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Abstract
OBJECTIVES Physiologic dead space is associated with mortality in acute respiratory distress syndrome, but its measurement is cumbersome. Alveolar dead space fraction relies on the difference between arterial and end-tidal carbon dioxide (alveolar dead space fraction = (PaCO2 - PetCO2) / PaCO2). We aimed to assess the relationship between alveolar dead space fraction and mortality in a cohort of children meeting criteria for acute respiratory distress syndrome (both the Berlin 2012 and the American-European Consensus Conference 1994 acute lung injury) and pediatric acute respiratory distress syndrome (as defined by the Pediatric Acute Lung Injury Consensus Conference in 2015). DESIGN Secondary analysis of a prospective, observational cohort. SETTING Tertiary care, university affiliated PICU. PATIENTS Invasively ventilated children with pediatric acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 283 children with pediatric acute respiratory distress syndrome, 266 had available PetCO2. Alveolar dead space fraction was lower in survivors (median 0.13; interquartile range, 0.06-0.23) than nonsurvivors (0.31; 0.19-0.42; p < 0.001) at pediatric acute respiratory distress syndrome onset, but not 24 hours after (survivors 0.12 [0.06-0.18], nonsurvivors 0.14 [0.06-0.25], p = 0.430). Alveolar dead space fraction at pediatric acute respiratory distress syndrome onset discriminated mortality with an area under receiver operating characteristic curve of 0.76 (95% CI, 0.66-0.85; p < 0.001), better than either initial oxygenation index or PaO2/FIO2. In multivariate analysis, alveolar dead space fraction at pediatric acute respiratory distress syndrome onset was independently associated with mortality, after adjustment for severity of illness, immunocompromised status, and organ failures. CONCLUSIONS Alveolar dead space fraction at pediatric acute respiratory distress syndrome onset discriminates mortality and is independently associated with nonsurvival. Alveolar dead space fraction represents a single, useful, readily obtained clinical biomarker reflective of pulmonary and nonpulmonary variables associated with mortality.
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Khemani RG. Databases for Research in Pediatric Acute Respiratory Distress Syndrome. J Pediatr Intensive Care 2015; 5:89-94. [PMID: 31110891 DOI: 10.1055/s-0035-1568159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/04/2015] [Indexed: 10/22/2022] Open
Abstract
Problem Addressed Observational data, either previously existing or gathered specifically for research, provide exciting opportunities to understand practice variation, generate hypotheses, test the feasibility of future clinical trials, and perform comparative effectiveness research. Pediatric acute respiratory distress syndrome (PARDS) provides a prototypical example of a disease state where our science can be furthered by using observational data in the form of research databases. Investigational Approach Literature review. Results There are several key issues that are important to consider in the creation of PARDS databases to inform future research and answer comparative effectiveness questions. They surround (1) time-sensitive measurements mandating careful annotations of key variables, (2) explicit methodology for ventilator-related variables, (3) explicit data to calculate outcome measures, (4) granularity of data to handle dose-dependent questions, and (5) operational definitions of crucial comorbidities or other factors implicated in PARDS outcome. These areas must be explicitly handled in the ontologic framework of PARDS databases. Conclusions In summary, there are many opportunities to use existing data to further our knowledge of PARDS. However, the aggregation of these data from previous studies, future studies, or existing electronic health care records must be done with careful consideration that the variables and data annotations are of adequate granularity and specificity to answer the questions we want to ask.
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Affiliation(s)
- Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California, United States.,Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California, United States
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Chen W, Ware LB. Prognostic factors in the acute respiratory distress syndrome. Clin Transl Med 2015; 4:65. [PMID: 26162279 PMCID: PMC4534483 DOI: 10.1186/s40169-015-0065-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 06/19/2015] [Indexed: 01/11/2023] Open
Abstract
Despite improvements in critical care, acute respiratory distress syndrome (ARDS) remains a devastating clinical problem with high rates of morbidity and mortality. A better understanding of the prognostic factors associated with ARDS is crucial for facilitating risk stratification and developing new therapeutic interventions that aim to improve clinical outcomes. In this article, we present an up-to-date summary of factors that predict mortality in ARDS in four categories: (1) clinical characteristics; (2) physiological parameters and oxygenation; (3) genetic polymorphisms and biomarkers; and (4) scoring systems. In addition, we discuss how a better understanding of clinical and basic pathogenic mechanisms can help to inform prognostication, decision-making, risk stratification, treatment selection, and improve study design for clinical trials.
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Affiliation(s)
- Wei Chen
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, USA,
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Oxygenation metrics in pediatric acute respiratory distress syndrome: is a timely evaluation the answer? Crit Care Med 2015; 43:1130-2. [PMID: 25876110 DOI: 10.1097/ccm.0000000000000894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
OBJECTIVE Although all definitions of acute respiratory distress syndrome use some measure of hypoxemia, neither the Berlin definition nor recently proposed pediatric-specific definitions proposed by the Pediatric Acute Lung Injury Consensus Conference utilizing oxygenation index specify which PaO2/FIO2 or oxygenation index best categorizes lung injury. We aimed to identify variables associated with mortality and ventilator-free days at 28 days in a large cohort of children with acute respiratory distress syndrome. DESIGN Prospective, observational, single-center study. SETTING Tertiary care, university-affiliated PICU. PATIENTS Two-hundred eighty-three invasively ventilated children with the Berlin-defined acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Between July 1, 2011, and June 30, 2014, 283 children had acute respiratory distress syndrome with 37 deaths (13%) at the Children's Hospital of Philadelphia. Neither initial PaO2/FO2 nor oxygenation index at time of meeting acute respiratory distress syndrome criteria discriminated mortality. However, 24 hours after, both PaO2/FIO2 and oxygenation index discriminated mortality (area under receiver operating characteristic curve, 0.68 [0.59-0.77] and 0.66 [0.57-0.75]; p < 0.001). PaO2/FIO2 at 24 hours categorized severity of lung injury, with increasing mortality rates of 5% (PaO2/FIO2, > 300), 8% (PaO2/FIO2, 201-300), 18% (PaO2/FIO2, 101-200), and 37% (PaO2/FIO2, ≤ 100) across worsening Berlin categories. This trend with 24-hour PaO2/FIO2 was seen for ventilator-free days (22, 19, 14, and 0 ventilator-free days across worsening Berlin categories; p < 0.001) and duration of ventilation in survivors (6, 9, 13, and 24 d across categories; p < 0.001). Similar results were obtained with 24-hour oxygenation index. CONCLUSIONS PaO2/FIO2 and oxygenation index 24 hours after meeting acute respiratory distress syndrome criteria accurately stratified outcomes in children. Initial values were not helpful for prognostication. Definitions of acute respiratory distress syndrome may benefit from addressing timing of oxygenation metrics to stratify disease severity.
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Caironi P, Carlesso E, Cressoni M, Chiumello D, Moerer O, Chiurazzi C, Brioni M, Bottino N, Lazzerini M, Bugedo G, Quintel M, Ranieri VM, Gattinoni L. Lung recruitability is better estimated according to the Berlin definition of acute respiratory distress syndrome at standard 5 cm H2O rather than higher positive end-expiratory pressure: a retrospective cohort study. Crit Care Med 2015; 43:781-90. [PMID: 25513785 DOI: 10.1097/ccm.0000000000000770] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The Berlin definition of acute respiratory distress syndrome has introduced three classes of severity according to PaO2/FIO2 thresholds. The level of positive end-expiratory pressure applied may greatly affect PaO2/FIO2, thereby masking acute respiratory distress syndrome severity, which should reflect the underlying lung injury (lung edema and recruitability). We hypothesized that the assessment of acute respiratory distress syndrome severity at standardized low positive end-expiratory pressure may improve the association between the underlying lung injury, as detected by CT, and PaO2/FIO2-derived severity. DESIGN Retrospective analysis. SETTING Four university hospitals (Italy, Germany, and Chile). PATIENTS One hundred forty-eight patients with acute lung injury or acute respiratory distress syndrome according to the American-European Consensus Conference criteria. INTERVENTIONS Patients underwent a three-step ventilator protocol (at clinical, 5 cm H2O, or 15 cm H2O positive end-expiratory pressure). Whole-lung CT scans were obtained at 5 and 45 cm H2O airway pressure. MEASUREMENTS AND MAIN RESULTS Nine patients did not fulfill acute respiratory distress syndrome criteria of the novel Berlin definition. Patients were then classified according to PaO2/FIO2 assessed at clinical, 5 cm H2O, or 15 cm H2O positive end-expiratory pressure. At clinical positive end-expiratory pressure (11±3 cm H2O), patients with severe acute respiratory distress syndrome had a greater lung tissue weight and recruitability than patients with mild or moderate acute respiratory distress syndrome (p<0.001). At 5 cm H2O, 54% of patients with mild acute respiratory distress syndrome at clinical positive end-expiratory pressure were reclassified to either moderate or severe acute respiratory distress syndrome. In these patients, lung recruitability and clinical positive end-expiratory pressure were higher than in patients who remained in the mild subgroup (p<0.05). When patients were classified at 5 cm H2O, but not at clinical or 15 cm H2O, lung recruitability linearly increases with acute respiratory distress syndrome severity (5% [2-12%] vs 12% [7-18%] vs 23% [12-30%], respectively, p<0.001). The potentially recruitable lung was the only CT-derived variable independently associated with ICU mortality (p=0.007). CONCLUSIONS The Berlin definition of acute respiratory distress syndrome assessed at 5 cm H2O allows a better evaluation of lung recruitability and edema than at higher positive end-expiratory pressure clinically set.
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Affiliation(s)
- Pietro Caironi
- 1Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy. 2Dipartimento di Anestesia, Rianimazione e Terapia del Dolore, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy. 3Department of Anesthesiology, Emergency and Intensive Care Medicine, Georg-August University of Göttingen, Göttingen, Germany. 4Dipartimento di Radiologia, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy. 5Departmentos de Anestesiologia y Medicina Intensiva, Facultad de Medicina, Pontificia, Universidad Catolica de Chile, Santiago, Chile. 6Dipartimento di Anestesia, Azienda Ospedaliera San Giovanni Battista-Molinette, Università degli Studi di Torino, Turin, Italy
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Applied physiology and process of care for patients with acute respiratory distress syndrome. Crit Care Med 2015; 43:913-4. [PMID: 25768355 DOI: 10.1097/ccm.0000000000000832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Khemani RG, Smith L. Are we ready to accept the Berlin definition of acute respiratory distress syndrome for use in children? Crit Care Med 2015; 43:1132-4. [PMID: 25876111 PMCID: PMC4400856 DOI: 10.1097/ccm.0000000000000893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Affiliation(s)
- Robinder G. Khemani
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles; Department of Pediatrics, University of Southern California Keck School of Medicine
| | - Lincoln Smith
- Seattle Children’s Hospital, University of Washington School of Medicine
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111
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Villar J, Blanco J, del Campo R, Andaluz-Ojeda D, Díaz-Domínguez FJ, Muriel A, Córcoles V, Suárez-Sipmann F, Tarancón C, González-Higueras E, López J, Blanch L, Pérez-Méndez L, Fernández RL, Kacmarek RM. Assessment of PaO₂/FiO₂ for stratification of patients with moderate and severe acute respiratory distress syndrome. BMJ Open 2015; 5:e006812. [PMID: 25818272 PMCID: PMC4386240 DOI: 10.1136/bmjopen-2014-006812] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES A recent update of the definition of acute respiratory distress syndrome (ARDS) proposed an empirical classification based on ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO₂/FiO₂) at ARDS onset. Since the proposal did not mandate PaO₂/FiO₂ calculation under standardised ventilator settings (SVS), we hypothesised that a stratification based on baseline PaO₂/FiOv would not provide accurate assessment of lung injury severity. DESIGN A prospective, multicentre, observational study. SETTING A network of teaching hospitals. PARTICIPANTS 478 patients with eligible criteria for moderate (100<PaO₂/FiO₂≤200) and severe (PaO₂/FiO₂≤100) ARDS and followed until hospital discharge. INTERVENTIONS We examined physiological and ventilator parameters in association with the PaO₂/FiO₂ at ARDS onset, after 24 h of usual care and at 24 h under a SVS. At 24 h, patients were reclassified as severe, moderate, mild (200<PaO₂/FiO₂≤300) ARDS and non-ARDS (PaO₂/FiO₂>300). PRIMARY AND SECONDARY OUTCOMES Group severity and hospital mortality. RESULTS At ARDS onset, 173 patients had a PaO₂/FiO₂≤100 but only 38.7% met criteria for severe ARDS at 24 h under SVS. When assessed under SVS, 61.3% of patients with severe ARDS were reclassified as moderate, mild and non-ARDS, while lung severity and hospital mortality changed markedly with every PaO₂/FiO₂ category (p<0.000001). Our model of risk stratification outperformed the stratification using baseline PaO₂/FiO₂ and non-standardised PaO₂/FiO₂ at 24 h, when analysed by the predictive receiver operating characteristic (ROC) curve: area under the ROC curve for stratification at baseline was 0.583 (95% CI 0.525 to 0.636), 0.605 (95% CI 0.552 to 0.658) at 24 h without SVS and 0.693 (95% CI 0.645 to 0.742) at 24 h under SVS (p<0.000001). CONCLUSIONS Our findings support the need for patient assessment under SVS at 24 h after ARDS onset to assess disease severity, and have implications for the diagnosis and management of ARDS patients. TRIAL REGISTRATION NUMBERS NCT00435110 and NCT00736892.
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Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr Negrín, Las Palmas, Spain
| | - Jesús Blanco
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Intensive Care Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Rafael del Campo
- Intensive Care Unit, Hospital General de Ciudad Real, Ciudad Real, Spain
| | - David Andaluz-Ojeda
- Intensive Care Unit, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Arturo Muriel
- Intensive Care Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Virgilio Córcoles
- Intensive Care Unit, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Fernando Suárez-Sipmann
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Department of Surgical Sciences, Anesthesiology & Critical Care, Hedenstierna Laboratory, Uppsala University Hospital, Uppsala, Sweden
| | | | | | - Julia López
- Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Lluis Blanch
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Critical Care Center, Corporació Sanitaria Parc Taulí, Sabadell, Spain
| | - Lina Pérez-Méndez
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario NS de Candelaria, Tenerife, Spain
| | - Rosa Lidia Fernández
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr Negrín, Las Palmas, Spain
| | - Robert M Kacmarek
- Department of Respiratory Care, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anesthesiology, Harvard University, Boston, Massachusetts, USA
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López-Aguilar J, Lucangelo U, Albaiceta GM, Nahum A, Murias G, Cañizares R, Oliva JC, Romero PV, Blanch L. Effects on lung stress of position and different doses of perfluorocarbon in a model of ARDS. Respir Physiol Neurobiol 2015; 210:30-7. [PMID: 25662756 DOI: 10.1016/j.resp.2015.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 01/22/2015] [Accepted: 01/30/2015] [Indexed: 01/09/2023]
Abstract
We determined whether the combination of low dose partial liquid ventilation (PLV) with perfluorocarbons (PFC) and prone positioning improved lung function while inducing minimal stress. Eighteen pigs with acute lung injury were assigned to conventional mechanical ventilation (CMV) or PLV (5 or 10 ml/kg of PFC). Positive end-expiratory pressure (PEEP) trials in supine and prone positions were performed. Data were analyzed by a multivariate polynomial regression model. The interplay between PLV and position depended on the PEEP level. In supine PLV dampened the stress induced by increased PEEP during the trial. The PFC dose of 5 ml/kg was more effective than the dose 10 ml/kg. This effect was not observed in prone. Oxygenation was significantly higher in prone than in supine position mainly at lower levels of PEEP. In conclusion, MV settings should take both gas exchange and stress/strain into account. When protective CMV fails, rescue strategies combining prone positioning and PLV with optimal PEEP should improve gas exchange with minimal stress.
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Affiliation(s)
- Josefina López-Aguilar
- Fundació Parc Taulí, Corporació Sanitària Parc Taulí, Sabadell, Spain; Institut de Investigació i Innovació Parc Taulí, Universitat Autònoma de Barcelona, Campus d' Excelència Internacional, Bellaterra, Spain; Critical Care Center, Hospital de Sabadell, Corporació Sanitària Parc Taulí, Sabadell, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - Umberto Lucangelo
- Department of Perioperative Medicine, Intensive Care and Emergency, Cattinara Hospital, Trieste University, Trieste, Italy
| | - Guillermo M Albaiceta
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Dpto. Biologia Funcional, Universidad de Oviedo, Instituto Universitario de Oncologia del Principado de Asturias, Oviedo, Spain; Intensive Care Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Avi Nahum
- Pulmonary and Critical Care Department, St. Paul-Ramsey Medical Center, University of Minnesota, St. Paul, MN, USA
| | - Gastón Murias
- Clínica Bazterrica y Clínica Santa Isabel, Buenos Aires, Argentina
| | | | - Joan Carles Oliva
- Fundació Parc Taulí, Corporació Sanitària Parc Taulí, Sabadell, Spain; Institut de Investigació i Innovació Parc Taulí, Universitat Autònoma de Barcelona, Campus d' Excelència Internacional, Bellaterra, Spain
| | - Pablo V Romero
- Laboratory of Experimental Pneumology, IDIBELL, L'Hospitalet, Spain
| | - Lluís Blanch
- Fundació Parc Taulí, Corporació Sanitària Parc Taulí, Sabadell, Spain; Institut de Investigació i Innovació Parc Taulí, Universitat Autònoma de Barcelona, Campus d' Excelència Internacional, Bellaterra, Spain; Critical Care Center, Hospital de Sabadell, Corporació Sanitària Parc Taulí, Sabadell, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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A Clinical Classification of the Acute Respiratory Distress Syndrome for Predicting Outcome and Guiding Medical Therapy*. Crit Care Med 2015; 43:346-53. [DOI: 10.1097/ccm.0000000000000703] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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114
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Curley GF, McAuley DF. Clinical trial design in prevention and treatment of acute respiratory distress syndrome. Clin Chest Med 2014; 35:713-27. [PMID: 25453420 DOI: 10.1016/j.ccm.2014.08.009] [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: 11/24/2022]
Abstract
Our ability to define appropriate molecular targets for preclinical development and develop better methods needs to be improved, to determine the clinical value of novel acute respiratory distress syndrome (ARDS) agents. Clinical trials must have realistic sample sizes and meaningful end points and use the available observation and meta-analytical data to inform design. Biomarker-driven studies or defined ARDS subsets should be considered to categorize specific at-risk populations most likely to benefit from a new treatment. Innovations in clinical trial design should be pursued to improve the outlook for future interventional trials in ARDS.
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Affiliation(s)
- Gerard F Curley
- Department of Anesthesia, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, 30, Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Daniel F McAuley
- School of Medicine, Dentistry and Biomedical Science, Centre for Infection and Immunity, Queen's University Belfast, Health Sciences Building, 97 Lisburn Road, Belfast, Northern Ireland BT9 7BL, UK.
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Importance of radiological detection of early pulmonary acute complications of liver transplantation: analysis of 259 cases. Radiol Med 2014; 120:413-20. [PMID: 25421263 DOI: 10.1007/s11547-014-0472-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 06/05/2014] [Indexed: 12/17/2022]
Abstract
PURPOSE Pulmonary complications are common causes of morbidity and mortality after orthotopic liver transplantation (OLT) and consist of atelectasis, pleural effusion, pulmonary oedema, adult respiratory distress syndrome (ARDS) and pneumonia. The aim of this paper is to describe the incidence of pulmonary complications after OLT during the first postoperative week and to evaluate the informative value of the chest X-ray (CXR) in clinical practice. MATERIALS AND METHODS Patients who underwent OLT at the Ancona Transplant Centre between August 2005 and August 2012 were included in this retrospective study. The CXR and, if performed, the thoracic computed tomography (TCT) scans performed during the first 7 postoperative days were reviewed, and the radiological findings for atelectasis, pleural effusion, pulmonary oedema, ARDS and pneumonia were independently assessed and quantified by two radiologists according to the Fleischner Society criteria. Cases of pneumothorax after thoracentesis were assessed. Development of pneumonia was defined as the simultaneous presence of positive CXR or TCT and positive serological or fluid samples and clinical symptoms; the prevalence of infectious agents was assessed. The radiological reports produced in the clinical setting were compared with the findings. RESULTS Among 259 patients included, atelectasis was observed in 227 patients (87.6 %); pleural effusion in 250 (96.5 %); pulmonary oedema in 204 (78 %); ARDS in seven patients (2.6 %); and pneumothorax in 37 patients (14 %). Pneumonia occurred in 32 cases (12.3 %). Pulmonary oedema was underestimated in the radiological reports in 104 cases (40 %). CONCLUSIONS Knowledge about postoperative pulmonary complications and collaboration between the radiologist and clinician are essential for improving the management of OLT recipients.
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Tidal volume and plateau pressure use for acute lung injury from 2000 to present: a systematic literature review. Crit Care Med 2014; 42:2278-89. [PMID: 25098333 DOI: 10.1097/ccm.0000000000000504] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Since publication of the Respiratory Management of Acute Lung Injury and Acute Respiratory Distress Syndrome (ARMA) trial in 2000, use of tidal volume (VT) less than or equal to 6 mL/kg predicted body weight with corresponding plateau airway pressures (PPlat) less than or equal to 30 cm H2O has been advocated for acute lung injury. However, compliance with these recommendations is unknown. We therefore investigated VT (mL/kg predicted body weight) and PPlat (cm H2O) practices reported in studies of acute lung injury since ARMA using a systematic literature review (i.e., not a meta-analysis). DATA SOURCES PubMed, Scopus, and EMBASE. STUDY SELECTION Randomized controlled trials and nonrandomized studies enrolling patients with acute lung injury from May 2000 to June 2013 and reporting VT. DATA EXTRACTION Whether the study was a randomized controlled trial or a nonrandomized study and performed or not at an Acute Respiratory Distress Syndrome Network center; in randomized controlled trials, the pre- and postrandomization VT (mL/kg predicted body weight) and PPlat (cm H2O) and whether a VT protocol was used postrandomization; in nonrandomized studies, baseline VT and PPlat. DATA SYNTHESIS Twenty-two randomized controlled trials and 71 nonrandomized studies were included. Since 2000 at acute respiratory distress syndrome Network centers, routine VT was similar comparing randomized controlled trials and nonrandomized studies (p = 0.25) and unchanged over time (p = 0.75) with a mean value of 6.81 (95% CI, 6.45, 7.18). At non-acute respiratory distress syndrome Network centers, routine VT was also similar when comparing randomized controlled trials and nonrandomized studies (p = 0.71), but decreased (p = 0.001); the most recent estimate for it was 6.77 (6.22, 7.32). All VT estimates were significantly greater than 6 (p ≤ 0.02). In randomized controlled trials employing VT protocols, routine VT was reduced in both acute respiratory distress syndrome Network (n = 4) and non-acute respiratory distress syndrome Network (n = 11) trials (p ≤ 0.01 for both), but even postrandomization was greater than 6 (6.47 [6.29, 6.65] and 6.80 [6.42, 7.17], respectively; p ≤ 0.0001 for both). In 59 studies providing data, routine PPlat, averaged across acute respiratory distress syndrome Network or non-acute respiratory distress syndrome Network centers, was significantly less than 30 (p ≤ 0.02). CONCLUSIONS For clinicians treating acute lung injury since 2000, achieving VT less than or equal to 6 mL/kg predicted body weight may not have been as attainable or important as PPlat less than or equal to 30 cm H2O. If so, there may be equipoise to test if VT less than or equal to 6 mL/kg predicted body weight are necessary to improve acute lung injury outcome.
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What is the future of acute respiratory distress syndrome after the Berlin definition? Curr Opin Crit Care 2014; 20:10-6. [PMID: 24316666 DOI: 10.1097/mcc.0000000000000058] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW To analyze recently published articles in the medical literature that studied distinct aspects of adult patients with acute respiratory distress syndrome (ARDS) after the new Berlin definition introduced in 2012. RECENT FINDINGS The degree of ARDS severity according to this new classification correlated well with extravascular lung water index, pulmonary vascular permeability index and the finding of diffuse alveolar damage on autopsy. The new possibility of bedside echocardiographic evaluation of biventricular cardiac function is indicating the necessity of including a subgroup of severity of patients with right ventricular dysfunction. High-resolution CT evaluation showed that signs of pulmonary fibroproliferation in early ARDS predict increased ventilator dependency, multiple organ failure and mortality. The median development of ARDS 1 or 2 days after hospital admission emphasizes the need for ARDS intrahospital prevention, especially protective ventilation in non-ARDS patients. The better outcome with the use of prone position in patients with PaO2/FIO2 below 150 recently observed questioned the Berlin definition thresholds to decide the future best treatment strategies according to the proposed degree of severity of the syndrome. SUMMARY The impact of the Berlin definition of ARDS on the incidence, better treatment stratification and mortality ratio of ARDS is still to be determined.
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Abstract
PURPOSE OF REVIEW Prone position can prevent ventilator-induced lung injury in acute respiratory distress syndrome (ARDS) patients receiving conventional mechanical ventilation and, hence, may have the potential to improve survival from this basis. Even though no single randomized controlled trial has proven benefit on patient outcome until recently, two meta-analyses, one on grouped data and the other on individual data, have shown that patients with PaO2/FIO2 ratio less than 100 mmHg at the time of inclusion did benefit from prone position. As a fifth trial completed recently has shown a significant reduction in mortality in patients with severe and confirmed ARDS from using prone position, the purpose of this review is to revisit prone positioning in ARDS in the light of these new findings. RECENT FINDINGS In this trial done in patients with severe ARDS severity criteria (PaO2/FIO2 ratio less than 150 mmHg with positive end expiratory pressure of 5 cmH2O or more, FIO2 of 60% or more and tidal volume around 6 ml/kg predicted body weight) confirmed 12-24 h after the onset of ARDS, the day 28 mortality in the supine group (229 patients) was 32.8 versus 16% in the prone group (237 patients) (P < 0.001). Significant reduction in mortality was confirmed at day 90. SUMMARY From the combined results of the two meta-analyses and the last randomized controlled trial, there is a very strong signal to use prone position in patients with severe ARDS, as early as possible and for long sessions.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to examine and discuss the incidence and outcome of patients with the acute respiratory distress syndrome (ARDS). This is a challenging task, as there is no specific clinical sign or diagnostic test that accurately identifies and adequately defines this syndrome. RECENT FINDINGS This review will focus on published epidemiological studies reporting population-based incidence of ARDS, as defined by the American-European Consensus Conference criteria. In addition, the current outcome figures for ARDS patients reported in observational and randomized controlled trials will be reviewed. The focus will be on studies published since 2000, when the ARDSnet study on protective mechanical ventilation was published, although particular emphasis will be on those articles published in the last 24 months. SUMMARY On the basis of current evidence, and despite the order of magnitude of reported European and USA incidence figures, it seems that the incidence and overall mortality of ARDS has not changed substantially since the original ARDSnet study. The current mortality of adult ARDS is still greater than 40%.
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Abstract
PURPOSE OF REVIEW This review discusses our present understanding of postoperative respiratory failure (PRF) pathogenesis, risk factors, and perioperative-risk reduction strategies. RECENT FINDINGS PRF, the most frequent postoperative pulmonary complication, is defined by impaired blood gas exchange appearing after surgery. PRF leads to longer hospital stays and higher mortality. The time frame for recognizing when respiratory failure is related to the surgical-anesthetic insult remains imprecise, however, and researchers have used different clinical events instead of blood gas measures to define the outcome. Still, studies in specific surgical populations or large patient samples have identified a range of predictors of PRF risk: type of surgery and comorbidity, mechanical ventilation, and multiple hits to the lung have been found to be relevant in most of these studies. Recently, risk-scoring systems for PRF have been developed and are being applied in new controlled trials of PRF-risk reduction measures. Current evidence favors carefully managing intraoperative ventilator use and fluids, reducing surgical aggression, and preventing wound infection and pain. SUMMARY PRF is a life-threatening event that is challenging for the surgical team. Risk prediction scales based on large population studies are being developed and validated. We need high-quality trials of preventive measures, particularly those related to ventilator use in both high risk and general populations.
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121
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Wagner PD. The physiological basis of pulmonary gas exchange: implications for clinical interpretation of arterial blood gases. Eur Respir J 2014; 45:227-43. [DOI: 10.1183/09031936.00039214] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The field of pulmonary gas exchange is mature, with the basic principles developed more than 60 years ago. Arterial blood gas measurements (tensions and concentrations of O2and CO2) constitute a mainstay of clinical care to assess the degree of pulmonary gas exchange abnormality. However, the factors that dictate arterial blood gas values are often multifactorial and complex, with six different causes of hypoxaemia (inspiratory hypoxia, hypoventilation, ventilation/perfusion inequality, diffusion limitation, shunting and reduced mixed venous oxygenation) contributing variably to the arterial O2and CO2tension in any given patient. Blood gas values are then usually further affected by the body's abilities to compensate for gas exchange disturbances by three tactics (greater O2extraction, increasing ventilation and increasing cardiac output). This article explains the basic principles of gas exchange in health, mechanisms of altered gas exchange in disease, how the body compensates for abnormal gas exchange, and based on these principles, the tools available to interpret blood gas data and, quantitatively, to best understand the physiological state of each patient. This understanding is important because therapeutic intervention to improve abnormal gas exchange in any given patient needs to be based on the particular physiological mechanisms affecting gas exchange in that patient.
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122
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Abstract
This review documents important progress made in 2013 in the field of critical care respirology, in particular with regard to acute respiratory failure and acute respiratory distress syndrome. Twenty-five original articles published in the respirology and critical care sections of Critical Care are discussed in the following categories: pre-clinical studies, protective lung ventilation – how low can we go, non-invasive ventilation for respiratory failure, diagnosis and prognosis in acute respiratory distress syndrome and respiratory failure, and promising interventions for acute respiratory distress syndrome.
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Sweatt AJ, Levitt JE. Evolving epidemiology and definitions of the acute respiratory distress syndrome and early acute lung injury. Clin Chest Med 2014; 35:609-24. [PMID: 25453413 DOI: 10.1016/j.ccm.2014.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This article reviews the evolving definitions and epidemiology of the acute respiratory distress syndrome (ARDS) and highlights current efforts to improve identification of high-risk patients, thus to target prevention and early treatment before progression to ARDS. This information will be important for general practitioners and intensivists interested in improving the care of patients at risk for ARDS, and clinical researchers interested in designing clinical trials targeting the prevention and early treatment of acute lung injury.
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Affiliation(s)
- Andrew J Sweatt
- Division of Pulmonary and Critical Care Medicine, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Joseph E Levitt
- Division of Pulmonary and Critical Care Medicine, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA.
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Khemani RG, Rubin S, Belani S, Leung D, Erickson S, Smith LS, Zimmerman JJ, Newth CJL. Pulse oximetry vs. PaO2 metrics in mechanically ventilated children: Berlin definition of ARDS and mortality risk. Intensive Care Med 2014; 41:94-102. [PMID: 25231293 DOI: 10.1007/s00134-014-3486-2] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 09/04/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Requiring PaO2/FiO2 ratio (PF) to define ARDS may bias towards children with cardiovascular dysfunction and hypoxemia. We sought to evaluate (1) the Berlin definition of ARDS in children using PF; (2) the effect of substituting SpO2/FiO2(SF) ratio; (3) differences between patients with and without arterial blood gases; and (4) the ability of SpO2 and PaO2 indices to discriminate ICU mortality. METHODS Single center retrospective review (3/2009-4/2013) of mechanically ventilated (MV) children. Initial values for PF, SF, oxygenation index (OI), and oxygen saturation index (OSI) after intubation and average values on day 1 of MV were analyzed against ICU mortality, subgrouped by Berlin severity categories. RESULTS Of the 1,833 children included, 129 met Berlin PF ARDS criteria (33 % mortality); 312 met Berlin SF ARDS criteria (22 % mortality). Children with a PaO2 on day 1 of MV had higher mortality and severity of illness, were older, and had more vasoactive-inotropic infusions (p < 0.001). SF could be calculated for 1,201 children (AUC for ICU mortality 0.821), OSI for 1,034 (0.793), PF for 695 (0.706), and OI for 673 (0.739). Average SF on day 1 discriminated mortality better than PF (p = 0.003). CONCLUSIONS Berlin PF criteria for ARDS identified less than half of the children with ARDS, favoring those with cardiovascular dysfunction. SF or OSI discriminate ICU mortality as well as PF and OI, double the number of children available for risk stratification, and should be considered for severity of illness scores and included in a pediatric-specific definition of ARDS. Multicenter validation is required.
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Affiliation(s)
- Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd. Mailstop 12, Los Angeles, CA, 90027, USA,
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What's new in ARDS (clinical studies). Intensive Care Med 2014; 40:1731-3. [PMID: 25183570 DOI: 10.1007/s00134-014-3457-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 08/16/2014] [Indexed: 01/21/2023]
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126
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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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127
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Acute respiratory distress syndrome in patients with malignancies. Intensive Care Med 2014; 40:1106-14. [PMID: 24898895 DOI: 10.1007/s00134-014-3354-0] [Citation(s) in RCA: 172] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 05/23/2014] [Indexed: 12/19/2022]
Abstract
PURPOSE Little attention has been given to ARDS in cancer patients, despite their high risk for pulmonary complications. We sought to describe outcomes in cancer patients with ARDS meeting the Berlin definition. METHODS Data from a cohort of patients admitted to 14 ICUs between 1990 and 2011 were used for a multivariable analysis of risk factors for hospital mortality. RESULTS Of 1,004 included patients (86 % with hematological malignancies and 14 % with solid tumors), 444 (44.2 %) had neutropenia. Admission SOFA score was 12 (10-13). Etiological categories were primary infection-related ARDS (n = 662, 65.9 %; 385 bacterial infections, 213 invasive aspergillosis, 64 Pneumocystis pneumonia); extrapulmonary septic shock-related ARDS (n = 225, 22.4 %; 33 % candidemia); noninfectious ARDS (n = 76, 7.6 %); and undetermined cause (n = 41, 4.1 %). Of 387 (38.6 %) patients given noninvasive ventilation (NIV), 276 (71 %) subsequently required endotracheal ventilation. Hospital mortality was 64 % overall. According to the Berlin definition, 252 (25.1 %) patients had mild, 426 (42.4 %) moderate and 326 (32.5 %) severe ARDS; mortality was 59, 63 and 68.5 %, respectively (p = 0.06). Mortality dropped from 89 % in 1990-1995 to 52 % in 2006-2011 (p < 0.0001). Solid tumors, primary ARDS, and later admission period were associated with lower mortality. Risk factors for higher mortality were allogeneic bone-marrow transplantation, modified SOFA, NIV failure, severe ARDS, and invasive fungal infection. CONCLUSIONS In cancer patients, 90 % of ARDS cases are infection-related, including one-third due to invasive fungal infections. Mortality has decreased over time. NIV failure is associated with increased mortality. The high mortality associated with invasive fungal infections warrants specific studies of early treatment strategies.
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Impact of distinct definitions of acute lung injury on its incidence and outcomes in Brazilian ICUs: prospective evaluation of 7,133 patients*. Crit Care Med 2014; 42:574-82. [PMID: 24158166 DOI: 10.1097/01.ccm.0000435676.68435.56] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Evaluation of prevalence and outcomes of acute lung injury in a large cohort of critically ill patients in Brazil and comparison of predictive receiver operating characteristic curve mortality of American European Consensus conference definition with new Berlin definition of acute respiratory distress syndrome. DESIGN A 15-month prospective, multicenter, observational study. SETTING Fourteen medical ICUs in Espirito Santo, a state of Brazil. PATIENTS Mechanically ventilated patients who fulfilled American European Consensus conference criteria of acute lung injury or Berlin definition of acute respiratory distress syndrome. INTERVENTIONS Clinical and respiratory data were collected for 7 consecutive days and on the 14 and 28 days. Twenty-eight day mortality, hospital mortality, and predictive receiver operating characteristic curve mortality were calculated. MEASUREMENTS AND MAIN RESULTS Of 7,133 patients, 130 patients (1.8%) fulfilled criteria for acute lung injury (American European Consensus conference) or acute respiratory distress syndrome (Berlin definition). Median time for diagnosis was 2 days (interquartile range, 0-3 d). Main risk factors were pneumonia (35.3%) and nonpulmonary sepsis (31.5%). Mean age was 44.2 ± 15.9 years, and 61.5% were men. Mean Acute Physiology and Chronic Health Evaluation II score was 20.7 ± 7.9. Mean PaO2/FIO2 was 206 ± 61.5, significantly lower in nonsurvivors on day 7 (p = 0.003). Mean mechanical ventilation time was 21 ± 15 days. Length of ICU stay was 26.4 ± 18.7 days. Twenty-eight-day mortality was 38.5% (95% CI, 30.1-46.8); hospital mortality was 49.2% (95% CI, 40.6-57.8). Predictive 28-day mortality area under the receiver operating characteristic curve for American European Consensus conference definition was 0.5625 (95% CI, 0.4783-0.6467) and for the Berlin definition 0.5664 (95% CI, 0.4759-0.6568; p = 0.9510). CONCLUSIONS In our population, prevalence of acute lung injury was low, most cases were diagnosed 2 days after ICU admission, and Berlin definition was not different from American European Consensus conference definition in predicting mortality. There are still several problems with the global epidemiology, definition, and mortality predictive indices that should be added to the classification of this still lethal syndrome to improve its predictive mortality power in the future.
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Villar J, Kacmarek RM, Guérin C. Clinical trials in patients with the acute respiratory distress syndrome: burn after reading. Intensive Care Med 2014; 40:900-2. [PMID: 24718644 DOI: 10.1007/s00134-014-3288-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 04/01/2014] [Indexed: 01/09/2023]
Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain,
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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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Enteral omega-3 fatty acid supplementation in adult patients with acute respiratory distress syndrome: a systematic review of randomized controlled trials with meta-analysis and trial sequential analysis. Intensive Care Med 2014; 40:504-12. [DOI: 10.1007/s00134-014-3244-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 02/06/2014] [Indexed: 12/18/2022]
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Kangelaris KN, Calfee CS, May AK, Zhuo H, Matthay MA, Ware LB. Is there still a role for the lung injury score in the era of the Berlin definition ARDS? Ann Intensive Care 2014; 4:4. [PMID: 24533450 PMCID: PMC3931496 DOI: 10.1186/2110-5820-4-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 02/01/2014] [Indexed: 01/12/2023] Open
Abstract
Background The Lung Injury Score (LIS) remains a commonly utilized measure of lung injury severity though the additive value of LIS to predict ARDS outcomes over the recent Berlin definition of ARDS, which incorporates severity, is not known. Methods We tested the association of LIS (in which scores range from 0 to 4, with higher scores indicating more severe lung injury) and its four components calculated on the day of ARDS diagnosis with ARDS morbidity and mortality in a large, multi-ICU cohort of patients with Berlin-defined ARDS. Receiver Operator Characteristic (ROC) curves were generated to compare the predictive validity of LIS for mortality to Berlin stages of severity (mild, moderate and severe). Results In 550 ARDS patients, a one-point increase in LIS was associated with 58% increased odds of in-hospital death (95% CI 14 to 219%, P = 0.006), a 7% reduction in ventilator-free days (95% CI 2 to 13%, P = 0.01), and, among patients surviving hospitalization, a 25% increase in days of mechanical ventilation (95% CI 9 to 43%, P = 0.001) and a 16% increase (95% CI 2 to 31%, P = 0.02) in the number of ICU days. However, the mean LIS was only 0.2 points higher (95% CI 0.1 to 0.3) among those who died compared to those who lived. Berlin stages of severity were highly correlated with LIS (Spearman’s rho 0.72, P < 0.0001) and were also significantly associated with ARDS mortality and similar morbidity measures. The predictive validity of LIS for mortality was similar to Berlin stages of severity with an area under the curve of 0.58 compared to 0.60, respectively (P-value 0.49). Conclusions In a large, multi-ICU cohort of patients with ARDS, both LIS and the Berlin definition severity stages were associated with increased in-hospital morbidity and mortality. However, predictive validity of both scores was marginal, and there was no additive value of LIS over Berlin. Although neither LIS nor the Berlin definition were designed to prognosticate outcomes, these findings suggest that the role of LIS in characterizing lung injury severity in the era of the Berlin definition ARDS may be limited.
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Acosta-Herrera M, Pino-Yanes M, Perez-Mendez L, Villar J, Flores C. Assessing the quality of studies supporting genetic susceptibility and outcomes of ARDS. Front Genet 2014; 5:20. [PMID: 24567738 PMCID: PMC3915143 DOI: 10.3389/fgene.2014.00020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 01/21/2014] [Indexed: 12/12/2022] Open
Abstract
The acute respiratory distress syndrome (ARDS) is a severe inflammatory disease manifested as a result of pulmonary and systemic responses to several insults. It is now well accepted that genetic variation influences these responses. However, little is known about the genes that are responsible for patient susceptibility and outcome of ARDS. Methodological flaws are still abundant among genetic association studies with ARDS and here, we aimed to highlight the quality criteria where the standards have not been reached, to expose the associated genes to facilitate replication attempts, and to provide quick-reference guidance for future studies. We conducted a PubMed search from January 2008 to September 2012 for original articles. Studies were considered if a statistically significant association was declared with either susceptibility or outcomes of all-cause ARDS. Fourteen criteria were used for evaluation and results were compared to those from a previous quality assessment report. Significant improvements affecting study design and statistical analysis were detected. However, major issues such as adjustments for the underlying population stratification and replication studies remain poorly addressed.
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Affiliation(s)
- Marialbert Acosta-Herrera
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III Madrid, Spain ; Research Unit, Hospital Universitario N.S. de Candelaria Santa Cruz de Tenerife, Spain ; Research Unit, Hospital Universitario Dr. Negrin Las Palmas de Gran Canaria, Spain
| | - Maria Pino-Yanes
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III Madrid, Spain ; Research Unit, Hospital Universitario N.S. de Candelaria Santa Cruz de Tenerife, Spain ; Department of Medicine, University of California San Francisco, CA, USA
| | - Lina Perez-Mendez
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III Madrid, Spain ; Research Unit, Hospital Universitario N.S. de Candelaria Santa Cruz de Tenerife, Spain
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III Madrid, Spain ; Research Unit, Hospital Universitario Dr. Negrin Las Palmas de Gran Canaria, Spain ; Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto, ON, Canada
| | - Carlos Flores
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III Madrid, Spain ; Research Unit, Hospital Universitario N.S. de Candelaria Santa Cruz de Tenerife, Spain ; Applied Genomics Group (G2A), Genetics Laboratory, Instituto Universitario de Enfermedades Tropicales y Salud Pública de Canarias, Universidad de La Laguna Santa Cruz de Tenerife, Spain
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Gattinoni L, Taccone P, Carlesso E, Marini JJ. Prone position in acute respiratory distress syndrome. Rationale, indications, and limits. Am J Respir Crit Care Med 2014; 188:1286-93. [PMID: 24134414 DOI: 10.1164/rccm.201308-1532ci] [Citation(s) in RCA: 273] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In the prone position, computed tomography scan densities redistribute from dorsal to ventral as the dorsal region tends to reexpand while the ventral zone tends to collapse. Although gravitational influence is similar in both positions, dorsal recruitment usually prevails over ventral derecruitment, because of the need for the lung and its confining chest wall to conform to the same volume. The final result of proning is that the overall lung inflation is more homogeneous from dorsal to ventral than in the supine position, with more homogeneously distributed stress and strain. As the distribution of perfusion remains nearly constant in both postures, proning usually improves oxygenation. Animal experiments clearly show that prone positioning delays or prevents ventilation-induced lung injury, likely due in large part to more homogeneously distributed stress and strain. Over the last 15 years, five major trials have been conducted to compare the prone and supine positions in acute respiratory distress syndrome, regarding survival advantage. The sequence of trials enrolled patients who were progressively more hypoxemic; exposure to the prone position was extended from 8 to 17 hours/day, and lung-protective ventilation was more rigorously applied. Single-patient and meta-analyses drawing from the four major trials showed significant survival benefit in patients with PaO2/FiO2 lower than 100. The latest PROSEVA (Proning Severe ARDS Patients) trial confirmed these benefits in a formal randomized study. The bulk of data indicates that in severe acute respiratory distress syndrome, carefully performed prone positioning offers an absolute survival advantage of 10-17%, making this intervention highly recommended in this specific population subset.
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Affiliation(s)
- Luciano Gattinoni
- 1 Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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Year in review in Intensive Care Medicine 2013: II. Sedation, invasive and noninvasive ventilation, airways, ARDS, ECMO, family satisfaction, end-of-life care, organ donation, informed consent, safety, hematological issues in critically ill patients. Intensive Care Med 2014; 40:305-19. [PMID: 24458282 DOI: 10.1007/s00134-014-3217-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 01/11/2014] [Indexed: 01/02/2023]
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One-year mortality and predictors of death among hospital survivors of acute respiratory distress syndrome. Intensive Care Med 2014; 40:388-96. [PMID: 24435201 PMCID: PMC3943651 DOI: 10.1007/s00134-013-3186-3] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 12/02/2013] [Indexed: 01/20/2023]
Abstract
PURPOSE Advances in supportive care and ventilator management for acute respiratory distress syndrome (ARDS) have resulted in declines in short-term mortality, but risks of death after survival to hospital discharge have not been well described. Our objective was to quantify the difference between short-term and long-term mortality in ARDS and to identify risk factors for death and causes of death at 1 year among hospital survivors. METHODS This multi-intensive care unit, prospective cohort included patients with ARDS enrolled between January 2006 and February 2010. We determined the clinical characteristics associated with in-hospital and 1-year mortality among hospital survivors and utilized death certificate data to identify causes of death. RESULTS Of 646 patients hospitalized with ARDS, mortality at 1 year was substantially higher (41 %, 95% CI 37-45%) than in-hospital mortality (24%, 95% CI 21-27%), P < 0.0001. Among 493 patients who survived to hospital discharge, the 110 (22%) who died in the subsequent year were older (P < 0.001) and more likely to have been discharged to a nursing home, other hospital, or hospice compared to patients alive at 1 year (P < 0.001). Important predictors of death among hospital survivors were comorbidities present at the time of ARDS, and not living at home prior to admission. ARDS-related measures of severity of illness did not emerge as independent predictors of mortality in hospital survivors. CONCLUSIONS Despite improvements in short-term ARDS outcomes, 1-year mortality is high, mostly because of the large burden of comorbidities, which are prevalent in patients with ARDS.
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Guérin C, Girbes ARJ. Improved ICU outcomes in ARDS patients: implication on long-term outcomes. Intensive Care Med 2014; 40:448-50. [DOI: 10.1007/s00134-013-3200-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 12/17/2013] [Indexed: 10/25/2022]
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138
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An attempt to validate the modification of the American-European consensus definition of acute lung injury/acute respiratory distress syndrome by the Berlin definition in a university hospital. Intensive Care Med 2013; 39:2161-70. [PMID: 24114319 DOI: 10.1007/s00134-013-3122-6] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 09/21/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The Berlin definition for acute respiratory distress syndrome (ARDS) is a new proposal for changing the American-European consensus definition but has not been assessed prospectively as yet. In the present study, we aimed to determine (1) the prevalence and incidence of ARDS with both definitions, and (2) the initial characteristics of patients with ARDS and 28-day mortality with the Berlin definition. METHODS We performed a 6-month prospective observational study in the ten adult ICUs affiliated to the Public University Hospital in Lyon, France, from March to September 2012. Patients under invasive or noninvasive mechanical ventilation, with PaO2/FiO2 <300 mmHg regardless of the positive end-expiratory pressure (PEEP) level, and acute onset of new or increased bilateral infiltrates or opacities on chest X-ray were screened from ICU admission up to discharge. Patients with cardiogenic pulmonary edema were excluded. Patients were further classified into specific categories by using the American-European Consensus Conference and the Berlin definition criteria. The complete data set was measured at the time of inclusion. Patient outcome was measured at day 28 after inclusion. RESULTS During the study period 3,504 patients were admitted and 278 fulfilled the American-European Consensus Conference criteria. Among them, 18 (6.5 %) did not comply with the Berlin criterion PEEP ≥ 5 cmH2O and 20 (7.2 %) had PaO2/FiO2 ratio ≤200 while on noninvasive ventilation. By using the Berlin definition in the remaining 240 patients (n = 42 mild, n = 123 moderate, n = 75 severe), the overall prevalence was 6.85 % and it was 1.20, 3.51, and 2.14 % for mild, moderate, and severe ARDS, respectively (P > 0.05 between the three groups). The incidence of ARDS amounted to 32 per 100,000 population per year, with values for mild, moderate, and severe ARDS of 5.6, 16.3, and 10 per 100,000 population per year, respectively (P < 0.05 between the three groups). The 28-day mortality was 35.0 %. It amounted to 30.9 % in mild, 27.9 % in moderate, and 49.3 % in severe categories (P < 0.01 between mild or moderate and severe, P = 0.70 between mild and moderate). In the Cox proportional hazard regression analysis ARDS stage was not significantly associated with patient death at day 28. CONCLUSIONS The present study did not validate the Berlin definition of ARDS. Neither the stratification by severity nor the PaO2/FiO2 at study entry was independently associated with mortality.
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Defining ARDS: do we need a mandatory waiting period? Intensive Care Med 2013; 39:775-8. [PMID: 23370830 DOI: 10.1007/s00134-013-2834-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 12/19/2012] [Indexed: 01/11/2023]
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