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Saez de la Fuente I, Saez de la Fuente J, Quintana Estelles MD, Garcia Gigorro R, Terceros Almanza LJ, Sanchez Izquierdo JA, Montejo Gonzalez JC. Enteral Nutrition in Patients Receiving Mechanical Ventilation in a Prone Position. JPEN J Parenter Enteral Nutr 2014; 40:250-5. [PMID: 25274497 DOI: 10.1177/0148607114553232] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 08/31/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients treated with mechanical ventilation in the prone position (PP) could have an increased risk for feeding intolerance. However, the available evidence supporting this hypothesis is limited and contradictory. OBJECTIVE To examine the feasibility and efficacy of enteral nutrition (EN) support and its associated complications in patients receiving mechanical ventilation in PP. METHODS Prospective observational study including 34 mechanically ventilated intensive care patients who were turned to the prone position over a 3-year period. End points related to efficacy and safety of EN support were studied. RESULTS In total, more than 1200 patients were admitted to the intensive care unit over a period of 3 years. Of these, 34 received mechanical ventilation in PP. The mean days under EN were 24.7 ± 12.3. Mean days under EN in the supine position were significantly higher than in PP (21.1 vs 3.6; P < .001), but there were no significant differences in gastric residual volume adjusted per day of EN (126.6 vs 189.2; P = .054) as well as diet volume ratio (94.1% vs 92.8%; P = .21). No significant differences in high gastric residual events per day of EN (0.06 vs 0.09; P = .39), vomiting per day of EN (0.016 vs 0.03; P = .53), or diet regurgitation per day of EN (0 vs 0.04; P = .051) were found. CONCLUSIONS EN in critically ill patients with severe hypoxemia receiving mechanical ventilation in PP is feasible, safe, and not associated with an increased risk of gastrointestinal complications. Larger studies are needed to confirm these findings.
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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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Hu SL, He HL, Pan C, Liu AR, Liu SQ, Liu L, Huang YZ, Guo FM, Yang Y, Qiu HB. The effect of prone positioning on mortality in patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R109. [PMID: 24887034 PMCID: PMC4075407 DOI: 10.1186/cc13896] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 05/13/2014] [Indexed: 12/31/2022]
Abstract
Introduction Prone positioning (PP) has been reported to improve the survival of patients with severe acute respiratory distress syndrome (ARDS). However, it is uncertain whether the beneficial effects of PP are associated with positive end-expiratory pressure (PEEP) levels and long durations of PP. In this meta-analysis, we aimed to evaluate whether the effects of PP on mortality could be affected by PEEP level and PP duration and to identify which patients might benefit the most from PP. Methods Publications describing randomized controlled trials (RCTs) in which investigators have compared prone and supine ventilation were retrieved by searching the following electronic databases: PubMed/MEDLINE, the Cochrane Library, the Web of Science and Elsevier Science (inception to May 2013). Two investigators independently selected RCTs and assessed their quality. The data extracted from the RCTs were combined in a cumulative meta-analysis and analyzed using methods recommended by the Cochrane Collaboration. Results A total of nine RCTs with an aggregate of 2,242 patients were included. All of the studies received scores of up to three points using the methods recommended by Jadad et al. One trial did not conceal allocation. This meta-analysis revealed that, compared with supine positioning, PP decreased the 28- to 30-day mortality of ARDS patients with a ratio of partial pressure of arterial oxygen/fraction of inspired oxygen ≤100 mmHg (n = 508, risk ratio (RR) = 0.71, 95 confidence interval (CI) = 0.57 to 0.89; P = 0.003). PP was shown to reduce both 60-day mortality (n = 518, RR = 0.82, 95% CI = 0.68 to 0.99; P = 0.04) and 90-day mortality (n = 516, RR = 0.57, 95% CI = 0.43 to 0.75; P < 0.0001) in ARDS patients ventilated with PEEP ≥10 cmH2O. Moreover, PP reduced 28- to 30-day mortality when the PP duration was >12 h/day (n = 1,067, RR = 0.73, 95% CI = 0.54 to 0.99; P = 0.04). Conclusions PP reduced mortality among patients with severe ARDS and patients receiving relatively high PEEP levels. Moreover, long-term PP improved the survival of ARDS patients.
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Tekwani SS, Murugan R. 'To prone or not to prone' in severe ARDS: questions answered, but others remain. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:305. [PMID: 25042412 PMCID: PMC4056436 DOI: 10.1186/cc13893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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The Efficacy and Safety of Prone Positional Ventilation in Acute Respiratory Distress Syndrome. Crit Care Med 2014; 42:1252-62. [DOI: 10.1097/ccm.0000000000000122] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Foëx BA. Hypoxia, haemorrhage and hypotension: the interface between emergency medicine and intensive care medicine. Emerg Med J 2014; 31:513-7. [PMID: 24741003 DOI: 10.1136/emermed-2014-203732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
This subjective review is based on a presentation made at the College of Emergency Medicine Scientific Conference in September 2013. My theme was that there are certain features of the critically ill which cause understandable anxiety, namely hypoxia, haemorrhage and hypotension. So, I have selected papers relevant to the management of these frightening situations.
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Effects of interventions on survival in acute respiratory distress syndrome: an umbrella review of 159 published randomized trials and 29 meta-analyses. Intensive Care Med 2014; 40:769-87. [PMID: 24667919 DOI: 10.1007/s00134-014-3272-1] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 03/14/2014] [Indexed: 12/16/2022]
Abstract
PURPOSE Multiple interventions have been tested in acute respiratory distress syndrome (ARDS). We examined the entire agenda of published randomized controlled trials (RCTs) in ARDS that reported on mortality and of respective meta-analyses. METHODS We searched PubMed, the Cochrane Library, and Web of Knowledge until July 2013. We included RCTs in ARDS published in English. We excluded trials of newborns and children; and those on short-term interventions, ARDS prevention, or post-traumatic lung injury. We also reviewed all meta-analyses of RCTs in this field that addressed mortality. Treatment modalities were grouped in five categories: mechanical ventilation strategies and respiratory care, enteral or parenteral therapies, inhaled/intratracheal medications, nutritional support, and hemodynamic monitoring. RESULTS We identified 159 published RCTs of which 93 had overall mortality reported (n = 20,671 patients)--44 trials (14,426 patients) reported mortality as a primary outcome. A statistically significant survival benefit was observed in eight trials (seven interventions) and two trials reported an adverse effect on survival. Among RCTs with more than 50 deaths in at least one treatment arm (n = 21), two showed a statistically significant mortality benefit of the intervention (lower tidal volumes and prone positioning), one showed a statistically significant mortality benefit only in adjusted analyses (cisatracurium), and one (high-frequency oscillatory ventilation) showed a significant detrimental effect. Across 29 meta-analyses, the most consistent evidence was seen for low tidal volumes and prone positioning in severe ARDS. CONCLUSIONS There is limited supportive evidence that specific interventions can decrease mortality in ARDS. While low tidal volumes and prone positioning in severe ARDS seem effective, most sporadic findings of interventions suggesting reduced mortality are not corroborated consistently in large-scale evidence including meta-analyses.
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Weig T, Janitza S, Zoller M, Dolch ME, Miller J, Frey L, Kneidinger N, Johnson T, Schubert MI, Irlbeck M. Influence of abdominal obesity on multiorgan dysfunction and mortality in acute respiratory distress syndrome patients treated with prone positioning. J Crit Care 2014; 29:557-61. [PMID: 24666961 DOI: 10.1016/j.jcrc.2014.02.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 01/28/2014] [Accepted: 02/16/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE Obesity is a worldwide pandemic, and obese patients face an increased risk of developing acute respiratory distress syndrome (ARDS). Prone positioning (PP) is a frequently used intervention in the treatment of ARDS. There are no data describing the impact of PP on morbidity and mortality in abdominally obese patients. We report our observations in abdominally obese ARDS patients treated with PP. MATERIALS AND METHODS Patients with ARDS (n=82) were retrospectively divided into 2 groups characterized by presence (n=41) or absence (n=41) of abdominal obesity as defined by a sagittal abdominal diameter of 26 cm or more. RESULTS There was no difference in cumulative time abdominally obese patients were placed in prone position from admission to day 7 (41.0 hours [interquartile range, 50.5 hours] vs 39.5 hours [interquartile range, 61.5 hours]; P=.65) or in overall intensive care unit mortality (34% vs 34%; P=1). However, abdominally obese patients developed renal failure (83% vs 35%; P<.001) and hypoxic hepatitis (22% vs 2%; P=.015) more frequently. A significant interaction effect between abdominal obesity and prone position with respect to mortality risk (likelihood ratio, P=.0004) was seen if abdominally obese patients were treated with prolonged cumulative PP. CONCLUSION A cautious approach to PP should be considered in abdominally obese patients.
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Affiliation(s)
- Thomas Weig
- Department of Anaesthesiology, Ludwig-Maximilians-University, 81377 Munich, Germany.
| | - Silke Janitza
- Department of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Michael Zoller
- Department of Anaesthesiology, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Michael E Dolch
- Department of Anaesthesiology, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Jens Miller
- Department of Anaesthesiology, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Lorenz Frey
- Department of Anaesthesiology, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Nikolaus Kneidinger
- Department of Internal Medicine V, Comprehensive Pulmonary Center, Member of the German Center for Lung Research, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Thorsten Johnson
- Department of Clinical Radiology, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Mirjam I Schubert
- Department of Clinical Radiology, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Michael Irlbeck
- Department of Anaesthesiology, Ludwig-Maximilians-University, 81377 Munich, Germany
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Cornejo RA, Díaz JC, Tobar EA, Bruhn AR, Ramos CA, González RA, Repetto CA, Romero CM, Gálvez LR, Llanos O, Arellano DH, Neira WR, Díaz GA, Zamorano AJ, Pereira GL. Effects of prone positioning on lung protection in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2014; 188:440-8. [PMID: 23348974 DOI: 10.1164/rccm.201207-1279oc] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Positive end-expiratory pressure (PEEP) and prone positioning may induce lung recruitment and affect alveolar dynamics in acute respiratory distress syndrome (ARDS). Whether there is interdependence between the effects of PEEP and prone positioning on these variables is unknown. OBJECTIVES To determine the effects of high PEEP and prone positioning on lung recruitment, cyclic recruitment/derecruitment, and tidal hyperinflation and how these effects are influenced by lung recruitability. METHODS Mechanically ventilated patients (Vt 6 ml/kg ideal body weight) underwent whole-lung computed tomography (CT) during breath-holding sessions at airway pressures of 5, 15, and 45 cm H2O and Cine-CTs on a fixed thoracic transverse slice at PEEP 5 and 15 cm H2O. CT images were repeated in supine and prone positioning. A recruitment maneuver at 45 cm H2O was performed before each PEEP change. Lung recruitability was defined as the difference in percentage of nonaerated tissue between 5 and 45 cm H2O. Cyclic recruitment/de-recruitment and tidal hyperinflation were determined as tidal changes in percentage of nonaerated and hyperinflated tissue, respectively. MEASUREMENTS AND MAIN RESULTS Twenty-four patients with ARDS were included. Increasing PEEP from 5 to 15 cm H2O decreased nonaerated tissue (501 ± 201 to 322 ± 132 grams; P < 0.001) and increased tidal-hyperinflation (0.41 ± 0.26 to 0.57 ± 0.30%; P = 0.004) in supine. Prone positioning further decreased nonaerated tissue (322 ± 132 to 290 ± 141 grams; P = 0.028) and reduced tidal hyperinflation observed at PEEP 15 in supine patients (0.57 ± 0.30 to 0.41 ± 0.22%). Cyclic recruitment/de-recruitment only decreased when high PEEP and prone positioning were applied together (4.1 ± 1.9 to 2.9 ± 0.9%; P = 0.003), particularly in patients with high lung recruitability. CONCLUSIONS Prone positioning enhances lung recruitment and decreases alveolar instability and hyperinflation observed at high PEEP in patients with ARDS.
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Affiliation(s)
- Rodrigo A Cornejo
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile.
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Beitler JR, Shaefi S, Montesi SB, Devlin A, Loring SH, Talmor D, Malhotra A. Prone positioning reduces mortality from acute respiratory distress syndrome in the low tidal volume era: a meta-analysis. Intensive Care Med 2014; 40:332-41. [PMID: 24435203 DOI: 10.1007/s00134-013-3194-3] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 12/09/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE Prone positioning for ARDS has been performed for decades without definitive evidence of clinical benefit. A recent multicenter trial demonstrated for the first time significantly reduced mortality with prone positioning. This meta-analysis was performed to integrate these findings with existing literature and test whether differences in tidal volume explain conflicting results among randomized trials. METHODS Studies were identified using MEDLINE, EMBASE, Cochrane Register of Controlled Trials, LILACS, and citation review. Included were randomized trials evaluating the effect on mortality of prone versus supine positioning during conventional ventilation for ARDS. The primary outcome was risk ratio of death at 60 days meta-analyzed using random effects models. Analysis stratified by high (>8 ml/kg predicted body weight) or low (≤ 8 ml/kg PBW) mean baseline tidal volume was planned a priori. RESULTS Seven trials were identified including 2,119 patients, of whom 1,088 received prone positioning. Overall, prone positioning was not significantly associated with the risk ratio of death (RR 0.83; 95% CI 0.68-1.02; p = 0.073; I (2) = 64%). When stratified by high or low tidal volume, prone positioning was associated with a significant decrease in RR of death only among studies with low baseline tidal volume (RR 0.66; 95% CI 0.50-0.86; p = 0.002; I (2) = 25%). Stratification by tidal volume explained over half the between-study heterogeneity observed in the unstratified analysis. CONCLUSIONS Prone positioning is associated with significantly reduced mortality from ARDS in the low tidal volume era. Substantial heterogeneity across studies can be explained by differences in tidal volume.
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Affiliation(s)
- Jeremy R Beitler
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, 221 Longwood Avenue, BLI 036, Boston, MA, 02115, USA,
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Solomons RS, van Elsland SL, Visser DH, Hoek KGP, Marais BJ, Schoeman JF, van Furth AM. Commercial nucleic acid amplification tests in tuberculous meningitis--a meta-analysis. Diagn Microbiol Infect Dis 2014; 78:398-403. [PMID: 24503504 DOI: 10.1016/j.diagmicrobio.2014.01.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 12/29/2013] [Accepted: 01/02/2014] [Indexed: 11/19/2022]
Abstract
Although nucleic acid amplification tests (NAATs) promise a rapid, definitive diagnosis of tuberculous meningitis, the performance of first-generation NAATs was suboptimal and variable. We conducted a meta-analysis of studies published between 2003 and 2013, using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool to evaluate methodological quality. The diagnostic accuracy of newer commercial NAATs was assessed. Pooled estimates of diagnostic accuracy for commercial NAATs measured against a cerebrospinal fluid Mycobacterium tuberculosis culture-positive gold standard were sensitivity 0.64, specificity 0.98, and diagnostic odds ratio 64.0. Heterogeneity was limited; P value = 0.147 and I(2) = 33.85%. The Xpert MTB/RIF® test was evaluated in 1 retrospective study and 4 prospective studies, with pooled sensitivity 0.70 and specificity 0.97. The QUADAS-2 tool revealed low risk of bias, as well as low concerns regarding applicability. Heterogeneity was pronounced among studies of in-house tests. Commercial NAATs proved to be highly specific with greatly reduced heterogeneity compared to in-house tests. Sub-optimal sensitivity remains a limitation.
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Affiliation(s)
- Regan S Solomons
- Department of Pediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg 7505, Cape, South Africa.
| | - Sabine L van Elsland
- Department of Pediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg 7505, Cape, South Africa; Department of Pediatric Infectious Diseases and Immunology, Vrije Universiteit Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Douwe H Visser
- Department of Pediatric Infectious Diseases and Immunology, Vrije Universiteit Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Kim G P Hoek
- Division of Medical Microbiology, Faculty of Health Sciences, National Health Laboratory Service and University of Stellenbosch, Tygerberg 7505, Western Cape, South Africa
| | - Ben J Marais
- Sydney Emerging Infectious Diseases and Biosecurity Institute (SEIB) and the Children's Hospital, Westmead. C29 - Children's Hospital Westmead, The University of Sydney, Westmead, NSW 2006, Australia
| | - Johan F Schoeman
- Department of Pediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg 7505, Cape, South Africa
| | - Anne M van Furth
- Department of Pediatric Infectious Diseases and Immunology, Vrije Universiteit Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
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Bellingan G, Maksimow M, Howell DC, Stotz M, Beale R, Beatty M, Walsh T, Binning A, Davidson A, Kuper M, Shah S, Cooper J, Waris M, Yegutkin GG, Jalkanen J, Salmi M, Piippo I, Jalkanen M, Montgomery H, Jalkanen S. The effect of intravenous interferon-beta-1a (FP-1201) on lung CD73 expression and on acute respiratory distress syndrome mortality: an open-label study. THE LANCET RESPIRATORY MEDICINE 2013; 2:98-107. [PMID: 24503265 DOI: 10.1016/s2213-2600(13)70259-5] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pulmonary vascular leakage occurs early in acute respiratory distress syndrome (ARDS). Mortality is high (35-45%), but no effective pharmacotherapy exists. Production of anti-inflammatory adenosine by ecto-5'-nucleotidase (CD73) helps maintain endothelial barrier function. We tested whether interferon-beta-1a (IFN-beta-1a), which increases CD73 synthesis, can reduce vascular leakage and mortality in patients with ARDS. METHODS In ex-vivo studies, we first established that IFN-beta-1a induced CD73 up-regulation in cultured human lung tissue samples. We then tested the safety, tolerability, and efficacy of intravenous human recombinant IFN-beta-1a (FP-1201) in patients with ARDS in an open-label study (comprising dose-escalation and expansion phases). We recruited patients from eight intensive care units in the UK. Eligible patients were aged 18 years or older, had ARDS, and were being treated with assisted ventilation. We established an optimal tolerated dose (OTD) in the first, dose-escalation phase. Once established, we gave all subsequently enrolled patients the OTD of intravenous FP-1201 for 6 days. We assessed 28-day mortality (our primary endpoint) in all patients receiving the OTD versus 28-day mortality in a group of patients who did not receive treatment (this control group comprised patients in the study but who did not receive treatment because they were screened during the safety windows after dose escalation). This trial is registered with ClinicalTrials.gov, number NCT00789685, and the EU Clinical Trials Register EudraCT, number 2008-000140-13. FINDINGS IFN-beta-1a increased the number of CD73-positive vessels in lung culture by four times on day 1 (p=0·04) and by 14·3 times by day 4 (p=0·004). For the clinical trial, between Feb 23, 2009, and April 7, 2011, we identified 150 patients, of whom 37 were enrolled into the trial and given treatment. The control group consisted of 59 patients who were recruited to take part in the study, but who did not receive treatment. Demographic characteristics and severity of illness did not differ between treatment and control groups. The optimal tolerated FP-1201 dose was 10 μg per day for 6 days. By day 28, 3 (8%) of 37 patients in the treatment cohort and 19 (32%) of 59 patients in the control cohort had died-thus, treatment with FP-1201 was associated with an 81% reduction in odds of 28-day mortality (odds ratio 0·19 [95% CI 0·03-0·72]; p=0·01). INTERPRETATION FP-1201 up-regulates human lung CD73 expression, and is associated with a reduction in 28-day mortality in patients with ARDS. Our findings need to be substantiated in large, prospective randomised trials, but suggest that FP-1201 could be the first effective, mechanistically targeted, disease-specific pharmacotherapy for patients with ARDS.
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Affiliation(s)
- Geoff Bellingan
- Critical Care, University College Hospital, London, UK; Department of Medicine, University College London and NIHR University College London Hospitals Biomedical Research Centre, UK
| | | | | | | | | | | | | | | | | | | | | | - Jackie Cooper
- Centre for Cardiovascular Genetics, Institute of Cardiovascular Science, University College London, UK
| | - Matti Waris
- Department of Virology, University of Turku, Finland
| | - Gennady G Yegutkin
- MediCity Research Laboratory, University of Turku, Finland; Department of Medical Microbiology, University of Turku, Finland
| | - Juho Jalkanen
- Department of Vascular Surgery, Turku University Hospital, Finland
| | - Marko Salmi
- MediCity Research Laboratory, University of Turku, Finland; Department of Medical Biochemistry and Genetics, University of Turku, Finland
| | | | | | - Hugh Montgomery
- Department of Medicine, University College London and NIHR University College London Hospitals Biomedical Research Centre, UK; Whittington Hospital London, UK
| | - Sirpa Jalkanen
- MediCity Research Laboratory, University of Turku, Finland; Department of Medical Microbiology, University of Turku, Finland.
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Jozwiak M, Teboul JL, Anguel N, Persichini R, Silva S, Chemla D, Richard C, Monnet X. Beneficial hemodynamic effects of prone positioning in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2013; 188:1428-33. [PMID: 24102072 DOI: 10.1164/rccm.201303-0593oc] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
RATIONALE The effects of prone positioning during acute respiratory distress syndrome on all the components of cardiac function have not been investigated under protective ventilation and maximal alveolar recruitment. OBJECTIVES To investigate the hemodynamic effects of prone positioning. METHODS We included 18 patients with acute respiratory distress syndrome ventilated with protective ventilation and an end-expiratory positive pressure titrated to a plateau pressure of 28-30 cm H2O. Before and within 20 minutes of starting prone positioning, hemodynamic, respiratory, intraabdominal pressure, and echocardiographic data were collected. Before prone positioning, preload reserve was assessed by a passive leg raising test. MEASUREMENTS AND MAIN RESULTS In all patients, prone positioning increased the ratio of arterial oxygen partial pressure over inspired oxygen fraction, the intraabdominal pressure, and the right and left cardiac preload. The pulmonary vascular resistance decreased along with the ratio of the right/left ventricular end-diastolic areas suggesting a decrease of the right ventricular afterload. In the nine patients with preload reserve, prone positioning significantly increased cardiac index (3.0 [2.3-3.5] to 3.6 [3.2-4.4] L/min/m(2)). In the remaining patients, cardiac index did not change despite a significant decrease in the pulmonary vascular resistance. CONCLUSIONS In patients with acute respiratory distress syndrome under protective ventilation and maximal alveolar recruitment, prone positioning increased the cardiac index only in patients with preload reserve, emphasizing the important role of preload in the hemodynamic effects of prone positioning.
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Cure L, Van Enk R, Tiong E. A systematic approach for the location of hand sanitizer dispensers in hospitals. Health Care Manag Sci 2013; 17:245-58. [PMID: 24194381 DOI: 10.1007/s10729-013-9254-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 10/16/2013] [Indexed: 10/26/2022]
Abstract
Compliance with hand hygiene practices is directly affected by the accessibility and availability of cleaning agents. Nevertheless, the decision of where to locate these dispensers is often not explicitly or fully addressed in the literature. In this paper, we study the problem of selecting the locations to install alcohol-based hand sanitizer dispensers throughout a hospital unit as an indirect approach to maximize compliance with hand hygiene practices. We investigate the relevant criteria in selecting dispenser locations that promote hand hygiene compliance, propose metrics for the evaluation of various location configurations, and formulate a dispenser location optimization model that systematically incorporates such criteria. A complete methodology to collect data and obtain the model parameters is described. We illustrate the proposed approach using data from a general care unit at a collaborating hospital. A cost analysis was performed to study the trade-offs between usability and cost. The proposed methodology can help in evaluating the current location configuration, determining the need for change, and establishing the best possible configuration. It can be adapted to incorporate alternative metrics, tailored to different institutions and updated as needed with new internal policies or safety regulation.
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Affiliation(s)
- Laila Cure
- Department of Industrial and Manufacturing Engineering, Western Michigan University, Kalamazoo, MI, 49008, USA,
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Alveolar recruitment during mechanical ventilation – Where are we in 2013? TRENDS IN ANAESTHESIA AND CRITICAL CARE 2013. [DOI: 10.1016/j.tacc.2013.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Gattinoni L, Pesenti A, Carlesso E. Body position changes redistribute lung computed-tomographic density in patients with acute respiratory failure: impact and clinical fallout through the following 20 years. Intensive Care Med 2013; 39:1909-15. [PMID: 24026295 DOI: 10.1007/s00134-013-3066-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 08/06/2013] [Indexed: 12/15/2022]
Abstract
In patients with acute respiratory distress syndrome (ARDS), in supine position, there is a decrease of inflation along the sternum vertebral axis, up to lung collapse. In 1991 we published a report showing that, in ARDS patients, shifting from supine to prone position led immediately to the inversion of the inflation gradient and to a redistribution of densities from dorsal to ventral lung regions. This led to a "sponge model" as a wet sponge, similar to a heavy edematous lung, squeezes out the gas in the most dependent regions, due to the weight-related increase of the compressive forces. The sponge model accounts for density distribution in prone position, for which the unloaded dorsal regions are recruited, while the loaded ventral region, collapses. In addition, the sponge model accounts for the mechanism through which the positive end-expiratory pressure acts as counterforce to oppose the collapsing, compressing forces. The final result of proning was that the inversion of gravitational forces, together with other factors such as lung-chest wall shape-matching and the heart weight led to a more homogeneous distribution of inflation throughout the lung parenchyma. This is associated with oxygenation improvement as the dorsal recruitment, for anatomical reasons, prevails on the ventral de-recruitment. The more homogeneous distribution of inflation (i.e. of stress and strain) decreases/prevents the ventilator-induced lung injury, as consistently shown in animal experiments. Finally, and a series of clinical trials led to the conclusion that in patients with severe ARDS, the prone position provides a significant survival advantage.
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Affiliation(s)
- Luciano Gattinoni
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via F. Sforza 35, 20122, Milan, Italy,
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De Jong A, Molinari N, Sebbane M, Prades A, Futier E, Jung B, Chanques G, Jaber S. Feasibility and effectiveness of prone position in morbidly obese patients with ARDS: a case-control clinical study. Chest 2013; 143:1554-1561. [PMID: 23450309 DOI: 10.1378/chest.12-2115] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Obese patients are at risk for developing atelectasis and ARDS. Prone position (PP) may reduce atelectasis, and it improves oxygenation and outcome in severe hypoxemic patients with ARDS, but little is known about its effect in obese patients with ARDS. METHODS Morbidly obese patients (BMI ≥ 35 kg/m²) with ARDS (Pao₂/FIo₂ ratio ≤ 200 mm Hg) were matched to nonobese (BMI < 30 kg/m²) patients with ARDS in a case-control clinical study. The primary end points were safety and complications of PP; the secondary end points were the effect on oxygenation (Pao₂/FIo₂ ratio at the end of PP), length of mechanical ventilation and ICU stay, nosocomial infections, and mortality. RESULTS Between January 2005 and December 2009, 149 patients were admitted for ARDS. Thirty-three obese patients were matched with 33 nonobese patients. Median (25th-75th percentile) PP duration was 9 h (6-11 h) in obese patients and 8 h (7-12 h) in nonobese patients (P = .28). We collected 51 complications: 25 in obese and 26 in nonobese patients. The number of patients with at least one complication was similar across groups (n = 10, 30%). Pao₂/FIo₂ ratio increased significantly more in obese patients (from 118 ± 43 mm Hg to 222 ± 84 mm Hg) than in nonobese patients (from 113 ± 43 mm Hg to 174 ± 80 mm Hg; P = .03). Length of mechanical ventilation, ICU stay, and nosocomial infections did not differ significantly, but mortality at 90 days was significantly lower in obese patients (27% vs 48%, P < .05). CONCLUSIONS PP seems safe in obese patients and may improve oxygenation more than in nonobese patients. Obese patients could be a subgroup of patients with ARDS who may benefit the most of PP.
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Affiliation(s)
- Audrey De Jong
- Intensive Care Unit and Transplantation Department (DAR B), Saint Eloi Hospital, University Hospital of Montpellier-INSERM U1046, France
| | - Nicolas Molinari
- Medical and Informatic Department, Lapeyronie University Hospital of Montpellier, UMR 729 MISTEA, Route de Ganges, Montpellier cedex 5, France
| | - Mustapha Sebbane
- Intensive Care Unit and Transplantation Department (DAR B), Saint Eloi Hospital, University Hospital of Montpellier-INSERM U1046, France
| | - Albert Prades
- Intensive Care Unit and Transplantation Department (DAR B), Saint Eloi Hospital, University Hospital of Montpellier-INSERM U1046, France
| | - Emmanuel Futier
- Intensive Care Unit and Transplantation Department (DAR B), Saint Eloi Hospital, University Hospital of Montpellier-INSERM U1046, France
| | - Boris Jung
- Intensive Care Unit and Transplantation Department (DAR B), Saint Eloi Hospital, University Hospital of Montpellier-INSERM U1046, France
| | - Gérald Chanques
- Intensive Care Unit and Transplantation Department (DAR B), Saint Eloi Hospital, University Hospital of Montpellier-INSERM U1046, France
| | - Samir Jaber
- Intensive Care Unit and Transplantation Department (DAR B), Saint Eloi Hospital, University Hospital of Montpellier-INSERM U1046, France.
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Prone Position Ventilation Used during a Transfer as a Bridge to Ecmo Therapy in Hantavirus-Induced Severe Cardiopulmonary Syndrome. Case Rep Crit Care 2013; 2013:415851. [PMID: 24829824 PMCID: PMC4010019 DOI: 10.1155/2013/415851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Accepted: 06/05/2013] [Indexed: 12/02/2022] Open
Abstract
Background. Transport of critically ill patients is a complex issue. We present a case using prone positioning as a bridge to extracorporeal membrane oxygenation (ECMO), performed by a critical retrieval team from a university hospital. Case Report. A 28-year-old male developed fever, progressive respiratory failure, and shock. He was admitted to ICU from a public hospital, and mechanical ventilation was begun, but clinical response was not adequate. ECMO was deemed necessary due to severe respiratory failure and severe shock. A critical retrieval team of our center was assembled to attempt transfer. Prone positioning was employed to stabilize and transfer the patient, after risk-benefit assessment. Once in our hospital, ECMO was useful to resolve shock and pulmonary edema secondary to Hantavirus cardiopulmonary syndrome. Finally, he was discharged with normal functioning.
Conclusion. This case exemplifies the relevance of a retrieval team and bridge therapy. Prone positioning improves oxygenation and is safe to perform as transport if performed by a trained team as in this case. Preparation and organization is necessary to improve outcomes, using teams and organized networks. Catastrophic respiratory failure and shock should not be contraindications to transferring patients, but it must be done with an experienced team.
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70
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Budinger GRS, Mutlu GM. Balancing the risks and benefits of oxygen therapy in critically III adults. Chest 2013; 143:1151-1162. [PMID: 23546490 DOI: 10.1378/chest.12-1215] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Oxygen therapy is an integral part of the treatment of critically ill patients. Maintenance of adequate oxygen delivery to vital organs often requires the administration of supplemental oxygen, sometimes at high concentrations. Although oxygen therapy is lifesaving, it may be associated with deleterious effects when administered for prolonged periods at high concentrations. Here, we review the recent advances in our understanding of the molecular responses to hypoxia and high levels of oxygen and review the current guidelines for oxygen therapy in critically ill patients.
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Affiliation(s)
- G R Scott Budinger
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Gökhan M Mutlu
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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71
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Zhang Z, Xu X, Ni H. Small studies may overestimate the effect sizes in critical care meta-analyses: a meta-epidemiological study. Crit Care 2013; 17:R2. [PMID: 23302257 PMCID: PMC4056100 DOI: 10.1186/cc11919] [Citation(s) in RCA: 216] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 01/07/2013] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Small-study effects refer to the fact that trials with limited sample sizes are more likely to report larger beneficial effects than large trials. However, this has never been investigated in critical care medicine. Thus, the present study aimed to examine the presence and extent of small-study effects in critical care medicine. METHODS Critical care meta-analyses involving randomized controlled trials and reported mortality as an outcome measure were considered eligible for the study. Component trials were classified as large (≥100 patients per arm) and small (<100 patients per arm) according to their sample sizes. Ratio of odds ratio (ROR) was calculated for each meta-analysis and then RORs were combined using a meta-analytic approach. ROR<1 indicated larger beneficial effect in small trials. Small and large trials were compared in methodological qualities including sequence generating, blinding, allocation concealment, intention to treat and sample size calculation. RESULTS A total of 27 critical care meta-analyses involving 317 trials were included. Of them, five meta-analyses showed statistically significant RORs <1, and other meta-analyses did not reach a statistical significance. Overall, the pooled ROR was 0.60 (95% CI: 0.53 to 0.68); the heterogeneity was moderate with an I2 of 50.3% (chi-squared = 52.30; P = 0.002). Large trials showed significantly better reporting quality than small trials in terms of sequence generating, allocation concealment, blinding, intention to treat, sample size calculation and incomplete follow-up data. CONCLUSIONS Small trials are more likely to report larger beneficial effects than large trials in critical care medicine, which could be partly explained by the lower methodological quality in small trials. Caution should be practiced in the interpretation of meta-analyses involving small trials.
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Affiliation(s)
- Zhongheng Zhang
- Department of Critical Care Medicine, Jinhua Municipal Central Hospital, 351 Mingyue Street, Jinhua City, Zhejiang 321004, PR China
| | - Xiao Xu
- Department of Critical Care Medicine, Jinhua Municipal Central Hospital, 351 Mingyue Street, Jinhua City, Zhejiang 321004, PR China
| | - Hongying Ni
- Department of Critical Care Medicine, Jinhua Municipal Central Hospital, 351 Mingyue Street, Jinhua City, Zhejiang 321004, PR China
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Weig T, Schubert MI, Gruener N, Dolch ME, Frey L, Miller J, Johnson T, Irlbeck M. Abdominal obesity and prolonged prone positioning increase risk of developing sclerosing cholangitis in critically ill patients with influenza A-associated ARDS. Eur J Med Res 2012; 17:30. [PMID: 23259907 PMCID: PMC3543205 DOI: 10.1186/2047-783x-17-30] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 12/07/2012] [Indexed: 12/11/2022] Open
Abstract
Background Secondary sclerosing cholangitis is a severe disease of the biliary tract. Over the last decade, several cases of sclerosing cholangitis in critically ill patients (SC-CIP) were reported. Reports in the literature so far are characterized by a wide variety of underlying causes of critical illness, thereby hindering a risk-factor analysis. We report on a homogenous cohort of critically ill patients with influenza A (H1N1) pneumonia and severe acute respiratory distress syndrome (ARDS), of whom a subgroup developed sclerosing cholangitis, allowing for probing of risk factors associated with SC-CIP. Methods Twenty-one patients (5 female, 16 male, 46.3 ± 10.8 years) with severe ARDS due to H1N1 pneumonia were retrospectively divided into two groups, characterized by the presence (n = 5) and absence of SC-CIP (n = 16). A large array of clinical data, laboratory parameters, and multi-detector computed tomography-derived measures were compared. Results Both patient groups showed severe pulmonary impairment. Severity of disease on admission day and during the first 14 days of treatment showed no difference. The patients developing SC-CIP had a higher body mass index (BMI) (37.4 ± 6.0 kg/m2 vs. 29.3 ± 6.8 kg/m2; P = 0.029) and a higher volume of intraperitoneal fat (8273 ± 3659 cm3 vs. 5131 ± 2268 cm3; P = 0.033) and spent a longer cumulative period in the prone position during the first 14 days (165 ± 117 h vs. 78 ± 61 h; P = 0.038). Conclusion Our results suggest that obesity, intraperitoneal fat volume, and a longer cumulative duration spent in the prone position may put patients with ARDS at risk of developing SC-CIP. These results lead us to propose that the prone position should be carefully deployed, particularly in abdominally obese patients, and that frequent checks be made for early hepatic dysfunction.
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Affiliation(s)
- Thomas Weig
- Department of Anaesthesiology, Ludwig-Maximilians-University, Munich, Germany
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Pelosi P, Vargas M. Mechanical ventilation and intra-abdominal hypertension: 'Beyond Good and Evil'. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:187. [PMID: 23256904 PMCID: PMC3672607 DOI: 10.1186/cc11874] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Intra-abdominal hypertension is frequent in surgical and medical critically ill patients. Intra-abdominal hypertension has a serious impact on the function of respiratory as well as peripheral organs. In the presence of alveolar capillary damage, which occurs in acute respiratory distress syndrome (ARDS), intra-abdominal hypertension promotes lung injury as well as edema, impedes the pulmonary lymphatic drainage, and increases intra-thoracic pressures, leading to atelectasis, airway closure, and deterioration of respiratory mechanics and gas exchange. The optimal setting of mechanical ventilation and its impact on respiratory function and hemodynamics in ARDS associated with intra-abdominal hypertension are far from being assessed. We suggest that the optimal ventilator management of patients with ARDS and intra-abdominal hypertension would include the following: (a) intra-abdominal, esophageal pressure, and hemodynamic monitoring; (b) ventilation setting with protective tidal volume, recruitment maneuver, and level of positive end-expiratory pressure set according to the 'best' compliance of the respiratory system or the lung; (c) deep sedation with or without neuromuscular paralysis in severe ARDS; and (d) open abdomen in selected patients with severe abdominal compartment syndrome.
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74
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Gaudry S, Dreyfuss D, Ricard JD. [New therapeutic strategies in ARDS]. MEDECINE INTENSIVE REANIMATION 2012; 22:336-342. [PMID: 32288733 PMCID: PMC7117833 DOI: 10.1007/s13546-012-0566-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 11/14/2012] [Indexed: 11/01/2022]
Abstract
Treatment of acute respiratory distress syndrome (ARDS) has been subject to many researches, sometimes leading to intense controversy. New findings in this field are varied. Effects on prognosis of commonly used treatments for ARDS have recently been investigated. Consistently, prone position, previously known to improve oxygenation without effect on mortality, has been shown to improve survival of the most severely hypoxemic patients. Administration of neuromuscular blocking agents in the acute phase of ARDS has been also shown to be beneficial on survival. In contrast, the exact place of extracorporeal membrane oxygenation (ECMO) in ARDS management remains to be defined despite data suggesting its possible efficiency. In addition, a new era of research has emerged with the advent of cell therapy. Mesenchymal stem cells are able to both promote alveolar epithelium repair and prevent infections. Their efficacy in animal models of ARDS still needs to be confirmed by clinical trials. Finally, other promising therapies including beta-2 adrenergic agonists and omega-3 fatty acids have shown significant limitations in large clinical studies on ARDS.
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Affiliation(s)
- S. Gaudry
- Service de réanimation médicochirurgicale, hôpital Louis Mourier, 178 rue des Renouillers, F-92700 Colombes, France
- Univ Paris Diderot, Sorbonne Paris Cité, UMRS 722, F-75018 Paris, France
| | - D. Dreyfuss
- Service de réanimation médicochirurgicale, hôpital Louis Mourier, 178 rue des Renouillers, F-92700 Colombes, France
- Univ Paris Diderot, Sorbonne Paris Cité, UMRS 722, F-75018 Paris, France
| | - J. -D. Ricard
- Service de réanimation médicochirurgicale, hôpital Louis Mourier, 178 rue des Renouillers, F-92700 Colombes, France
- Univ Paris Diderot, Sorbonne Paris Cité, UMRS 722, F-75018 Paris, France
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Abstract
Acute respiratory distress syndrome (ARDS) is the clinical manifestation of an acute lung injury caused by a variety of direct and indirect injuries to the lung. The cardinal clinical feature of ARDS, refractory arterial hypoxemia, is the result of protein-rich alveolar edema with impaired surfactant function, due to vascular leakage and dysfunction with consequently impaired matching of ventilation to perfusion. Better understanding of the pathophysiology of ARDS has led to the development of novel therapies, pharmacological strategies, and advances in mechanical ventilation. However, protective ventilation is the only confirmed option in ARDS management improving survival, and few other therapies have translated into improved oxygenation or reduced ventilation time. The development of innovative therapy options, such as extracorporeal membrane oxygenation, have the potential to further improve survival of this devastating disease.
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Affiliation(s)
- M Hecker
- Medizinische Klinik II (Pneumologie/internistische Intensivmedizin), Universitätsklinikum Gießen und Marburg, Standort Gießen, Klinikstrasse 33, Gießen, Germany
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Prone positioning improves oxygenation in adult burn patients with severe acute respiratory distress syndrome. J Trauma Acute Care Surg 2012; 72:1634-9. [PMID: 22695433 DOI: 10.1097/ta.0b013e318247cd4f] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Prone positioning (PP) improves oxygenation and may provide a benefit in patients with acute respiratory distress syndrome (ARDS). This approach adds significant challenges to patients in intensive care by limiting access to the endotracheal or tracheostomy tube and vascular access. PP also significantly complicates burn care by making skin protection and wound care more difficult. We hypothesize that PP improves oxygenation and can be performed safely in burn patients with ARDS. METHODS PP was implemented in a burn intensive care unit for 18 patients with severe refractory ARDS. The characteristics of these patients were retrospectively reviewed to evaluate the impact of PP on Pao2:FiO2 ratio (PFR) during the first 48 hours of therapy. Each patient was considered his or her own control before initiation of PP, and trends in PFR were evaluated with one-way analysis of variance. Secondary measures of complications and mortality were also evaluated. RESULTS Mean PFR before PP was 87 (± 38) with a mean sequential organ failure assessment score of 11 (± 4). PFR improved during 48 hours in 12 of 14 survivors (p < 0.05). Mean PFR was 133 (± 77) immediately after PP, 165 (± 118) at 6 hours, 170 (± 115) at 12 hours, 214 (± 126) at 24 hours, 236 (± 137) at 36 hours, and 210 (± 97) at 48 hours. At each measured time interval except the last, PFR significantly improved. There were no unintended extubations. Facial pressure ulcers developed in four patients (22%). Overall, 14 survived 48 hours (78%), 12 survived 28 days (67%), and six survived to hospital discharge (33%). CONCLUSIONS PP improves oxygenation in burn patients with severe ARDS and was safely implemented in a burn intensive care unit. Mortality in this population remains high, warranting investigation into additional complementary rescue therapies. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Goal-oriented respiratory management for critically ill patients with acute respiratory distress syndrome. Crit Care Res Pract 2012; 2012:952168. [PMID: 22957224 PMCID: PMC3432327 DOI: 10.1155/2012/952168] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2012] [Accepted: 07/19/2012] [Indexed: 02/07/2023] Open
Abstract
This paper, based on relevant literature articles and the authors' clinical experience, presents a goal-oriented respiratory management for critically ill patients with acute respiratory distress syndrome (ARDS) that can help improve clinicians' ability to care for these patients. Early recognition of ARDS modified risk factors and avoidance of aggravating factors during hospital stay such as nonprotective mechanical ventilation, multiple blood products transfusions, positive fluid balance, ventilator-associated pneumonia, and gastric aspiration can help decrease its incidence. An early extensive clinical, laboratory, and imaging evaluation of “at risk patients” allows a correct diagnosis of ARDS, assessment of comorbidities, and calculation of prognostic indices, so that a careful treatment can be planned. Rapid administration of antibiotics and resuscitative measures in case of sepsis and septic shock associated with protective ventilatory strategies and early short-term paralysis associated with differential ventilatory techniques (recruitment maneuvers with adequate positive end-expiratory pressure titration, prone position, and new extracorporeal membrane oxygenation techniques) in severe ARDS can help improve its prognosis. Revaluation of ARDS patients on the third day of evolution (Sequential Organ Failure Assessment (SOFA), biomarkers and response to infection therapy) allows changes in the initial treatment plans and can help decrease ARDS mortality.
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Lanza FDC, Barcellos PG, Dal Corso S. Benefícios do decúbito ventral associado ao CPAP em recém-nascidos prematuros. FISIOTERAPIA E PESQUISA 2012. [DOI: 10.1590/s1809-29502012000200008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
O objetivo deste estudo foi avaliar os benefícios nas variáveis clínicas do decúbito ventral (DV) associado a pressão positiva contínua nas vias aéreas (CPAP), em recém-nascido pré-termo (RNPT). Foi feito um estudo transversal em RNPT com utilização do CPAP internados na unidade de terapia intensiva (UTI). As frequências cardíaca (FC) e respiratória (FR), SpO2, quantificação do desconforto respiratório pelo boletim de Silverman e Andersen (BSA: quanto maior o valor, pior o desconforto respiratório) foram avaliados em cinco fases. Na fase I foram avaliadas a FC, FR, SpO2 e BSA em decúbito supino. Nas fases II, III, IV e V foram coletadas as mesmas variáveis da fase I após 5, 15, 30 e 60 min, respectivamente. O RNPT foi posicionado em DV logo após a fase I. Foi realizada análise de variância repetida para comparação entre todas as variáveis estudadas nas cinco fases, e utilizado-se teste de Bonferroni para análise post hoc. Foi considerada significância estatística quando p<0,05. No estudo, foram incluídos 13 RNPT, com média idade gestacional 33±1,5 semanas, sendo 7 do gênero masculino. Não houve alteração significante na FC, FR e SpO2, entre todas as fases. Houve redução no BSA nas fases III e IV quando comparadas à fase I: fase 1, 4,6±1,6 vs. fase III, 2,4±0,5 (p=0,02); fase I, 4,6±1,6 vs. fase IV, 2,4±0,5 (p=0,002). Concluiu-se, então, então que DV reduz o desconforto respiratório em RNPT quando associado ao CPAP, quando permanecem por, pelo menos, 15 min, sem alteração na FC, FR e SpO2.
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Abstract
PURPOSE OF REVIEW Several alternative treatments have been proposed to decrease mortality of patients with acute respiratory distress syndrome (ARDS). We will discuss most recent trials and meta-analysis studies on nonconventional ventilatory and pharmacological treatments of ARDS patients. RECENT FINDINGS Nonconventional ventilatory treatments such as prone positioning, high frequency oscillatory ventilation (HFOV), and extracorporeal membrane oxygenation (ECMO) aim to restore gas exchange while further decreasing ventilator induced lung injury. Though randomized trials failed to prove survival benefits with the use of prone positioning or HFOV, recent meta-analyses have shown, for both treatments, a decrease in mortality in the subpopulation of more severe ARDS patients. In a randomized controlled trial, referral of ARDS patients in a center with experience on ECMO was associated with an improved survival rate. Promising results come from new miniaturized extracorporeal techniques optimized for effective CO(2) removal from low blood flow. These techniques should allow early application of superprotective ventilator strategies. Pharmacological treatments such as neuromuscular blocking and intravenous β2 agonist may be effective in specific times and subsets of patients. SUMMARY Existing data suggest that some of the available nonconventional treatments may be effective in more severe ARDS patients. New techniques and drugs that should facilitate prevention or healing of lung injury are under investigation.
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Gordo-Vidal F, Enciso-Calderón V. Síndrome de distrés respiratorio agudo, ventilación mecánica y función ventricular derecha. Med Intensiva 2012; 36:138-42. [DOI: 10.1016/j.medin.2011.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 08/31/2011] [Indexed: 12/17/2022]
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Abstract
Management of acute respiratory failure is an important component of intensive care. In this review, we analyze 21 original research articles published last year in Critical Care in the field of respiratory and critical care medicine. The articles are summarized according to the following topic categories: acute respiratory distress syndrome, mechanical ventilation, adjunctive therapies, and pneumonia.
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Roche-Campo F, Aguirre-Bermeo H, Mancebo J. Glucocorticoids in the treatment of acute respiratory distress syndrome. MEDECINE INTENSIVE REANIMATION 2012; 21:391-398. [PMID: 32288728 PMCID: PMC7117829 DOI: 10.1007/s13546-011-0316-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 10/03/2011] [Indexed: 12/02/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by local inflammation and an intense systemic inflammatory reaction. Glucocorticoid administration has been suggested due to their anti-inflammatory properties. However, results from the initial studies of glucocorticoids in ARDS, which evaluated high-dose and short-term treatments, were negative. More recent studies have evaluated the effect of lower doses of glucocorticoids administered over longer periods, but the results thus far have been inconclusive.
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Affiliation(s)
- F. Roche-Campo
- Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Espagne
| | - H. Aguirre-Bermeo
- Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Espagne
| | - J. Mancebo
- Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Espagne
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83
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Abstract
The prone position has been used to improve oxygenation in patients with severe hypoxemia and acute respiratory failure since 1974. All studies with the prone position document an improvement in systemic oxygenation in 70% to 80% of patients with acute respiratory distress syndrome (ARDS), with maximal improvement seen in the most hypoxemic patients. This article reviews data regarding efficacy for use of the prone position in patients with ARDS. Also described is a simple, safe, quick, and inexpensive procedure used to prone patients with severe ARDS on a standard bed in the intensive care unit at the University of Michigan.
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Roche-Campo F, Aguirre-Bermeo H, Mancebo J. Prone positioning in acute respiratory distress syndrome (ARDS): when and how? Presse Med 2011; 40:e585-94. [PMID: 22078089 DOI: 10.1016/j.lpm.2011.03.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 03/15/2011] [Accepted: 03/17/2011] [Indexed: 01/12/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a severe form of respiratory failure. It remains one of the most devastating conditions in the intensive care unit. Mechanical ventilation with positive end-expiratory pressure is a cornerstone therapy for ARDS patients. One adjuvant alternative is to place the patient in a prone position. Since it was first described in 1976, prone positioning has been safely employed to improve oxygenation in many patients with ARDS. Prone positioning may also minimize secondary lung injury induced by mechanical ventilation, although this benefit has not been investigated as extensively, despite its potential. In spite of a strong physiological justification, prone positioning is still not widely accepted as an adjunct therapy in ARDS patients and it is only used regularly in only 10% of ICUs. This may be explained in part by the reluctance to change position, risks and unclear effects on relevant outcomes. In this paper, we review all aspects of prone positioning, from the pathophysiology to the clinical studies of patient outcome, and we also discuss the latest controversies surrounding this treatment.
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Rival G, Patry C, Floret N, Navellou JC, Belle E, Capellier G. Prone position and recruitment manoeuvre: the combined effect improves oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R125. [PMID: 21575205 PMCID: PMC3218988 DOI: 10.1186/cc10235] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2011] [Revised: 04/20/2011] [Accepted: 05/16/2011] [Indexed: 12/15/2022]
Abstract
Introduction Among the various methods for improving oxygenation while decreasing the risk of ventilation-induced lung injury in patients with acute respiratory distress syndrome (ARDS), a ventilation strategy combining prone position (PP) and recruitment manoeuvres (RMs) can be practiced. We studied the effects on oxygenation of both RM and PP applied in early ARDS patients. Methods We conducted a prospective study. Sixteen consecutive patients with early ARDS fulfilling our criteria (ratio of arterial oxygen partial pressure to fraction of inspired oxygen (PaO2/FiO2) 98.3 ± 28 mmHg; positive end expiratory pressure, 10.7 ± 2.8 cmH2O) were analysed. Each patient was ventilated in both the supine position (SP) and the PP (six hours in each position). A 45 cmH2O extended sigh in pressure control mode was performed at the beginning of SP (RM1), one hour after turning to the PP (RM2) and at the end of the six-hour PP period (RM3). Results The mean arterial oxygen partial pressure (PaO2) changes after RM1, RM2 and RM3 were 9.6%, 15% and 19%, respectively. The PaO2 improvement after a single RM was significant after RM3 only (P < 0.05). Improvements in PaO2 level and PaO2/FiO2 ratio were transient in SP but durable during PP. PaO2/FiO2 ratio peaked at 218 mmHg after RM3. PaO2/FiO2 changes were significant only after RM3 and in the pulmonary ARDS group (P = 0.008). This global strategy had a benefit with regard to oxygenation: PaO2/FiO2 ratio increased from 98.3 mmHg to 165.6 mmHg 13 hours later at the end of the study (P < 0.05). Plateau airway pressures decreased after each RM and over the entire PP period and significantly after RM3 (P = 0.02). Some reversible side effects such as significant blood arterial pressure variations were found when extended sighs were performed. Conclusions In our study, interventions such as a 45 cmH2O extended sigh during PP resulted in marked oxygenation improvement. Combined RM and PP led to the highest increase in PaO2/FiO2 ratio without major clinical side effects.
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Affiliation(s)
- Gilles Rival
- Service de pneumologie, Centre Hospitalier Régional et Universitaire de Besançon, 3 Bd. Fleming, Besançon, France.
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Abstract
The acute respiratory distress syndrome (ARDS) is a complex disorder of heterogeneous etiologies characterized by a consistent, recognizable pattern of lung injury. Extensive epidemiologic studies and clinical intervention trials have been conducted to address the high mortality of this disorder and have provided significant insight into the complexity of studying new therapies for this condition. The existing clinical investigations in ARDS will be highlighted in this review. The limitations to current definitions, patient selection, and outcome assessment will be considered. While significant attention has been focused on the parenchymal injury that characterizes this disorder and the clinical support of gas exchange function, relatively limited focus has been directed to hemodynamic and pulmonary vascular dysfunction equally prominent in the disease. The limited available clinical information in this area will also be reviewed. The current standards for cardiopulmonary management of the condition will be outlined. Current gaps in our understanding of the clinical condition will be highlighted with the expectation that continued progress will contribute to a decline in disease mortality.
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Affiliation(s)
- Michael Donahoe
- Department of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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