimer levels (4.2 versus 9.7 mg/L, p = 0.02) and higher mortality (43% versus 67%, p = 0.02). In pneumonia associated ARDS, there was significant difference in proportion of shock (p = 0.005) between bacterial and non-bacterial pneumonia. Conclusion This study showed that there was remarkable etiology-associated heterogeneity in ARDS. Heterogeneity was also observed within pneumonia associated ARDS when bacterial pneumonia was compared with other non-bacterial pneumonia. Future studies on ARDS should consider reporting etiology-specific data and exploring possible effect modification associated with etiology. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01557-9.
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Affiliation(s)
- Sheng-Yuan Ruan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan.
| | - Chun-Ta Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Ying-Chun Chien
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Chun-Kai Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Jung-Yien Chien
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Lu-Cheng Kuo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Ping-Hung Kuo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Shih-Chi Ku
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Huey-Dong Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
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71
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Changes in Plasma Soluble Receptor for Advanced Glycation End-Products Are Associated with Survival in Patients with Acute Respiratory Distress Syndrome. J Clin Med 2021; 10:jcm10102076. [PMID: 34066048 PMCID: PMC8150905 DOI: 10.3390/jcm10102076] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 01/11/2023] Open
Abstract
The plasma soluble receptor for advanced glycation end-products (sRAGE) is a marker of lung epithelial injury with prognostic value when measured at baseline in acute respiratory distress syndrome (ARDS). However, whether changes in plasma sRAGE could inform prognosis in ARDS remains unknown. In this secondary analysis of the Lung Imaging for Ventilator Setting in ARDS (LIVE) multicenter randomized controlled trial, which evaluated a personalized ventilation strategy tailored to lung morphology, plasma sRAGE was measured upon study entry (baseline) and on days one, two, three, four and six. The association between changes in plasma sRAGE over time and 90-day survival was evaluated. Higher baseline plasma sRAGE (HR per-one log increment, 1.53; 95% CI, 1.16–2.03; p = 0.003) and an increase in sRAGE over time (HR for each one-log increment in plasma sRAGE per time unit, 1.01; 95% CI, 1.01–1.02; p < 10−3) were both associated with increased 90-day mortality. Each 100-unit increase in the plasma sRAGE level per unit of time increased the risk of death at day 90 by 1% in joint modeling. Plasma sRAGE increased over time when a strategy of maximal alveolar recruitment was applied in patients with focal ARDS. Current findings suggest that the rate of change in plasma sRAGE over time is associated with 90-day survival and could be helpful as a surrogate outcome in ARDS.
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72
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Peñaloza HF, Olonisakin TF, Bain WG, Qu Y, van der Geest R, Zupetic J, Hulver M, Xiong Z, Newstead MW, Zou C, Alder JK, Ybe JA, Standiford TJ, Lee JS. Thrombospondin-1 Restricts Interleukin-36γ-Mediated Neutrophilic Inflammation during Pseudomonas aeruginosa Pulmonary Infection. mBio 2021; 12:e03336-20. [PMID: 33824208 PMCID: PMC8092289 DOI: 10.1128/mbio.03336-20] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/25/2021] [Indexed: 01/05/2023] Open
Abstract
Interleukin-36γ (IL-36γ), a member of the IL-1 cytokine superfamily, amplifies lung inflammation and impairs host defense during acute pulmonary Pseudomonas aeruginosa infection. To be fully active, IL-36γ is cleaved at its N-terminal region by proteases such as neutrophil elastase (NE) and cathepsin S (CatS). However, it remains unclear whether limiting extracellular proteolysis restrains the inflammatory cascade triggered by IL-36γ during P. aeruginosa infection. Thrombospondin-1 (TSP-1) is a matricellular protein with inhibitory activity against NE and the pathogen-secreted Pseudomonas elastase LasB-both proteases implicated in amplifying inflammation. We hypothesized that TSP-1 tempers the inflammatory response during lung P. aeruginosa infection by inhibiting the proteolytic environment required for IL-36γ activation. Compared to wild-type (WT) mice, TSP-1-deficient (Thbs1-/-) mice exhibited a hyperinflammatory response in the lungs during P. aeruginosa infection, with increased cytokine production and an unrestrained extracellular proteolytic environment characterized by higher free NE and LasB, but not CatS activity. LasB cleaved IL-36γ proximally to M19 at a cleavage site distinct from those generated by NE and CatS, which cleave IL-36γ proximally to Y16 and S18, respectively. N-terminal truncation experiments in silico predicted that the M19 and the S18 isoforms bind the IL-36R complex almost identically. IL-36γ neutralization ameliorated the hyperinflammatory response and improved lung immunity in Thbs1-/- mice during P. aeruginosa infection. Moreover, administration of cleaved IL-36γ induced cytokine production and neutrophil recruitment and activation that was accentuated in Thbs1-/- mice lungs. Collectively, our data show that TSP-1 regulates lung neutrophilic inflammation and facilitates host defense by restraining the extracellular proteolytic environment required for IL-36γ activation.IMPORTANCEPseudomonas aeruginosa pulmonary infection can lead to exaggerated neutrophilic inflammation and tissue destruction, yet host factors that regulate the neutrophilic response are not fully known. IL-36γ is a proinflammatory cytokine that dramatically increases in bioactivity following N-terminal processing by proteases. Here, we demonstrate that thrombospondin-1, a host matricellular protein, limits N-terminal processing of IL-36γ by neutrophil elastase and the Pseudomonas aeruginosa-secreted protease LasB. Thrombospondin-1-deficient mice (Thbs1-/-) exhibit a hyperinflammatory response following infection. Whereas IL-36γ neutralization reduces inflammatory cytokine production, limits neutrophil activation, and improves host defense in Thbs1-/- mice, cleaved IL-36γ administration amplifies neutrophilic inflammation in Thbs1-/- mice. Our findings indicate that thrombospondin-1 guards against feed-forward neutrophilic inflammation mediated by IL-36γ in the lung by restraining the extracellular proteolytic environment.
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Affiliation(s)
- Hernán F Peñaloza
- Acute Lung Injury Center of Excellence, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tolani F Olonisakin
- Acute Lung Injury Center of Excellence, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - William G Bain
- Acute Lung Injury Center of Excellence, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yanyan Qu
- Acute Lung Injury Center of Excellence, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rick van der Geest
- Acute Lung Injury Center of Excellence, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jill Zupetic
- Acute Lung Injury Center of Excellence, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mei Hulver
- Acute Lung Injury Center of Excellence, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Zeyu Xiong
- Acute Lung Injury Center of Excellence, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael W Newstead
- Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Chunbin Zou
- Acute Lung Injury Center of Excellence, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan K Alder
- Acute Lung Injury Center of Excellence, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joel A Ybe
- Department of Environmental and Occupational Health, School of Public Health, Indiana University, Bloomington, Indiana, USA
| | - Theodore J Standiford
- Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Janet S Lee
- Acute Lung Injury Center of Excellence, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Retamozo S, Brito-Zerón P, Sisó-Almirall A, Flores-Chávez A, Soto-Cárdenas MJ, Ramos-Casals M. Haemophagocytic syndrome and COVID-19. Clin Rheumatol 2021; 40:1233-1244. [PMID: 33389315 PMCID: PMC7778844 DOI: 10.1007/s10067-020-05569-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/19/2020] [Accepted: 12/22/2020] [Indexed: 12/15/2022]
Abstract
Primary and secondary haemophagocytic lymphohistiocytosis (HLH) are hyperferritinaemic hyperinflammatory syndromes with a common terminal pathway triggered by different etiopathogenetic factors. HLH is characterised by a decreased capacity of interferon gamma production with an activated NK phenotype profile similar to other hyperinflammatory syndromes. Viruses are closely linked to the development of HLH as infectious triggers, and the break of tolerance to self-antigens is considered a critical mechanism involved in the development of immune-mediated conditions triggered by viral infections. Emerging studies in patients with COVID-19 are suggesting a key role of monocytes/macrophages in the pathogenesis of this viral infection, and there is a significant overlap between several features reported in severe COVID-19 and the features included in the HLH-2004 diagnostic criteria. Therefore, SARS-Cov-2, as other respiratory viruses, may also be considered a potential etiological trigger of HLH. The frequency of HLH in adult patients with severe COVID-19 is lower than 5%, although this figure could be underestimated considering that most reported cases lacked information about some specific criteria (mainly the histopathological criteria and the measurement of NK cell function and sCD25 levels). Because HLH is a multi-organ syndrome, the diagnostic approach in a patient with severe COVID-19 in whom HLH is suspected must be carried out in a syndromic and holistic way, and not in the light of isolated clinical or laboratory features. In COVID-19 patients presenting with persistent high fever, progressive pancytopenia, and hepatosplenic involvement, together with the characteristic triad of laboratory abnormalities (hyperferritinaemia, hypertriglyceridaemia, and hypofibrinogenaemia), the suspicion of HLH is high, and the diagnostic workup must be completed with specific immunological and histopathological studies.
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Affiliation(s)
- Soledad Retamozo
- Instituto Modelo de Cardiología Privado S.R.L- Córdoba - Argentina, Instituto Universitario de Ciencias Biomédicas de Córdoba (IUCBC), Córdoba, Argentina
| | - Pilar Brito-Zerón
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA- Sanitas, Barcelona, Spain
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Barcelona, Spain
| | - Antoni Sisó-Almirall
- Grup Tranversal de Recerca en Atenció Primària, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre d'Atenció Primària Les Corts, Consorci d'Atenció Primària de Salut Barcelona Esquerre (CAPSBE), Barcelona, Spain
| | | | - María-José Soto-Cárdenas
- Department of Internal Medicine, Hospital Universitario Puerta del Mar, Cádiz, University of Cadiz, Cadiz, Spain
| | - Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Barcelona, Spain.
- Department of Medicine, University of Barcelona, Barcelona, Spain.
- Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.
- Servei de Malalties Autoimmunes Sistèmiques, Hospital Clínic, C/Villarroel, 170, 08036, Barcelona, Spain.
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Peukert K, Fox M, Schulz S, Feuerborn C, Frede S, Putensen C, Wrigge H, Kümmerer BM, David S, Seeliger B, Welte T, Latz E, Klinman D, Wilhelm C, Steinhagen F, Bode C. Inhibition of Caspase-1 with Tetracycline Ameliorates Acute Lung Injury. Am J Respir Crit Care Med 2021; 204:53-63. [PMID: 33760701 DOI: 10.1164/rccm.202005-1916oc] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Acute respiratory distress syndrome (ARDS) is a heterogeneous syndrome with a mortality of up to 40%. Precision medicine approaches targeting patients on the basis of their molecular phenotypes of ARDS might help to identify effective pharmacotherapies. The inflammasome-caspase-1 pathway contributes to the development of ARDS via IL-1β and IL-18 production. Recent studies indicate that tetracycline can be used to treat inflammatory diseases mediated by IL-1β and IL-18, although the molecular mechanism by which tetracycline inhibits inflammasome-caspase-1 signaling remains unknown. Objectives: To identify patients with ARDS characterized by IL-1β and IL-18 expression and investigate the ability of tetracycline to inhibit inflammasome-caspase-1 signaling in ARDS. Methods: IL-1β and IL-18 concentrations were quantified in BAL fluid from patients with ARDS. Tetracycline's effects on lung injury and inflammation were assessed in two mouse models of direct (pulmonary) acute lung injury, and its effects on IL-1β and IL-18 production were assessed by alveolar leukocytes from patients with direct ARDS ex vivo. Murine macrophages were used to further characterize the effect of tetracycline on the inflammasome-caspase-1 pathway. Measurements and Main Results: BAL fluid concentrations of IL-1β and IL-18 are significantly higher in patients with direct ARDS than those with indirect (nonpulmonary) ARDS. In experimental acute lung injury, tetracycline significantly diminished lung injury and pulmonary inflammation by selectively inhibiting caspase-1-dependent IL-1β and IL-18 production, leading to improved survival. Tetracycline also reduced the production of IL-1β and IL-18 by alveolar leukocytes from patients with direct ARDS. Conclusions: Tetracycline may be effective in the treatment of direct ARDS in patients with elevated caspase-1 activity. Clinical Trial registered with www.clinicaltrials.gov (NCT04079426).
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Affiliation(s)
- Konrad Peukert
- Department of Anesthesiology and Intensive Care Medicine
| | - Mario Fox
- Department of Anesthesiology and Intensive Care Medicine
| | - Susanne Schulz
- Department of Anesthesiology and Intensive Care Medicine
| | | | - Stilla Frede
- Department of Anesthesiology and Intensive Care Medicine
| | | | - Hermann Wrigge
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | | | - Sascha David
- Department of Nephrology and Hypertension and.,Institute of Intensive Care Medicine, University Hospital Zurich, Zürich, Switzerland; and
| | - Benjamin Seeliger
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | | | - Dennis Klinman
- Cancer and Inflammation Program, National Cancer Institute, Frederick, Maryland
| | - Christoph Wilhelm
- Institute of Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, Bonn, Germany
| | | | - Christian Bode
- Department of Anesthesiology and Intensive Care Medicine
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75
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Spinelli E, Mauri T. Why improved PF ratio should not be our target when treating ARDS. Minerva Anestesiol 2021; 87:752-754. [PMID: 33688707 DOI: 10.23736/s0375-9393.21.15664-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Maggiore Polyclinic Hospital, Milan, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Maggiore Polyclinic Hospital, Milan, Italy - .,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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76
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De Luca D, Cogo P, Kneyber MC, Biban P, Semple MG, Perez-Gil J, Conti G, Tissieres P, Rimensberger PC. Surfactant therapies for pediatric and neonatal ARDS: ESPNIC expert consensus opinion for future research steps. Crit Care 2021; 25:75. [PMID: 33618742 PMCID: PMC7898495 DOI: 10.1186/s13054-021-03489-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 02/04/2021] [Indexed: 12/14/2022] Open
Abstract
Pediatric (PARDS) and neonatal (NARDS) acute respiratory distress syndrome have different age-specific characteristics and definitions. Trials on surfactant for ARDS in children and neonates have been performed well before the PARDS and NARDS definitions and yielded conflicting results. This is mainly due to heterogeneity in study design reflecting historic lack of pathobiology knowledge. We reviewed the available clinical and preclinical data to create an expert consensus aiming to inform future research steps and advance the knowledge in this area. Eight trials investigated the use of surfactant for ARDS in children and ten in neonates, respectively. There were improvements in oxygenation (7/8 trials in children, 7/10 in neonates) and mortality (3/8 trials in children, 1/10 in neonates) improved. Trials were heterogeneous for patients' characteristics, surfactant type and administration strategy. Key pathobiological concepts were missed in study design. Consensus with strong agreement was reached on four statements: 1. There are sufficient preclinical and clinical data to support targeted research on surfactant therapies for PARDS and NARDS. Studies should be performed according to the currently available definitions and considering recent pathobiology knowledge. 2. PARDS and NARDS should be considered as syndromes and should be pre-clinically studied according to key characteristics, such as direct or indirect (primary or secondary) nature, clinical severity, infectious or non-infectious origin or patients' age. 3. Explanatory should be preferred over pragmatic design for future trials on PARDS and NARDS. 4. Different clinical outcomes need to be chosen for PARDS and NARDS, according to the trial phase and design, trigger type, severity class and/or surfactant treatment policy. We advocate for further well-designed preclinical and clinical studies to investigate the use of surfactant for PARDS and NARDS following these principles.
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Affiliation(s)
- Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, 157 Rue de la Porte de Trivaux, 92140, Clamart (Paris-IDF), France.
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France.
| | - Paola Cogo
- Department of Pediatrics, University of Udine, Udine, Italy
| | - Martin C Kneyber
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Beatrix Children's Hospital Groningen, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- Critical Care, Anesthesiology, Peri-Operative and Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Paolo Biban
- Department of Neonatal and Pediatric Critical Care, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Malcolm Grace Semple
- Health Protection Research Unit in Emerging and Zoonotic Infections, Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Jesus Perez-Gil
- Department of Biochemistry and Molecular Biology and Research Institute "Hospital 12 de Octubre", Complutense University, Madrid, Spain
| | - Giorgio Conti
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Rome, Italy
| | - Pierre Tissieres
- Division of Pediatric Critical Care and Neonatal Medicine, "Kremlin-Bicetre" Medical Center, Paris Saclay University Hospitals, APHP, Paris, France
- Integrative Cellular Biology Institute-UMR 9198, Host-Pathogen Interactions Team, Paris Saclay University, Paris, France
| | - Peter C Rimensberger
- Division of Neonatology and Pediatric Critical Care, Department of Pediatrics, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
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Bos LDJ, Artigas A, Constantin JM, Hagens LA, Heijnen N, Laffey JG, Meyer N, Papazian L, Pisani L, Schultz MJ, Shankar-Hari M, Smit MR, Summers C, Ware LB, Scala R, Calfee CS. Precision medicine in acute respiratory distress syndrome: workshop report and recommendations for future research. Eur Respir Rev 2021; 30:30/159/200317. [PMID: 33536264 DOI: 10.1183/16000617.0317-2020] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/11/2020] [Indexed: 12/18/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a devastating critical illness that can be triggered by a wide range of insults and remains associated with a high mortality of around 40%. The search for targeted treatment for ARDS has been disappointing, possibly due to the enormous heterogeneity within the syndrome. In this perspective from the European Respiratory Society research seminar on "Precision medicine in ARDS", we will summarise the current evidence for heterogeneity, explore the evidence in favour of precision medicine and provide a roadmap for further research in ARDS. There is evident variation in the presentation of ARDS on three distinct levels: 1) aetiological; 2) physiological and 3) biological, which leads us to the conclusion that there is no typical ARDS. The lack of a common presentation implies that intervention studies in patients with ARDS need to be phenotype aware and apply a precision medicine approach in order to avoid the lack of success in therapeutic trials that we faced in recent decades. Deeper phenotyping and integrative analysis of the sources of variation might result in identification of additional treatable traits that represent specific pathobiological mechanisms, or so-called endotypes.
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Affiliation(s)
- Lieuwe D J Bos
- Intensive Care, Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands .,Laboratory of Intensive Care and Anesthesiology Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Dept of Respiratory Medicine, Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Antonio Artigas
- Critical Care Center, Corporació Sanitaria Universitaria Parc Tauli, CIBER Enfermedades Respiratorias, Autonomouus University of Barcelona, Sabadell, Spain
| | - Jean-Michel Constantin
- Dept of Anaesthesiology and Critical Care, Sorbonne University, GRC 29, AP-HP, DMU DREAM, Pitié-Salpêtrière Hospital, Paris, France
| | - Laura A Hagens
- Intensive Care, Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nanon Heijnen
- Intensive care, Maastricht UMC, University of Maastricht, Maastricht, The Netherlands
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.,Dept of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Galway, Ireland
| | - Nuala Meyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Laurent Papazian
- Intensive Care Medicine and regional ECMO center, North hospital - Aix-Marseille University, Marseille, France
| | - Lara Pisani
- Dipartimento Cardio-Toraco-Vascolare, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Marcus J Schultz
- Intensive Care, Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Intensive Care and Anesthesiology Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Dept of Respiratory Medicine, Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Manu Shankar-Hari
- School of Immunology & Microbial Sciences, Kings College London, London, UK
| | - Marry R Smit
- Intensive Care, Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Raffaele Scala
- Respiratory Division with Pulmonary Intensive Care Unit, S. Donato Hospital, Usl Toscana Sudest, Arezzo, Italy
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Dept of Medicine, University of California, San Francisco, CA, USA.,Dept of Anesthesia, University of California, San Francisco, CA, USA
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Abstract
PURPOSE OF REVIEW This article provides an overview of protein biomarkers for acute respiratory distress syndrome (ARDS) and their potential use in future clinical trials. RECENT FINDINGS The protein biomarkers studied as indices of biological processes involved in the pathogenesis of ARDS may have diagnostic and/or prognostic value. Recently, they also proved useful for identifying ARDS phenotypes and assessing heterogeneity of treatment effect in retrospective analyses of completed clinical trials. SUMMARY This article summarizes the current research on ARDS biomarkers and provides insights into how they should be integrated as prognostic and predictive enrichment tools in future clinical trials.
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Affiliation(s)
- Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand
- GReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine
| | - Raiko Blondonnet
- Department of Perioperative Medicine, CHU Clermont-Ferrand
- GReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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79
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De Luca D. Respiratory distress syndrome in preterm neonates in the era of precision medicine: A modern critical care-based approach. Pediatr Neonatol 2021; 62 Suppl 1:S3-S9. [PMID: 33358440 DOI: 10.1016/j.pedneo.2020.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/30/2020] [Indexed: 02/07/2023] Open
Abstract
Respiratory distress syndrome (RDS) was recognized to be caused by primary surfactant deficiency almost 70 years ago and continuous positive airway pressure was introduced approximately 50 years ago. Since then, there have been many developments in neonatology; we know many things but others are still controversial. The more we know, the more questions arise. However, this review aims to indicate what is more needed to understand and how should be the modern approach to RDS in the era of precision medicine. The review is divided between new concepts and new tools. We will explain the interaction between steroids, CPAP and surfactant, as well as the surfactant catabolism and the diagnosis of NARDS; lung ultrasound and new tools to optimize CPAP will also be covered. How these concepts are integrated in the author's personal experience is also illustrated.
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Affiliation(s)
- Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP, Paris, France; Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France.
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80
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Hagens LA, Heijnen NFL, Smit MR, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Systematic review of diagnostic methods for acute respiratory distress syndrome. ERJ Open Res 2021; 7:00504-2020. [PMID: 33532455 PMCID: PMC7836439 DOI: 10.1183/23120541.00504-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/18/2020] [Indexed: 01/10/2023] Open
Abstract
Rationale Acute respiratory distress syndrome (ARDS) is currently diagnosed by the Berlin definition, which does not include a direct measure of pulmonary oedema, endothelial permeability or pulmonary inflammation. We hypothesised that biomarkers of these processes have good diagnostic accuracy for ARDS. Methods Medline and Scopus were searched for original diagnostic studies using minimally invasive testing. Primary outcome was the diagnostic accuracy per test and was categorised by control group. The methodological quality was assessed with QUADAS-2 tool. Biomarkers that had an area under the receiver operating characteristic curve (AUROCC) of >0.75 and were studied with minimal bias against an unselected control group were considered to be promising. Results Forty-four articles were included. The median AUROCC for all evaluated tests was 0.80 (25th to 75th percentile: 0.72–0.88). The type of control group influenced the diagnostic accuracy (p=0.0095). Higher risk of bias was associated with higher diagnostic accuracy (AUROCC 0.75 for low-bias, 0.77 for intermediate-bias and 0.84 for high-bias studies; p=0.0023). Club cell protein 16 and soluble receptor for advanced glycation end-products in plasma and two panels with biomarkers of oxidative stress in breath showed good diagnostic accuracy in low-bias studies that compared ARDS patients to an unselected intensive care unit (ICU) population. Conclusion This systematic review revealed only four diagnostic tests fulfilling stringent criteria for a promising biomarker in a low-bias setting. For implementation into the clinical setting, prospective studies in a general unselected ICU population with good methodological quality are needed. Accuracy of diagnosis of acute respiratory distress syndrome (ARDS) is associated with risk of bias. There is a lack of validated diagnostic tests in an unbiased setting, emphasising the need for quality driven diagnostic research in ARDS.https://bit.ly/2GfPAvf
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Affiliation(s)
- Laura A Hagens
- Dept of Intensive Care, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nanon F L Heijnen
- Dept of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marry R Smit
- Dept of Intensive Care, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Dept of Intensive Care, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Dennis C J J Bergmans
- Dept of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | | | - Lieuwe D J Bos
- Dept of Intensive Care, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Dept of Respiratory Medicine, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
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81
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Molecular and biophysical mechanisms behind the enhancement of lung surfactant function during controlled therapeutic hypothermia. Sci Rep 2021; 11:728. [PMID: 33436647 PMCID: PMC7804441 DOI: 10.1038/s41598-020-79025-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/27/2020] [Indexed: 12/11/2022] Open
Abstract
Therapeutic hypothermia (TH) enhances pulmonary surfactant performance in vivo by molecular mechanisms still unknown. Here, the interfacial structure and the composition of lung surfactant films have been analysed in vitro under TH as well as the molecular basis of its improved performance both under physiological and inhibitory conditions. The biophysical activity of a purified porcine surfactant was tested under slow and breathing-like dynamics by constrained drop surfactometry (CDS) and in the captive bubble surfactometer (CBS) at both 33 and 37 °C. Additionally, the temperature-dependent surfactant activity was also analysed upon inhibition by plasma and subsequent restoration by further surfactant supplementation. Interfacial performance was correlated with lateral structure and lipid composition of films made of native surfactant. Lipid/protein mixtures designed as models to mimic different surfactant contexts were also studied. The capability of surfactant to drastically reduce surface tension was enhanced at 33 °C. Larger DPPC-enriched domains and lower percentages of less active lipids were detected in surfactant films exposed to TH-like conditions. Surfactant resistance to plasma inhibition was boosted and restoration therapies were more effective at 33 °C. This may explain the improved respiratory outcomes observed in cooled patients with acute respiratory distress syndrome and opens new opportunities in the treatment of acute lung injury.
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82
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Sinha P, Calfee CS, Delucchi KL. Practitioner's Guide to Latent Class Analysis: Methodological Considerations and Common Pitfalls. Crit Care Med 2021; 49:e63-e79. [PMID: 33165028 PMCID: PMC7746621 DOI: 10.1097/ccm.0000000000004710] [Citation(s) in RCA: 234] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Latent class analysis is a probabilistic modeling algorithm that allows clustering of data and statistical inference. There has been a recent upsurge in the application of latent class analysis in the fields of critical care, respiratory medicine, and beyond. In this review, we present a brief overview of the principles behind latent class analysis. Furthermore, in a stepwise manner, we outline the key processes necessary to perform latent class analysis including some of the challenges and pitfalls faced at each of these steps. The review provides a one-stop shop for investigators seeking to apply latent class analysis to their data.
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Affiliation(s)
- Pratik Sinha
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine; University of California, San Francisco; San Francisco, CA
- Department of Anesthesia; University of California, San Francisco; San Francisco, CA
| | - Carolyn S. Calfee
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine; University of California, San Francisco; San Francisco, CA
- Department of Anesthesia; University of California, San Francisco; San Francisco, CA
| | - Kevin L. Delucchi
- Department of Psychiatry; University of California, San Francisco; San Francisco, CA
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83
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Anti-inflammatory Effects of Statins in Lung Vascular Pathology: From Basic Science to Clinical Trials. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1303:33-56. [PMID: 33788186 DOI: 10.1007/978-3-030-63046-1_3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
HMG-CoA reductase inhibitors (or statins) are cholesterol-lowering drugs and are among the most widely prescribed medications in the United States. Statins exhibit pleiotropic effects that extend beyond cholesterol reduction including anti-atherosclerotic, antiproliferative, anti-inflammatory, and antithrombotic effects. Over the last 20 years, statins have been studied and examined in pulmonary vascular disorders, including both chronic pulmonary vascular disease such as pulmonary hypertension, and acute pulmonary vascular endothelial injury such as acute lung injury. In both research and clinical settings, statins have demonstrated promising vascular protection through modulation of the endothelium, attenuation of vascular leak, and promotion of endothelial repair following lung inflammation. This chapter provides a summary of the rapidly changing literature, summarizes the anti-inflammatory mechanism of statins on pulmonary vascular disorders, and explores clinical evidence for statins as a potential therapeutic approach to modulation of the endothelium as well as a means to broaden our understanding of pulmonary vasculopathy pathophysiology.
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84
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Abstract
PURPOSE OF REVIEW Most clinical trials of lung-protective ventilation have tested one-size-fits-all strategies with mixed results. Data are lacking on how best to tailor mechanical ventilation to patient-specific risk of lung injury. RECENT FINDINGS Risk of ventilation-induced lung injury is determined by biological predisposition to biophysical lung injury and physical mechanical perturbations that concentrate stress and strain regionally within the lung. Recent investigations have identified molecular subphenotypes classified as hyperinflammatory and hypoinflammatory acute respiratory distress syndrome (ARDS), which may have dissimilar risk for ventilation-induced lung injury. Mechanically, gravity-dependent atelectasis has long been recognized to decrease total aerated lung volume available for tidal ventilation, a concept termed the 'ARDS baby lung'. Recent studies have demonstrated that the aerated baby lung also has nonuniform stress/strain distribution, with potentially injurious forces concentrated in zones of heterogeneity where aerated alveoli are adjacent to flooded or atelectatic alveoli. The preponderance of evidence also indicates that current standard-of-care tidal volume management is not universally protective in ARDS. When considering escalation of lung-protective interventions, potential benefits of the intervention should be weighed against tradeoffs of accompanying cointerventions required, for example, deeper sedation or neuromuscular blockade. A precision medicine approach to lung-protection would weigh. SUMMARY A precision medicine approach to lung-protective ventilation requires weighing four key factors in each patient: biological predisposition to biophysical lung injury, mechanical predisposition to biophysical injury accounting for spatial mechanical heterogeneity within the lung, anticipated benefits of escalating lung-protective interventions, and potential unintended adverse effects of mandatory cointerventions.
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85
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Matthay MA, Arabi YM, Siegel ER, Ware LB, Bos LDJ, Sinha P, Beitler JR, Wick KD, Curley MAQ, Constantin JM, Levitt JE, Calfee CS. Phenotypes and personalized medicine in the acute respiratory distress syndrome. Intensive Care Med 2020; 46:2136-2152. [PMID: 33206201 PMCID: PMC7673253 DOI: 10.1007/s00134-020-06296-9] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/13/2020] [Indexed: 12/15/2022]
Abstract
Although the acute respiratory distress syndrome (ARDS) is well defined by the development of acute hypoxemia, bilateral infiltrates and non-cardiogenic pulmonary edema, ARDS is heterogeneous in terms of clinical risk factors, physiology of lung injury, microbiology, and biology, potentially explaining why pharmacologic therapies have been mostly unsuccessful in treating ARDS. Identifying phenotypes of ARDS and integrating this information into patient selection for clinical trials may increase the chance for efficacy with new treatments. In this review, we focus on classifying ARDS by the associated clinical disorders, physiological data, and radiographic imaging. We consider biologic phenotypes, including plasma protein biomarkers, gene expression, and common causative microbiologic pathogens. We will also discuss the issue of focusing clinical trials on the patient's phase of lung injury, including prevention, administration of therapy during early acute lung injury, and treatment of established ARDS. A more in depth understanding of the interplay of these variables in ARDS should provide more success in designing and conducting clinical trials and achieving the goal of personalized medicine.
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Affiliation(s)
- Michael A Matthay
- Department of Anesthesia, University of California San Francisco, San Francisco, CA, USA.
- Cardiovascular Research Institute, University of California, San Francisco, USA.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, USA.
| | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Emily R Siegel
- Cardiovascular Research Institute, University of California, San Francisco, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lieuwe D J Bos
- Department of Respiratory Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Infection and Immunity, Amsterdam, The Netherlands
| | - Pratik Sinha
- Department of Anesthesiology, Washington University, Saint Louis, MO, USA
| | - Jeremy R Beitler
- Division of Pulmonary, Allergy, and Critical Care Medicine, Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Katherine D Wick
- Cardiovascular Research Institute, University of California, San Francisco, USA
| | - Martha A Q Curley
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Jean-Michel Constantin
- Department of Anesthesia and Critical Care, La Pitié Salpetriere Hospital, University Paris-Sorbonne, Paris, France
| | - Joseph E Levitt
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Carolyn S Calfee
- Department of Anesthesia, University of California San Francisco, San Francisco, CA, USA
- Cardiovascular Research Institute, University of California, San Francisco, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, USA
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86
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Sinha P, Churpek MM, Calfee CS. Machine Learning Classifier Models Can Identify Acute Respiratory Distress Syndrome Phenotypes Using Readily Available Clinical Data. Am J Respir Crit Care Med 2020; 202:996-1004. [PMID: 32551817 DOI: 10.1164/rccm.202002-0347oc] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Rationale: Two distinct phenotypes of acute respiratory distress syndrome (ARDS) with differential clinical outcomes and responses to randomly assigned treatment have consistently been identified in randomized controlled trial cohorts using latent class analysis. Plasma biomarkers, key components in phenotype identification, currently lack point-of-care assays and represent a barrier to the clinical implementation of phenotypes.Objectives: The objective of this study was to develop models to classify ARDS phenotypes using readily available clinical data only.Methods: Three randomized controlled trial cohorts served as the training data set (ARMA [High vs. Low Vt], ALVEOLI [Assessment of Low Vt and Elevated End-Expiratory Pressure to Obviate Lung Injury], and FACTT [Fluids and Catheter Treatment Trial]; n = 2,022), and a fourth served as the validation data set (SAILS [Statins for Acutely Injured Lungs from Sepsis]; n = 745). A gradient-boosted machine algorithm was used to develop classifier models using 24 variables (demographics, vital signs, laboratory, and respiratory variables) at enrollment. In two secondary analyses, the ALVEOLI and FACTT cohorts each, individually, served as the validation data set, and the remaining combined cohorts formed the training data set for each analysis. Model performance was evaluated against the latent class analysis-derived phenotype.Measurements and Main Results: For the primary analysis, the model accurately classified the phenotypes in the validation cohort (area under the receiver operating characteristic curve [AUC], 0.95; 95% confidence interval [CI], 0.94-0.96). Using a probability cutoff of 0.5 to assign class, inflammatory biomarkers (IL-6, IL-8, and sTNFR-1; P < 0.0001) and 90-day mortality (38% vs. 24%; P = 0.0002) were significantly higher in the hyperinflammatory phenotype as classified by the model. Model accuracy was similar when ALVEOLI (AUC, 0.94; 95% CI, 0.92-0.96) and FACTT (AUC, 0.94; 95% CI, 0.92-0.95) were used as the validation cohorts. Significant treatment interactions were observed with the clinical classifier model-assigned phenotypes in both ALVEOLI (P = 0.0113) and FACTT (P = 0.0072) cohorts.Conclusions: ARDS phenotypes can be accurately identified using machine learning models based on readily available clinical data and may enable rapid phenotype identification at the bedside.
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Affiliation(s)
- Pratik Sinha
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, and.,Department of Anesthesia, University of California San Francisco, San Francisco, California; and
| | - Matthew M Churpek
- Department of Medicine, University of Wisconsin, Madison, Madison, Wisconsin
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, and.,Department of Anesthesia, University of California San Francisco, San Francisco, California; and
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87
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Current and evolving standards of care for patients with ARDS. Intensive Care Med 2020; 46:2157-2167. [PMID: 33156382 PMCID: PMC7646492 DOI: 10.1007/s00134-020-06299-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/13/2020] [Indexed: 12/16/2022]
Abstract
Care for patients with acute respiratory distress syndrome (ARDS) has changed considerably over the 50 years since its original description. Indeed, standards of care continue to evolve as does how this clinical entity is defined and how patients are grouped and treated in clinical practice. In this narrative review we discuss current standards – treatments that have a solid evidence base and are well established as targets for usual care – and also evolving standards – treatments that have promise and may become widely adopted in the future. We focus on three broad domains of ventilatory management, ventilation adjuncts, and pharmacotherapy. Current standards for ventilatory management include limitation of tidal volume and airway pressure and standard approaches to setting PEEP, while evolving standards might focus on limitation of driving pressure or mechanical power, individual titration of PEEP, and monitoring efforts during spontaneous breathing. Current standards in ventilation adjuncts include prone positioning in moderate-severe ARDS and veno-venous extracorporeal life support after prone positioning in patients with severe hypoxemia or who are difficult to ventilate. Pharmacotherapy current standards include corticosteroids for patients with ARDS due to COVID-19 and employing a conservative fluid strategy for patients not in shock; evolving standards may include steroids for ARDS not related to COVID-19, or specific biological agents being tested in appropriate sub-phenotypes of ARDS. While much progress has been made, certainly significant work remains to be done and we look forward to these future developments.
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88
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Pelletier JH, Horvat CM. Can Computer Decision Support Help Us Follow Our Own Rules in Pediatric Acute Respiratory Distress Syndrome? Pediatr Crit Care Med 2020; 21:1000-1001. [PMID: 33136985 PMCID: PMC7884101 DOI: 10.1097/pcc.0000000000002567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Computerized decision support in pediatric #ARDS may improve guideline compliance. Can #MachineLearning improve on this further? @drjonpelly and @cmhorvat discuss a new phase one clinical trial in this month’s @PedCritCareMed.
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Affiliation(s)
- Jonathan H Pelletier
- Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Christopher M Horvat
- Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh; and Division of Health Informatics, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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89
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Loftus TJ, Upchurch GR, Delitto D, Rashidi P, Bihorac A. Mysteries, Epistemological Modesty, and Artificial Intelligence in Surgery. Front Artif Intell 2020; 2. [PMID: 33117989 PMCID: PMC7591149 DOI: 10.3389/frai.2019.00032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Life is filled with puzzles and mysteries, and we often fail to recognize the difference. As described by Gregory Treverton and Malcolm Gladwell, puzzles are solved by gathering and assimilating all relevant data in a logical, linear fashion, as in deciding which antibiotic to prescribe for an infection. In contrast, mysteries remain unsolved until all relevant data are analyzed and interpreted in a way that appreciates their depth and complexity, as in determining how to best modulate the host immune response to infection. When investigating mysteries, we often fail to appreciate their depth and complexity. Instead, we gather and assimilate more data, treating the mystery like a puzzle. This strategy is often unsuccessful. Traditional approaches to predictive analytics and phenotyping in surgery use this strategy.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Gilbert R Upchurch
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Daniel Delitto
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Parisa Rashidi
- Departments of Biomedical Engineering, Computer and Information Science and Engineering, and Electrical and Computer Engineering, University of Florida, Gainesville, FL, United States
| | - Azra Bihorac
- Department of Medicine, University of Florida Health, Gainesville, FL, United States
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90
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de Rivero Vaccari JC, Dietrich WD, Keane RW, de Rivero Vaccari JP. The Inflammasome in Times of COVID-19. Front Immunol 2020; 11:583373. [PMID: 33149733 PMCID: PMC7580384 DOI: 10.3389/fimmu.2020.583373] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/07/2020] [Indexed: 12/15/2022] Open
Abstract
Coronaviruses (CoVs) are members of the genus Betacoronavirus and the Coronaviridiae family responsible for infections such as severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and more recently, coronavirus disease-2019 (COVID-19). CoV infections present mainly as respiratory infections that lead to acute respiratory distress syndrome (ARDS). However, CoVs, such as COVID-19, also present as a hyperactivation of the inflammatory response that results in increased production of inflammatory cytokines such as interleukin (IL)-1β and its downstream molecule IL-6. The inflammasome is a multiprotein complex involved in the activation of caspase-1 that leads to the activation of IL-1β in a variety of diseases and infections such as CoV infection and in different tissues such as lungs, brain, intestines and kidneys, all of which have been shown to be affected in COVID-19 patients. Here we review the literature regarding the mechanism of inflammasome activation by CoV infection, the role of the inflammasome in ARDS, ventilator-induced lung injury (VILI), and Disseminated Intravascular Coagulation (DIC) as well as the potential mechanism by which the inflammasome may contribute to the damaging effects of inflammation in the cardiac, renal, digestive, and nervous systems in COVID-19 patients.
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Affiliation(s)
| | - W Dalton Dietrich
- Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Robert W Keane
- Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States.,Department of Physiology and Biophysics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Juan Pablo de Rivero Vaccari
- Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States.,Center for Cognitive Neuroscience and Aging University of Miami Miller School of Medicine, Miami, FL, United States
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91
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De Stefano L, Bobbio-Pallavicini F, Manzo A, Montecucco C, Bugatti S. A "Window of Therapeutic Opportunity" for Anti-Cytokine Therapy in Patients With Coronavirus Disease 2019. Front Immunol 2020; 11:572635. [PMID: 33123149 PMCID: PMC7572850 DOI: 10.3389/fimmu.2020.572635] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/21/2020] [Indexed: 12/15/2022] Open
Abstract
The effects of cytokine inhibition in the different phases of the severe coronavirus disease 2019 (COVID-19) are currently at the center of intense debate, and preliminary results from observational studies and case reports offer conflicting results thus far. The identification of the correct timing of administration of anti-cytokine therapies and other immunosuppressants in COVID-19 should take into account the intricate relationship between the viral burden, the hyperactivation of the innate immune system and the adaptive immune dysfunction. The main challenge for effective administration of anti-cytokine therapy in COVID-19 will be therefore to better define a precise "window of therapeutic opportunity." Only considering a more specific set of criteria able to integrate information on direct viral damage, the cytokine burden, and the patient's immune vulnerability, it will be possible to decide, carefully balancing both benefits and risks, the appropriateness of using immunosuppressive drugs even in patients affected primarily by an infectious disease.
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Affiliation(s)
- Ludovico De Stefano
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | | | - Antonio Manzo
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Carlomaurizio Montecucco
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Serena Bugatti
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
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92
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Bos LDJ, Paulus F, Vlaar APJ, Beenen LFM, Schultz MJ. Subphenotyping Acute Respiratory Distress Syndrome in Patients with COVID-19: Consequences for Ventilator Management. Ann Am Thorac Soc 2020; 17:1161-1163. [PMID: 32396457 PMCID: PMC7462326 DOI: 10.1513/annalsats.202004-376rl] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Lieuwe D. J. Bos
- UMC Amsterdam Amsterdam, the Netherlands
- University of AmsterdamAmsterdam, the Netherlands
| | | | | | | | - Marcus J. Schultz
- UMC Amsterdam Amsterdam, the Netherlands
- Mahidol UniversityBangkok, Thailandand
- University of OxfordOxford, United Kingdom
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93
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Sinha P, Calfee CS, Cherian S, Brealey D, Cutler S, King C, Killick C, Richards O, Cheema Y, Bailey C, Reddy K, Delucchi KL, Shankar-Hari M, Gordon AC, Shyamsundar M, O'Kane CM, McAuley DF, Szakmany T. Prevalence of phenotypes of acute respiratory distress syndrome in critically ill patients with COVID-19: a prospective observational study. THE LANCET RESPIRATORY MEDICINE 2020; 8:1209-1218. [PMID: 32861275 PMCID: PMC7718296 DOI: 10.1016/s2213-2600(20)30366-0] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/04/2020] [Accepted: 07/27/2020] [Indexed: 12/21/2022]
Abstract
Background In acute respiratory distress syndrome (ARDS) unrelated to COVID-19, two phenotypes, based on the severity of systemic inflammation (hyperinflammatory and hypoinflammatory), have been described. The hyperinflammatory phenotype is known to be associated with increased multiorgan failure and mortality. In this study, we aimed to identify these phenotypes in COVID-19-related ARDS. Methods In this prospective observational study done at two UK intensive care units, we recruited patients with ARDS due to COVID-19. Demographic, clinical, and laboratory data were collected at baseline. Plasma samples were analysed for interleukin-6 (IL-6) and soluble tumour necrosis factor receptor superfamily member 1A (TNFR1) using a novel point-of-care assay. A parsimonious regression classifier model was used to calculate the probability for the hyperinflammatory phenotype in COVID-19 using IL-6, soluble TNFR1, and bicarbonate levels. Data from this cohort was compared with patients with ARDS due to causes other than COVID-19 recruited to a previous UK multicentre, randomised controlled trial of simvastatin (HARP-2). Findings Between March 17 and April 25, 2020, 39 patients were recruited to the study. Median ratio of partial pressure of arterial oxygen to fractional concentration of oxygen in inspired air (PaO2/FiO2) was 18 kpa (IQR 15–21) and acute physiology and chronic health evaluation II score was 12 (10–16). 17 (44%) of 39 patients had died by day 28 of the study. Compared with survivors, patients who died were older and had lower PaO2/FiO2. The median probability for the hyperinflammatory phenotype was 0·03 (IQR 0·01–0·2). Depending on the probability cutoff used to assign class, the prevalence of the hyperinflammatory phenotype was between four (10%) and eight (21%) of 39, which is lower than the proportion of patients with the hyperinflammatory phenotype in HARP-2 (186 [35%] of 539). Using the Youden index cutoff (0·274) to classify phenotype, five (63%) of eight patients with the hyperinflammatory phenotype and 12 (39%) of 31 with the hypoinflammatory phenotype died. Compared with matched patients recruited to HARP-2, levels of IL-6 were similar in our cohort, whereas soluble TNFR1 was significantly lower in patients with COVID-19-associated ARDS. Interpretation In this exploratory analysis of 39 patients, ARDS due to COVID-19 was not associated with higher systemic inflammation and was associated with a lower prevalence of the hyperinflammatory phenotype than that observed in historical ARDS data. This finding suggests that the excess mortality observed in COVID-19-related ARDS is unlikely to be due to the upregulation of inflammatory pathways described by the parsimonious model. Funding US National Institutes of Health, Innovate UK, and Randox.
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Affiliation(s)
- Pratik Sinha
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Department of Anesthesia, University of California San Francisco, San Francisco, CA, USA.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Department of Anesthesia, University of California San Francisco, San Francisco, CA, USA
| | - Shiney Cherian
- Critical Care Directorate, Royal Gwent Hospital, Newport, UK
| | - David Brealey
- Division of Critical Care, National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
| | - Sean Cutler
- Critical Care Directorate, Royal Gwent Hospital, Newport, UK
| | - Charles King
- Critical Care Directorate, Royal Gwent Hospital, Newport, UK; Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Charlotte Killick
- Critical Care Directorate, Royal Gwent Hospital, Newport, UK; Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Owen Richards
- Critical Care Directorate, Royal Gwent Hospital, Newport, UK; Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Yusuf Cheema
- Critical Care Directorate, Royal Gwent Hospital, Newport, UK; Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | - Kiran Reddy
- Department of Anaesthesiology and Critical Care, Beaumont Hospital, Dublin, Ireland
| | - Kevin L Delucchi
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA
| | - Manu Shankar-Hari
- ICU support offices, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Immunology and Microbial Sciences, Kings College London, London, UK
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Murali Shyamsundar
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK; Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | - Cecilia M O'Kane
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK; Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | - Tamas Szakmany
- Critical Care Directorate, Royal Gwent Hospital, Newport, UK; Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff, UK
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94
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Tirolien JA, Garnier M. [COVID-19, an atypical acute respiratory distress syndrome]. LE PRATICIEN EN ANESTHESIE REANIMATION 2020; 24:225-229. [PMID: 32837209 PMCID: PMC7351392 DOI: 10.1016/j.pratan.2020.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
L’infection au nouveau coronavirus Sars-Cov2 est responsable d’une forme sévère de pneumonie, la COVID-19 pouvant évoluer vers un tableau de syndrome de détresse respiratoire aiguë. Cependant, bien que les critères d’hypoxémie soient présents, ce SDRA diffère des formes classiques, notamment en raison d’une compliance pulmonaire le plus souvent normale au stade initial. Ceci suggère des mécanismes physiopathologiques spécifiques encore mal compris, qui aboutissent à des profils de la maladie devant faire repenser la ventilation protectrice, afin de limiter la genèse des lésions pulmonaires induites par la ventilation.
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Affiliation(s)
- Jo-Anna Tirolien
- Service d'anesthésie réanimation, hôpital Saint-Antoine, hôpitaux Sorbonne Université, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Marc Garnier
- Service d'anesthésie réanimation, hôpital Saint-Antoine, hôpitaux Sorbonne Université, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
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95
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Bos LDJ. COVID-19-related Acute Respiratory Distress Syndrome: Not So Atypical. Am J Respir Crit Care Med 2020; 202:622-624. [PMID: 32579026 PMCID: PMC7427387 DOI: 10.1164/rccm.202004-1423le] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Lieuwe D J Bos
- Amsterdam University Medical Center, location Academic Medical Centerand.,University of AmsterdamAmsterdam, the Netherlands
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96
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Matera MG, Rogliani P, Bianco A, Cazzola M. Pharmacological management of adult patients with acute respiratory distress syndrome. Expert Opin Pharmacother 2020; 21:2169-2183. [PMID: 32783481 DOI: 10.1080/14656566.2020.1801636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION There is still no definite drug for acute respiratory distress syndrome (ARDS) that is capable of reducing either short-term or long-term mortality. Therefore, great efforts are being made to identify a pharmacological approach that can be really effective. AREAS COVERED This review focuses on current challenges and future directions in the pharmacological management of ARDS, regardless of anti-infective treatments. The authors have excluded small randomized controlled trials (RCTs) with less than 60 patients because those studies do not have statistical power for outcome data, and also anecdotal trials but have considered the last meta-analysis on any drug. EXPERT OPINION There has been substantial progress in our knowledge of ARDS over the past two decades and many drugs have been used in its treatment. Nevertheless, effective targeted pharmacological treatments for ARDS are still lacking. The likely reason why a pharmacological approach is beneficial for some patients, but harmful for others is that ARDS is an extremely heterogeneous syndrome. To overcome this issue, a precision approach for ARDS, whereby therapies are specifically targeted to patients most likely to benefit, has been proposed. At present, however, the application of this approach seems to be a difficult task.
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Affiliation(s)
- Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Paola Rogliani
- Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome, Italy
| | - Andrea Bianco
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli"/Monaldi Hospital , Naples, Italy
| | - Mario Cazzola
- Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome, Italy
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97
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Theuerkauf N, Weismüller T, Weißbrich C, Schewe JC, Putensen C, Bode C. Direct acute respiratory distress syndrome after gastric perforation caused by an intragastric balloon: a case report. BMC Anesthesiol 2020; 20:182. [PMID: 32711459 PMCID: PMC7382036 DOI: 10.1186/s12871-020-01101-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 07/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a life-threatening condition and the identification of the underlying direct (pulmonary) or indirect (non-pulmonary) cause is mandatory for a successful treatment. Intragastric balloon (IGB) therapy is a minimal invasive and supposedly harmless option to reduce body weight for the growing number of obese people. We present a case of a young patient who developed a direct ARDS due to initially undiagnosed abdominal pathologies caused by an IGB therapy. CASE PRESENTATION A 23-year old woman was admitted because of a direct ARDS for extracorporeal membrane oxygenation (ECMO) therapy. Weeks before, an IGB has been removed because of abdominal pain and free intraabdominal air. Diagnostic work-up of free intraabdominal air, previous pain of the left shoulder and newly developed abscess pneumonia revealed a perforation of the posterior wall of the gastral antrum. This resulted in a left subphrenic abscess with destruction of the diaphragm, development of pneumonia per continuitatem and subsequent direct lung injury. The gastric perforation was endoscopically clipped and the ARDS was successfully treated under ECMO therapy. CONCLUSION This case illustrates that a patient presenting with direct ARDS may have upper abdominal pathologies caused by a rare complication of a supposedly harmless treatment.
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Affiliation(s)
- Nils Theuerkauf
- Department of Anesthesiology and Critical Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Tobias Weismüller
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Carsten Weißbrich
- Department of Anesthesiology and Critical Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jens-Christian Schewe
- Department of Anesthesiology and Critical Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Christian Putensen
- Department of Anesthesiology and Critical Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Christian Bode
- Department of Anesthesiology and Critical Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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98
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Jabaudon M, Audard J, Pereira B, Jaber S, Lefrant JY, Blondonnet R, Godet T, Futier E, Lambert C, Bazin JE, Bastarache JA, Constantin JM, Ware LB. Early Changes Over Time in the Radiographic Assessment of Lung Edema Score Are Associated With Survival in ARDS. Chest 2020; 158:2394-2403. [PMID: 32659235 PMCID: PMC7768934 DOI: 10.1016/j.chest.2020.06.070] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/10/2020] [Accepted: 06/26/2020] [Indexed: 12/12/2022] Open
Abstract
Background The Radiographic Assessment of Lung Edema (RALE) score is associated with the severity of ARDS, and treatments targeted at reducing pulmonary edema such as conservative fluid management cause a reduction in RALE score over time. Research Question Are early changes in RALE score over time associated with survival in patients with ARDS? Study Design and Methods Data from patients enrolled in three centers in the Lung Imaging for Ventilation sEtting in ARDS (LIVE) trial with available chest radiographs at baseline (day 0) and days 2 or 3 were used. The RALE was scored by two independent reviewers. The primary end point was death by day 90, considering RALE score both at baseline and as a time-varying covariate in a marginal Cox survival model. Results RALE was scored from 135, 64, and 88 radiographs on days 0, 2, and 3, respectively. Both baseline RALE (hazard ratio [HR] for each one-point increment, 1.04; 95% CI, 1.01-1.08; P = .006) and the change in RALE over time (HR for each one-point decrease per unit of time, 0.99; 95% CI, 0.99-0.99; P = .03) were associated with death by day 90, even after adjustment for age, sex, BMI, Simplified Acute Physiology Score II, vasopressor use, and total volume of fluids received since study entry. Interpretation The change in RALE during the first days after ARDS onset is independently associated with survival and may be useful as a surrogate end point in future clinical trials of new therapeutics in ARDS.
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Affiliation(s)
- Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France; GReD, CNRS UMR 6293, INSERM U1103, Université Clermont Auvergne, Clermont-Ferrand, France; Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.
| | - Jules Audard
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France; GReD, CNRS UMR 6293, INSERM U1103, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics and Data Management Unit, Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Samir Jaber
- Montpellier University Hospital, Saint Eloi Intensive Care Unit and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Jean-Yves Lefrant
- Service de Recherche Clinique en Soins Critiques, Pôle Anesthésie Douleur Urgences Réanimation, Centre Hospitalier Universitaire de Nîmes, Université de Montpellier, Montpellier, France
| | - Raiko Blondonnet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France; GReD, CNRS UMR 6293, INSERM U1103, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Thomas Godet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France; GReD, CNRS UMR 6293, INSERM U1103, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Céline Lambert
- Biostatistics and Data Management Unit, Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Etienne Bazin
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Julie A Bastarache
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Departments of Cell and Developmental Biology, Vanderbilt University, Nashville, TN; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Jean-Michel Constantin
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
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99
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Robinson MJ, Krasnodembskaya AD. Therapeutic targeting of metabolic alterations in acute respiratory distress syndrome. Eur Respir Rev 2020; 29:29/156/200114. [PMID: 32620587 DOI: 10.1183/16000617.0114-2020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/04/2020] [Indexed: 12/29/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) remains a significant source of mortality in critically ill patients. Characterised by acute, widespread alveolar inflammation and pulmonary oedema, its pathophysiological heterogeneity has meant that targeted treatments have remained elusive. Metabolomic analysis has made initial steps in characterising the underlying metabolic derangements of ARDS as an indicator of phenotypical class and has identified mitochondrial dysfunction as a potential therapeutic target. Mesenchymal stem cells and their derived extracellular vesicles have shown significant promise as potential therapies in delivering mitochondria in order to redivert metabolism onto physiological pathways.
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Affiliation(s)
- Matthew John Robinson
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University of Belfast, Belfast, UK
| | - Anna D Krasnodembskaya
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University of Belfast, Belfast, UK
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100
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External Validation of an Acute Respiratory Distress Syndrome Prediction Model Using Radiology Reports. Crit Care Med 2020; 48:e791-e798. [PMID: 32590389 DOI: 10.1097/ccm.0000000000004468] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Acute respiratory distress syndrome is frequently under recognized and associated with increased mortality. Previously, we developed a model that used machine learning and natural language processing of text from radiology reports to identify acute respiratory distress syndrome. The model showed improved performance in diagnosing acute respiratory distress syndrome when compared to a rule-based method. In this study, our objective was to externally validate the natural language processing model in patients from an independent hospital setting. DESIGN Secondary analysis of data across five prospective clinical studies. SETTING An urban, tertiary care, academic hospital. PATIENTS Adult patients admitted to the medical ICU and at-risk for acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The natural language processing model was previously derived and internally validated in burn, trauma, and medical patients at Loyola University Medical Center. Two machine learning models were examined with the following text features from qualifying radiology reports: 1) word representations (n-grams) and 2) standardized clinical named entity mentions mapped from the National Library of Medicine Unified Medical Language System. The models were externally validated in a cohort of 235 patients at the University of Chicago Medicine, among which 110 (47%) were diagnosed with acute respiratory distress syndrome by expert annotation. During external validation, the n-gram model demonstrated good discrimination between acute respiratory distress syndrome and nonacute respiratory distress syndrome patients (C-statistic, 0.78; 95% CI, 0.72-0.84). The n-gram model had a higher discrimination for acute respiratory distress syndrome when compared with the standardized named entity model, although not statistically significant (C-statistic 0.78 vs 0.72; p = 0.09). The most important features in the model had good face validity for acute respiratory distress syndrome characteristics but differences in frequencies did occur between hospital settings. CONCLUSIONS Our computable phenotype for acute respiratory distress syndrome had good discrimination in external validation and may be used by other health systems for case-identification. Discrepancies in feature representation are likely due to differences in characteristics of the patient cohorts.
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