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Longobardo A, Snow TA, Tam K, Singer M, Bellingan G, Arulkumaran N. Non-specialist therapeutic strategies in acute respiratory distress syndrome. Minerva Anestesiol 2021; 87:803-816. [PMID: 33594874 DOI: 10.23736/s0375-9393.21.15254-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Acute respiratory distress syndrome (ARDS) is associated with significant morbidity and mortality. We undertook a meta-analysis of randomized controlled trials (RCTs) to determine the mortality benefit of non-specialist therapeutic interventions for ARDS available to general critical care units. EVIDENCE ACQUISITION A systematic search of MEDLINE, Embase, and the Cochrane Central Register for RCTs investigating therapeutic interventions in ARDS including corticosteroids, fluid management strategy, high PEEP, low tidal volume ventilation, neuromuscular blockade, prone position ventilation, or recruitment maneuvers. Data was collected on demographic information, treatment strategy, duration and dose of treatment, and primary (28 or 30-day mortality) and secondary (P<inf>a</inf>O<inf>2</inf>:FiO<inf>2</inf> ratio at 24-48 hours) outcomes. EVIDENCE SYNTHESIS No improvement in 28-day mortality could be demonstrated in three RCTs investigating high PEEP (28.0% vs. 30.2% control; risk ratio [confidence interval] 0.93 [0.82-1.06]; eight assessing prone position ventilation (39.3% vs. 44.5%; RR 0.83 [0.68-1.01]; seven investigating neuromuscular blockade (37.8% vs. 42.0%; RR 0.91 [0.81-1.03]); ten investigating recruitment maneuvers (42.4% vs. 42.1%; RR 1.01 [0.91-1.12]); eight investigating steroids (34.8% vs. 41.1%; RR 0.81 [0.59-1.12]); and one investigating conservative fluid strategies (25.4% vs. 28.4%; RR 0.90 [0.73-1.10]). Three studies assessing low tidal volume ventilation (33.1% vs. 41.9%; RR 0.79 (0.68-0.91); P=0.001), and subgroup analyses within studies investigating prone position ventilation greater than 12 hours (33.1% vs. 44.4%; RR 0.75 [0.59-0.95), P=0.02) did reveal outcome benefit. CONCLUSIONS Among non-specialist therapeutic strategies available to general critical care units, low tidal volumes and prone position ventilation for greater than 12 hours improve mortality in ARDS.
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Affiliation(s)
- Alessia Longobardo
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Timothy A Snow
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK - .,Royal Free Perioperative Research Group, Royal Free Hospital, London, UK
| | - Karen Tam
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Geoff Bellingan
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
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202
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Resuscitation and emergency care in drowning: A scoping review. Resuscitation 2021; 162:205-217. [PMID: 33549689 DOI: 10.1016/j.resuscitation.2021.01.033] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 01/23/2021] [Accepted: 01/24/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The ILCOR Basic Life Support Task Force and the international drowning research community considered it timely to undertake a scoping review of the literature to identify evidence relating to the initial resuscitation, hospital-based interventions and criteria for safe discharge related to drowning. METHODS Medline, PreMedline, Embase, Cochrane Reviews and Cochrane CENTRAL were searched from 2000 to June 2020 to identify relevant literature. Titles and abstracts and if necessary full text were reviewed in duplicate. Studies were eligible for inclusion if they reported on the population (adults and children who are submerged in water), interventions (resuscitation in water/boats, airway management, oxygen administration, AED use, bystander CPR, ventilation strategies, ECMO, protocols for hospital discharge (I), comparator (standard care) and outcomes (O) survival, survival with a favourable neurological outcome, CPR quality, physiological end-points). RESULTS The database search yielded 3242 references (Medline 1104, Pre-Medline 202, Embase 1722, Cochrane reviews 12, Cochrane CENTRAL 202). After removal of duplicates 2377 papers were left for screening titles and abstracts. In total 65 unique papers were included. The evidence identified was from predominantly high-income countries and lacked consistency in the populations, interventions and outcomes reported. Clinical studies were exclusively observational in nature. CONCLUSION This scoping review found that there is very limited evidence from observational studies to inform evidence based clinical practice guidelines for drowning. The review highlights an urgent need for high quality research in drowning.
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203
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Apte Y, Jacobs K, Shewdin S, Murray A, Tung L, Ramanan M, Massey D. Prone positioning in patients with acute respiratory distress syndrome, translating research and implementing practice change from bench to bedside in the era of coronavirus disease 2019. Aust Crit Care 2021; 34:176-181. [PMID: 33487546 PMCID: PMC7825921 DOI: 10.1016/j.aucc.2020.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/07/2020] [Accepted: 08/08/2020] [Indexed: 01/21/2023] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is a relatively common condition of varied aetiology associated with high morbidity and mortality. A range of therapies have been proven to be useful for patients with ARDS, including ventilatory and nonventilatory strategies. Prone positioning is one of the nonventilatory strategies and has been proven to be safe and is associated with significant mortality benefit in patients with moderate to severe ARDS. It is now included in several international guidelines as the standard of care for these cases. Objectives The aim of the study was to develop, implement, and evaluate a prone positioning program in two nonmetropolitan, nontertiary intensive care units in South East Queensland. Methods A Plan–Do–Study–Act quality improvement model was used to implement changes in clinical practice in relation to prone positioning of patients. Results A description of the methods used to promote a complex change strategy is provided in this article. Conclusions In this article, we demonstrate the feasibility of introducing a nonventilatory intervention of prone positioning in the management of patients with moderate to severe ARDS in regional intensive care in South East Queensland. This implementation strategy could be replicated and adopted in other similar intensive care units that do not have the ability to provide tertiary services such as extracorporeal life support.
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Affiliation(s)
- Yogesh Apte
- Intensive Care Unit, Redcliffe Hospital, Australia; Intensive Care Unit, Caboolture Hospital, Australia; University of Queensland, Australia.
| | - Kylie Jacobs
- Intensive Care Unit, Redcliffe Hospital, Australia; University of Queensland, Australia
| | - Shaun Shewdin
- Intensive Care Unit, Redcliffe Hospital, Australia; Intensive Care Unit, Caboolture Hospital, Australia; University of Queensland, Australia
| | - Andrew Murray
- Intensive Care Unit, Redcliffe Hospital, Australia; Intensive Care Unit, Caboolture Hospital, Australia; University of Queensland, Australia
| | - Luke Tung
- Intensive Care Unit, Redcliffe Hospital, Australia; Intensive Care Unit, Caboolture Hospital, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, Redcliffe Hospital, Australia; Intensive Care Unit, Caboolture Hospital, Australia; University of Queensland, Australia; Intensive Care Unit, Prince Charles Hospital, Australia; The George Institute for Global Health, Australia; University of New South Wales, Australia
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204
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Wildi K, Livingstone S, Palmieri C, LiBassi G, Suen J, Fraser J. The discovery of biological subphenotypes in ARDS: a novel approach to targeted medicine? J Intensive Care 2021; 9:14. [PMID: 33478589 PMCID: PMC7817965 DOI: 10.1186/s40560-021-00528-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/11/2021] [Indexed: 12/13/2022] Open
Abstract
The acute respiratory distress syndrome (ARDS) is a severe lung disorder with a high morbidity and mortality which affects all age groups. Despite active research with intense, ongoing attempts in developing pharmacological agents to treat ARDS, its mortality rate remains unaltered high and treatment is still only supportive. Over the years, there have been many attempts to identify meaningful subgroups likely to react differently to treatment among the heterogenous ARDS population, most of them unsuccessful. Only recently, analysis of large ARDS cohorts from randomized controlled trials have identified the presence of distinct biological subphenotypes among ARDS patients: a hypoinflammatory (or uninflamed; named P1) and a hyperinflammatory (or reactive; named P2) subphenotype have been proposed and corroborated with existing retrospective data. The hyperinflammatory subphenotyope was clearly associated with shock state, metabolic acidosis, and worse clinical outcomes. Core features of the respective subphenotypes were identified consistently in all assessed cohorts, independently of the studied population, the geographical location, the study design, or the analysis method. Additionally and clinically even more relevant treatment efficacies, as assessed retrospectively, appeared to be highly dependent on the respective subphenotype. This discovery launches a promising new approach to targeted medicine in ARDS. Even though it is now widely accepted that each ARDS subphenotype has distinct functional, biological, and mechanistic differences, there are crucial gaps in our knowledge, hindering the translation to bedside application. First of all, the underlying driving biological factors are still largely unknown, and secondly, there is currently no option for fast and easy identification of ARDS subphenotypes. This narrative review aims to summarize the evidence in biological subphenotyping in ARDS and tries to point out the current issues that will need addressing before translation of biological subohenotypes into clinical practice will be possible.
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Affiliation(s)
- Karin Wildi
- The Critical Care Research Group, The Prince Charles Hospital, Clinical Sciences Building, Level 3, Chermside, Brisbane, QLD, 4032, Australia. .,Faculty of Medicine, The University of Queensland, Brisbane, Australia. .,Cardiovascular Research Group, Basel, Switzerland.
| | - Samantha Livingstone
- The Critical Care Research Group, The Prince Charles Hospital, Clinical Sciences Building, Level 3, Chermside, Brisbane, QLD, 4032, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Chiara Palmieri
- School of Veterinary Science, the University of Queensland, Brisbane, Australia
| | - Gianluigi LiBassi
- The Critical Care Research Group, The Prince Charles Hospital, Clinical Sciences Building, Level 3, Chermside, Brisbane, QLD, 4032, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jacky Suen
- The Critical Care Research Group, The Prince Charles Hospital, Clinical Sciences Building, Level 3, Chermside, Brisbane, QLD, 4032, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - John Fraser
- The Critical Care Research Group, The Prince Charles Hospital, Clinical Sciences Building, Level 3, Chermside, Brisbane, QLD, 4032, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
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205
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Prevent deterioration and long-term ventilation: intensive care following thoracic surgery. Curr Opin Anaesthesiol 2021; 34:20-24. [PMID: 33315639 DOI: 10.1097/aco.0000000000000944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Patients with indication for lung surgery besides the pulmonary pathology often suffer from independent comorbidities affecting several other organ systems. Preventing patients from harmful complications due to decompensation of underlying organ insufficiencies perioperatively is pivotal. This review draws attention to the peri- and postoperative responsibility of the anaesthetist and intensivist to prevent patients undergoing lung surgery deterioration. RECENT FINDINGS During the last decades we had to accept that 'traditional' intensive care medicine implying deep sedation, controlled ventilation, liberal fluid therapy, and broad-spectrum antimicrobial therapy because of several side-effects resulted in prolongation of hospital length of stay and a decline in quality of life. Modern therapy therefore should focus on the convalescence of the patient and earliest possible reintegration in the 'life-before.' Avoidance of sedative and anticholinergic drugs, early extubation, prophylactic noninvasive ventilation and high-flow nasal oxygen therapy, early mobilization, well-adjusted fluid balance and reasonable use of antibiotics are the keystones of success. SUMMARY A perioperative interprofessional approach and a change in paradigms are the prerequisites to improve outcome and provide treatment for elder and comorbid patients with an indication for thoracic surgery.
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206
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Stevanović P. Treatment of critically ill COVID-19 patients: Practical guidelines. MEDICINSKI PODMLADAK 2021. [DOI: 10.5937/mp72-33371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
The coronavirus disease pandemic (2019) has burdened health systems around the world with a large number of severe patients in a short period of time. According to the law of large numbers, a significant number of critically ill COVID-19 patients appear in such conditions which require treatment in the intensive care unit. That percentage of those patients is around 3 - 5% in different countries. It is similar in Serbia; however, every rule has its exceptions. KBC "Dr Dragiša Mišović-Dedinje" in Belgrade has been determined to take care of the most difficult COVID-19 patients since the beginning of the epidemic due to its space, organizational and personnel possibilities. Out of the total number of patients treated in KBC "Dr Dragiša Mišović-Dedinje", about 25% of patients were treated in the intensive care unit for the above mentioned reasons. Guided by valid treatment protocols, Anesthesiology and Intensive Care clinic of the KBC "Dr Dragiša Mišović-Dedinje" has developed its own work protocols for rapid diagnosis, isolation and clinical management of such difficult patients. These protocols are important not only for the treatment of the most severe COVID-19 patients, but also for the best utilization of hospital resources, as well as for the prevention of the spread of the infection to the medical staff. Extensive experience in the treatment of critically ill patients was gained from the entire engagement during the epidemic, experienced doctors, anesthesiologists-intensivists with great knowledge in the field of work in the intensive care unit, but also managers of clinics and institutions, who can share their experience with health care policy makers. It is clear that in the future, the capacities and organization of work in the field of intensive care medicine should be redefined, as well as health workers should be trained to work in the most demanding field of medicine. Expert experience in the form of practical guidelines, derived from over fourteen months of continuous work in the red zone of COVID-19, where they fought for every breath of the patient, in this review are translated into simplified guidelines for orientation of those who find themselves in a similar situation.
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207
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Madsen LW, Lindvig SO, Rasmussen LD, Knudtzen FC, Laursen CB, Øvrehus A, Nielsen SL, Johansen IS. Low mortality of hospitalised patients with COVID-19 in a tertiary Danish hospital setting. Int J Infect Dis 2021; 102:212-219. [PMID: 33059095 PMCID: PMC7550098 DOI: 10.1016/j.ijid.2020.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/07/2020] [Accepted: 10/07/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES We aimed to describe clinical characteristics and outcomes of admitted COVID-19 patients in a Danish hospital setting where an early active government intervention was taken. METHODS Prospective cohort study including all admitted patients to the COVID-19 unit at Odense University Hospital from March 10 to April 21, 2020. Patients were assessed by a multidisciplinary team at admission. Outcome parameters were development of acute respiratory distress syndrome (ARDS), intensive care unit (ICU) admission, death and admission time. RESULTS We included 83 patients (median age 62 years, 62.7% male). At hospitalization, 31.3% needed oxygen supplementation and the median National Early Warning Score was four. Median admission time was 7 days (Interquartile ranges (IQR) 3-12). In total, ARDS was diagnosed in 33.7% (28/83) of the patients corresponding to an incidence rate of 7.1 per 100 person days (95% CI: 4.1-10.2). Overall 13 patients (15.7%) were transferred to the ICU of whom 11 (84.6%) received corticosteroids.. No patients died while admitted to the ICU. Four patients (4.8%) died during admission. CONCLUSION Despite similar patient characteristics compared to those reported by others, we found a low overall mortality of < 5%.
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Affiliation(s)
- Lone Wulff Madsen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark; OPEN, Open Patient data Explorative Network, Odense University Hospital, University of Southern Denmark, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Susan Olaf Lindvig
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark.
| | | | - Fredrikke Christie Knudtzen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Clinical Center of Emerging and Vector-borne Infections, Odense University Hospital, Denmark.
| | - Christian B Laursen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Department of Respiratory Medicine, Odense University Hospital, Denmark.
| | - Anne Øvrehus
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | | | - Isik Somuncu Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
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208
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Mikolka P, Curstedt T, Feinstein R, Larsson A, Grendar M, Rising A, Johansson J. Impact of synthetic surfactant CHF5633 with SP-B and SP-C analogues on lung function and inflammation in rabbit model of acute respiratory distress syndrome. Physiol Rep 2021; 9:e14700. [PMID: 33403805 PMCID: PMC7786196 DOI: 10.14814/phy2.14700] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/29/2020] [Accepted: 12/03/2020] [Indexed: 02/04/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is associated with diffuse inflammation, alveolar epithelial damage, and leakage of plasma proteins into the alveolar space, which together contribute to inactivation of pulmonary surfactant and respiratory failure. Exogenous surfactant delivery is therefore considered to hold potential for ARDS treatment, but clinical trials with natural derived surfactant or synthetic surfactant containing a surfactant protein C (SP-C) analogue have been negative. Synthetic surfactant CHF5633, containing analogues of SP-B and SP-C, may be effective against ARDS. The aim here was to compare treatment effects of CHF5633 and animal-derived surfactant poractant alfa in animal model of ARDS. ARDS was induced in adult New Zealand rabbits by mild lung lavages followed by injurious ventilation until respiratory failure (P/F ratio <26.7 kPa). The animals were then treated with intratracheal bolus of 200 mg/kg CHF5633 or poractant alfa (Curosurf® ), or air as control. The animals were subsequently ventilated for an additional 4 hr and respiratory parameters were recorded regularly. Postmortem, histological analysis, degree of lung edema, and levels of the cytokines TNFα, IL-6, and IL-8 in lung homogenates were evaluated. Both surfactant preparations improved lung function, reduced the levels of pro-inflammatory cytokines, and degree of lung edema to very similar degrees versus the controls. No significant differences in any of the analyzed parameters were observed between the CHF5633- and poractant alfa-treated groups. This study indicates that single dose of CHF5633 improves lung function and attenuates inflammation as effectively as poractant alfa in experimental ARDS caused by injurious ventilation.
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Affiliation(s)
- Pavol Mikolka
- Division for NeurogeriatricsDepartment of Neurobiology, Care Sciences and SocietyKarolinska InstitutetHuddingeSweden
- Biomedical Center MartinJessenius Faculty of Medicine in MartinComenius University in BratislavaMartinSlovakia
- Department of PhysiologyJessenius Faculty of Medicine in MartinComenius University in BratislavaMartinSlovakia
| | - Tore Curstedt
- Department of Molecular Medicine and SurgeryKarolinska InstitutetKarolinska University HospitalStockholmSweden
| | - Riccardo Feinstein
- Department of PathologyThe Swedish National Veterinary InstituteUppsalaSweden
| | - Anders Larsson
- Hedenstierna LaboratoryDepartment of Surgical SciencesUppsala UniversityUppsalaSweden
| | - Marian Grendar
- Biomedical Center MartinJessenius Faculty of Medicine in MartinComenius University in BratislavaMartinSlovakia
| | - Anna Rising
- Division for NeurogeriatricsDepartment of Neurobiology, Care Sciences and SocietyKarolinska InstitutetHuddingeSweden
- Department of Anatomy, Physiology and BiochemistrySwedish University of Agricultural SciencesUppsalaSweden
| | - Jan Johansson
- Division for NeurogeriatricsDepartment of Neurobiology, Care Sciences and SocietyKarolinska InstitutetHuddingeSweden
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209
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Zhou H, Chanda B, Chen YF, Wang XJ, You MY, Zhang YH, Cheng R, Yang Y, Chen XQ. Microarray and Bioinformatics Analysis of Circular RNA Differential Expression in Newborns With Acute Respiratory Distress Syndrome. Front Pediatr 2021; 9:728462. [PMID: 34796151 PMCID: PMC8592891 DOI: 10.3389/fped.2021.728462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/05/2021] [Indexed: 12/02/2022] Open
Abstract
Previous studies pointed out that a variety of microRNAs (miRNAs) are involved in the pathogenesis of neonatal acute respiratory distress syndrome (NARDS) and play different roles in the pathological process. However, there have been few studies reporting the connection between circular RNA (circRNA) and NARDS, so the expression profile of circRNAs in newborns with acute respiratory distress syndrome remains largely unknown. In the present study, 10 samples obtained from remaining clinical blood samples of newborns hospitalized in a neonatal ward of the First Affiliated Hospital of Nanjing Medical University from January 2020 to October 2020 were divided into the "NARDS" group and "non-NARDS" group according to the Montelux standard and then were analyzed in microarray, and 10 other samples collected from the same place and from January 1, 2021 to August 31, 2021, were used to do RT-qPCR experiment. circRNA expression profiles, in which 741 circRNAs were downregulated and 588 were upregulated, were screened with circRNA high-throughput sequencing. Subsequently, Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analysis of parent genes of the differentially expressed circRNAs revealed that these circRNAs may be related to the process of protein synthesis and metabolism in NARDS. Moreover, five circRNAs-hsa_circ_0058495, hsa_circ_0000367, hsa_circ_0005389, hsa_circ_0059571, and hsa_circ_0006608-were selected randomly among the top 10 circRNAs of the downregulated or upregulated expression profiles. Then, bioinformatics tools were used to predict correlative miRNA and its target genes, which were also subjected to the same bioinformatics analysis for further study. The top 30 enriched KEGG pathway analyses of the 125 target genes suggested that these target genes are widely involved in the synthesis and secretion of endocrine hormones, and the top 30 enriched GO terms based on the 125 target genes are also focused on the protein and DNA processing. Thus, the present results show that circRNAs could promote the inflammation of NARDS which may provide a new therapeutic direction and it can be used as molecular markers for early diagnosis of NARDS, but further molecular biology verification is needed to define the specific role of differentially expressed circRNAs in NARDS.
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Affiliation(s)
- Huan Zhou
- Department of Pediatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bwalya Chanda
- Department of Pediatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yu-Fei Chen
- Department of Pediatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xue-Juan Wang
- Department of Pediatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ming-Yu You
- Department of Pediatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yi-Han Zhang
- Department of Pediatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Rui Cheng
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yang Yang
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xiao-Qing Chen
- Department of Pediatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Jasiński T, Stefaniak J. COVID-19 and haemodynamic failure: a point of view on mechanisms and treatment. Anaesthesiol Intensive Ther 2020; 52:409-417. [PMID: 33327700 PMCID: PMC10183984 DOI: 10.5114/ait.2020.101813] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 11/29/2020] [Indexed: 11/17/2022] Open
Abstract
The SARS-CoV-2-related disease has an undoubted impact on the healthcare system. In the treatment of severe COVID-19 cases, the main focus is on respiratory failure. However, available data suggest an important contribution of haemodynamic impairment in the course of this disease. SARS-CoV-2 may affect the circulatory system in various ways that are universal for septic conditions. Nonetheless, unique features of this pathogen, e.g. direct insult leading to myocarditis and renin-angiotensin-aldosterone axis dysregulation, must be taken into account. Although current recommendations on COVID-19 resemble previous septic shock guidelines, special attention to haemodynamic monitoring and treatment is necessary. Regarding treatment, one must take into account the potential profound hypovolaemia of severe COVID-19 patients. Pharmacological cardiovascular support should follow existing guidelines and practice. Interesting concepts of decatecholaminisation and the effect of vasopressors on pulmonary circulation are also presented in this review on COVID-19-related haemodynamic failure.
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Affiliation(s)
- Tomasz Jasiński
- Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Poland
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211
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Banavasi H, Nguyen P, Osman H, Soubani AO. Management of ARDS - What Works and What Does Not. Am J Med Sci 2020; 362:13-23. [PMID: 34090669 PMCID: PMC7997862 DOI: 10.1016/j.amjms.2020.12.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/21/2020] [Indexed: 12/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a clinically and biologically heterogeneous disorder associated with a variety of disease processes that lead to acute lung injury with increased non-hydrostatic extravascular lung water, reduced compliance, and severe hypoxemia. Despite significant advances, mortality associated with this syndrome remains high. Mechanical ventilation remains the most important aspect of managing patients with ARDS. An in-depth knowledge of lung protective ventilation, optimal PEEP strategies, modes of ventilation and recruitment maneuvers are essential for ventilatory management of ARDS. Although, the management of ARDS is constantly evolving as new studies are published and guidelines being updated; we present a detailed review of the literature including the most up-to-date studies and guidelines in the management of ARDS. We believe this review is particularly helpful in the current times where more than half of the acute care hospitals lack in-house intensivists and the burden of ARDS is at large.
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Affiliation(s)
- Harsha Banavasi
- Division of Pulmonary Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Paul Nguyen
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Heba Osman
- Department of Medicine-Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA
| | - Ayman O Soubani
- Division of Pulmonary Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA.
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212
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Gardner L. Prone Positioning in Patients With Acute Respiratory Distress Syndrome and Other Respiratory Conditions: Challenges, Complications, and Solutions. PATIENT SAFETY 2020. [DOI: 10.33940/data/2020.12.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) and respiratory failure are characterized by hypoxemia, i.e., low levels of blood oxygen. Infections such as influenza and COVID-19 can lead to ARDS or respiratory failure. Treatment is through supportive measures. In severe cases, patients receive oxygen through a ventilator and, when appropriate, are placed in a prone position for an extended period. A retrospective review of events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) identified 98 prone position–related events in patients with ARDS, respiratory failure, distress, and pneumonia from January 1, 2010, through June 30, 2020; 30 events were associated with COVID-19. Skin integrity injuries accounted for 83.7% (82 of 98) of the events. The remaining events, 16.3% (16 of 98), involved unplanned extubations, cardiac arrests, displaced lines, enteral feedings, medication errors, a dental issue, and posterior ischemic optic neuropathy.
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Hunsicker O, Materne L, Bünger V, Krannich A, Balzer F, Spies C, Francis RC, Weber-Carstens S, Menk M, Graw JA. Lower versus higher hemoglobin threshold for transfusion in ARDS patients with and without ECMO. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:697. [PMID: 33327953 PMCID: PMC7740070 DOI: 10.1186/s13054-020-03405-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 11/24/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Efficacy and safety of different hemoglobin thresholds for transfusion of red blood cells (RBCs) in adults with an acute respiratory distress syndrome (ARDS) are unknown. We therefore assessed the effect of two transfusion thresholds on short-term outcome in patients with ARDS. METHODS Patients who received transfusions of RBCs were identified from a cohort of 1044 ARDS patients. After propensity score matching, patients transfused at a hemoglobin concentration of 8 g/dl or less (lower-threshold) were compared to patients transfused at a hemoglobin concentration of 10 g/dl or less (higher-threshold). The primary endpoint was 28-day mortality. Secondary endpoints included ECMO-free, ventilator-free, sedation-free, and organ dysfunction-free composites. MEASUREMENTS AND MAIN RESULTS One hundred ninety-two patients were eligible for analysis of the matched cohort. Patients in the lower-threshold group had similar baseline characteristics and hemoglobin levels at ARDS onset but received fewer RBC units and had lower hemoglobin levels compared with the higher-threshold group during the course on the ICU (9.1 [IQR, 8.7-9.7] vs. 10.4 [10-11] g/dl, P < 0.001). There was no difference in 28-day mortality between the lower-threshold group compared with the higher-threshold group (hazard ratio, 0.94 [95%-CI, 0.59-1.48], P = 0.78). Within 28 days, 36.5% (95%-CI, 27.0-46.9) of the patients in the lower-threshold group compared with 39.5% (29.9-50.1) of the patients in the higher-threshold group had died. While there were no differences in ECMO-free, sedation-free, and organ dysfunction-free composites, the chance for successful weaning from mechanical ventilation within 28 days after ARDS onset was lower in the lower-threshold group (subdistribution hazard ratio, 0.36 [95%-CI, 0.15-0.86], P = 0.02). CONCLUSIONS Transfusion at a hemoglobin concentration of 8 g/dl, as compared with a hemoglobin concentration of 10 g/dl, was not associated with an increase in 28-day mortality in adults with ARDS. However, a transfusion at a hemoglobin concentration of 8 g/dl was associated with a lower chance for successful weaning from the ventilator during the first 28 days after ARDS onset. TRIAL REGISTRATION ClinicalTrials.gov NCT03871166.
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Affiliation(s)
- O Hunsicker
- Department of Anesthesiology and Operative Intensive Care Medicine CCM / CVK Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.,ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - L Materne
- Department of Anesthesiology and Operative Intensive Care Medicine CCM / CVK Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - V Bünger
- Department of Anesthesiology and Operative Intensive Care Medicine CCM / CVK Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - A Krannich
- Clinical Trial Office, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - F Balzer
- Department of Anesthesiology and Operative Intensive Care Medicine CCM / CVK Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - C Spies
- Department of Anesthesiology and Operative Intensive Care Medicine CCM / CVK Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.,ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - R C Francis
- Department of Anesthesiology and Operative Intensive Care Medicine CCM / CVK Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.,ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - S Weber-Carstens
- Department of Anesthesiology and Operative Intensive Care Medicine CCM / CVK Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.,ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - M Menk
- Department of Anesthesiology and Operative Intensive Care Medicine CCM / CVK Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.,ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - J A Graw
- Department of Anesthesiology and Operative Intensive Care Medicine CCM / CVK Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany. .,ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Berlin Institute of Health (BIH), Berlin, Germany.
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Diagnosis and Management of Acute Respiratory Distress Syndrome in a Time of COVID-19. Diagnostics (Basel) 2020; 10:diagnostics10121053. [PMID: 33291238 PMCID: PMC7762111 DOI: 10.3390/diagnostics10121053] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 01/08/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) remains a serious illness with significant morbidity and mortality, characterized by hypoxemic respiratory failure most commonly due to pneumonia, sepsis, and aspiration. Early and accurate diagnosis of ARDS depends upon clinical suspicion and chest imaging. Coronavirus disease 2019 (COVID-19) is an important novel cause of ARDS with a distinct time course, imaging and laboratory features from the time of SARS-CoV-2 infection to hypoxemic respiratory failure, which may allow diagnosis and management prior to or at earlier stages of ARDS. Treatment of ARDS remains largely supportive, and consists of incremental respiratory support (high flow nasal oxygen, non-invasive respiratory support, and invasive mechanical ventilation), and avoidance of iatrogenic complications, all of which improve clinical outcomes. COVID-19-associated ARDS is largely similar to other causes of ARDS with respect to pathology and respiratory physiology, and as such, COVID-19 patients with hypoxemic respiratory failure should typically be managed as other patients with ARDS. Non-invasive respiratory support may be beneficial in avoiding intubation in COVID-19 respiratory failure including mild ARDS, especially under conditions of resource constraints or to avoid overwhelming critical care resources. Compared to other causes of ARDS, medical therapies may improve outcomes in COVID-19-associated ARDS, such as dexamethasone and remdesivir. Future improved clinical outcomes in ARDS of all causes depends upon individual patient physiological and biological endotyping in order to improve accuracy and timeliness of diagnosis as well as optimal targeting of future therapies in the right patient at the right time in their disease.
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215
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Bell J, Horner D. BET 1: Prone positioning of awake patients with acute hypoxaemic respiratory failure. Emerg Med J 2020; 37:379-381. [PMID: 32487709 DOI: 10.1136/emermed-2020-209962.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
A short-cut review of the literature was carried out to examine the potential utility of prone positioning in awake patients with hypoxaemic respiratory failure. Four papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that there is no evidence that regular prone positioning in the awake patient with hypoxaemic respiratory failure impacts on clinically relevant outcomes. Further research is required to evaluate the safety and effectiveness of this intervention, compared with routine mobilisation strategies.
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Affiliation(s)
- Jack Bell
- Emergency Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Daniel Horner
- Emergency and Critical Care Medicine, Salford Royal NHS Foundation Trust, Salford, UK
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216
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Rafiullah M, Siddiqui K. Corticosteroid use in viral pneumonia: experience so far and the dexamethasone breakthrough in coronavirus disease-2019. J Comp Eff Res 2020; 9:1247-1254. [PMID: 33245242 PMCID: PMC7694443 DOI: 10.2217/cer-2020-0146] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Dexamethasone was shown to decrease the mortality in coronavirus disease-2019 (COVID-19) recently. Use of corticosteroids was harmful in other coronavirus infections previously. WHO recommended against routine use of corticosteroids in COVID-19. In view of these, we reviewed the evidence about the use of corticosteroids in virus-induced acute respiratory distress syndrome (ARDS). Corticosteroids are beneficial in ARDS regardless of etiology. However, they increased the mortality rate in influenza-associated ARDS. In SARS and the Middle East respiratory syndrome, corticosteroids increased the mortality, delayed the viral clearance and increased the length of hospital stay. In the case of COVID-19, the available evidence from retrospective and observational studies is inconclusive about the corticosteroid use. Low-dose therapies appear to be effective. Evidence from a randomized control study found dexamethasone is effective in decreasing mortality in severe COVID-19 cases. More studies are needed to validate the benefit of corticosteroids in COVID-19.
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Affiliation(s)
- Mohamed Rafiullah
- Strategic Center for Diabetes Research, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khalid Siddiqui
- Strategic Center for Diabetes Research, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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217
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Gorman E, Millar J, McAuley D, O'Kane C. Mesenchymal stromal cells for acute respiratory distress syndrome (ARDS), sepsis, and COVID-19 infection: optimizing the therapeutic potential. Expert Rev Respir Med 2020; 15:301-324. [PMID: 33172313 DOI: 10.1080/17476348.2021.1848555] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Mesenchymal stromal (stem) cell (MSC) therapies are emerging as a promising therapeutic intervention in patients with Acute Respiratory Distress Syndrome (ARDS) and sepsis due to their reparative, immunomodulatory, and antimicrobial properties.Areas covered: This review provides an overview of Mesenchymal stromal cells (MSCs) and their mechanisms of effect in ARDS and sepsis. The preclinical and clinical evidence to support MSC therapy in ARDS and sepsis is discussed. The potential for MSC therapy in COVID-19 ARDS is discussed with insights from respiratory viral models and early clinical reports of MSC therapy in COVID-19. Strategies to optimize the therapeutic potential of MSCs in ARDS and sepsis are considered including preconditioning, altered gene expression, and alternative cell-free MSC-derived products, such as extracellular vesicles and conditioned medium.Expert opinion: MSC products present considerable therapeutic promise for ARDS and sepsis. Preclinical investigations report significant benefits and early phase clinical studies have not highlighted safety concerns. Optimization of MSC function in preclinical models of ARDS and sepsis has enhanced their beneficial effects. MSC-derived products, as cell-free alternatives, may provide further advantages in this field. These strategies present opportunity for the clinical development of MSCs and MSC-derived products with enhanced therapeutic efficacy.
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Affiliation(s)
- Ellen Gorman
- School of Medicine Dentistry and Biomedical Science, Queen's University Belfast, UK
| | - Jonathan Millar
- Division of Functional Genetics and Development, Roslin Institute, University of Edinburgh, Edinburgh, UK
| | - Danny McAuley
- School of Medicine Dentistry and Biomedical Science, Queen's University Belfast, UK
| | - Cecilia O'Kane
- School of Medicine Dentistry and Biomedical Science, Queen's University Belfast, UK
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218
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Millar JE, Bartnikowski N, Passmore MR, Obonyo NG, Malfertheiner MV, von Bahr V, Redd MA, See Hoe L, Ki KK, Pedersen S, Boyle AJ, Baillie JK, Shekar K, Palpant N, Suen JY, Matthay MA, McAuley DF, Fraser JF. Combined Mesenchymal Stromal Cell Therapy and Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome. A Randomized Controlled Trial in Sheep. Am J Respir Crit Care Med 2020; 202:383-392. [PMID: 32293914 DOI: 10.1164/rccm.201911-2143oc] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Rationale: Mesenchymal stromal cell (MSC) therapy is a promising intervention for acute respiratory distress syndrome (ARDS), although trials to date have not investigated its use alongside extracorporeal membrane oxygenation (ECMO). Recent preclinical studies have suggested that combining these interventions may attenuate the efficacy of ECMO.Objectives: To determine the safety and efficacy of MSC therapy in a model of ARDS and ECMO.Methods: ARDS was induced in 14 sheep, after which they were established on venovenous ECMO. Subsequently, they received either endobronchial induced pluripotent stem cell-derived human MSCs (hMSCs) (n = 7) or cell-free carrier vehicle (vehicle control; n = 7). During ECMO, a low Vt ventilation strategy was employed in addition to protocolized hemodynamic support. Animals were monitored and supported for 24 hours. Lung tissue, bronchoalveolar fluid, and plasma were analyzed, in addition to continuous respiratory and hemodynamic monitoring.Measurements and Main Results: The administration of hMSCs did not improve oxygenation (PaO2/FiO2 mean difference = -146 mm Hg; P = 0.076) or pulmonary function. However, histological evidence of lung injury (lung injury score mean difference = -0.07; P = 0.04) and BAL IL-8 were reduced. In addition, hMSC-treated animals had a significantly lower cumulative requirement for vasopressor. Despite endobronchial administration, animals treated with hMSCs had a significant elevation in transmembrane oxygenator pressure gradients. This was accompanied by more pulmonary artery thromboses and adherent hMSCs found on explanted oxygenator fibers.Conclusions: Endobronchial hMSC therapy in an ovine model of ARDS and ECMO can impair membrane oxygenator function and does not improve oxygenation. These data do not recommend the safe use of hMSCs during venovenous ECMO.
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Affiliation(s)
- Jonathan E Millar
- Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine and.,Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - Nicole Bartnikowski
- Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Margaret R Passmore
- Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine and
| | - Nchafatso G Obonyo
- Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Wellcome Trust Centre for Global Health Research, Imperial College London, London, United Kingdom
| | - Maximillian V Malfertheiner
- Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Viktor von Bahr
- Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Meredith A Redd
- Institute for Molecular Bioscience, University of Queensland, Brisbane, Queensland, Australia
| | - Louise See Hoe
- Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine and
| | - Katrina K Ki
- Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine and
| | - Sanne Pedersen
- Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Andrew J Boyle
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - J Kenneth Baillie
- Roslin Institute, University of Edinburgh, Edinburgh, United Kingdom; and
| | - Kiran Shekar
- Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine and
| | - Nathan Palpant
- Institute for Molecular Bioscience, University of Queensland, Brisbane, Queensland, Australia
| | - Jacky Y Suen
- Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine and
| | - Michael A Matthay
- Department of Medicine and.,Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - John F Fraser
- Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine and
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219
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Vieira PC, de Oliveira RB, da Silva Mendonça TM. Should oral chlorhexidine remain in ventilator-associated pneumonia prevention bundles? Med Intensiva 2020; 46:S0210-5691(20)30325-9. [PMID: 33160703 DOI: 10.1016/j.medin.2020.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/15/2020] [Accepted: 09/23/2020] [Indexed: 12/12/2022]
Abstract
Ventilator-associated pneumonia (VAP) is related with high mortality, duration of mechanical ventilation and costs. Recent studies have questioned the safety and effectiveness of oral chlorhexidine to prevent VAP. We sought to verify whether the adverse effects of this substance outweigh its benefits. We searched several databases and selected studies that investigated the use of oral chlorhexidine and its impact on mortality. No association between oral chlorhexidine and lower VAP rates was found on meta-analyses of double-blind randomized trials, however significant increase in mortality was reported. It is speculated that chlorhexidine can cause damage to several organic sectors and cytotoxicity. Although it still can be beneficial in specific settings, robust evidence to recommend its routine application for all mechanically ventilated patients is lacking; therefore, given the possibility of harm, it would be better to follow the principle of non-maleficence until more studies becomes available.
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Affiliation(s)
- P C Vieira
- Intensive Care Unit, Uberlândia Clinical Hospital, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil; Health Science PhD Program, Faculty of Medicine, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil; Neurointensivism Postgraduate Program, Teaching and Research Institute, Sírio-Libanês Hospital, Bela Vista, São Paulo, Brazil.
| | - R B de Oliveira
- Intensive Care Unit, Uberlândia Clinical Hospital, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil
| | - T M da Silva Mendonça
- Health Science PhD Program, Faculty of Medicine, Uberlândia Federal University, Uberlândia, Minas Gerais, Brazil
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220
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Martinelli AW, Ingle T, Newman J, Nadeem I, Jackson K, Lane ND, Melhorn J, Davies HE, Rostron AJ, Adeni A, Conroy K, Woznitza N, Matson M, Brill SE, Murray J, Shah A, Naran R, Hare SS, Collas O, Bigham S, Spiro M, Huang MM, Iqbal B, Trenfield S, Ledot S, Desai S, Standing L, Babar J, Mahroof R, Smith I, Lee K, Tchrakian N, Uys S, Ricketts W, Patel ARC, Aujayeb A, Kokosi M, Wilkinson AJK, Marciniak SJ. COVID-19 and pneumothorax: a multicentre retrospective case series. Eur Respir J 2020; 56:2002697. [PMID: 32907891 PMCID: PMC7487269 DOI: 10.1183/13993003.02697-2020] [Citation(s) in RCA: 195] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/27/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Pneumothorax and pneumomediastinum have both been noted to complicate cases of coronavirus disease 2019 (COVID-19) requiring hospital admission. We report the largest case series yet described of patients with both these pathologies (including nonventilated patients). METHODS Cases were collected retrospectively from UK hospitals with inclusion criteria limited to a diagnosis of COVID-19 and the presence of either pneumothorax or pneumomediastinum. Patients included in the study presented between March and June 2020. Details obtained from the medical record included demographics, radiology, laboratory investigations, clinical management and survival. RESULTS 71 patients from 16 centres were included in the study, of whom 60 had pneumothoraces (six with pneumomediastinum in addition) and 11 had pneumomediastinum alone. Two of these patients had two distinct episodes of pneumothorax, occurring bilaterally in sequential fashion, bringing the total number of pneumothoraces included to 62. Clinical scenarios included patients who had presented to hospital with pneumothorax, patients who had developed pneumothorax or pneumomediastinum during their inpatient admission with COVID-19 and patients who developed their complication while intubated and ventilated, either with or without concurrent extracorporeal membrane oxygenation. Survival at 28 days was not significantly different following pneumothorax (63.1±6.5%) or isolated pneumomediastinum (53.0±18.7%; p=0.854). The incidence of pneumothorax was higher in males. 28-day survival was not different between the sexes (males 62.5±7.7% versus females 68.4±10.7%; p=0.619). Patients aged ≥70 years had a significantly lower 28-day survival than younger individuals (≥70 years 41.7±13.5% survival versus <70 years 70.9±6.8% survival; p=0.018 log-rank). CONCLUSION These cases suggest that pneumothorax is a complication of COVID-19. Pneumothorax does not seem to be an independent marker of poor prognosis and we encourage continuation of active treatment where clinically possible.
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Affiliation(s)
- Anthony W Martinelli
- Addenbrooke's Hospital, Cambridge, UK
- CITIID, University of Cambridge, Cambridge, UK
- Both authors contributed equally
| | - Tejas Ingle
- The Lister Hospital, Stevenage, UK
- Both authors contributed equally
| | | | | | - Karl Jackson
- Northumbria Specialist Emergency Care Hospital, Cramlington, UK
| | - Nicholas D Lane
- Respiratory Medicine, The Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Anthony J Rostron
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Aldrin Adeni
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | | | - Nick Woznitza
- NHS Nightingale Hospital, Royal Docks, London, UK
- Canterbury Christ Church University, Canterbury, UK
| | | | - Simon E Brill
- Royal Free London NHS Foundation Trust, Hampstead, London, UK
| | - James Murray
- Royal Free London NHS Foundation Trust, Hampstead, London, UK
| | - Amar Shah
- Royal Free London NHS Foundation Trust, Hampstead, London, UK
| | - Revati Naran
- Royal Free London NHS Foundation Trust, Hampstead, London, UK
| | - Samanjit S Hare
- Royal Free London NHS Foundation Trust, Hampstead, London, UK
| | - Oliver Collas
- Royal Free London NHS Foundation Trust, Hampstead, London, UK
| | - Sarah Bigham
- Royal Free London NHS Foundation Trust, Hampstead, London, UK
| | - Michael Spiro
- Royal Free London NHS Foundation Trust, Hampstead, London, UK
| | | | | | | | | | | | | | | | | | - Ian Smith
- Royal Papworth Hospital, Cambridge, UK
| | - Kai Lee
- King's College Hospital, London, UK
| | | | | | | | - Anant R C Patel
- Royal Free London NHS Foundation Trust, Hampstead, London, UK
| | - Avinash Aujayeb
- Northumbria Specialist Emergency Care Hospital, Cramlington, UK
| | | | | | - Stefan J Marciniak
- Addenbrooke's Hospital, Cambridge, UK
- CIMR, University of Cambridge, Cambridge, UK
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221
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Chien SC, Chien SC, Hu TY. Rapid-onset acute respiratory distress syndrome after mastectomy in a breast cancer patient: A case report and review of literature. Medicine (Baltimore) 2020; 99:e22795. [PMID: 33120797 PMCID: PMC7581031 DOI: 10.1097/md.0000000000022795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Postoperative acute respiratory distress syndrome (ARDS) often results in severe morbidity and mortality in surgical patients. The etiology of this condition is complex, especially in cancer patients. PATIENT CONCERNS We encountered a 53-year-old woman with left breast cancer, cT1cN2M0, stage IIIA with left axillary lymph node metastasis. She had received chemotherapy with 4 cycles of doxorubicin plus cyclophosphamide, and 4 cycles of trastuzumab plus docetaxel within a span of 6 months. Subsequently, she underwent left simple mastectomy and axillary lymph node dissection, shortly after which she developed respiratory distress with progressive desaturation and hemoptysis. DIAGNOSIS ARDS was diagnosed using the Berlin criteria. Her arterial blood gas analysis revealed profound hypoxemia and her chest imaging was suggestive of pulmonary edema. She developed diffuse alveolar hemorrhage (DAH) that was confirmed with bronchoscopy and hemorrhagic samples on bronchoalveolar lavage. INTERVENTIONS She was mechanically ventilated with lung protective measures for management of ARDS. In addition to antibiotic cover with amoxicillin sodium-potassium clavulanate for occult infections during her stay in the intensive care unit, we administered epinephrine inhalations, intravenous treatment with tranexamic acid, and methylprednisolone for DAH. OUTCOMES Her clinical course improved; she was extubated successfully on day 7 and discharged home on day 11. LESSONS SUBSECTIONS Chemotherapeutic agents may cause pulmonary toxicity through a direct cytotoxic effect or immune-mediated reactions and result in an increased risk of development of ARDS. Furthermore, surgery may trigger a systemic inflammatory response syndrome that can also induce ARDS. In our patient, the development of ARDS was attributed to the combined effects of surgery and chemotherapeutic agents (trastuzumab or docetaxel). When patients undergo major surgery after receiving chemotherapeutic agents, careful consideration is necessary to prevent the development of ARDS.
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Affiliation(s)
| | | | - Ting-Yu Hu
- Department of Critical Care Medicine, Mackay Memorial Hospital, Taipei
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
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222
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Management for the Drowning Patient. Chest 2020; 159:1473-1483. [PMID: 33065105 DOI: 10.1016/j.chest.2020.10.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 12/20/2022] Open
Abstract
Drowning is "the process of experiencing respiratory impairment from submersion or immersion in liquid." According to the World Health Organization, drowning claims the lives of > 40 people every hour of every day. Drowning involves some physiological principles and medical interventions that are unique. It occurs in a deceptively hostile environment that involves an underestimation of the dangers or an overestimation of water competency. It has been estimated that > 90% of drownings are preventable. When water is aspirated into the airways, coughing is the initial reflex response. The acute lung injury alters the exchange of oxygen in different proportions. The combined effects of fluid in the lungs, loss of surfactant, and increased capillary-alveolar permeability result in decreased lung compliance, increased right-to-left shunting in the lungs, atelectasis, and alveolitis, a noncardiogenic pulmonary edema. Salt and fresh water aspirations cause similar pathology. If the person is not rescued, aspiration continues, and hypoxemia leads to loss of consciousness and apnea in seconds to minutes. As a consequence, hypoxic cardiac arrest occurs. The decision to admit to an ICU should consider the patient's drowning severity and comorbid or premorbid conditions. Ventilation therapy should achieve an intrapulmonary shunt ≤ 20% or Pao2:Fio2 ≥ 250. Premature ventilatory weaning may cause the return of pulmonary edema with the need for re-intubation and an anticipation of prolonged hospital stays and further morbidity. This review includes all the essential steps from the first call to action until the best practice at the prehospital, ED, and hospitalization.
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Seitz KP, Caldwell ES, Hough CL. Fluid management in ARDS: an evaluation of current practice and the association between early diuretic use and hospital mortality. J Intensive Care 2020; 8:78. [PMID: 33062283 PMCID: PMC7549083 DOI: 10.1186/s40560-020-00496-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/25/2020] [Indexed: 12/15/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) and volume overload are associated with increased hospital mortality. Evidence supports conservative fluid management in ARDS, but whether current practice reflects the implementation of that evidence has not been described. This study reports the variability in contemporary fluid management for ICU patients with ARDS. We compared routine care to trial protocols and analyzed whether more conservative management with diuretic medications in contemporary, usual care is associated with outcomes. Methods We performed a retrospective cohort study in nine ICUs at two academic hospitals during 2016 and 2017. We included 234 adult patients with ARDS in an ICU at least 3 days after meeting moderate-severe ARDS criteria (PaO2:FIO2 ≤ 150). The primary exposure was any diuretic use in 48 to 72 h after meeting ARDS criteria. The primary outcome was hospital mortality. Unadjusted statistical analyses and multivariable logistic regression were used. Results In 48–72 h after meeting ARDS criteria, 116 patients (50%) received a diuretic. In-hospital mortality was lower in the group that received diuretics than in the group that did not (14% vs 25%; p = 0.025). At ARDS onset, both groups had similar Sequential Organ Failure Assessment scores and ICU fluid balances. During the first 48 h after ARDS, the diuretic group received less crystalloid fluid than the no diuretic group (median [inter-quartile range]: 1.2 L [0.2–2.8] vs 2.4 L [1.2-5.0]; p < 0.001), but both groups received more fluid from medications and nutrition than from crystalloid. At 48 h, the prevalence of volume overload (ICU fluid balance >10% of body weight) in each group was 16% and 25%(p = 0.09), respectively. During 48–72 h after ARDS, the overall prevalence of shock was 44% and similar across both groups. Central venous pressure was recorded in only 18% of patients. Adjusting for confounders, early diuretic use was independently associated with lower hospital mortality (AOR 0.46, 95%CI [0.22, 0.96]). Conclusions In this sample of ARDS patients, volume overload was common, and early diuretic use was independently associated with lower hospital mortality. These findings support the importance of fluid management in ARDS and suggest opportunities for further study and implementation of conservative fluid strategies into usual care.
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Affiliation(s)
- Kevin P Seitz
- Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University, Nashville, TN USA.,Vanderbilt University Medical Center, T1218 MCN, 1161 21st Avenue, Nashville, TN 37232 USA
| | - Ellen S Caldwell
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR USA
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224
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Dardeir A, Marudhai S, Patel M, Ghani MR, Busa V. Factors Influencing Prone Positioning in Treating Acute Respiratory Distress Syndrome and the Effect on Mortality Rate. Cureus 2020; 12:e10767. [PMID: 33033667 PMCID: PMC7532878 DOI: 10.7759/cureus.10767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is often associated with severe hypoxemia and a high mortality rate. Prone positioning is a well-established intervention for ARDS. It has been shown to improve oxygenation and prevent ventilator-induced lung injury due to the more uniform distribution of lung stress and strain. This narrative review aims to compare the various factors that may influence how prone positioning affects mortality rates. We will examine the duration of time a patient is in the prone position, severity of ARDS, use of lung-protective ventilation, and the time elapsed between ARDS diagnosis and placing a patient in the prone position. A literature review on prone positioning in ARDS was performed and searched data from PubMed and Google Scholar for articles published from 2010 to 2020. Although no single variable used during prone positioning reduces mortality rates in ARDS patients, combining several optimal conditions may yield increased survival benefits. Early initiation of extended prone positioning sessions combined with low tidal volumes shows encouraging results in severe ARDS patients. Future research on this subject should focus on further examining these variables in a study enrolling a larger number of subjects in a setting with adequately trained staff familiar with proper prone positioning techniques.
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Affiliation(s)
- Ahmed Dardeir
- Physical Medicine and Rehabilitation, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Suganya Marudhai
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Mauli Patel
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Mohammad R Ghani
- Neurology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Vishal Busa
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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225
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Yen S, Song Y, Preissner M, Bennett E, Wilson R, Pavez M, Dubsky S, Dargaville PA, Fouras A, Zosky GR. The proteomic response is linked to regional lung volumes in ventilator-induced lung injury. J Appl Physiol (1985) 2020; 129:837-845. [PMID: 32758039 DOI: 10.1152/japplphysiol.00097.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
It is unclear how acid-induced lung injury alters the regional lung volume response to mechanical ventilation (MV) and how this impacts protein expression. Using a mouse model, we investigated the separate and combined effects of acid aspiration and MV on regional lung volumes and how these were associated with the proteome. Adult BALB/c mice were divided into four groups: intratracheal saline, intratracheal acid, saline/MV, or acid/MV. Specific tidal volume (sVt) and specific end-expiratory volume (sEEV) were measured at baseline and after 2 h of ventilation using dynamic high-resolution four-dimensional computed tomography (4DCT) images. Lung tissue was dissected into 10 regions corresponding to the image segmentation for label-free quantitative proteomic analysis. Our data showed that acid aspiration significantly reduced sVt and caused further reductions in sVt and sEEV after 2 h of ventilation. Proteomic analysis revealed 42 dysregulated proteins in both Saline/MV and Acid/MV groups, and 37 differentially expressed proteins in the Acid/MV group. Mapping of the overlapping proteins showed significant enrichment of complement/coagulation cascades (CCC). Analysis of 37 unique proteins in the Acid/MV group identified six additional CCC proteins and seven downregulated proteins involved in the mitochondrial respiratory chain (MRC). Regional MRC protein levels were positively correlated with sEEV, while the CCC protein levels were negatively associated with sVt. Therefore, this study showed that tidal volume was associated with the expression of CCC proteins, while low end-expiratory lung volumes were associated with MRC protein expression, suggesting that tidal stretch and lung collapse activate different injury pathways.NEW & NOTEWORTHY This study provides novel insights into the regional response to mechanical ventilation in the setting of acid-induced lung injury and highlights the complex interaction between tidal stretch and low-end-expiratory lung volumes; both of which caused altered regulation of different injury pathways.
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Affiliation(s)
- Seiha Yen
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Yong Song
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Melissa Preissner
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, Victoria, Australia
| | - Ellen Bennett
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Richard Wilson
- Central Science Laboratory, University of Tasmania, Hobart, Tasmania, Australia
| | - Macarena Pavez
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Stephen Dubsky
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, Victoria, Australia
| | - Peter A Dargaville
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Graeme R Zosky
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia.,Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
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226
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Rajdev K, Farr LA, Saeed MA, Hooten R, Baus J, Boer B. A Case of Extracorporeal Membrane Oxygenation as a Salvage Therapy for COVID-19-Associated Severe Acute Respiratory Distress Syndrome: Mounting Evidence. J Investig Med High Impact Case Rep 2020; 8:2324709620957778. [PMID: 32911986 PMCID: PMC7488892 DOI: 10.1177/2324709620957778] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) caused by a novel human coronavirus has led to a tsunami of viral illness across the globe, originating from Wuhan, China. Although the value and effectiveness of extracorporeal membrane oxygenation (ECMO) in severe respiratory illness from COVID-19 remains unclear at this time, there is emerging evidence suggesting that it could be utilized as an ultimate treatment in appropriately selected patients not responding to conventional care. We present a case of a 32-year-old COVID-19 positive male with a history of diabetes mellitus who was intubated for severe acute respiratory distress syndrome (ARDS). The patient's hypoxemia failed to improve despite positive pressure ventilation, prone positioning, and use of neuromuscular blockade for ventilator asynchrony. He was evaluated by a multidisciplinary team for considering ECMO for refractory ARDS. He was initiated on venovenous ECMO via dual-site cannulation performed at the bedside. Although his ECMO course was complicated by bleeding, he showed a remarkable improvement in his lung function. ECMO was successfully decannulated after 17 days of initiation. The patient was discharged home after 47 days of hospitalization without any supplemental oxygen and was able to undergo active physical rehabilitation. A multidisciplinary approach is imperative in the initiation and management of ECMO in COVID-19 patients with severe ARDS. While ECMO is labor-intensive, using it in the right phenotype and in specialized centers may lead to positive results. Patients who are young, with fewer comorbidities and single organ dysfunction portray a better prognosis for patients in which ECMO is utilized.
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Affiliation(s)
| | - Lyndie A Farr
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Rorak Hooten
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Joseph Baus
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Brian Boer
- University of Nebraska Medical Center, Omaha, NE, USA
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227
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Tully RP, Hopley N, Lawrence G. The successful use of extracorporeal carbon dioxide removal as a rescue therapy in a patient with severe COVID-19 pneumonitis. Anaesth Rep 2020; 8:e12072. [PMID: 33015631 DOI: 10.1002/anr3.12072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2020] [Indexed: 01/08/2023] Open
Abstract
We present a patient with severe COVID-19 pneumonitis; poor respiratory compliance; dangerously high ventilator pressures; and hypercapnia refractory to conventional treatment including low tidal volume ventilation, neuromuscular blockade and prone position ventilation. Extracorporeal carbon dioxide removal was used as a rescue therapy to facilitate safer ventilator pressures and arterial partial pressures of carbon dioxide. After 6 days of treatment, the patient had improved to the extent that the extracorporeal support was able to be weaned and the patient was decannulated from the device. Following a prolonged respiratory wean, the patient was subsequently discharged from the intensive care unit and then from the hospital to home with no adverse events related to the therapy.
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Affiliation(s)
- R P Tully
- Intensive Care Medicine and Anaesthesia Royal Oldham Hospital Oldham UK
| | - N Hopley
- Intensive Care Medicine Royal Oldham Hospital Oldham UK
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228
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Brave H, MacLoughlin R. State of the Art Review of Cell Therapy in the Treatment of Lung Disease, and the Potential for Aerosol Delivery. Int J Mol Sci 2020; 21:E6435. [PMID: 32899381 PMCID: PMC7503246 DOI: 10.3390/ijms21176435] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 02/07/2023] Open
Abstract
Respiratory and pulmonary diseases are among the leading causes of death globally. Despite tremendous advancements, there are no effective pharmacological therapies capable of curing diseases such as COPD (chronic obstructive pulmonary disease), ARDS (acute respiratory distress syndrome), and COVID-19. Novel and innovative therapies such as advanced therapy medicinal products (ATMPs) are still in early development. However, they have exhibited significant potential preclinically and clinically. There are several longitudinal studies published, primarily focusing on the use of cell therapies for respiratory diseases due to their anti-inflammatory and reparative properties, thereby hinting that they have the capability of reducing mortality and improving the quality of life for patients. The primary objective of this paper is to set out a state of the art review on the use of aerosolized MSCs and their potential to treat these incurable diseases. This review will examine selected respiratory and pulmonary diseases, present an overview of the therapeutic potential of cell therapy and finally provide insight into potential routes of administration, with a focus on aerosol-mediated ATMP delivery.
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Affiliation(s)
- Hosanna Brave
- College of Medicine, Nursing & Health Sciences, National University of Ireland, H91 TK33 Galway, Ireland;
| | - Ronan MacLoughlin
- Department of Chemistry, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, D02 PN40 Dublin, Ireland
- Aerogen Ltd. Galway Business Park, H91 HE94 Galway, Ireland
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229
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How I Select Which Patients With ARDS Should Be Treated With Venovenous Extracorporeal Membrane Oxygenation. Chest 2020; 158:1036-1045. [DOI: 10.1016/j.chest.2020.04.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/30/2020] [Accepted: 04/16/2020] [Indexed: 02/07/2023] Open
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230
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Chand S, Kapoor S, Orsi D, Fazzari MJ, Tanner TG, Umeh GC, Islam M, Dicpinigaitis PV. COVID-19-Associated Critical Illness-Report of the First 300 Patients Admitted to Intensive Care Units at a New York City Medical Center. J Intensive Care Med 2020; 35:963-970. [PMID: 32812834 DOI: 10.1177/0885066620946692] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The first confirmed case of novel coronavirus (2019-nCoV) infection in the United States was reported from the state of Washington in January, 2020. By March, 2020, New York City had become the epicenter of the outbreak in the United States. METHODS We tracked all patients with confirmed coronavirus-19 (COVID-19) infection admitted to intensive care units (ICU) at Montefiore Medical Center (Bronx, NY). Data were obtained through manual review of electronic medical records. Patients had at least 30 days of follow-up. RESULTS Our first 300 ICU patients were admitted March 10 through April 11, 2020. The majority (60.7%) of patients were men. Acute respiratory distress syndrome (ARDS) was documented in 91.7% of patients; 91.3% required mechanical ventilation. Prone positioning was employed in 58% of patients and neuromuscular blockade in 47.8% of mechanically-ventilated patients. Neither intervention was associated with decreased mortality. Vasopressors were required in 77.7% of patients. Acute kidney injury (AKI) was present on admission in 40.7% of patients, and developed subsequently in 36.0%; 50.9% of patients with AKI received renal replacement therapy (RRT). Overall 30-day mortality rate was 52.3%, and 55.8% among patients receiving mechanical ventilation. In univariate analysis, higher mortality rate was associated with increasing age, male sex, hypertension, obesity, smoking, number of comorbidities, AKI on presentation, and need for vasopressor support. A representative multivariable model for 30-day mortality is also presented, containing patient age, gender, body mass index, and AKI at admission. As of May 11, 2020, 2 patients (0.7%) remained hospitalized. CONCLUSIONS Mortality in critical illness associated with COVID-19 is high. The majority of patients develop ARDS requiring mechanical ventilation, vasopressor-dependent shock, and AKI. The variation in mortality rates reported to date likely reflects differences in the severity of illness of the evaluated populations.
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Affiliation(s)
- Sudham Chand
- Division of Critical Care Medicine, Department of Medicine, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sumit Kapoor
- Division of Critical Care Medicine, Department of Medicine, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Deborah Orsi
- Division of Critical Care Medicine, Department of Medicine, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Melissa J Fazzari
- Department of Epidemiology and Population Health, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Tristan G Tanner
- Division of Critical Care Medicine, Department of Medicine, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Genevieve C Umeh
- Department of Obstetrics and Gynecology, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marjan Islam
- Division of Pulmonary Medicine, Department of Medicine, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Peter V Dicpinigaitis
- Division of Critical Care Medicine, Department of Medicine, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
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231
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Asgharpour M, Mehdinezhad H, Bayani M, Zavareh MSH, Hamidi SH, Akbari R, Ghadimi R, Bijani A, Mouodi S. Effectiveness of extracorporeal blood purification (hemoadsorption) in patients with severe coronavirus disease 2019 (COVID-19). BMC Nephrol 2020; 21:356. [PMID: 32819292 PMCID: PMC7439633 DOI: 10.1186/s12882-020-02020-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/13/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Extracorporeal blood purification has been proposed as one of the therapeutic approaches in patients with coronavirus infection, because of its beneficial impact on elimination of inflammatory cytokines. METHODS This controlled trial has been conducted on critically ill COVID-19 patients admitted in the state hospital affiliated to Babol University of Medical Sciences, Iran who received different antiviral and antibacterial drugs, and different modalities of respiratory treatments and did not have positive clinical improvement. No randomization and blindness was considered. All of the participants underwent three sessions of resin-directed hemoperfusion using continuous renal replacement therapy with a mode of continuous venovenous hemofiltration (CVVH). RESULTS Five men and five women with a mean age of 57.30 ± 18.07 years have been enrolled in the study; and six of them have improved after the intervention. Peripheral capillary oxygen saturation (SpO2) changed after each session. Mean SpO2 before the three sessions of hemoperfusion was 89.60% ± 3.94% and increased to 92.13% ± 3.28% after them (p < 0.001). Serum IL-6 showed a reduction from 139.70 ± 105.62 to 72.06 ± 65.87 pg/mL (p = 0.073); and c-reactive protein decreased from 136.25 ± 84.39 to 78.25 ± 38.67 mg/L (P = 0.016). CONCLUSIONS Extracorporeal hemoadsorption could improve the general condition in most of recruited patients with severe coronavirus disease; however, large prospective multicenter trials in carefully selected patients are needed to definitely evaluate the efficacy of hemoperfusion in COVID-19 patients. TRIAL REGISTRATION The research protocol has been registered in the website of Iranian Registry of Clinical Trials with the reference number IRCT20150704023055N2 .
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Affiliation(s)
- Masoumeh Asgharpour
- Department of Internal Medicine, Rouhani Hospital, Babol University of Medical Sciences, Babol, Iran
| | - Hamed Mehdinezhad
- Department of Internal Medicine, Rouhani Hospital, Babol University of Medical Sciences, Babol, Iran
| | - Masoumeh Bayani
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Mahmoud Sadeghi Haddad Zavareh
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Seyed Hossein Hamidi
- Department of Anesthesiology, School of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Roghayeh Akbari
- Department of Internal Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Reza Ghadimi
- Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Ganjafrooz Street, Babol, Iran
| | - Ali Bijani
- Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Ganjafrooz Street, Babol, Iran
| | - Simin Mouodi
- Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Ganjafrooz Street, Babol, Iran.
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232
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Matera MG, Rogliani P, Bianco A, Cazzola M. Pharmacological management of adult patients with acute respiratory distress syndrome. Expert Opin Pharmacother 2020; 21:2169-2183. [PMID: 32783481 DOI: 10.1080/14656566.2020.1801636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION There is still no definite drug for acute respiratory distress syndrome (ARDS) that is capable of reducing either short-term or long-term mortality. Therefore, great efforts are being made to identify a pharmacological approach that can be really effective. AREAS COVERED This review focuses on current challenges and future directions in the pharmacological management of ARDS, regardless of anti-infective treatments. The authors have excluded small randomized controlled trials (RCTs) with less than 60 patients because those studies do not have statistical power for outcome data, and also anecdotal trials but have considered the last meta-analysis on any drug. EXPERT OPINION There has been substantial progress in our knowledge of ARDS over the past two decades and many drugs have been used in its treatment. Nevertheless, effective targeted pharmacological treatments for ARDS are still lacking. The likely reason why a pharmacological approach is beneficial for some patients, but harmful for others is that ARDS is an extremely heterogeneous syndrome. To overcome this issue, a precision approach for ARDS, whereby therapies are specifically targeted to patients most likely to benefit, has been proposed. At present, however, the application of this approach seems to be a difficult task.
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Affiliation(s)
- Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Paola Rogliani
- Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome, Italy
| | - Andrea Bianco
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli"/Monaldi Hospital , Naples, Italy
| | - Mario Cazzola
- Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome, Italy
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233
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Cruces P, Retamal J, Hurtado DE, Erranz B, Iturrieta P, González C, Díaz F. A physiological approach to understand the role of respiratory effort in the progression of lung injury in SARS-CoV-2 infection. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:494. [PMID: 32778136 PMCID: PMC7416996 DOI: 10.1186/s13054-020-03197-7] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/22/2020] [Indexed: 12/16/2022]
Abstract
Deterioration of lung function during the first week of COVID-19 has been observed when patients remain with insufficient respiratory support. Patient self-inflicted lung injury (P-SILI) is theorized as the responsible, but there is not robust experimental and clinical data to support it. Given the limited understanding of P-SILI, we describe the physiological basis of P-SILI and we show experimental data to comprehend the role of regional strain and heterogeneity in lung injury due to increased work of breathing. In addition, we discuss the current approach to respiratory support for COVID-19 under this point of view.
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Affiliation(s)
- Pablo Cruces
- Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile.,Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago, Chile
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile.,Instituto de Ingeniería Biológica y Médica, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniel E Hurtado
- Department of Structural and Geotechnical Engineering, School of Engineering Pontificia Universidad Católica de Chile, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile.,Millennium Nucleus for Cardiovascular Magnetic Resonance, Santiago, Chile
| | - Benjamín Erranz
- Centro de Medicina Regenerativa, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | - Pablo Iturrieta
- Department of Structural and Geotechnical Engineering, School of Engineering Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carlos González
- Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Franco Díaz
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago, Chile. .,Unidad de Paciente Crítico Pediátrico, Hospital Clínico La Florida Dra. Eloísa Díaz Insunza, Santiago, Chile. .,Instituto de Ciencias e Innovacion en Medicina (ICIM), Universidad del Desarrollo, Santiago, Chile.
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234
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Zhang P, Chen Y, Li S, Li C, Zhang S, Zheng W, Chen Y, Ma J, Zhang X, Huang Y, Liu S. Metagenomic next-generation sequencing for the clinical diagnosis and prognosis of acute respiratory distress syndrome caused by severe pneumonia: a retrospective study. PeerJ 2020; 8:e9623. [PMID: 32821543 PMCID: PMC7395598 DOI: 10.7717/peerj.9623] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 07/07/2020] [Indexed: 12/25/2022] Open
Abstract
Background Metagenome next-generation sequencing (mNGS) is a valuable diagnostic tool that can be used for the identification of early pathogens of acute respiratory distress syndrome (ARDS) in severe pneumonia. Little is known about the use of this technology in clinical application and the evaluation of the prognostic value of ARDS. Methods We performed a retrospective cohort study of patients with ARDS caused by severe pneumonia. Samples were collected from patients in the intensive care unit (ICU) of Jiangmen Central Hospital from January 2018 to August 2019. The no-next generation sequencing (NGS) group was composed of patients given conventional microbiological tests to examine sputum, blood, or bronchoalveolar lavage fluid. The NGS group was composed of patients tested using mNGS and conventional microbiological tests. We evaluated the etiological diagnostic effect and clinical prognostic value of mNGS in patients with ARDS caused by severe pneumonia. Results The overall positive rate (91.1%) detected by the mNGS method was significantly higher than that of the culture method (62.2%, P = 0.001), and antibody plus polymerase chain reaction (28.9%, P < 0.001). Following adjustment of the treatment plan based on microbial testing results, the Acute Physiology and Chronic Health Evaluation-II (APACHE II) score of the NGS group was lower than that of the no-NGS group 7 days after treatment (P < 0.05). The 28-day mortality rate of the NGS group was significantly lower than that of the no-NGS group (P < 0.05). Longer ICU stay, higher APACHE II score and sequential organ failure assessment score were risk factors for the death of ARDS, and adjusting the medication regimen based on mNGS results was a protective factor. The detection of mNGS can significantly shorten the ICU stay of immunosuppressed patients (P < 0.01), shorten the ventilation time (P < 0.01), and reduce the ICU hospitalization cost (P < 0.05). Conclusions Metagenome next-generation sequencing is a valuable tool to determine the etiological value of ARDS caused by severe pneumonia to improve diagnostic accuracy and prognosis for this disease. For immunosuppressed patients, mNGS technology can be used in the early stage to provide more diagnostic evidence and guide medications.
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Affiliation(s)
- Peng Zhang
- Department of Respiratory Medicine, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China.,Department of Critical Care Medicine, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-sen University, Jiangmen, Guangdong, China
| | - Yan Chen
- BGI PathoGenesis Pharmaceutical Technology Co., Ltd, BGI-Shenzhen, Shenzhen, Guangdong, China.,BGI Wuhan Biotechnology, BGI-Shenzhen, Wuhan, Hubei, China
| | - Shuyun Li
- Department of Neurology, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-sen University, Jiangmen, Guangdong, China
| | - Chaoliang Li
- Department of Critical Care Medicine, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-sen University, Jiangmen, Guangdong, China
| | - Shuang Zhang
- Department of Critical Care Medicine, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-sen University, Jiangmen, Guangdong, China
| | - Weihao Zheng
- Department of Critical Care Medicine, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-sen University, Jiangmen, Guangdong, China
| | - Yantang Chen
- Department of Critical Care Medicine, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-sen University, Jiangmen, Guangdong, China
| | - Jie Ma
- Department of Critical Care Medicine, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-sen University, Jiangmen, Guangdong, China
| | - Xin Zhang
- Clinical Experimental Center, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-sen University, Jiangmen, Guangdong, China
| | - Yanming Huang
- Department of Respiration Medicine, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-sen University, Jiangmen, Guangdong, China
| | - Shengming Liu
- Department of Respiratory Medicine, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
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Graça L, Abreu IG, Santos AS, Graça L, Dias PF, Santos ML. Descriptive Acute Respiratory Distress Syndrome (ARDS) in adults with imported severe Plasmodium falciparum malaria: A 10 year-study in a Portuguese tertiary care hospital. PLoS One 2020; 15:e0235437. [PMID: 32645025 PMCID: PMC7347120 DOI: 10.1371/journal.pone.0235437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/15/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a severe complication of malaria that remains largely unstudied. We aim to describe the development of ARDS associated with severe P. falciparum malaria, its management and impact on clinical outcome. METHODS Retrospective observational study of adult patients admitted with severe P. falciparum malaria in an Intensive Care Unit (ICU) of a tertiary care hospital from Portugal from 2008 to 2018. A multivariate logistic regression analysis was used to identify factors associated with the development of ARDS, defined according to Berlin Criteria. Prognosis was assessed by case-fatality ratio, nosocomial infection and length of stay. RESULTS 98 patients were enrolled, of which 32 (33%) developed ARDS, a median of 2 days after starting antimalarial medication (IQR 0-4, range 0-6). Length of stay in ICU and in hospital were significantly longer in patients who developed ARDS: 13 days (IQR 10-18) vs 3 days (IQR 2-5) and 21 days (IQR 15-30.5) vs 7 days (IQR 6-10), respectively. Overall case-fatality ratio in ICU was 4.1% and did not differ between groups. The risk of ARDS development is difficult to establish. CONCLUSION ARDS is a hard to predict late complication of severe malaria. A low threshold for ICU admission and monitoring should be used. Ideally patients should be managed in a centre with experience and access to advanced techniques.
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Affiliation(s)
- Luísa Graça
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Isabel Gomes Abreu
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Ana Sofia Santos
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- * E-mail:
| | - Luís Graça
- Escola Superior de Saúde do Instituto Politécnico de Viana do Castelo, Viana do Castelo, Portugal
- Unidade de Investigação em Ciências da Saúde: Enfermagem da Escola Superior de Enfermagem de Coimbra, Coimbra, Portugal
| | - Paulo Figueiredo Dias
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Maria Lurdes Santos
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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236
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Fan E, Beitler JR, Brochard L, Calfee CS, Ferguson ND, Slutsky AS, Brodie D. COVID-19-associated acute respiratory distress syndrome: is a different approach to management warranted? THE LANCET RESPIRATORY MEDICINE 2020; 8:816-821. [PMID: 32645311 PMCID: PMC7338016 DOI: 10.1016/s2213-2600(20)30304-0] [Citation(s) in RCA: 308] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 02/07/2023]
Abstract
The COVID-19 pandemic has seen a surge of patients with acute respiratory distress syndrome (ARDS) in intensive care units across the globe. As experience of managing patients with COVID-19-associated ARDS has grown, so too have efforts to classify patients according to respiratory system mechanics, with a view to optimising ventilatory management. Personalised lung-protective mechanical ventilation reduces mortality and has become the mainstay of treatment in ARDS. In this Viewpoint, we address ventilatory strategies in the context of recent discussions on phenotypic heterogeneity in patients with COVID-19-associated ARDS. Although early reports suggested that COVID-19-associated ARDS has distinctive features that set it apart from historical ARDS, emerging evidence indicates that the respiratory system mechanics of patients with ARDS, with or without COVID-19, are broadly similar. In the absence of evidence to support a shift away from the current paradigm of ventilatory management, we strongly recommend adherence to evidence-based management, informed by bedside physiology, as resources permit.
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Affiliation(s)
- Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network and Sinai Health System, Toronto, ON, Canada.
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure, New York-Presbyterian Medical Center, New York, NY, USA; Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, The University of California, San Francisco, San Francisco, CA, USA
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network and Sinai Health System, Toronto, ON, Canada
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
| | - Daniel Brodie
- Center for Acute Respiratory Failure, New York-Presbyterian Medical Center, New York, NY, USA; Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
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237
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McGurk K, Riveros T, Johnson N, Dyer S. A primer on proning in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:1703-1708. [PMID: 32838382 PMCID: PMC7361258 DOI: 10.1002/emp2.12175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/29/2020] [Accepted: 06/08/2020] [Indexed: 12/23/2022] Open
Abstract
Historically, the prone position was used almost exclusively in the ICU for patients suffering from refractory hypoxemia due to acute respiratory distress syndrome (ARDS). Amidst the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic, however, this technique has been increasingly utilized in settings outside of the ICU, particularly in the emergency department. With emerging evidence that patients diagnosed with COVID‐19 who are not intubated and mechanically ventilated may benefit from the prone position, this strategy should not be isolated to only those with critical illness. This is a review of the pertinent physiology and evidence supporting prone positioning along with a step‐by‐step guide meant to familiarize those who are not already comfortable with the maneuver. Placing a patient in the prone position helps to improve ventilation‐perfusion matching, dorsal lung recruitment, and ultimately gas exchange. Evidence also suggests there is improved oxygenation in both mechanically ventilated patients and those who are awake and spontaneously breathing, further reinforcing the utility of the prone position in non‐ICU settings. Given present concerns about resource limitations because of the pandemic, prone positioning has especially demonstrable value as a technique to delay or even prevent intubation. Patients who are able to self‐prone should be directed into the ''swimmer's position'' and then placed in reverse Trendelenburg position if further oxygenation is needed. If a mechanically ventilated patient is to be placed in the prone position, specific precautions should be taken to ensure the patient's safety and to prevent any unwanted sequelae of prone positioning.
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Affiliation(s)
- Kevin McGurk
- Department of Emergency Medicine Cook County Health Chicago Illinois USA
| | - Toni Riveros
- Division of Pulmonary Critical Care and Sleep Medicine University of Washington Seattle Washington USA
| | - Nicholas Johnson
- Division of Pulmonary Critical Care and Sleep Medicine University of Washington Seattle Washington USA.,Division of Emergency Medicine University of Washington Seattle Washington USA
| | - Sean Dyer
- Department of Emergency Medicine Cook County Health Chicago Illinois USA
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238
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Lentz S, Roginski MA, Montrief T, Ramzy M, Gottlieb M, Long B. Initial emergency department mechanical ventilation strategies for COVID-19 hypoxemic respiratory failure and ARDS. Am J Emerg Med 2020; 38:2194-2202. [PMID: 33071092 PMCID: PMC7335247 DOI: 10.1016/j.ajem.2020.06.082] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/24/2020] [Accepted: 06/29/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an emerging viral pathogen that causes the novel coronavirus disease of 2019 (COVID-19) and may result in hypoxemic respiratory failure necessitating invasive mechanical ventilation in the most severe cases. OBJECTIVE This narrative review provides evidence-based recommendations for the treatment of COVID-19 related respiratory failure requiring invasive mechanical ventilation. DISCUSSION In severe cases, COVID-19 leads to hypoxemic respiratory failure that may meet criteria for acute respiratory distress syndrome (ARDS). The mainstay of treatment for ARDS includes a lung protective ventilation strategy with low tidal volumes (4-8 mL/kg predicted body weight), adequate positive end-expiratory pressure (PEEP), and maintaining a plateau pressure of < 30 cm H2O. While further COVID-19 specific studies are needed, current management should focus on supportive care, preventing further lung injury from mechanical ventilation, and treating the underlying cause. CONCLUSIONS This review provides evidence-based recommendations for the treatment of COVID-19 related respiratory failure requiring invasive mechanical ventilation.
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Affiliation(s)
- Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, The University of Vermont Larner College of Medicine, USA
| | - Matthew A Roginski
- Divisions of Emergency Medicine and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, USA
| | - Tim Montrief
- Department of Emergency Medicine, Jackson Memorial Health System, USA
| | - Mark Ramzy
- Department of Emergency Medicine, Maimonides Medical Center, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, USA
| | - Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, USA.
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239
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Hall MW, Joshi I, Leal L, Ooi EE. Immune modulation in COVID-19: Strategic considerations for personalized therapeutic intervention. Clin Infect Dis 2020; 74:144-148. [PMID: 32604407 PMCID: PMC7337699 DOI: 10.1093/cid/ciaa904] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Indexed: 12/26/2022] Open
Abstract
We are learning that the host response to severe acute respiratory syndrome coronavirus 2 ( SARS-CoV-2) infection is complex and highly dynamic. Effective initial host defense in the lung is associated with mild symptoms and disease resolution. Viral evasion of the immune response can lead to refractory alveolar damage, ineffective lung repair mechanisms, and systemic inflammation with associated organ dysfunction. The immune response in these patients is highly variable and can include moderate to severe systemic inflammation and/or marked systemic immune suppression. There is unlikely to be a “one size fits all” approach to immunomodulation in patients with coronavirus disease 2019 (COVID-19). We believe that a personalized, immunophenotype-driven approach to immunomodulation that may include anticytokine therapy in carefully selected patients and immunostimulatory therapies in others is the shortest path to success in the study and treatment of patients with critical illness due to COVID-19.
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Affiliation(s)
- Mark W Hall
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | | | | | - Eng Eong Ooi
- Duke-National University of Singapore Medical School, Singapore
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240
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Greenland JR, Michelow MD, Wang L, London MJ. COVID-19 Infection: Implications for Perioperative and Critical Care Physicians. Anesthesiology 2020; 132:1346-1361. [PMID: 32195698 PMCID: PMC7155909 DOI: 10.1097/aln.0000000000003303] [Citation(s) in RCA: 132] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 03/10/2020] [Indexed: 01/08/2023]
Abstract
Healthcare systems worldwide are responding to Coronavirus Disease 2019 (COVID-19), an emerging infectious syndrome caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus. Patients with COVID-19 can progress from asymptomatic or mild illness to hypoxemic respiratory failure or multisystem organ failure, necessitating intubation and intensive care management. Healthcare providers, and particularly anesthesiologists, are at the frontline of this epidemic, and they need to be aware of the best available evidence to guide therapeutic management of patients with COVID-19 and to keep themselves safe while doing so. Here, the authors review COVID-19 pathogenesis, presentation, diagnosis, and potential therapeutics, with a focus on management of COVID-19-associated respiratory failure. The authors draw on literature from other viral epidemics, treatment of acute respiratory distress syndrome, and recent publications on COVID-19, as well as guidelines from major health organizations. This review provides a comprehensive summary of the evidence currently available to guide management of critically ill patients with COVID-19.
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Affiliation(s)
- John R Greenland
- From Pulmonary and Critical Care Medicine (J.R.G.) Anesthesia and Perioperative Care (M.D.M., M.J.L.), San Francisco Veterans Administration Health Care System, San Francisco, California Laboratory Medicine (L.W.) University of California, San Francisco, California (J.R.G., M.D.M., M.J.L.)
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241
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Valesky W, Chow L. Prone Positioning for Acute Respiratory Distress Syndrome in Adults. Acad Emerg Med 2020; 27:520-522. [PMID: 32096893 DOI: 10.1111/acem.13948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/19/2020] [Accepted: 02/22/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Walter Valesky
- From the Department of Emergency Medicine Kings County Hospital—NYC Health + Hospitals Brooklyn NY
| | - Lillian Chow
- and the Department of Medicine Division of Pulmonary and Critical Care Medicine SUNY Downstate Health Sciences University Brooklyn NY
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242
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Bera KD, Shah A, English MR, Harvey D, Ploeg RJ. Optimisation of the organ donor and effects on transplanted organs: a narrative review on current practice and future directions. Anaesthesia 2020; 75:1191-1204. [PMID: 32430910 DOI: 10.1111/anae.15037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 12/16/2022]
Abstract
Mortality remains high for patients on the waiting list for organ transplantation. A marked imbalance between the number of available organs and recipients that need to be transplanted persists. Organs from deceased donors are often declined due to perceived and actual suboptimal quality. Adequate donor management offers an opportunity to reduce organ injury and maximise the number of organs than can be offered in order to respect the donor's altruistic gift. The cornerstones of management include: correction of hypovolaemia; maintenance of organ perfusion; prompt treatment of diabetes insipidus; corticosteroid therapy; and lung protective ventilation. The interventions used to deliver these goals are largely based on pathophysiological rationale or extrapolations from general critical care patients. There is currently insufficient high-quality evidence that has assessed whether any interventions in the donor after brain death may actually improve immediate post-transplant function and long-term graft survival or recipient survival after transplantation. Improvements in our understanding of the underlying mechanisms following brain death, in particular the role of immunological and metabolic changes in donors, offer promising future therapeutic opportunities to increase organ utilisation. Establishing a UK donor management research programme involves consideration of ethical, logistical and legal issues that will benefit transplanted patients while respecting the wishes of donors and their families.
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Affiliation(s)
- K D Bera
- Oxford Biomedical Research Centre and Oxford University Hospital NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - M R English
- University of Oxford Medical School, Oxford, UK
| | - D Harvey
- Department of Intensive Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R J Ploeg
- Nuffield Department of Surgical Sciences and Oxford Biomedical Research Centre, University of Oxford, UK
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243
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Woyke S, Rauch S, Ströhle M, Gatterer H. Modulation of Hb-O 2 affinity to improve hypoxemia in COVID-19 patients. Clin Nutr 2020; 40:38-39. [PMID: 32360083 PMCID: PMC7195129 DOI: 10.1016/j.clnu.2020.04.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/24/2020] [Indexed: 01/06/2023]
Abstract
This opinion paper aims at discussing the potential impact of modulating the Hb-O2 affinity by the nutritional supplement 5-HMF on patients affected by COVID-19. The paper describes the critical role of the oxygen affinity in hypoxemic COVID-19 patients and the potential positive effect of 5-HMF, a compound shown to increase the Hb-O2 affinity.
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Affiliation(s)
- Simon Woyke
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Simon Rauch
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy; Department of Anesthesia and Intensive Care Medicine, "F. Tappeiner" Hospital, Merano, Italy
| | - Mathias Ströhle
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Hannes Gatterer
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.
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244
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Werner AK, Koumans EH, Chatham-Stephens K, Salvatore PP, Armatas C, Byers P, Clark CR, Ghinai I, Holzbauer SM, Navarette KA, Danielson ML, Ellington S, Moritz ED, Petersen EE, Kiernan EA, Baldwin GT, Briss P, Jones CM, King BA, Krishnasamy V, Rose DA, Reagan-Steiner S. Hospitalizations and Deaths Associated with EVALI. N Engl J Med 2020; 382:1589-1598. [PMID: 32320569 PMCID: PMC8826745 DOI: 10.1056/nejmoa1915314] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND As of January 7, 2020, a total of 2558 hospitalized patients with nonfatal cases and 60 patients with fatal cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) had been reported to the Centers for Disease Control and Prevention (CDC). METHODS In a national study, we compared the characteristics of patients with fatal cases of EVALI with those of patients with nonfatal cases to improve the ability of clinicians to identify patients at increased risk for death from the condition. Health departments reported cases of EVALI to the CDC and included, when available, data from medical-record abstractions and patient interviews. Analyses included all the patients with fatal or nonfatal cases of EVALI that were reported to the CDC as of January 7, 2020. We also present three case reports of patients who died from EVALI to illustrate the clinical characteristics common among such patients. RESULTS Most of the patients with fatal or nonfatal cases of EVALI were male (32 of 60 [53%] and 1666 of 2498 [67%], respectively). The proportion of patients with fatal or nonfatal cases was higher among those who were non-Hispanic white (39 of 49 [80%] and 1104 of 1818 [61%], respectively) than among those in other race or ethnic groups. The proportion of patients with fatal cases was higher among those 35 years of age or older (44 of 60 [73%]) than among those younger than 35 years, but the proportion with nonfatal cases was lower among those 35 years of age or older (551 of 2514 [22%]). Among the patients who had an available medical history, a higher proportion of those with fatal cases than those with nonfatal cases had a history of asthma (13 of 57 [23%] vs. 102 of 1297 [8%]), cardiac disease (26 of 55 [47%] vs. 115 of 1169 [10%]), or a mental health condition (32 of 49 [65%] vs. 575 of 1398 [41%]). A total of 26 of 50 patients (52%) with fatal cases had obesity. Half the patients with fatal cases (25 of 54 [46%]) were seen in an outpatient setting before hospitalization or death. CONCLUSIONS Chronic conditions, including cardiac and respiratory diseases and mental health conditions, were common among hospitalized patients with EVALI.
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Affiliation(s)
- Angela K Werner
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Emilia H Koumans
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Kevin Chatham-Stephens
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Phillip P Salvatore
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Christina Armatas
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Paul Byers
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Charles R Clark
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Isaac Ghinai
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Stacy M Holzbauer
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Kristen A Navarette
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Melissa L Danielson
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Sascha Ellington
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Erin D Moritz
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Emily E Petersen
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Emily A Kiernan
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Grant T Baldwin
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Peter Briss
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Christopher M Jones
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Brian A King
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Vikram Krishnasamy
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Dale A Rose
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
| | - Sarah Reagan-Steiner
- From the National Center for Environmental Health (A.K.W., E.D.M.), the National Center for Chronic Disease Prevention and Health Promotion (E.H.K., S.E., E.E.P., P. Briss, B.A.K.), the National Center on Birth Defects and Developmental Disabilities (K.C.-S., M.L.D.), the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (P.P.S., I.G.), the National Center for Injury Prevention and Control (P.P.S., G.T.B., C.M.J., V.K.), the Center for Preparedness and Response (S.M.H.), the Agency for Toxic Substances and Disease Registry (E.A.K.), and the National Center for Emerging and Zoonotic Infectious Diseases (D.A.R., S.R.-S.), Centers for Disease Control and Prevention, and Emory University School of Medicine (E.A.K.) - all in Atlanta; the California Department of Public Health, Sacramento (C.A.); the Mississippi State Department of Health, Jackson (P. Byers); the Indiana State Department of Health, Indianapolis (C.R.C.); the Illinois Department of Public Health, Springfield (I.G.); the Minnesota Department of Health, St. Paul (S.M.H.); and the New York State Department of Health, Albany (K.A.N.)
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Sahu AK, Nayer J, Aggarwal P. Novel coronavirus: A capsule review for primary care and acute care physicians. J Family Med Prim Care 2020; 9:1820-1824. [PMID: 32670925 PMCID: PMC7346926 DOI: 10.4103/jfmpc.jfmpc_217_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/13/2020] [Accepted: 03/15/2020] [Indexed: 01/08/2023] Open
Abstract
Novel coronavirus (nCoV) is a new emerging infectious agent causing coronavirus disease 2019 (COVID-19). Since the reporting of early cases of COVID-19 from China on December 29, 2019 till March 15, 2020, it has affected 1,42,539 humans in 135 countries, including 82 cases in India. As it is a difficult task for first-contact physicians, i.e. primary care and acute care physicians, to comprehend the fast-growing knowledge about nCoV and apply for prevention and care of suspected cases of COVID-19, we have tried to provide an updated capsule review of nCoV infection and management of COVID-19. It includes the evidence-based information on epidemiological determinants (agent, host, and environment) of the disease, its clinical features, clinical and laboratory diagnosis, basic infection prevention and control measures, and clinical management of COVID-19 cases. This review also includes the succinct summary of World Health Organization and Center for Diseases Control and Prevention interim guidelines (as of March 15, 2020) on nCoV.
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Affiliation(s)
- Ankit Kumar Sahu
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Jamshed Nayer
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
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Benge CD, Barwise JA. Aerosolization of COVID-19 and Contamination Risks During Respiratory Treatments. Fed Pract 2020; 37:160-163. [PMID: 32322146 PMCID: PMC7173638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Aerosolized medications are frequently administered across the health care continuum to acutely ill patients. During viral pandemics, the World Health Organization and the Centers for Disease Control and Prevention advise the application of airborne precautions when performing aerosol-generating medical procedures, such as aerosolized medications. OBSERVATIONS Appropriate personal protective equipment (PPE), including fit-tested particulate respirators should be worn when administering nebulized medications to patients. These PPEs have been in short supply in the US during early phases of the COVID-19 pandemic, which is increasing the risk faced by health care workers (HCWs) who are treating patients using aerosolized medications. Despite taking appropriate precautions, HCWs are becoming infected with COVID-19. This may be related to secondary exposure related to viral longevity in fugitive emissions and viability on fomites. CONCLUSIONS We have expanded on non-US public health recommendations to provide guidance to frontline HCWs to enhance collaboration between clinicians, who are often siloed in their clinical practices, and ultimately to protect the federal workforce, which cannot sustain a significant loss of frontline HCWs.
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Affiliation(s)
- Cassandra D Benge
- is a Clinical Pharmacy Specialist, and is a Staff Physician and Medical Director of the Surgical Intensive Care Unit, both at VA Tennessee Valley Healthcare System in Nashville. John Barwise is Associate Professor of Clinical Anesthesiology at Vanderbilt University Medical Center in Nashville
| | - John Alan Barwise
- is a Clinical Pharmacy Specialist, and is a Staff Physician and Medical Director of the Surgical Intensive Care Unit, both at VA Tennessee Valley Healthcare System in Nashville. John Barwise is Associate Professor of Clinical Anesthesiology at Vanderbilt University Medical Center in Nashville
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Buckley MS, Agarwal SK, Garcia-Orr R, Saggar R, MacLaren R. Comparison of Fixed-Dose Inhaled Epoprostenol and Inhaled Nitric Oxide for Acute Respiratory Distress Syndrome in Critically Ill Adults. J Intensive Care Med 2020; 36:466-476. [PMID: 32133901 DOI: 10.1177/0885066620906800] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Several reports have demonstrated similar effects on oxygenation between inhaled epoprostenol (iEPO) compared to inhaled nitric oxide (iNO) for acute respiratory distress syndrome (ARDS). Previous studies directly comparing oxygenation and clinical outcomes between iEPO and iNO exclusively in an adult ARDS patient population utilized a weight-based dosing strategy. The purpose of this study was to compare the clinical and economic impact between iNO and fixed-dosed iEPO for ARDS in adult intensive care unit (ICU) patients. METHODS This retrospective cohort study was conducted at a major academic medical center between January 1, 2014, and October 31, 2018. Patients ≥18 years of age with moderate-to-severe ARDS were included. The primary end point was to compare the mean change in partial arterial oxygen pressure to fraction of inspired oxygen (Pao 2: Fio 2) at 4 hours from baseline between iEPO and iNO. Other secondary aims were total acquisition drug costs, in-hospital mortality, ICU and hospital length of stay, and duration of mechanical ventilation. RESULTS A total of 239 patients were included with 139 (58.2%) and 100 (41.8%) in the iEPO and iNO groups, respectively. The mean change in Pao 2: Fio 2 at 4 hours from baseline in the iEPO and iNO groups were 31.4 ± 54.6 and 32.4 ± 42.7 mm Hg, respectively (P = .88). The responder rate at 4 hours was similar between iEPO and iNO groups (64.7% and 66.0%, respectively, P = .84). Clinical outcomes including mortality, overall hospital and ICU length of stay, and mechanical ventilation duration were similar between iEPO and iNO groups. Estimated annual cost-savings realized with iEPO was USD1 074 433. CONCLUSION Fixed-dose iEPO was comparable to iNO in patients with moderate-to-severe ARDS for oxygenation and ventilation parameters as well as clinical outcomes. Significant cost-savings were realized with iEPO use.
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Affiliation(s)
- Mitchell S Buckley
- 22386Banner-University Medical Center Phoenix, Department of Pharmacy, Phoenix, AZ, USA
| | - Sumit K Agarwal
- 22386Banner-University Medical Center Phoenix, Care Transformation, Phoenix, AZ, USA
| | - Roxanne Garcia-Orr
- 22386Banner-University Medical Center Phoenix, Department of Critical Care, Phoenix, AZ, USA
| | - Rajeev Saggar
- 22386Banner-University Medical Center Phoenix, Department of Critical Care, Phoenix, AZ, USA
| | - Robert MacLaren
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Reddy K, O'Kane C, McAuley D. Corticosteroids in acute respiratory distress syndrome: a step forward, but more evidence is needed. THE LANCET RESPIRATORY MEDICINE 2020; 8:220-222. [PMID: 32043984 DOI: 10.1016/s2213-2600(20)30048-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 11/14/2019] [Accepted: 11/14/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Kiran Reddy
- Department of Anaesthesiology and Critical Care, Tallaght University Hospital, Dublin D24 NR0A, Ireland.
| | - Cecilia O'Kane
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast BT9 7BL, Northern Ireland
| | - Daniel McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast BT9 7BL, Northern Ireland; Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland
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Abstract
Hypoxaemia is a common presentation in critically ill patients, with the potential for severe harm if not addressed appropriately. This review provides a framework to guide the management of any hypoxaemic patient, regardless of the clinical setting. Key steps in managing such patients include ascertaining the severity of hypoxaemia, the underlying diagnosis and implementing the most appropriate treatment. Oxygen therapy can be delivered by variable or fixed rate devices, and non-invasive ventilation; if patients deteriorate they may require tracheal intubation and mechanical ventilation. Early critical care team involvement is a key part of this pathway. Specialist treatments for severe hypoxaemia can only be undertaken on an intensive care unit and this field is developing rapidly as trial results become available. It is important that each new scenario is approached in a structured manner with an open diagnostic mind and a clear escalation plan.
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Affiliation(s)
- Luke Flower
- Anaesthetics Department, University College Hospital, London, UK
| | - Daniel Martin
- Intensive Care Unit, Royal Free Hospital, London, UK
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250
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Ho ATN, Patolia S, Guervilly C. Neuromuscular blockade in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. J Intensive Care 2020; 8:12. [PMID: 32015880 PMCID: PMC6986163 DOI: 10.1186/s40560-020-0431-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/16/2020] [Indexed: 12/15/2022] Open
Abstract
Background Neuromuscular blocking agent (NMBA) has been proposed by medical guidelines for early severe acute respiratory distress syndrome (ARDS) because of its survival benefits. However, new studies have provided evidence contradicting these results. Method A search was performed of the Pubmed, Scopus, Clinicaltrials.gov, and Virtual Health Library databases for randomized controlled trials (RCT) evaluating 28-day mortality in ARDS patients treated with NMBA within 48 h. An English language restriction was applied. Relevant data were extracted and pooled into risk ratios (RR), mean differences (MD), and corresponding 95% confidence intervals (CI) using random-effect model. Sensitivity and meta-regression analysis were performed. Results From 2675 studies, we included five RCTs in the analysis, for a total of 1461 patients with a mean PaO2/FIO2 of 104 ± 35 mmHg. The cisatracurium group had the same risk of death at 28 days (RR, 0.90; 95% CI, 0.78–1.03; I2 = 50%, p = 0.12) and 90 days (RR, 0.81; 95% CI, 0.62–1.06; I2 = 56%, p = 0.06) as the control group (no cisatracurium). The secondary outcomes of mechanical ventilation duration and ventilator-free days were not different between the two groups. Cisatracurium had a significantly lower risk of barotrauma than the control group with no difference in intensive care unit (ICU)–induced weakness. The PaO2/FIO2 ratio was higher in the cisatracurium group but not until 48 h. Meta-regression analysis of the baseline PaO2/FIO2 ratio, positive end-expiratory pressure (PEEP) revealed no heterogeneity. Subgroup analysis excluding the trial using high PEEP and light sedation strategy yielded an improvement in all mortality outcomes. Conclusion NMBA improves oxygenation only after 48 h in moderate, severe ARDS patients and has a lower barotrauma risk without affecting ICU weakness. However, NMBA does not reduce ventilator-free days, duration of mechanical ventilation or, most importantly, the mortality risk regardless of the severity of ARDS.
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Affiliation(s)
- An Thi Nhat Ho
- 1Pulmonary and Critical Care Medicine, Saint Louis University, 3635 Vista Avenue, St Louis, MO 63104 USA
| | - Setu Patolia
- 1Pulmonary and Critical Care Medicine, Saint Louis University, 3635 Vista Avenue, St Louis, MO 63104 USA
| | - Christophe Guervilly
- 2Medical Intensive Care Unit, North Hospital, APHM, Marseille, France.,3CEReSS, Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
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