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Moderate Peep After Tracheal Lipopolysaccharide Instillation Prevents Inflammation and Modifies the Pattern of Brain Neuronal Activation. Shock 2016; 44:601-8. [PMID: 26398809 PMCID: PMC4851224 DOI: 10.1097/shk.0000000000000469] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Ventilatory strategy and specifically positive end-expiratory pressure (PEEP) can modulate the inflammatory response and pulmonary-to-systemic translocation of lipopolysaccharide (LPS). Both inflammation and ventilatory pattern may modify brain activation, possibly worsening the patient's outcome and resulting in cognitive sequelae. Methods: We prospectively studied Sprague–Dawley rats randomly assigned to undergo 3 h mechanical ventilation with 7 mL/kg tidal ventilation and either 2 cmH2O or 7 cmH2O PEEP after intratracheal instillation of LPS or saline. Healthy nonventilated rats served as baseline. We analyzed lung mechanics, gas exchange, lung and plasma cytokine levels, lung apoptotic cells, and lung neutrophil infiltration. To evaluate brain neuronal activation, we counted c-Fos immunopositive cells in the retrosplenial cortex (RS), thalamus, supraoptic nucleus (SON), nucleus of the solitary tract (NTS), paraventricular nucleus (PVN), and central amygdala (CeA). Results: LPS increased lung neutrophilic infiltration, lung and systemic MCP-1 levels, and neuronal activation in the CeA and NTS. LPS-instilled rats receiving 7 cmH2O PEEP had less lung and systemic inflammation and more c-Fos-immunopositive cells in the RS, SON, and thalamus than those receiving 2 cmH2O PEEP. Applying 7 cmH2O PEEP increased neuronal activation in the CeA and NTS in saline-instilled rats, but not in LPS-instilled rats. Conclusions: Moderate PEEP prevented lung and systemic inflammation secondary to intratracheal LPS instillation. PEEP also modified the neuronal activation pattern in the RS, SON, and thalamus. The relevance of these differential brain c-Fos expression patterns in neurocognitive outcomes should be explored.
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Lung-brain cross talk in the critically ill. Intensive Care Med 2016; 43:557-559. [PMID: 27714405 DOI: 10.1007/s00134-016-4583-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 09/28/2016] [Indexed: 12/13/2022]
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Borsellino B, Schultz MJ, Gama de Abreu M, Robba C, Bilotta F. Mechanical ventilation in neurocritical care patients: a systematic literature review. Expert Rev Respir Med 2016; 10:1123-32. [DOI: 10.1080/17476348.2017.1235976] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Chen T, Chen C, Zhang Z, Zou Y, Peng M, Wang Y. Toll-like receptor 4 knockout ameliorates neuroinflammation due to lung-brain interaction in mechanically ventilated mice. Brain Behav Immun 2016; 56:42-55. [PMID: 27067748 DOI: 10.1016/j.bbi.2016.04.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/31/2016] [Accepted: 04/08/2016] [Indexed: 02/07/2023] Open
Abstract
Toll-like receptor 4 (TLR4) is a crucial receptor in the innate immune system, and increasing evidence supports its role in inflammation, stress, and tissue injury, including injury to the lung and brain. We aimed to investigate the effects of TLR4 on neuroinflammation due to the lung-brain interaction in mechanically ventilated mice. Male wild-type (WT) C57BL/6 and TLR4 knockout (TLR4 KO) mice were divided into three groups: (1) control group (C): spontaneous breathing; (2) anesthesia group (A): spontaneous breathing under anesthesia; and (3) mechanical ventilation group (MV): 6h of MV under anesthesia. The behavioral responses of mice were tested with fear conditioning tests. The histological changes in the lung and brain were assessed using hematoxylin-eosin (HE) staining. The level of TLR4 mRNA in tissue was measured using reverse transcription-polymerase chain reaction (RT-PCR). The levels of inflammatory cytokines were measured with an enzyme-linked immunosorbent assay (ELISA). Microgliosis, astrocytosis, and the TLR4 immunoreactivity in the hippocampus were measured by double immunofluorescence. MV mice exhibited impaired cognition, and this impairment was less severe in TLR4 KO mice than in WT mice. In WT mice, MV increased TLR4 mRNA expression in the lung and brain. MV induced mild lung injury, which was prevented in TLR4 KO mice. MV mice exhibited increased levels of inflammatory cytokines, increased microglia and astrocyte activation. Microgliosis was alleviated in TLR4 KO mice. MV mice exhibited increased TLR4 immunoreactivity, which was expressed in microglia and astrocytes. These results demonstrate that TLR4 is involved in neuroinflammation due to the lung-brain interaction and that TLR4 KO ameliorates neuroinflammation due to lung-brain interaction after prolonged MV. In addition, Administration of a TLR4 antagonist (100μg/mice) to WT mice also significantly attenuated neuroinflammation of lung-brain interaction due to prolonged MV. TLR4 antagonism may be a new and novel approach for the treatment and management of neuroinflammation in long-term mechanically ventilated patients.
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Affiliation(s)
- Ting Chen
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, Hubei 430071, China.
| | - Chang Chen
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, Hubei 430071, China.
| | - Zongze Zhang
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, Hubei 430071, China.
| | - Yufeng Zou
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, Hubei 430071, China
| | - Mian Peng
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, Hubei 430071, China
| | - Yanlin Wang
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, Hubei 430071, China
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Abstract
PURPOSE OF REVIEW The purpose of this study is to review the recent literature describing how to assess and treat postcardiac arrest syndrome associated haemodynamics and manage oxygenation and ventilation derangements. RECENT FINDINGS Postcardiac arrest syndrome is a well described entity that includes systemic ischemia-reperfusion response, myocardial dysfunction and neurologic dysfunction. Continued resuscitation in the hours to days following return of spontaneous circulation (ROSC) is important to increase the likelihood of long-term survival and neurological recovery. Post-ROSC hypotension is common and associated with worse outcome. Myocardial dysfunction peaks in the first 24 h following ROSC and in survivors resolves over the next few days. Hyperoxemia (paO₂>300 mmHg) and hypoxemia (paO₂<60 mmHg) are associated with worse outcomes and hyperventilation may exacerbate cerebral ischemic injury by decreasing cerebral oxygenation. SUMMARY Patients who are successfully resuscitated from cardiac arrest often have hypotension and myocardial dysfunction. Careful attention to haemodynamic and ventilator management targeting normal blood pressure, normoxemia and normocapnia may help to avoid secondary organ injury and potentially improve outcomes.
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Chen C, Zhang Z, Chen T, Peng M, Xu X, Wang Y. Prolonged mechanical ventilation-induced neuroinflammation affects postoperative memory dysfunction in surgical mice. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:159. [PMID: 25887955 PMCID: PMC4423516 DOI: 10.1186/s13054-015-0882-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 03/13/2015] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Patients undergoing surgery frequently develop neuropsychological disturbances, including cognitive decline or memory impairment, and routine clinical procedures such as mechanical ventilation (MV) may affect acute-phase brain outcome. We aimed to investigate the effect of the prolonged MV on postoperative memory dysfunction in surgical mice. METHODS Male C57BL/6 mice were randomly divided into the following three groups: (1) The control group (group C) comprised anesthetized, unventilated animals; (2) the surgery group (subgroups S1h, S3h and S6h) was unventilated animals that underwent surgery under general anesthesia; and (3) the MV group (subgroups MV1h, MV3h and MV6h) was made up of animals under MV for 1 hour, 3 hours or 6 hours after surgery. Separate cohorts of animals were tested for memory function with fear conditioning tests or were killed at 6 hours, 1 day or 3 days postsurgery or post-MV to examine levels systemic and hippocampal interleukin (IL)-1β, IL-6 and tumor necrosis factor α (TNFα), and assessed synaptic structure and microglial activation. Nuclear factor κB (NF-κB) p65, cytochrome c, cleaved caspase-3 and cleaved poly(ADP-ribose) polymerase (PARP) activation were analyzed by Western blotting. RESULTS The MV6h group showed increased CD11b-immunopositive cells, synapse degeneration, cytochrome c release, cleaved caspase-3 and cleaved PARP-1 activation after surgery, as well as a decrease in freezing time after surgery. At 6 hours and 1 day post-MV, MV6h increased NF-κB activation and levels of systemic and hippocampal IL-1β, IL-6 and TNFα after surgery. CONCLUSIONS Prolonged MV after surgery further aggravates cognitive decline that may stem from upregulation of hippocampal IL-1β, IL-6 and TNFα, partially via activation of gliocytes in the surgical mouse hippocampus.
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Affiliation(s)
- Chang Chen
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, 430071, Hubei, China.
| | - Zongze Zhang
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, 430071, Hubei, China.
| | - Ting Chen
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, 430071, Hubei, China.
| | - Mian Peng
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, 430071, Hubei, China.
| | - Xing Xu
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, 430071, Hubei, China.
| | - Yanlin Wang
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, 430071, Hubei, China.
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Dangmann R. An insulin based model to explain changes and interactions in human breath-holding. Med Hypotheses 2015; 84:532-8. [PMID: 25801485 DOI: 10.1016/j.mehy.2015.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 12/15/2014] [Accepted: 02/19/2015] [Indexed: 12/17/2022]
Abstract
Until now oxygen was thought to be the leading factor of hypoxic conditions. Whereas now it appears that insulin is the key regulator of hypoxic conditions. Insulin seems to regulate the redox state of the organism and to determine the breakpoint of human breath-holding. This new hypoxia-insulin hypotheses might have major clinical relevance. Besides the clinical relevance, this hypothesis could explain, for the first time, why the training of the diaphragm, among other factors, results in an increase in breath-holding performance. Elite freedivers/apnea divers are able to reach static breath-holding times to over 6 min. Untrained persons exhibit an unpleasant feeling after more or less a minute. Breath-holding is stopped at the breakpoint. The partial oxygen pressure as well as the carbon dioxide pressure failed to directly influence the breakpoint in earlier studies. The factors that contribute to the breakpoint are still under debate. Under hypoxic conditions the organism needs more glucose, because it changes from the oxygen consuming pentose phosphate (36 ATP/glucose molecule) to the anaerobic glycolytic pathway (2ATP/glucose molecule). Hence insulin, as it promotes the absorption of glucose, is set in the center of interest regarding hypoxic conditions. This paper provides an insulin based model that could explain the changes and interactions in human breath-holding. The correlation between hypoxia and reactive oxygen species (ROS) and their influence on the sympathetic nerve system and hypoxia-inducible factor 1 alpha (HIF-1α) is dealt with. It reviews as well the direct interrelation of HIF-1α and insulin. The depression of insulin secretion through the vagus nerve activation via inspiration is discussed. Furthermore the paper describes the action of insulin on the carotid bodies and the diaphragm and therefore a possible role in respiration pattern. Freedivers that go over the breakpoint of breath-holding could exhibit seizures and thus the effect of insulin, blood glucose levels and corticosteroids in hippocampal seizures is highlighted.
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González-López A, Albaiceta GM, Talbot K. Newly identified precipitating factors in mechanical ventilation-induced brain damage: implications for treating ICU delirium. Expert Rev Neurother 2015; 14:583-8. [PMID: 24852225 DOI: 10.1586/14737175.2014.915743] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Delirium is 1.5 to 4.1 times as likely in intensive care unit patients when they are mechanically ventilated. While progress in treatment has occurred, delirium is still a major problem in mechanically ventilated patients. Based on studies of a murine mechanical ventilation model, we summarize evidence here for a novel mechanism by which such ventilation can quickly initiate brain damage likely to cause cognitive deficits expressed as delirium. That mechanism consists of aberrant vagal sensory input driving sustained dopamine D2 receptor (D2R) signaling in the hippocampal formation, which induces apoptosis in that brain area within 90 min without causing hypoxia, oxidative stress, or inflammatory responses. This argues for minimizing the duration and tidal volumes of mechanical ventilation and for more effectively reducing sustained D2R signaling than achieved with haloperidol alone. The latter might be accomplished by reducing D2R cell surface expression and D2R-mediated Akt inhibition by elevating protein expression of dysbindin-1C.
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Affiliation(s)
- Adrián González-López
- Charité - Universitätsmedizin Berlin - Anesthesiology and Intensive Care Medicine, Berlin, Germany
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Hsieh SJ, Soto GJ, Hope AA, Ponea A, Gong MN. The association between acute respiratory distress syndrome, delirium, and in-hospital mortality in intensive care unit patients. Am J Respir Crit Care Med 2015; 191:71-8. [PMID: 25393331 PMCID: PMC4299633 DOI: 10.1164/rccm.201409-1690oc] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Both acute respiratory distress syndrome (ARDS) and intensive care unit (ICU) delirium are associated with significant morbidity and mortality. However, the risk of delirium and its impact on mortality in ARDS patients is unknown. OBJECTIVES To determine if ARDS is associated with a higher risk for delirium compared with respiratory failure without ARDS, and to determine the association between ARDS and in-hospital mortality after adjusting for delirium. METHODS Prospective observational cohort study of adult ICU patients admitted to two urban academic hospitals. MEASUREMENTS AND MAIN RESULTS Delirium was assessed daily using the Confusion Assessment Method for the ICU and Richmond Agitation and Sedation Scale. Of the 564 patients in our cohort, 48 had ARDS (9%). Intubated patients with ARDS had the highest prevalence of delirium compared with intubated patients without ARDS and nonintubated patients (73% vs. 52% vs. 21%, respectively; P < 0.001). After adjusting for common risk factors for delirium, ARDS was associated with a higher risk for delirium compared with mechanical ventilation without ARDS (odds ratio [OR], 6.55 [1.56-27.54]; P = 0.01 vs. OR, 1.98 [1.16-3.40]; P < 0.013); reference was nonintubated patients. Although ARDS was significantly associated with hospital mortality (OR, 10.44 [3.16-34.50]), the effect was largely reduced after adjusting for delirium and persistent coma (OR, 5.63 [1.55-20.45]). CONCLUSIONS Our findings suggest that ARDS is associated with a greater risk for ICU delirium than mechanical ventilation alone, and that the association between ARDS and in-hospital mortality is weakened after adjusting for delirium and coma. Future studies are needed to determine if prevention and reduction of delirium in ARDS patients can improve outcomes.
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Affiliation(s)
- S. Jean Hsieh
- Albert Einstein College of Medicine and,Department of Medicine, Montefiore Medical
Center, Bronx, New York
| | - Graciela J. Soto
- Albert Einstein College of Medicine and,Department of Medicine, Montefiore Medical
Center, Bronx, New York
| | - Aluko A. Hope
- Albert Einstein College of Medicine and,Department of Medicine, Montefiore Medical
Center, Bronx, New York
| | - Ana Ponea
- Department of Medicine, Montefiore Medical
Center, Bronx, New York
| | - Michelle N. Gong
- Albert Einstein College of Medicine and,Department of Medicine, Montefiore Medical
Center, Bronx, New York
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Rodríguez-González R, Ramos-Nuez Á, Martín-Barrasa JL, López-Aguilar J, Baluja A, Álvarez J, Rocco PRM, Pelosi P, Villar J. Endotoxin-induced lung alveolar cell injury causes brain cell damage. Exp Biol Med (Maywood) 2014; 240:135-42. [PMID: 25135986 DOI: 10.1177/1535370214547156] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Sepsis is the most common cause of acute respiratory distress syndrome, a severe lung inflammatory disorder with an elevated morbidity and mortality. Sepsis and acute respiratory distress syndrome involve the release of inflammatory mediators to the systemic circulation, propagating the cellular and molecular response and affecting distal organs, including the brain. Since it has been reported that sepsis and acute respiratory distress syndrome contribute to brain dysfunction, we investigated the brain-lung crosstalk using a combined experimental in vitro airway epithelial and brain cell injury model. Conditioned medium collected from an in vitro lipopolysaccharide-induced airway epithelial cell injury model using human A549 alveolar cells was subsequently added at increasing concentrations (no conditioned, 2%, 5%, 10%, 15%, 25%, and 50%) to a rat mixed brain cell culture containing both astrocytes and neurons. Samples from culture media and cells from mixed brain cultures were collected before treatment, and at 6 and 24 h for analysis. Conditioned medium at 15% significantly increased apoptosis in brain cell cultures 24 h after treatment, whereas 25% and 50% significantly increased both necrosis and apoptosis. Levels of brain damage markers S100 calcium binding protein B and neuron-specific enolase, interleukin-6, macrophage inflammatory protein-2, as well as matrix metalloproteinase-9 increased significantly after treating brain cells with ≥2% conditioned medium. Our findings demonstrated that human epithelial pulmonary cells stimulated with bacterial lipopolysaccharide release inflammatory mediators that are able to induce a translational clinically relevant and harmful response in brain cells. These results support a brain-lung crosstalk during sepsis and sepsis-induced acute respiratory distress syndrome.
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Affiliation(s)
- Raquel Rodríguez-González
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029 Madrid, Spain Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrín, 35010 Las Palmas de Gran Canaria, Spain Critical Patient Translational Research Group, Department of Anesthesiology, Intensive Care and Pain Management, Hospital Clínico Universitario, Instituto de Investigación Sanitaria (IDIS), Universidad de Santiago de Compostela, Santiago de Compostela, 15706, Spain
| | - Ángela Ramos-Nuez
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029 Madrid, Spain Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrín, 35010 Las Palmas de Gran Canaria, Spain
| | - José Luis Martín-Barrasa
- Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrín, 35010 Las Palmas de Gran Canaria, Spain Animal Facility Service, Research Unit, Hospital Universitario Dr. Negrín, 35010 Las Palmas de Gran Canaria, Spain
| | - Josefina López-Aguilar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029 Madrid, Spain Critical Care Center, Corporació Sanitaria Parc Taulí, Sabadell, 08208 Barcelona, Spain
| | - Aurora Baluja
- Critical Patient Translational Research Group, Department of Anesthesiology, Intensive Care and Pain Management, Hospital Clínico Universitario, Instituto de Investigación Sanitaria (IDIS), Universidad de Santiago de Compostela, Santiago de Compostela, 15706, Spain
| | - Julián Álvarez
- Critical Patient Translational Research Group, Department of Anesthesiology, Intensive Care and Pain Management, Hospital Clínico Universitario, Instituto de Investigación Sanitaria (IDIS), Universidad de Santiago de Compostela, Santiago de Compostela, 15706, Spain
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, 16126 Genoa, Italy
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029 Madrid, Spain Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrín, 35010 Las Palmas de Gran Canaria, Spain Li Ka Shing Knowledge Institute at the St. Michael's Hospital, Toronto, Ontario M5B 1W8, Canada
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Beloncle F, Lorente JA, Esteban A, Brochard L. Update in acute lung injury and mechanical ventilation 2013. Am J Respir Crit Care Med 2014; 189:1187-93. [PMID: 24832743 DOI: 10.1164/rccm.201402-0262up] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- François Beloncle
- 1 Critical Care Department and Keenan Research Centre, St Michael's Hospital, Toronto, Ontario, Canada
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Jobe AH, Tibboel D. Update in pediatric lung disease 2013. Am J Respir Crit Care Med 2014; 189:1031-6. [PMID: 24787065 DOI: 10.1164/rccm.201402-0230up] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Alan H Jobe
- 1 Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, Ohio; and
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Mikkelsen ME, Anderson B, Christie JD, Hopkins RO, Lanken PN. Can we optimize long-term outcomes in acute respiratory distress syndrome by targeting normoxemia? Ann Am Thorac Soc 2014; 11:613-8. [PMID: 24621125 PMCID: PMC4225797 DOI: 10.1513/annalsats.201401-001ps] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 01/17/2014] [Indexed: 11/20/2022] Open
Abstract
Since its original description in 1967, acute respiratory distress syndrome (ARDS) has been recognized as a devastating condition associated with significant morbidity and mortality. Advances in critical care medicine and ARDS management have led to a substantial increase in the number of ARDS survivors. Long-term cognitive impairment after critical illness is a significant public health concern. ARDS survivors frequently experience long-term cognitive impairment, as well as physical impairment, psychiatric morbidity, and reduced health-related quality of life. At present, no intensive care unit-based intervention has been proven to reduce the risk of long-term cognitive impairment after ARDS. To address the urgent need to identify strategies to preserve long-term health, investigators have advocated the measurement of short- and long-term outcomes in clinical trials. Maintaining adequate oxygen delivery to preserve organ function is of vital importance in ARDS management. The optimal target range for arterial oxygenation in ARDS remains unknown, due in part to the challenge to maintain adequate tissue oxygenation and to minimize harm, such as oxygen toxicity. An approach targeted to subnormal oxygenation values (partial pressure of arterial oxygen, 55-80 mm Hg) has emerged as a means to accomplish these aims. In this perspective, we critically evaluate this strategy from short- and long-term perspectives, with a focus on the potential long-term cognitive effects of the strategy. We conclude with a proposal to consider resetting the target range for arterial oxygenation higher (85-110 mm Hg) as a potential strategy to improve the long-term outcomes of ARDS survivors.
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Affiliation(s)
- Mark E. Mikkelsen
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine
- Fostering Improvement in End-of-Life Decision Science, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Brian Anderson
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine
- Center for Clinical Epidemiology and Biostatistics, and
| | - Jason D. Christie
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine
- Center for Clinical Epidemiology and Biostatistics, and
| | - Ramona O. Hopkins
- Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Murray, Utah; and
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah
| | - Paul N. Lanken
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine
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