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Cho YJ, Moon JY, Shin ES, Kim JH, Jung H, Park SY, Kim HC, Sim YS, Rhee CK, Lim J, Lee SJ, Lee WY, Lee HJ, Kwak SH, Kang EK, Chung KS, Choi WI. Clinical Practice Guideline of Acute Respiratory Distress Syndrome. Korean J Crit Care Med 2016. [DOI: 10.4266/kjccm.2016.31.2.76] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Young Moon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Ein-Soon Shin
- Research Agency for Clinical Practice Guidelines, Korean Academy of Medical Sciences Research Center, Seoul, Korea
| | - Je Hyeong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea University College of Medicine, Korea
| | - Hoon Jung
- Department of Pulmonary and Critical Care Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - So Young Park
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Medical Center, Seoul, Korea
| | - Ho Cheol Kim
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Yun Su Sim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Chin Kook Rhee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Korea
| | - Jaemin Lim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Gangneung Asan Hospital, University of Ulsan Medical College of Medicine, Gangneung, Korea
| | - Seok Jeong Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Won-Yeon Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Jeong Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Sang Hyun Kwak
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Eun Kyeong Kang
- Department of Pediatrics, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Kyung Soo Chung
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Won-Il Choi
- Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
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Hunt JL, Bronicki RA, Anas N. Role of Inhaled Nitric Oxide in the Management of Severe Acute Respiratory Distress Syndrome. Front Pediatr 2016; 4:74. [PMID: 27532031 PMCID: PMC4970488 DOI: 10.3389/fped.2016.00074] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 07/05/2016] [Indexed: 01/18/2023] Open
Abstract
To date, there have been several systematic reviews with meta-analysis that have shown no reduction in mortality with the use of inhaled nitric oxide (iNO) in patients with acute respiratory distress syndrome (ARDS). Importantly, these reports fail to make a distinction between the pediatric and adult patient. The number of adult patients in these reviews are far greater than the number of pediatric patients, which makes it difficult to interpret the data regarding the role of iNO on the pediatric population. Extrapolating data from the adult population to the pediatric population is complicated as we know that physiology and the body's response to disease can be different between adult and pediatric patients. iNO has been demonstrated to improve outcomes in term and near-term infants with hypoxic respiratory failure associated with pulmonary hypertension. Recently, Bronicki et al. published a prospective randomized control trial investigating the impact of iNO on the pediatric patient population with acute respiratory failure. In this study, a benefit of decreased duration of mechanical ventilation and an increased rate of ECMO-free survival was demonstrated in patients who were randomized to receiving iNO, suggesting that there may be benefit to the use of iNO in pediatric ARDS (PARDS) that has not been demonstrated in adults. iNO has repeatedly been shown to transiently improve oxygenation in all age groups, and yet neonates and pediatric patients have shown improvement in other outcomes that have not been seen in adults. The mechanism that explains improvement with the use of iNO in these patient populations are not well understood but does not appear to be solely a result of sustained improvement in oxygenation. There are physiologic studies that suggest alternative mechanisms for explaining the positive effects of iNO, such as platelet aggregation inhibition and reduction in systemic inflammation. Hence, the role of iNO by various mechanisms and in various age groups warrants further investigation.
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Affiliation(s)
| | | | - Nick Anas
- CHOC Children's Hospital , Orange, CA , USA
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Abstract
BACKGROUND Acute hypoxaemia de novo or on a background of chronic hypoxaemia is a common reason for admission to intensive care and for provision of mechanical ventilation. Various refinements of mechanical ventilation or adjuncts are employed to improve patient outcomes. Mortality from acute respiratory distress syndrome, one of the main contributors to the need for mechanical ventilation for hypoxaemia, remains approximately 40%. Ventilation in the prone position may improve lung mechanics and gas exchange and could improve outcomes. OBJECTIVES The objectives of this review are (1) to ascertain whether prone ventilation offers a mortality advantage when compared with traditional supine or semi recumbent ventilation in patients with severe acute respiratory failure requiring conventional invasive artificial ventilation, and (2) to supplement previous systematic reviews on prone ventilation for hypoxaemic respiratory failure in an adult population. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 1), Ovid MEDLINE (1950 to 31 January 2014), EMBASE (1980 to 31 January 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 31 January 2014) and Latin American Caribbean Health Sciences Literature (LILACS) (1992 to 31 January 2014) in Ovid MEDLINE for eligible randomized controlled trials. We also searched for studies by handsearching reference lists of relevant articles, by contacting colleagues and by handsearching published proceedings of relevant journals. We applied no language constraints, and we reran the searches in CENTRAL, MEDLINE, EMBASE, CINAHL and LILACS in June 2015. We added five new studies of potential interest to the list of "Studies awaiting classification" and will incorporate them into formal review findings during the review update. SELECTION CRITERIA We included randomized controlled trials (RCTs) that examined the effects of prone position versus supine/semi recumbent position during conventional mechanical ventilation in adult participants with acute hypoxaemia. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed all trials identified by the search and assessed them for suitability, methods and quality. Two review authors extracted data, and three review authors reviewed the data extracted. We analysed data using Review Manager software and pooled included studies to determine the risk ratio (RR) for mortality and the risk ratio or mean difference (MD) for secondary outcomes; we also performed subgroup analyses and sensitivity analyses. MAIN RESULTS We identified nine relevant RCTs, which enrolled a total of 2165 participants (10 publications). All recruited participants suffered from disorders of lung function causing moderate to severe hypoxaemia and requiring mechanical ventilation, so they were fairly comparable, given the heterogeneity of specific disease diagnoses in intensive care. Risk of bias, although acceptable in the view of the review authors, was inevitable: Blinding of participants and carers to treatment allocation was not possible (face-up vs face-down).Primary analyses of short- and longer-term mortality pooled from six trials demonstrated an RR of 0.84 to 0.86 in favour of the prone position (PP), but findings were not statistically significant: In the short term, mortality for those ventilated prone was 33.4% (363/1086) and supine 38.3% (395/1031). This resulted in an RR of 0.84 (95% confidence interval (CI) 0.69 to 1.02) marginally in favour of PP. For longer-term mortality, results showed 41.7% (462/1107) for prone and 47.1% (490/1041) for supine positions, with an RR of 0.86 (95% CI 0.72 to 1.03). The quality of the evidence for both outcomes was rated as low as a result of important potential bias and serious inconsistency.Subgroup analyses for mortality identified three groups consistently favouring PP: those recruited within 48 hours of meeting entry criteria (five trials; 1024 participants showed an RR of 0.75 (95% CI 0.59 to 94)); those treated in the PP for 16 or more hours per day (five trials; 1005 participants showed an RR of 0.77 (95% CI 0.61 to 0.99)); and participants with more severe hypoxaemia at trial entry (six trials; 1108 participants showed an RR of 0.77 (95% CI 0.65 to 0.92)). The quality of the evidence for these outcomes was rated as moderate as a result of potentially important bias.Prone positioning appeared to influence adverse effects: Pressure sores (three trials; 366 participants) with an RR of 1.37 (95% CI 1.05 to 1.79) and tracheal tube obstruction with an RR of 1.78 (95% CI 1.22 to 2.60) were increased with prone ventilation. Reporting of arrhythmias was reduced with PP, with an RR of 0.64 (95% CI 0.47 to 0.87). AUTHORS' CONCLUSIONS We found no convincing evidence of benefit nor harm from universal application of PP in adults with hypoxaemia mechanically ventilated in intensive care units (ICUs). Three subgroups (early implementation of PP, prolonged adoption of PP and severe hypoxaemia at study entry) suggested that prone positioning may confer a statistically significant mortality advantage. Additional adequately powered studies would be required to confirm or refute these possibilities of subgroup benefit but are unlikely, given results of the most recent study and recommendations derived from several published subgroup analyses. Meta-analysis of individual patient data could be useful for further data exploration in this regard. Complications such as tracheal obstruction are increased with use of prone ventilation. Long-term mortality data (12 months and beyond), as well as functional, neuro-psychological and quality of life data, are required if future studies are to better inform the role of PP in the management of hypoxaemic respiratory failure in the ICU.
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Affiliation(s)
- Roxanna Bloomfield
- Intensive Care Unit and Department of Anaesthesia, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZN
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Przybysz TM, Heffner AC. Early Treatment of Severe Acute Respiratory Distress Syndrome. Emerg Med Clin North Am 2015; 34:1-14. [PMID: 26614238 DOI: 10.1016/j.emc.2015.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is defined by acute diffuse inflammatory lung injury invoked by a variety of systemic or pulmonary insults. Despite medical progress in management, mortality remains 27% to 45%. Patients with ARDS should be managed with low tidal volume ventilation. Permissive hypercapnea is well tolerated. Conservative fluid strategy can reduce ventilator and hospital days in patients without shock. Prone positioning and neuromuscular blockers reduce mortality in some patients. Early management of ARDS is relevant to emergency medicine. Identifying ARDS patients who should be transferred to an extracorporeal membrane oxygenation center is an important task for emergency providers.
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Affiliation(s)
- Thomas M Przybysz
- Division of Critical Care Medicine, Department of Internal Medicine, Carolinas Medical Center, 1000 Blyth Boulevard, Charlotte, NC 28203, USA
| | - Alan C Heffner
- Division of Critical Care Medicine, Department of Internal Medicine, Carolinas Medical Center, 1000 Blyth Boulevard, Charlotte, NC 28203, USA; Medical ICU, Department of Emergency Medicine, Carolinas Medical Center, University of North Carolina, Charlotte Campus, 1000 Blyth Boulevard, Charlotte, NC 28203, USA.
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105
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Bhatraju P, Crawford J, Hall M, Lang JD. Inhaled nitric oxide: Current clinical concepts. Nitric Oxide 2015; 50:114-128. [DOI: 10.1016/j.niox.2015.08.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 07/31/2015] [Accepted: 08/26/2015] [Indexed: 12/12/2022]
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Hawkes MT, Conroy AL, Opoka RO, Hermann L, Thorpe KE, McDonald C, Kim H, Higgins S, Namasopo S, John C, Miller C, Liles WC, Kain KC. Inhaled nitric oxide as adjunctive therapy for severe malaria: a randomized controlled trial. Malar J 2015; 14:421. [PMID: 26510464 PMCID: PMC4625637 DOI: 10.1186/s12936-015-0946-2] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 10/21/2015] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Severe malaria remains a major cause of childhood mortality globally. Decreased endothelial nitric oxide is associated with severe and fatal malaria. The hypothesis was that adjunctive inhaled nitric oxide (iNO) would improve outcomes in African children with severe malaria. METHODS A randomized, blinded, placebo-controlled trial of iNO at 80 ppm by non-rebreather mask versus room air placebo as adjunctive treatment to artesunate in children with severe malaria was conducted. The primary outcome was the longitudinal course of angiopoietin-2 (Ang-2), an endothelial biomarker of malaria severity and clinical outcome. RESULTS One hundred and eighty children were enrolled; 88 were assigned to iNO and 92 to placebo (all received IV artesunate). Ang-2 levels measured over the first 72 h of hospitalization were not significantly different between groups. The mortality at 48 h was similar between groups [6/87 (6.9 %) in the iNO group vs 8/92 (8.7 %) in the placebo group; OR 0.78, 95 % CI 0.26-2.3; p = 0.65]. Clinical recovery times and parasite clearance kinetics were similar (p > 0.05). Methaemoglobinaemia >7 % occurred in 25 % of patients receiving iNO and resolved without sequelae. The incidence of neurologic deficits (<14 days), acute kidney injury, hypoglycaemia, anaemia, and haemoglobinuria was similar between groups (p > 0.05). CONCLUSIONS iNO at 80 ppm administered by non-rebreather mask was safe but did not affect circulating levels of Ang-2. Alternative methods of enhancing endothelial NO bioavailability may be necessary to achieve a biological effect and improve clinical outcome. TRIAL REGISTRATION ClinicalTrials.gov NCT01255215.
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Affiliation(s)
- Michael T Hawkes
- 3-588D Edmonton Clinic Health Academy, University of Alberta, 11405 87 Ave NW, Edmonton, AB, T6G 1C9, Canada.
| | - Andrea L Conroy
- Sandra Rotman Centre for Global Health, MaRS Centre, University of Toronto, 101 College St TMDT 10-360A, Toronto, ON, M5G 1L7, Canada.
| | - Robert O Opoka
- Global Health Uganda, Upper Paediatrics Office, Mulago Hospital, PO Box 33842, Plot 138, Upper Mawanda Road, Kawempe, Kampala, Uganda.
| | - Laura Hermann
- Sandra Rotman Centre for Global Health, MaRS Centre, University of Toronto, 101 College St TMDT 10-360A, Toronto, ON, M5G 1L7, Canada.
| | - Kevin E Thorpe
- Applied Health Research Centre, St Michael's Hospital, 250 Yonge St, 6th Floor, Toronto, ON, M5T 3M7, Canada.
| | - Chloe McDonald
- Sandra Rotman Centre for Global Health, MaRS Centre, University of Toronto, 101 College St TMDT 10-360A, Toronto, ON, M5G 1L7, Canada.
| | - Hani Kim
- Johns Hopkins School of Public Health, International Vaccine Access Center, 615 N Wolfe St, Baltimore, MD, 21205, USA.
| | - Sarah Higgins
- Sandra Rotman Centre for Global Health, MaRS Centre, University of Toronto, 101 College St TMDT 10-360A, Toronto, ON, M5G 1L7, Canada.
| | - Sophie Namasopo
- Jinja Regional Referral Hospital, Plot 7, Nalufenya Road, Jinja, Uganda.
| | - Chandy John
- Department of Pediatrics, Indiana University, 702 Barnhill Dr, Room 5900, Indianapolis, IN, 46202, USA.
| | - Chris Miller
- Division of Infectious Disease, University of British Columbia, Rm D433, HP East, Vancouver Hospital, 2733 Heather Street, Vancouver, BC, V5Z-3J5, Canada.
| | - W Conrad Liles
- Department of Medicine, University of Washington, 1959 NE Pacific Street, HSB RR-511, Box 356420, Seattle, WA, 98195-6420, USA.
| | - Kevin C Kain
- Sandra Rotman Centre for Global Health, MaRS Centre, University of Toronto, 101 College St TMDT 10-360A, Toronto, ON, M5G 1L7, Canada.
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107
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Parissopoulos S, Mpouzika MDA, Timmins F. Optimal support techniques when providing mechanical ventilation to patients with acute respiratory distress syndrome. Nurs Crit Care 2015; 22:40-51. [PMID: 26493043 DOI: 10.1111/nicc.12205] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 07/17/2015] [Accepted: 07/27/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Adult respiratory distress syndrome (ARDS) is a type of acute diffuse lung injury characterized by severe inflammation, increased pulmonary vascular permeability and a loss of aerated lung tissue. The effects of high fraction of inspired oxygen (FiO2 ) include oxygen toxicity manifested by damage to the lung parenchyma in the acute phase of lung injury. There is still a high mortality rate among this group of patients, so clinically sensitive evidence-based interventions are paramount to maximize survival chances during critical care. AIMS AND OBJECTIVES The aim of this article is to explore the current opinion concerning optimal mechanical ventilation support techniques for patients with acute respiratory distress syndrome. SEARCH STRATEGY, INCLUSION AND EXCLUSION CRITERIA A literature search of clinical trials and observation studies, reviews, discussion papers, meta-analyses and clinical guidelines written in English up to 2015, derived from the databases of Scopus, CINAHL, Cochrane Library databases and PubMed was conducted. CONCLUSIONS Low tidal volume, pressure limitation and prone positioning in severe ARDS patients appear to be of some benefit. More research is required and further development and use of standardized protocols is an important strategy for reducing practice variations across disciplines, as well as giving clear guidelines to nurses practising in critical care. There is also evidence that this syndrome is under-diagnosed and the utilization of lung protective ventilation is still variable. RELEVANCE TO CLINICAL PRACTICE It is important that nurses have underlying knowledge of both aetiology of ARDS and ventilation management, and that they monitor patients very closely. The adoption of a low tidal ventilation protocol, which is based on quality evidence guidelines, the value of rescue therapies and patient observation practices in the overall patient management, and the need to place emphasis on long-term patient outcomes, all these emerge as key factors for consideration and future research. However, there is also a need for more research that would explore the unique contribution of nurses in the management of this patient group, as it is difficult to discern this in the current literature.
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Affiliation(s)
- Stelios Parissopoulos
- Department of Nursing, Technological Educational Institute (T.E.I.) of Athens, Egaleo, Greece
| | | | - Fiona Timmins
- School of Nursing and Midwifery, Trinity College, Dublin, Ireland
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108
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Kim BS, Kyoung KH, Park H. Therapeutic Role of Inhaled Nitric Oxide for Acute Respiratory Failure in the Early Phase of Trauma. JOURNAL OF TRAUMA AND INJURY 2015. [DOI: 10.20408/jti.2015.28.3.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Byoung Sung Kim
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Kyu-Hyouck Kyoung
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hojong Park
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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109
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Searcy RJ, Morales JR, Ferreira JA, Johnson DW. The role of inhaled prostacyclin in treating acute respiratory distress syndrome. Ther Adv Respir Dis 2015; 9:302-12. [PMID: 26294418 DOI: 10.1177/1753465815599345] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a syndrome of acute lung injury that is characterized by noncardiogenic pulmonary edema and severe hypoxemia second to a pathogenic impairment of gas exchange. Despite significant advances in the area, mortality remains high among ARDS patients. High mortality and a limited spectrum of therapeutic options have left clinicians searching for alternatives, spiking interest in selective pulmonary vasodilators (SPVs). Despite the lack of robust evidence, SPVs are commonly employed for their therapeutic role in improving oxygenation in patients who have developed refractory hypoxemia in ARDS. While inhaled epoprostenol (iEPO) also impacts arterial oxygenation by decreasing ventilation-perfusion (V/Q) mismatching and pulmonary shunt flow, this effect is not different from inhaled nitric oxide (iNO). The most effective and safest dose for yielding a clinically significant increase in PaO2 and reduction in pulmonary artery pressure (PAP) appears to be 20-30 ng/kg/min in adults and 30 ng/kg/min in pediatric patients. iEPO appears to have a ceiling effect above these doses in which no additional benefit may be derived. iNO and iEPO have shown similar efficacy profiles; however, they differ with respect to cost and ease of therapeutic administration. The most beneficial effects of iEPO have been seen in adult patients with secondary ARDS as compared with primary ARDS, most likely due to the difference in etiology of the two disease states, and in patients suffering from baseline right ventricular heart failure. Although iEPO has demonstrated improvements in hemodynamic parameters and oxygenation in ARDS patients, due to the limited number of randomized clinical trials and the lack of studies investigating mortality, the use of iEPO cannot be recommended as standard of care in ARDS. iEPO should be reserved for those refractory to traditional therapies.
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Affiliation(s)
- Randi J Searcy
- Department of Pharmacy, University of Florida Health Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - James R Morales
- University of Florida Health Jacksonville, Jacksonville, Florida, USA
| | - Jason A Ferreira
- University of Florida Health Jacksonville, Jacksonville, Florida, USA
| | - Donald W Johnson
- University of Florida Health Jacksonville, Jacksonville, Florida, USA
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110
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Fuller BM, Mohr NM, Skrupky L, Fowler S, Kollef MH, Carpenter CR. The use of inhaled prostaglandins in patients with ARDS: a systematic review and meta-analysis. Chest 2015; 147:1510-1522. [PMID: 25742022 PMCID: PMC4451707 DOI: 10.1378/chest.14-3161] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 02/02/2015] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE This study aimed to determine whether inhaled prostaglandins are associated with improvement in pulmonary physiology or mortality in patients with ARDS and assess adverse effects. METHODS The following data sources were used: PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, reference lists, conference proceedings, and ClinicalTrials.gov. Studies selected included randomized controlled trials and nonrandomized studies. For data extraction, two reviewers independently screened titles and abstracts for eligibility. With regard to data synthesis, 25 studies (two RCTs) published over 21 years (1993-2014) were included. The PROSPERO registration number was CRD42014013180. RESULTS One randomized controlled trial showed no difference in the change in mean Pao2 to Fio2 ratio when comparing inhaled alprostadil to placebo: 141.2 (95% CI, 120.8-161.5) to 161.5 (95% CI, 134.6-188.3) vs 163.4 (95% CI, 140.8-186.0) to 186.8 (95% CI, 162.9-210.7), P = .21. Meta-analysis of the remaining studies demonstrated that inhaled prostaglandins were associated with improvement in Pao2 to Fio2 ratio (16 studies; 39.0% higher; 95% CI, 26.7%-51.3%), and Pao2 (eight studies; 21.4% higher; 95% CI, 12.2%-30.6%), and a decrease in pulmonary artery pressure (-4.8 mm Hg; 95% CI, -6.8 mm Hg to -2.8 mm Hg). Risk of bias and heterogeneity were high. Meta-regression found no association with publication year (P = .862), baseline oxygenation (P = .106), and ARDS etiology (P = .816) with the treatment effect. Hypotension occurred in 17.4% of patients in observational studies. CONCLUSIONS In ARDS, inhaled prostaglandins improve oxygenation and decrease pulmonary artery pressures and may be associated with harm. Data are limited both in terms of methodologic quality and demonstration of clinical benefit. The use of inhaled prostaglandins in ARDS needs further study.
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Affiliation(s)
- Brian M Fuller
- Department of Anesthesiology, Division of Critical Care, Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO.
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, The University of Iowa, Iowa City, IA
| | - Lee Skrupky
- Department of Pharmacy, Aurora BayCare Medical Center, Green Bay, WI
| | - Susan Fowler
- Bernard Becker Medical Library, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
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111
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Krishnan S, Schmidt GA. Acute right ventricular dysfunction: real-time management with echocardiography. Chest 2015; 147:835-846. [PMID: 25732449 DOI: 10.1378/chest.14-1335] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
In critically ill patients, the right ventricle is susceptible to dysfunction due to increased afterload, decreased contractility, or alterations in preload. With the increased use of point-of-care ultrasonography and a decline in the use of pulmonary artery catheters, echocardiography can be the ideal tool for evaluation and to guide hemodynamic and respiratory therapy. We review the epidemiology of right ventricular failure in critically ill patients; echocardiographic parameters for evaluating the right ventricle; and the impact of mechanical ventilation, fluid therapy, and vasoactive infusions on the right ventricle. Finally, we summarize the principles of management in the context of right ventricular dysfunction and provide recommendations for echocardiography-guided management.
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112
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BUSKOP C, BREDMOSE PP, SANDBERG M. A 10-year retrospective study of interhospital patient transport using inhaled nitric oxide in Norway. Acta Anaesthesiol Scand 2015; 59:648-53. [PMID: 25782015 DOI: 10.1111/aas.12505] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 01/27/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Anaesthesiologists from Oslo University Hospital have transported patients with severe oxygenation failure with inhaled nitric oxide (usually 20 ppm) from other hospitals to a tertiary care centre since 2002 in an effort to reduce the number of patients that otherwise would require transport with ongoing extracorporeal membrane oxygenation. The aim of this study was to evaluate the patient safety during transport with inhaled nitric oxide. METHODS All patient transports with ongoing nitric oxide treatment undertaken from 2003 to 2012 were identified in the transport database. The frequency of adverse events and their impact on patient safety were studied in addition to response to inhaled nitric oxide and adjusted intensive care treatment and time aspects of the transports. Information about in-hospital treatment and survival were extracted from the hospital patient records. RESULTS Adverse events were recorded in 12 of the 104 transports. Seven of the adverse events were due to malfunctioning technical equipment, three were related to medication other than the inhaled nitric oxide and two were related to ventilation. No adverse events resulted in permanent negative patient consequences or in discontinuation of the transport. Out of 104 patients, 79 responded to treatment with inhaled nitric oxide and other treatment changes by an increase in oxygen saturation of more than 5%. The 30-day mortality was 27% in the group transported with inhaled nitric oxide. CONCLUSION Transporting patients on inhaled nitric oxide is an alternative in selected patients who would otherwise require extracorporeal membrane oxygenation during transport.
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Affiliation(s)
- C. BUSKOP
- Air Ambulance Department; Oslo University Hospital; Nordbyhagen Norway
| | - P. P. BREDMOSE
- Air Ambulance Department; Oslo University Hospital; Nordbyhagen Norway
| | - M. SANDBERG
- Air Ambulance Department; Oslo University Hospital; Nordbyhagen Norway
- Faculty of Medicine; University of Oslo; Oslo Norway
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113
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Rubenfeld GD. Who cares about preventing acute respiratory distress syndrome? Am J Respir Crit Care Med 2015; 191:255-60. [PMID: 25478722 DOI: 10.1164/rccm.201408-1574cp] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a common, lethal, and morbid respiratory complication primarily seen in the setting of major trauma and infection. Despite advances in mechanical ventilation for ARDS, many interventions have not been successful in reducing mortality. Recent grant announcements and ongoing clinical trials indicate an interest in preventing ARDS. This Perspective challenges some of the basic assumptions of ARDS prevention and preventive care in the intensive care unit. ARDS is an organ function surrogate outcome. Studies of surrogate outcomes in medicine have repeatedly failed to show an association with patient-centered outcomes that might include mortality, quality of life, patient satisfaction, and cost. Organ failure surrogate outcomes in critical care, including oxygenation, cardiac output, and blood pressure, have similarly failed to show a consistent association with patient-centered benefit. Trials designed to demonstrate an effect on surrogate outcomes will rarely be able to demonstrate small, but important, harms so that the net benefit of prevention can be calculated. This will leave clinicians with insufficient information to balance the unknown benefits of ARDS prevention with imprecisely estimated costs or risks of prevention. Because ARDS diagnosis relies on oxygenation and the chest radiograph that might be directly influenced by the prophylactic intervention, studies must be designed to insure that the prevention is not merely cosmetic. Strategies that prevent ARDS need to be tested in trials sufficiently powered to demonstrate their patient-centered costs, benefits and harms before widespread adoption.
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Affiliation(s)
- Gordon D Rubenfeld
- Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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114
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Kruzliak P, Maruyama J, Maruyama K. Role of nitric oxide in pathophysiology and treatment of pulmonary hypertension. VITAMINS AND HORMONES 2015; 96:407-24. [PMID: 25189396 DOI: 10.1016/b978-0-12-800254-4.00016-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Pulmonary hypertension is a condition characterized by vasoconstriction, vascular cell proliferation, inflammation, microthrombosis, and vessel wall remodelation. Pulmonary endothelial cells produce vasoactive substances with vasoconstrictive as well as vasodilatative effects. The imbalance of these endothelium-derived vasoactive substances induced by endothelial dysfunction is very important in the pathogenesis of PH. One of most important substances with vasodilatative effect is nitric oxide. We provide a comprehensive insight into role of NO in the pathgenesis of PH and discuss perspectives and challenges in PH therapy based on NO administration.
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Affiliation(s)
- Peter Kruzliak
- Department of Cardiovascular Diseases, International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic.
| | - Junko Maruyama
- Department of Anesthesiology and Critical Care Medicine, Mie University School of Medicine, Mie, Japan; Department of Clinical Engineering, Suzuka University of Medical Science, Mie, Japan
| | - Kazuo Maruyama
- Department of Anesthesiology and Critical Care Medicine, Mie University School of Medicine, Mie, Japan; Department of Clinical Engineering, Suzuka University of Medical Science, Mie, Japan
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Ruan SY, Huang TM, Wu HY, Wu HD, Yu CJ, Lai MS. Inhaled nitric oxide therapy and risk of renal dysfunction: a systematic review and meta-analysis of randomized trials. Crit Care 2015; 19:137. [PMID: 25887847 PMCID: PMC4384233 DOI: 10.1186/s13054-015-0880-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/13/2015] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Inhaled nitric oxide (iNO) is an important therapy for acute respiratory distress syndrome (ARDS), pulmonary hypertension and pediatric hypoxemic respiratory failure. Safety concerns regarding iNO and renal dysfunction have been reported; however, there are currently no systematic reviews on this issue. Our objective was to evaluate published randomized controlled trials (RCTs) to ascertain the risk of renal dysfunction associated with iNO therapy in patients with and without ARDS. METHODS A systematic review of databases was performed to identify RCTs which compared iNO with controls up to September 2014. Effect estimates for risk ratio (RR) of acute kidney injury (AKI) were pooled using a random-effects model. RESULTS Ten RCTs involving 1363 participants were included. Inhaled nitric oxide significantly increased the risk of AKI compared with controls (RR, 1.4, 95%CI, 1.06 to 1.83, p = 0.02). In the stratified analysis, a high cumulative-dose of iNO significantly increased the risk of AKI (RR, 1.52, 95%CI, 1.14 to 2.02, p = 0.004), whereas medium and low cumulative-doses did not (RR, 0.64, 95%CI, 0.23 to 1.81 and RR, 0.56, 95%CI, 0.11 to 2.86 respectively). In subgroup analysis by study population, an increased risk of AKI was observed in patients with ARDS (RR, 1.55, 95%CI, 1.15 to 2.09, p = 0.005) but not in those without (RR, 0.90, 95%CI, 0.49 to 1.67, p = 0.75). CONCLUSIONS The available data show that iNO therapy may increase the risk of renal dysfunction, especially with prolonged use and in patients with ARDS. The risk in pediatric population is unknown owing to limited data. We suggest monitoring renal function during iNO therapy, and that future trials of iNO should evaluate renal safety.
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Affiliation(s)
- Sheng-Yuan Ruan
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, No.17 Xu-Zhou Road, Taipei, 10020, Taiwan.
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Tao-Min Huang
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, No.17 Xu-Zhou Road, Taipei, 10020, Taiwan.
| | - Hon-Yen Wu
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, No.17 Xu-Zhou Road, Taipei, 10020, Taiwan.
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
| | - Huey-Dong Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Chong-Jen Yu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Mei-Shu Lai
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, No.17 Xu-Zhou Road, Taipei, 10020, Taiwan.
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Modrykamien AM, Gupta P. The acute respiratory distress syndrome. Proc (Bayl Univ Med Cent) 2015; 28:163-71. [PMID: 25829644 DOI: 10.1080/08998280.2015.11929219] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The acute respiratory distress syndrome (ARDS) is a major cause of acute respiratory failure. Its development leads to high rates of mortality, as well as short- and long-term complications, such as physical and cognitive impairment. Therefore, early recognition of this syndrome and application of demonstrated therapeutic interventions are essential to change the natural course of this devastating entity. In this review article, we describe updated concepts in ARDS. Specifically, we discuss the new definition of ARDS, its risk factors and pathophysiology, and current evidence regarding ventilation management, adjunctive therapies, and intervention required in refractory hypoxemia.
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Affiliation(s)
- Ariel M Modrykamien
- Division of Pulmonary and Critical Care Medicine, Baylor University Medical Center at Dallas, Dallas, Texas (Modrykamien), and the Division of Pulmonary, Sleep, and Critical Care Medicine, Creighton University Medical Center, Omaha, Nebraska (Gupta)
| | - Pooja Gupta
- Division of Pulmonary and Critical Care Medicine, Baylor University Medical Center at Dallas, Dallas, Texas (Modrykamien), and the Division of Pulmonary, Sleep, and Critical Care Medicine, Creighton University Medical Center, Omaha, Nebraska (Gupta)
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Vale VV, Vilhena TC, Trindade RCS, Ferreira MRC, Percário S, Soares LF, Pereira WLA, Brandão GC, Oliveira AB, Dolabela MF, De Vasconcelos F. Anti-malarial activity and toxicity assessment of Himatanthus articulatus, a plant used to treat malaria in the Brazilian Amazon. Malar J 2015; 14:132. [PMID: 25888719 PMCID: PMC4379762 DOI: 10.1186/s12936-015-0643-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 03/07/2015] [Indexed: 12/27/2022] Open
Abstract
Background Plasmodium falciparum has become resistant to some of the available drugs. Several plant species are used for the treatment of malaria, such as Himatanthus articulatus in parts of Brazil. The present paper reports the phyto-chemistry, the anti-plasmodial and anti-malarial activity, as well as the toxicity of H. articulatus. Methods Ethanol and dichloromethane extracts were obtained from the powder of stem barks of H. articulatus and later fractionated and analysed. The anti-plasmodial activity was assessed against a chloroquine resistant strain P. falciparum (W2) in vitro, whilst in vivo anti-malarial activity against Plasmodium berghei (ANKA strain) was tested in mice, evaluating the role of oxidative stress (total antioxidant capacity - TEAC; lipid peroxidation – TBARS, and nitrites and nitrates - NN). In addition, cytotoxicity was evaluated using the HepG2 A16 cell-line. The acute oral and sub-chronic toxicity of the ethanol extract were evaluated in both male and female mice. Results Plumieride was isolated from the ethyl acetate fraction of ethanol extract, Only the dichloromethane extract was active against clone W2. Nevertheless, both extracts reduced parasitaemia in P. berghei-infected mice. Besides, a significant reduction in pulmonary and cerebral levels of NN (nitrites and nitrates) was found, as well as in pulmonary TBARS, indicating a reduced oxidative damage to these organs. The ethanol extract showed low cytotoxicity to HepG2 A16 cells in the concentrations used. No significant changes were observed in the in vivo toxicity studies. Conclusions The ethanol extract of H. articulatus proved to be promising as anti-malarial medicine and showed low toxicity.
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Affiliation(s)
- Valdicley V Vale
- Programa de Pós-graduação em Ciências Farmacêuticas, Instituto de Ciências da Saúde (ICS), Universidade Federal do Pará (UFPA), Rua Augusto Corrêa 1, 68075-110, Belém, PA, Brazil.
| | - Thyago C Vilhena
- Programa de Pós-graduação em Ciências Farmacêuticas, Instituto de Ciências da Saúde (ICS), Universidade Federal do Pará (UFPA), Rua Augusto Corrêa 1, 68075-110, Belém, PA, Brazil.
| | | | | | - Sandro Percário
- Laboratório de Pesquisa em Estresse Oxidativo, Instituto de Ciências Biológicas (ICB), Universidade Federal do Pará (UFPA), Belém, PA, Brazil. .,US Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA.
| | - Luciana F Soares
- Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.
| | - Washington Luiz A Pereira
- Departamento de Patologia Veterinária e Medicina Preventiva, Instituto de Saúde e Produção Animal (ISPA), Universidade Federal Rural da Amazônia, Belém, PA, Brazil.
| | - Geraldo C Brandão
- Escola de Farmácia, Universidade Federal de Ouro Preto, Ouro Preto, MG, Brazil.
| | - Alaíde B Oliveira
- Programa de Pós-graduação em Ciências Farmacêuticas, Instituto de Ciências da Saúde (ICS), Universidade Federal do Pará (UFPA), Rua Augusto Corrêa 1, 68075-110, Belém, PA, Brazil. .,Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.
| | - Maria F Dolabela
- Programa de Pós-graduação em Ciências Farmacêuticas, Instituto de Ciências da Saúde (ICS), Universidade Federal do Pará (UFPA), Rua Augusto Corrêa 1, 68075-110, Belém, PA, Brazil. .,Programa de Pós-graduação em Inovação Farmacêutica, Instituto de Ciências da Saúde (ICS), Universidade Federal do Pará (UFPA), Belém, PA, Brazil.
| | - Flávio De Vasconcelos
- Programa de Pós-graduação em Ciências Farmacêuticas, Instituto de Ciências da Saúde (ICS), Universidade Federal do Pará (UFPA), Rua Augusto Corrêa 1, 68075-110, Belém, PA, Brazil.
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Chung YC, Ko SC, Lu CL, Huang MC, Cheng KC. Analysis of Medical Resource Utilization and Outcome of Inhaled Nitric Oxide in Patients Undergoing Mechanical Ventilation. INT J GERONTOL 2015. [DOI: 10.1016/j.ijge.2014.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Double-blind, placebo-controlled pilot randomized trial of methylprednisolone infusion in pediatric acute respiratory distress syndrome. Pediatr Crit Care Med 2015; 16:e74-81. [PMID: 25634565 DOI: 10.1097/pcc.0000000000000349] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Low-dose methylprednisolone therapy in adults with early acute respiratory distress syndrome reduces systemic inflammation, duration of mechanical ventilation, and ICU length of stay. We report a pilot randomized trial of glucocorticoid treatment in early pediatric acute respiratory distress syndrome. DESIGN Double-blind, placebo-controlled randomized clinical trial. SETTING Le Bonheur Children's Hospital, Memphis, TN. PATIENTS Children (0-18 yr) with acute respiratory distress syndrome undergoing mechanical ventilation. INTERVENTIONS Patients were randomly assigned to steroid or placebo groups within 72 hours of intubation. IV methylprednisolone administered as loading dose (2 mg/kg) and continuous infusions (1 mg/kg/d) on days 1-7 and then tapered over days 8-14. Both groups were ventilated according to the Acute Respiratory Distress Syndrome Network protocol modified for children. Daily surveillance was performed for adverse effects. MEASUREMENTS AND MAIN RESULTS Thirty-five patients were randomized to the steroid (n = 17, no death) and placebo groups (n = 18, two deaths). No differences occurred in length of mechanical ventilation, ICU stay, hospital stay, or mortality between the two groups. At baseline, higher plateau pressures (p = 0.006) and lower Pediatric Logistic Organ Dysfunction scores (p = 0.04) occurred in the steroid group; other characteristics were similar. Despite higher plateau pressures on days 1 (p = 0.006) and 2 (p = 0.025) due to poorer lung compliance in the steroid group, they had lower PaCO2 values on days 2 (p = 0.009) and 3 (p = 0.014), higher pH values on day 2 (p = 0.018), and higher PaO2/FIO2 ratios on days 8 (p = 0.047) and 9 (p = 0.002) compared with the placebo group. Fewer patients in the steroid group required treatment for postextubation stridor (p = 0.04) or supplemental oxygen at ICU transfer (p = 0.012). Steroid therapy was not associated with detectable adverse effects. CONCLUSION This study demonstrates the feasibility of administering low-dose glucocorticoid therapy and measuring clinically relevant outcomes in pediatric acute respiratory distress syndrome. Changes in oxygenation and/or ventilation are consistent with early acute respiratory distress syndrome pathophysiology and results of similar clinical trials in adults. We propose and design a larger randomized trial to define the role of glucocorticoid therapy in pediatric acute respiratory distress syndrome.
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Mortality is the only relevant outcome in ARDS: yes. Intensive Care Med 2014; 41:141-3. [PMID: 25476981 DOI: 10.1007/s00134-014-3440-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 08/06/2014] [Indexed: 10/24/2022]
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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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Dzierba AL, Abel EE, Buckley MS, Lat I. A review of inhaled nitric oxide and aerosolized epoprostenol in acute lung injury or acute respiratory distress syndrome. Pharmacotherapy 2014; 34:279-90. [PMID: 24734313 DOI: 10.1002/phar.1365] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) are conditions associated with an estimated mortality of 40–50%. The use of inhaled vasodilators can help to improve oxygenation without hemodynamic effects. This article reviews relevant studies addressing the safety and efficacy of inhaled nitric oxide (iNO) and aerosolized epoprostenol (aEPO) in the treatment of life-threatening hypoxemia associated with ARDS and ALI. In addition, the article also provides a practicable guide to the clinical application of these therapies. Nine prospective randomized controlled trials were included for iNO reporting on changes in oxygenation or clinical outcomes. Seven reports of aEPO were examined for changes in oxygenation. Based on currently available data, the use of either iNO or aEPO is safe to use in patients with ALI or ARDS to transiently improve oxygenation. No differences have been observed in survival, ventilator-free days, or attenuation in disease severity. Further studies with consistent end points using standard delivery devices and standard modes of mechanical ventilation are needed to determine the overall benefit with iNO or aEPO.
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Abstract
PURPOSE OF REVIEW Despite recent advances in the management of patients with acute respiratory distress syndrome (ARDS) by using protective ventilator strategies, the mortality rate of ARDS remains high. The complexity of the pathogenesis and the heterogeneity of coexisting diseases in patients with ARDS require critical care physicians and researchers to search for multiple therapeutic approaches in order to further improve patient outcome. This review article therefore focuses on the recent studies in the field of pharmacological intervention in ARDS. RECENT FINDINGS A number of approaches for pharmacological intervention have been evaluated in patients with ARDS, but most of them failed to reduce mortality or improve outcomes despite some promising observations seen in preclinical studies. Prior methods such as nitric oxide inhalation, neuromuscular blocking agents and corticosteroids may still have a place in the treatment, while novel therapeutic approaches including the use of angiotensin-converting enzyme inhibitors, statins and stem cells are currently under investigation. SUMMARY Overall, there is no proven pharmacological therapy in ARDS, but some pharmacological interventions were associated with beneficial effects in certain subgroups of patients depending on the cause, underlying diseases, the concurrent supportive therapies and timing. Further clinical trials are warranted to assess multiple outcome measurement of the promising pharmacological interventions in selected patients with ARDS.
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Our paper 20 years later: Inhaled nitric oxide for the acute respiratory distress syndrome—discovery, current understanding, and focussed targets of future applications. Intensive Care Med 2014; 40:1649-58. [DOI: 10.1007/s00134-014-3458-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/18/2014] [Indexed: 11/26/2022]
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Mok YH, Lee JH, Rehder KJ, Turner DA. Adjunctive treatments in pediatric acute respiratory distress syndrome. Expert Rev Respir Med 2014; 8:703-16. [PMID: 25119574 DOI: 10.1586/17476348.2014.948854] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a devastating process that involves pulmonary inflammation, alveolar damage and hypoxemic respiratory failure. Although advances in management approaches over the past two decades have resulted in significantly improved outcomes, death from pediatric ARDS may still occur in up to 35% of patients. While invasive mechanical ventilation is an essential component of ARDS management, various adjuncts have been utilized as treatment for these patients. However, evidence-based data in infants and children in this area are lacking. In this article, the authors review the available evidence supporting (or not supporting) the use of non-ventilatory adjunctive strategies in the management of pediatric ARDS, including prone positioning, pulmonary vasodilators, β-agonists, steroids and surfactant.
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Affiliation(s)
- Yee Hui Mok
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore
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Long-term survival in patients with severe acute respiratory distress syndrome and rescue therapies for refractory hypoxemia*. Crit Care Med 2014; 42:1610-8. [PMID: 24732240 DOI: 10.1097/ccm.0000000000000322] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To describe long-term survival in patients with severe acute respiratory distress syndrome and assess differences in patient characteristics and outcomes among those who receive rescue therapies (prone position ventilation, inhaled nitric oxide, or inhaled epoprostenol) versus conventional treatment. DESIGN Cohort study of patients with severe hypoxemia. SETTING University-affiliated level 1 trauma center. PATIENTS Patients diagnosed with severe acute respiratory distress syndrome within 72 hours of ICU admission between January 1, 2008, and December 31, 2011. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data were abstracted from the medical record and included demographic and clinical variables, hospital and ICU length of stay, discharge disposition, and hospital costs. Patient-level data were linked to the Washington State Death Registry. Kaplan-Meier methods and Cox's proportional hazards models were used to estimate survival and hazard ratios. Four hundred twenty-eight patients meeting study inclusion criteria were identified; 62 (14%) were initiated on a rescue therapy. PaO2/FIO2 ratios were comparable at admission between patients treated with a rescue therapy and those treated conventionally but were substantially lower by 72 hours in those who received rescue therapies (54 ± 17 vs 69 ± 17 mm Hg; p < 0.01). For the entire cohort, estimated survival probability at 3 years was 55% (95% CI, 51-61%). Among 280 hospital survivors (65%), 3-year survival was 85% (95% CI, 80-89%). The relative hazard of in-hospital mortality was 68% higher among patients who received rescue therapy compared with patients treated conventionally (95% CI, 8-162%; p = 0.02). For long-term survival, the hazard ratio of death following ICU admission was 1.56 (95% CI, 1.02-2.37; p = 0.04), comparing rescue versus conventional treatment. CONCLUSIONS Despite high hospital mortality, severe acute respiratory distress syndrome patients surviving to hospital discharge have relatively good long-term survival. Worsening hypoxemia was associated with initiation of rescue therapy. Patients on rescue therapy had higher in-hospital mortality; however, survivors to hospital discharge had long-term survival that was comparable to other acute respiratory distress syndrome survivors.
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Wilson JG, Matthay MA. Mechanical ventilation in acute hypoxemic respiratory failure: a review of new strategies for the practicing hospitalist. J Hosp Med 2014; 9:469-75. [PMID: 24733692 PMCID: PMC4139286 DOI: 10.1002/jhm.2192] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 03/07/2014] [Accepted: 03/10/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND The goal of mechanical ventilation in acute hypoxemic respiratory failure is to support adequate gas exchange without harming the lungs. How patients are mechanically ventilated can significantly impact their ultimate outcomes. METHODS This review focuses on emerging evidence regarding strategies for mechanical ventilation in patients with acute hypoxemic respiratory failure including: low tidal volume ventilation in the acute respiratory distress syndrome (ARDS), novel ventilator modes as alternatives to low tidal volume ventilation, adjunctive strategies that may enhance recovery in ARDS, the use of lung-protective strategies in patients without ARDS, rescue therapies in refractory hypoxemia, and an evidence-based approach to weaning from mechanical ventilation. RESULTS Once a patient is intubated and mechanically ventilated, low tidal volume ventilation remains the best strategy in ARDS. Adjunctive therapies in ARDS include a conservative fluid management strategy, as well as neuromuscular blockade and prone positioning in moderate-to-severe disease. There is also emerging evidence that a lung-protective strategy may benefit non-ARDS patients. For patients with refractory hypoxemia, extracorporeal membrane oxygenation should be considered. Once the patient demonstrates signs of recovery, the best approach to liberation from mechanical ventilation involves daily spontaneous breathing trials and protocolized assessment of readiness for extubation. CONCLUSIONS Prompt recognition of ARDS and use of lung-protective ventilation, as well as evidence-based adjunctive therapies, remain the cornerstones of caring for patients with acute hypoxemic respiratory failure. In the absence of contraindications, it is reasonable to consider lung-protective ventilation in non-ARDS patients as well, though the evidence supporting this practice is less conclusive.
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Affiliation(s)
- Jennifer G. Wilson
- Department of Medicine, Division of Critical Care, University of California San Francisco, San Francisco, California
| | - Michael A. Matthay
- Cardiovascular Research Institute and Departments of Medicine and Anesthesiology, Division of Pulmonary and Critical Care, University of California San Francisco, San Francisco, California
- Address for correspondence and reprint requests: Michael A. Matthay, MD, University of California Cardiovascular Research Institute, Box 0624, 505 Parnassus Avenue, Room M917, San Francisco, CA 94143; Telephone: 415-353-1206; Fax: 415-353-1990;
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Schmidt M, Bailey M, Sheldrake J, Hodgson C, Aubron C, Rycus PT, Scheinkestel C, Cooper DJ, Brodie D, Pellegrino V, Combes A, Pilcher D. Predicting Survival after Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) Score. Am J Respir Crit Care Med 2014; 189:1374-82. [DOI: 10.1164/rccm.201311-2023oc] [Citation(s) in RCA: 463] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Luks AM. Ventilatory strategies and supportive care in acute respiratory distress syndrome. Influenza Other Respir Viruses 2014; 7 Suppl 3:8-17. [PMID: 24215377 DOI: 10.1111/irv.12178] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
While antiviral therapy is an important component of care in patients with the acute respiratory distress syndrome (ARDS) following influenza infection, it is not sufficient to ensure good outcomes, and additional measures are usually necessary. Patients usually receive high levels of supplemental oxygen to counteract the hypoxemia resulting from severe gas exchange abnormalities. Many patients also receive invasive mechanical ventilation for support for oxygenation, while in resource-poor settings, supplemental oxygen via face mask may be the only available intervention. Patients with ARDS receiving mechanical ventilation should receive lung-protective ventilation, whereby tidal volume is decreased to 6 ml/kg of their predicted weight and distending pressures are maintained ≤ 30 cm H2 O, as well as increased inspired oxygen concentrations and positive end-expiratory pressure (PEEP) to prevent atelectasis and support oxygenation. While these measures are sufficient in most patients, a minority develop refractory hypoxemia and may receive additional therapies, including prone positioning, inhaled vasodilators, extracorporeal membrane oxygenation, recruitment maneuvers followed by high PEEP, and neuromuscular blockade, although recent data suggest that this last option may be warranted earlier in the clinical course before development of refractory hypoxemia. Application of these "rescue strategies" is complicated by the lack of guidance in the literature regarding implementation. While much attention is devoted to these strategies, clinicians must not lose sight of simple interventions that affect patient outcomes including head of bed elevation, prophylaxis against venous thromboembolism and gastrointestinal bleeding, judicious use of fluids in the post-resuscitative phase, and a protocol-based approach to sedation and spontaneous breathing trials.
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Affiliation(s)
- Andrew M Luks
- Division of Pulmonary and Critical Care Medicine and the International Respiratory and Severe Illness Center (INTERSECT), University of Washington, Seattle, WA, USA
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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: 96] [Impact Index Per Article: 9.6] [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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131
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Inhaled nitric oxide in patients with acute respiratory distress syndrome: an end to the debate? Crit Care Med 2014; 42:472-3. [PMID: 24434457 DOI: 10.1097/ccm.0b013e3182a51f1a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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132
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Inhaled Nitric Oxide Does Not Reduce Mortality in Patients With Acute Respiratory Distress Syndrome Regardless of Severity. Crit Care Med 2014; 42:404-12. [DOI: 10.1097/ccm.0b013e3182a27909] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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133
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De Cruz SJ, Kenyon NJ, Sandrock CE. Bench-to-bedside review: the role of nitric oxide in sepsis. Expert Rev Respir Med 2014; 3:511-21. [DOI: 10.1586/ers.09.39] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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134
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Hodgson C, Carteaux G, Tuxen DV, Davies AR, Pellegrino V, Capellier G, Cooper DJ, Nichol A. Hypoxaemic rescue therapies in acute respiratory distress syndrome: Why, when, what and which one? Injury 2013; 44:1700-9. [PMID: 23261071 DOI: 10.1016/j.injury.2012.11.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 11/12/2012] [Accepted: 11/20/2012] [Indexed: 02/02/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is an inflammatory condition of the lungs which can result in refractory and life-threatening hypoxaemic respiratory failure. The risk factors for the development of ARDS are many but include trauma, multiple blood transfusions, burns and major surgery, therefore this condition is not uncommon in the severely injured patient. When ARDS is severe, high-inspired oxygen concentrations are frequently required to minimise hypoxaemia. In these situations clinicians commonly utilise interventions termed 'hypoxaemic rescue therapies' in an attempt to improve oxygenation, as without these, conventional mechanical ventilation can be associated with high mortality. However, their lack of efficacy on mortality when used prophylactically in generalised ARDS cohorts has resulted in their use being confined to clinical trials and the subset of ARDS patients with refractory hypoxaemia. First line hypoxaemic rescue therapies include inhaled nitric oxide, prone positioning, alveolar recruitment manoeuvres and high frequency oscillatory ventilation, which have all been shown to be effective in improving oxygenation. In situations where these first line rescue therapies are inadequate extra-corporeal membrane oxygenation has emerged as a lifesaving second line rescue therapy. Rescue therapies in critically ill patients with traumatic injuries presents specific challenges and requires careful assessment of both the short and longer term benefits, therapeutic limitations, and specific adverse effects before their use.
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Affiliation(s)
- Carol Hodgson
- Australia and New Zealand Intensive Care Research Centre, Department of Epidemiology & Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Australia; The Alfred Hospital, Melbourne 3181, Australia.
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Abstract
The primary function of the pulmonary circulation is to deliver blood to the alveolar capillaries to exchange gases. Distributing blood over a vast surface area facilitates gas exchange, yet the pulmonary vascular tree must be constrained to fit within the thoracic cavity. In addition, pressures must remain low within the circulatory system to protect the thin alveolar capillary membranes that allow efficient gas exchange. The pulmonary circulation is engineered for these unique requirements and in turn these special attributes affect the spatial distribution of blood flow. As the largest organ in the body, the physical characteristics of the lung vary regionally, influencing the spatial distribution on large-, moderate-, and small-scale levels.
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Affiliation(s)
- Robb W Glenny
- Department of Medicine, University of Washington, Seattle, Washington, USA.
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136
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Prone position during ECMO is safe and improves oxygenation. Int J Artif Organs 2013; 36:821-32. [PMID: 24338657 DOI: 10.5301/ijao.5000254] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2013] [Indexed: 11/20/2022]
Abstract
PURPOSE Combination of prone positioning (PrP) and extracorporeal membrane oxygenation (ECMO) might be beneficial in severe acute respiratory distress syndrome (ARDS), because both approaches are recommended. However, PrP during ECMO might be associated with complications such as dislocation of ECMO cannulae. We investigated complications and change of oxygenation effects of PrP during ECMO to identify "responders" and discuss our results considering different definitions of response in the literature.
METHODS Retrospective analysis of complications, gas exchange, and invasiveness of mechanical ventilation during first and second PrP on ECMO at specified time points (before, during, and after PrP). We used multivariate nonparametric analysis of longitudinal data (MANOVA) to compare changes of mechanical ventilation and hemodynamics associated with the first and second procedures.
RESULTS In 12 ECMO patients, 74 PrPs were performed (median ECMO duration: 10 days (IQR: 6.3-
15.5 days)). No dislocations of intravascular catheters/cannulae, endotracheal tubes or chest tubes were observed. Two PrPs had to be interrupted (endotracheal tube obstruction, acute pulmonary embolism). PaO2/FiO2-ratio increased associated with the first and second PrP (p = 0.002) and lasted after PrP in 58% of these turning procedures ("responders") without changes in ECMO blood flow, respiratory pressures, minute ventilation, portion of spontaneously triggered breathing, and compliance. Hemodynamics did not change with exception of increased mean pulmonary arterial pressure during PrP and decrease after PrP (p<0.001), while norepinephrine dosage decreased (p = 0.03) (MANOVA).
CONCLUSIONS Prone position during ECMO is safe and improves oxygenation even after repositioning. This might ameliorate hypoxemia and reduce the harm from mechanical ventilation.
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137
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Shekar K, Davies AR, Mullany DV, Tiruvoipati R, Fraser JF. To ventilate, oscillate, or cannulate? J Crit Care 2013; 28:655-62. [PMID: 23827735 DOI: 10.1016/j.jcrc.2013.04.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 03/09/2013] [Accepted: 04/17/2013] [Indexed: 02/05/2023]
Abstract
Ventilatory management of acute respiratory distress syndrome has evolved significantly in the last few decades. The aims have shifted from optimal gas transfer without concern for iatrogenic risks to adequate gas transfer while minimizing lung injury. This change in focus, along with improved ventilator and multiorgan system management, has resulted in a significant improvement in patient outcomes. Despite this, a number of patients develop hypoxemic respiratory failure refractory to lung-protective ventilation (LPV). The intensivist then faces the dilemma of either persisting with LPV using adjuncts (neuromuscular blocking agents, prone positioning, recruitment maneuvers, inhaled nitric oxide, inhaled prostacyclin, steroids, and surfactant) or making a transition to rescue therapies such as high-frequency oscillatory ventilation (HFOV) and/or extracorporeal membrane oxygenation (ECMO) when both these modalities are at their disposal. The lack of quality evidence and potential harm reported in recent studies question the use of HFOV as a routine rescue option. Based on current literature, the role for venovenous (VV) ECMO is probably sequential as a salvage therapy to ensure ultraprotective ventilation in selected young patients with potentially reversible respiratory failure who fail LPV despite neuromuscular paralysis and prone ventilation. Given the risk profile and the economic impact, future research should identify the patients who benefit most from VV ECMO. These choices may be further influenced by the emerging novel extracorporeal carbon dioxide removal devices that can compliment LPV. Given the heterogeneity of acute respiratory distress syndrome, each of these modalities may play a role in an individual patient. Future studies comparing LPV, HFOV, and VV ECMO should not only focus on defining the patients who benefit most from each of these therapies but also consider long-term functional outcomes.
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Affiliation(s)
- Kiran Shekar
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, The University of Queensland, Brisbane, Queensland, Australia.
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138
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Herold S, Gabrielli NM, Vadász I. Novel concepts of acute lung injury and alveolar-capillary barrier dysfunction. Am J Physiol Lung Cell Mol Physiol 2013; 305:L665-81. [PMID: 24039257 DOI: 10.1152/ajplung.00232.2013] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
In this review we summarize recent major advances in our understanding on the molecular mechanisms, mediators, and biomarkers of acute lung injury (ALI) and alveolar-capillary barrier dysfunction, highlighting the role of immune cells, inflammatory and noninflammatory signaling events, mechanical noxae, and the affected cellular and molecular entities and functions. Furthermore, we address novel aspects of resolution and repair of ALI, as well as putative candidates for treatment of ALI, including pharmacological and cellular therapeutic means.
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Affiliation(s)
- Susanne Herold
- Dept. of Internal Medicine, Justus Liebig Univ., Universities of Giessen and Marburg Lung Center, Klinikstrasse 33, 35392 Giessen, Germany.
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139
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Boyle AJ, Mac Sweeney R, McAuley DF. Pharmacological treatments in ARDS; a state-of-the-art update. BMC Med 2013; 11:166. [PMID: 23957905 PMCID: PMC3765621 DOI: 10.1186/1741-7015-11-166] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 06/11/2013] [Indexed: 12/20/2022] Open
Abstract
Despite its high incidence and devastating outcomes, acute respiratory distress syndrome (ARDS) has no specific treatment, with effective therapy currently limited to minimizing potentially harmful ventilation and avoiding a positive fluid balance. Many pharmacological therapies have been investigated with limited success to date. In this review article we provide a state-of-the-art update on recent and ongoing trials, as well as reviewing promising future pharmacological therapies in ARDS.
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Affiliation(s)
- Andrew James Boyle
- Centre for Infection and Immunity, Health Sciences Building, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK.
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140
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Estrategias frente a la hipoxemia refractaria en el síndrome de dificultad respiratoria del adulto. Med Intensiva 2013; 37:423-30. [DOI: 10.1016/j.medin.2012.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Revised: 11/27/2012] [Accepted: 12/13/2012] [Indexed: 11/20/2022]
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141
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Galvin IM, Steel A, Pinto R, Ferguson ND, Davies MW. Partial liquid ventilation for preventing death and morbidity in adults with acute lung injury and acute respiratory distress syndrome. Cochrane Database Syst Rev 2013; 2013:CD003707. [PMID: 23881653 PMCID: PMC6516802 DOI: 10.1002/14651858.cd003707.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are syndromes of severe respiratory failure that are associated with substantial mortality and morbidity. Artifical ventilatory support is commonly required and may exacerbate lung injury. Partial liquid ventilation (PLV) has been proposed as a less injurious form of ventilatory support for these patients. Although PLV has been shown to improve gas exchange and to reduce inflammation in experimental models of ALI, a previous systematic review did not find any evidence to support or refute its use in humans with ALI and ARDS. OBJECTIVES The primary objective of this review was to assess whether PLV reduced mortality (at 28 d, at discharge from the intensive care unit (ICU), at discharge from hospital and at one, two and five years) in adults with ALI or ARDS when compared with conventional ventilatory support.Secondary objectives were to determine how PLV compared with conventional ventilation with regard to duration of invasive mechanical ventilation, duration of respiratory support, duration of oxygen therapy, length of ICU stay, length of hospital stay, incidence of infection, long-term cognitive impairment, long-term health related quality of life, long- term lung function, long-term morbidity costs and adverse events. The following adverse events were considered: hypoxia (arterial PO2 <80 mm Hg), pneumothorax (any air leak into the pleural space requiring therapeutic intervention), hypotension (systolic blood pressure < 90 mm Hg sustained for longer than two minutes or requiring treatment with fluids or vasoactive drugs), bradycardia (heart rate < 50 beats per minute sustained for longer than one minute or requiring therapeutic intervention) and cardiac arrest (absence of effective cardiac output). SEARCH METHODS In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL Issue 10, 2012, in The Cochrane Library; MEDLINE (Ovid SP, 1966 to November 2012); EMBASE (Ovid SP, 1980 to November 2012) and CINAHL (EBSCOhost,1982 to November 2012) for published studies. In our original review, we searched until May 2004.Grey literature was identified by searching conference proceedings and trial registries and by contacting experts in the field. SELECTION CRITERIA As in the original review, review authors selected randomized controlled trials that compared PLV with other forms of ventilation in adults (16 y of age or older) with ALI or ARDS, reporting one or more of the following: mortality; duration of mechanical ventilation, respiratory support, oxygen therapy, stay in the intensive care unit or stay in hospital; infection; long-term cognitive impairment or health-related quality of life; long-term lung function or cost. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated the quality of the relevant studies and extracted the data from included studies. MAIN RESULTS In this updated review, one new eligible study was identified and included, yielding a total of two eligible studies (including a combined total of 401 participants). Of those 401 participants, 170 received 'high'-dose partial liquid ventilation (i.e. a mean dose of at least 20 mL/kg), 99 received 'low-dose' partial liquid ventilation (i.e. a dose of 10 mL/kg) and 132 received conventional mechanical ventilation (CMV). Pooled estimates of effect were calculated for all those who received 'high'-dose PLV versus conventional ventilation. No evidence indicated that 'high'-dose PLV either reduced mortality at 28 d (risk ratio (RR) 1.21, 95% confidence interval (CI) 0.79 to 1.85, P = 0.37) or increased the number of days free of CMV at 28 d (mean difference (MD) -2.24, 95% CI -4.71 to 0.23, P = 0.08). The pooled estimate of effect for bradycardia in those who received PLV was significantly greater than in those who received CMV (RR 2.51, 95% CI 1.31 to 4.81, P = 0.005). Pooled estimates of effect for the following adverse events- hypoxia, pneumothorax, hypotension and cardiac arrest- all showed a nonsignificant trend towards a higher occurrence of these events in those treated with PLV. Because neither eligible study addressed morbidity or mortality beyond 28 d, it was not possible to determine the effect of PLV on these outcomes. AUTHORS' CONCLUSIONS No evidence supports the use of PLV in ALI or ARDS; some evidence suggests an increased risk of adverse events associated with its use.
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142
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Fanelli V, Vlachou A, Ghannadian S, Simonetti U, Slutsky AS, Zhang H. Acute respiratory distress syndrome: new definition, current and future therapeutic options. J Thorac Dis 2013; 5:326-34. [PMID: 23825769 DOI: 10.3978/j.issn.2072-1439.2013.04.05] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 04/07/2013] [Indexed: 12/17/2022]
Abstract
Since acute respiratory distress syndrome (ARDS) was first described in 1967 there has been large number of studies addressing its pathogenesis and therapies. Despite this intense research activity, there are very few effective therapies for ARDS other than the use of lung protection strategies. This lack of therapeutic modalities is not only related to the complex pathogenesis of this syndrome but also the insensitive and nonspecific diagnostic criteria to diagnose ARDS. This review article will summarize the key features of the new definition of ARDS, and provide a brief overview of innovative therapeutic options that are being assessed in the management of ARDS.
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Affiliation(s)
- Vito Fanelli
- Department of Anesthesia and Critical Care Medicine, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Italy
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143
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Roch A, Hraiech S, Dizier S, Papazian L. Pharmacological interventions in acute respiratory distress syndrome. Ann Intensive Care 2013; 3:20. [PMID: 23822630 PMCID: PMC3701581 DOI: 10.1186/2110-5820-3-20] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 06/14/2013] [Indexed: 01/11/2023] Open
Abstract
Pharmacological interventions are commonly considered in acute respiratory distress syndrome (ARDS) patients. Inhaled nitric oxide (iNO) and neuromuscular blockers (NMBs) are used in patients with severe hypoxemia. No outcome benefit has been observed with the systematic use of iNO. However, a sometimes important improvement in oxygenation can occur shortly after starting administration. Therefore, its ease of use and its good tolerance justify iNO optionally combined with almitirne as a rescue therapy on a trial basis. Recent data from the literature support the use of a 48-h infusion of NMBs in patients with a PaO2 to FiO2 ratio <120 mmHg. No strong evidence exists on the increase of ICU-acquired paresis after a short course of NMBs. Fluid management with the goal to obtain zero fluid balance in ARDS patients without shock or renal failure significantly increases the number of days without mechanical ventilation. On the other hand, patients with hemodynamic failure must receive early and adapted fluid resuscitation. Liberal and conservative fluid strategies therefore are complementary and should ideally follow each other in time in the same patient whose hemodynamic state progressively stabilizes. At present, albumin treatment does not appear to be justified for limitation of pulmonary edema and respiratory morbidity. Aerosolized β2-agonists do not improve outcome in patients with ARDS and one study strongly suggests that intravenous salbutamol may worsen outcome in those patients. The early use of high doses of corticosteroids for the prevention of ARDS in septic shock patients or in patients with confirmed ARDS significantly reduced the duration of mechanical ventilation but had no effect or even increased mortality. In patients with persistent ARDS after 7 to 28 days, a randomized trial showed no reduction in mortality with moderate doses of corticosteroids but an increased PaO2 to FiO2 ratio and thoracopulmonary compliance were found, as well as shorter durations of mechanical ventilation and of ICU stay. Conflicting data exist on the interest of low doses of corticosteroids (200 mg/day of hydrocortisone) in ARDS patients. In the context of a persistent ARDS with histological proof of fibroproliferation, a corticosteroid treatment with a progressive decrease of doses can be proposed.
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Affiliation(s)
- Antoine Roch
- URMITE, UM63, CNRS 7278, Aix Marseille Université, IRD 198, Inserm 1095, Marseille, 13005, France
- APHM, CHU Nord, Réanimation, Marseille, 13015, France
- Intensive Care Unit, CHU Nord, Chemin des Bourrely, Marseille, 13015, France
| | - Sami Hraiech
- URMITE, UM63, CNRS 7278, Aix Marseille Université, IRD 198, Inserm 1095, Marseille, 13005, France
- APHM, CHU Nord, Réanimation, Marseille, 13015, France
| | | | - Laurent Papazian
- URMITE, UM63, CNRS 7278, Aix Marseille Université, IRD 198, Inserm 1095, Marseille, 13005, France
- APHM, CHU Nord, Réanimation, Marseille, 13015, France
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144
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McCartney R, Saha S, Rees J, Lawy T, Mosaheb R. Inhaled Nitric Oxide: A Review of the Action, Current Literature, and An Analysis of its Use in the NHS Today. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Nitric oxide is a potent vasodilator which when inhaled causes dilatation in the pulmonary vasculature. It is this action that has been studied in intensive care medicine, especially in relation to hypoxic vasoconstriction associated with acute respiratory distress syndrome (ARDS). The use of inhaled nitric oxide has been shown to improve ventilation:perfusion matching, and thus to improve oxygenation. This article reviews the chemistry and clinical properties of nitric oxide as well as its potential uses, clinical effectiveness and side effects. The authors also surveyed UK intensive care units to review the current prevalence of the use of inhaled nitric oxide. It was found that while the majority do not currently use inhaled nitric oxide in ARDS patients, it had still been used in 27% (n=61) of the departments surveyed.
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Affiliation(s)
- Robert McCartney
- Year One Core Medical Trainee, Respiratory Medicine Department, Whipps Cross Hospital, Leytonstone, London
| | - Shibaji Saha
- Consultant Anaesthetist, Queen's Hospital, Romford, Essex
| | - James Rees
- Year One Anaesthetic Trainee, Queen's Hospital, Romford, Essex
| | - Tom Lawy
- Senior House Officer, Critical Care Department, Queen's Hospital, Romford, Essex
| | - Rishi Mosaheb
- Senior House Officer, Critical Care Department, Queen's Hospital, Romford, Essex
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145
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Abstract
This article focuses on the respiratory management and monitoring of pediatric acute lung injury (ALI) as a specific cause for respiratory failure. Definitive, randomized, controlled trials in pediatrics to guide optimal ventilatory management are few. The only adjunct therapy that has been proved to improve clinical outcome is low tidal volume ventilation, but only in adult patients. Careful monitoring of the patient's respiratory status with airway graphic analysis and capnography can be helpful. Definitive data are needed in the pediatric population to assist in the care of infants, children, and adolescents with ALI to improve survival and functional outcome.
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146
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Silversides JA, Ferguson ND. Clinical review: Acute respiratory distress syndrome - clinical ventilator management and adjunct therapy. Crit Care 2013; 17:225. [PMID: 23672857 PMCID: PMC3672489 DOI: 10.1186/cc11867] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a potentially devastating form of acute inflammatory lung injury with a high short-term mortality rate and significant long-term consequences among survivors. Supportive care, principally with mechanical ventilation, remains the cornerstone of therapy - although the goals of this support have changed in recent years - from maintaining normal physiological parameters to avoiding ventilator-induced lung injury while providing adequate gas exchange. In this article we discuss the current evidence base for ventilatory support and adjunctive therapies in patients with ARDS. Key components of such a strategy include avoiding lung overdistension by limiting tidal volumes and airway pressures, and the use of positive end-expiratory pressure with or without lung recruitment manoeuvres in patients with severe ARDS. Adjunctive therapies discussed include pharmacologic techniques (for example, vasodilators, diuretics, neuromuscular blockade) and nonpharmacologic techniques (for example, prone position, alternative modes of ventilation).
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Affiliation(s)
- Jonathan A Silversides
- Interdepartmental Division of Critical Care, University of Toronto, 600 University Avenue, Suite 18-206, Toronto, ON, Canada M5G 1X5
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care, University of Toronto, 600 University Avenue, Suite 18-206, Toronto, ON, Canada M5G 1X5
- Department of Medicine, Division of Respirology, University Health Network and Mount Sinai Hospital, University of Toronto, Mount Sinai Hospital, 600 University Avenue, Suite 18-206, Toronto, ON, Canada M5G 1X5
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147
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Villar J, Kacmarek RM. What is new in refractory hypoxemia? Intensive Care Med 2013; 39:1207-10. [PMID: 23575611 DOI: 10.1007/s00134-013-2905-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 03/16/2013] [Indexed: 01/19/2023]
Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
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148
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Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580-637. [PMID: 23353941 DOI: 10.1097/ccm.0b013e31827e83af] [Citation(s) in RCA: 3898] [Impact Index Per Article: 354.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. DESIGN A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations. RESULTS Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). CONCLUSIONS Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.
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Barrett N, Camporota L, Langrish C, Glover G, Beale R. Individualising Management of Severe Respiratory Failure and the Specialist Commissioned Severe Respiratory Failure Service for England. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Despite the improvement in the survival rate in patients with acute respiratory distress syndrome, there is a cohort of patients with severe hypoxaemia and hypercapnia who offer a significant therapeutic challenge and may require some of the more contentious rescue therapies, including prone positioning, high-frequency oscillatory ventilation and extracorporeal support. It is essential to implement a protocolised pathway for diagnosis and individualised treatment for these patients. In 2011, the English National Specialist Commissioning Service established a number of severe respiratory centres for England including the provision of extracorporeal membrane oxygenation. Early referral is essential for the successful use of rescue therapy as the evidence indicates that the time of mechanical ventilation prior to rescue therapy is a key predictor of mortality. Guy's and St Thomas' NHS Foundation Trust has been commissioned as one of the severe respiratory failure services and we describe the process of assessment and management that we have instituted to manage patients with severe respiratory failure.
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Affiliation(s)
- Nicholas Barrett
- Consultant in Critical Care
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners
| | - Luigi Camporota
- Consultant in Critical Care
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners
| | - Chris Langrish
- Consultant in Critical Care
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners
| | - Guy Glover
- Consultant in Critical Care
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners
| | - Richard Beale
- Consultant in Critical Care
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners
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Severe pneumonia in intensive care: cause, diagnosis, treatment and management: a review of the literature. Curr Opin Pulm Med 2013; 18:213-21. [PMID: 22388582 DOI: 10.1097/mcp.0b013e328351f9bd] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Severe pneumonia is a common disease that intensive care physicians have to face. The review highlights recent findings about microbiology, diagnosis and treatment, including the management of critically ill patients with severe respiratory failure. RECENT FINDINGS Epidemiological and clinical risk factors strongly influence microbiological cause in patients with severe pneumonia. In addition to typical respiratory pathogens, less common microrganisms and multidrug-resistant (MDR) germs may cause severe lung infections. New molecular diagnostic techniques appear promising for early detection of microbes involved in severe pneumonia. Antimicrobials remain the mainstay of causative severe pneumonia treatment and the optimization of antibiotic therapy may be obtained by applying their pharmacodynamic/pharmacokinetic properties. Several new strategies have been implemented for the management of acute respiratory failure (ARF) due to severe pneumonia; however, their extensive clinical application is limited by the need for well trained physicians and adequate hospital centers. SUMMARY Despite advancements in antibiotic and life-supportive treatments, severe pneumonia remains a leading cause of intensive care unit (ICU) admission and death. Prompt and appropriate antimicrobial therapy is essential. The use of new nonconventional strategies for ARF management might be effective in more severe patients.
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