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Renaudier P, Rebibo D, Waller C, Schlanger S, Vo Mai MP, Ounnoughene N, Breton P, Cheze S, Girard A, Hauser L, Legras JF, Saillol A, Willaert B, Caldani C. Complications pulmonaires de la transfusion (TACO–TRALI). Transfus Clin Biol 2009; 16:218-32. [DOI: 10.1016/j.tracli.2009.04.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Accepted: 04/09/2009] [Indexed: 01/13/2023]
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202
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[Prone position for the treatment of acute respiratory distress syndrome: a review of current literature]. Arch Bronconeumol 2009; 45:291-6. [PMID: 19403223 DOI: 10.1016/j.arbres.2008.05.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Accepted: 05/29/2008] [Indexed: 11/21/2022]
Abstract
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) have high incidence and mortality rates. Most of the recently introduced treatments have failed to improve the prognosis of patients with ALI or ARDS or to reduce mortality. Several studies have shown improved oxygenation in the prone position during mechanical ventilation in patients with ARDS. However, current evidence strongly suggests that placing ARDS patients in prone position does not improve survival or reduce the duration of mechanical ventilation. Therefore, though in clinical practice this position may improve refractory hypoxemia in patients with ARDS, there is no evidence to support its systematic use.
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203
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Ennett CM, Lee KP, Eshelman LJ, Gross B, Nielsen L, Frassica JJ, Saeed M. Predicting respiratory instability in the ICU. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2009; 2008:2848-51. [PMID: 19163299 DOI: 10.1109/iembs.2008.4649796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) contribute to the morbidity and mortality of intensive care patients worldwide, and have large associated human and financial costs. We identified a reference data set of 624 mechanically-ventilated patients in the MIMIC-II intensive care database with and without low PaO(2)/FiO(2) ratios (termed respiratory instability), and developed prediction algorithms for distinguishing these patients prior to the critical event. In the end, we had four rule sets using mean airway pressure, plateau pressure, total respiratory rate and oxygen saturation (SpO(2)), where the specificity/sensitivity rates were either 80%/60% or 90%/50%.
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204
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Kopterides P, Siempos II, Armaganidis A. Prone positioning in hypoxemic respiratory failure: meta-analysis of randomized controlled trials. J Crit Care 2009; 24:89-100. [PMID: 19272544 DOI: 10.1016/j.jcrc.2007.12.014] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Accepted: 12/28/2007] [Indexed: 02/07/2023]
Abstract
PURPOSE Prone positioning is used to improve oxygenation in patients with hypoxemic respiratory failure (HRF). However, its role in clinical practice is not yet clearly defined. The aim of this meta-analysis was to assess the effect of prone positioning on relevant clinical outcomes, such as intensive care unit (ICU) and hospital mortality, days of mechanical ventilation, length of stay, incidence of ventilator-associated pneumonia (VAP) and pneumothorax, and associated complications. METHODS We used literature search of MEDLINE, Current Contents, and Cochrane Central Register of Controlled Trials. We focused only on randomized controlled trials reporting clinical outcomes in adult patients with HRF. Four trials met our inclusion criteria, including 662 patients randomized to prone ventilation and 609 patients to supine ventilation. RESULTS The pooled odds ratio (OR) for the ICU mortality in the intention-to-treat analysis was 0.97 (95% confidence interval [CI], 0.77-1.22), for the comparison between prone and supine ventilated patients. Interestingly, the pooled OR for the ICU mortality in the selected group of the more severely ill patients favored prone positioning (OR, 0.34; 95% CI, 0.18-0.66). The duration of mechanical ventilation and the incidence of pneumothorax were not different between the 2 groups. The incidence of VAP was lower but not statistically significant in patients treated with prone positioning (OR, 0.81; 95% CI, 0.61-1.10). However, prone positioning was associated with a higher risk of pressure sores (OR, 1.49; 95% CI, 1.17-1.89) and a trend for more complications related to the endotracheal tube (OR, 1.30; 95% CI, 0.94-1.80). CONCLUSIONS Despite the inherent limitations of the meta-analytic approach, it seems that prone positioning has no discernible effect on mortality in patients with HRF. It may decrease the incidence of VAP at the expense of more pressure sores and complications related to the endotracheal tube. However, a subgroup of the most severely ill patients may benefit most from this intervention.
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Affiliation(s)
- Petros Kopterides
- 2nd Critical Care Department, University of Athens Medical School, Attiko University Hospital, Athens 12462, Greece.
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205
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Adhikari NKJ, McAndrews MP, Tansey CM, Matté A, Pinto R, Cheung AM, Diaz-Granados N, Barr A, Herridge MS. Self-reported symptoms of depression and memory dysfunction in survivors of ARDS. Chest 2009; 135:678-687. [PMID: 19265087 PMCID: PMC5233444 DOI: 10.1378/chest.08-0974] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Survivors of ARDS have well documented physical limitations, but psychological effects are less clear. We determined the prevalence of self-reported depression and memory dysfunction in ARDS survivors. METHODS Six to 48 (median 22) months after ICU discharge, we administered instruments assessing depression symptoms (Beck Depression Inventory-II [BDI-II]) and memory dysfunction (Memory Assessment Clinics Self-Rating Scale [MAC-S]) to 82 ARDS patients who were enrolled in a prospective cohort study in four university-affiliated ICUs. RESULTS Sixty-one (74%), 64 (78%), and 61 (74%) patients fully completed the BDI-II, MAC-S (Ability subscale), and MAC-S (Frequency of Occurrence subscale) instruments. Responders (similar to nonresponders) were young (median 42 years, interquartile range [IQR] 35 to 56), with high admission illness severity and organ dysfunction. The median BDI-II score was 12 (IQR 5 to 25). Twenty-five (41%) patients reported moderate-severe depression symptoms and were less likely to return to work than those with minimal-mild symptoms (8/25 [32%] vs 25/36 [69%]; p = 0.005). Median MAC-S (Ability) and MAC-S (Frequency of Occurrence) scores were 76 (IQR 61 to 93) and 91 (IQR 77 to 102), respectively; 8%, 16%, and 20% scored > 2, > 1.5, and > 1 SD(s), respectively, below age-adjusted population norms for each subscale. BDI-II and MAC-S scores were negatively correlated (Spearman coefficient -0.58 and -0.50 for Ability and Frequency of Occurrence subscales, respectively; p < 0.0001). Univariable analyses showed no demographic or illness-severity predictors of BDI-II (including the Cognitive subscale) or MAC-S (both subscales); results were similar when restricted to patients whose primary language was English. CONCLUSIONS ARDS survivors report a high prevalence of depression symptoms and a lower prevalence of memory dysfunction 6 to 48 months after ICU discharge. Depression symptoms may hinder the return to work, or patients may report these symptoms because of inability to re-enter the workforce.
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Affiliation(s)
- Neill K J Adhikari
- Interdepartmental Division of Critical Care and Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Mary Pat McAndrews
- Krembil Neuroscience Program, University Health Network, Toronto, ON, Canada
| | - Catherine M Tansey
- Medical-Surgical Intensive Care Unit, University Health Network, Toronto, ON, Canada
| | - Andrea Matté
- Medical-Surgical Intensive Care Unit, University Health Network, Toronto, ON, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Angela M Cheung
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Aiala Barr
- Department of Public Health Sciences, University of Toronto, Toronto, ON, Canada
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care and Department of Medicine, University of Toronto, Toronto, ON, Canada
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206
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Genetic Susceptibility in ALI/ARDS: What have we Learned? Intensive Care Med 2009. [DOI: 10.1007/978-0-387-77383-4_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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207
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Hong SB, Oh BJ, Kim YS, Kang EH, Kim CH, Park YB, Han MS, Shin C. Characteristics of mechanical ventilation employed in intensive care units: a multicenter survey of hospitals. J Korean Med Sci 2008; 23:948-53. [PMID: 19119434 PMCID: PMC2610657 DOI: 10.3346/jkms.2008.23.6.948] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Accepted: 02/19/2008] [Indexed: 11/20/2022] Open
Abstract
A 1D point-prevalence study was performed to describe the characteristics of conventional mechanical ventilation in intensive care units (ICUs). In addition, a survey was conducted to determine the characteristics of ICUs. A prospective, multicenter study was performed in ICUs at 24 university hospitals. The study population consisted of 223 patients who were receiving mechanical ventilation or had been weaned off mechanical ventilation within the past 24 hr. Common indications for the initiation of mechanical ventilation included acute respiratory failure (66%), acute exacerbation of chronic respiratory failure (15%) (including tuberculosis-destroyed lung [5%]), coma (13%), and neuromuscular disorders (6%). Mechanical ventilation was delivered via an endotracheal tube in 68% of the patients, tracheostomy in 28% and facial mask with noninvasive ventilation (NIV) in 4%. NIV was used in 2 centers. In patients who had undergone tracheostomy, the procedure had been performed 16.9+/-8.1 days after intubation. Intensivists treated 29% of the patients. A need for additional educational programs regarding clinical practice in the ICU was expressed by 62% of the staff and 42% of the nurses. Tuberculosis-destroyed lung is a common indication for mechanical ventilation in acute exacerbation of chronic respiratory failure, and noninvasive ventilation was used in a limited number of ICUs.
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Affiliation(s)
- Sang-Bum Hong
- Division of Pulmonary and Critical Care Medicine, Department of Emergency Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea.
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208
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Abstract
OBJECTIVE Acute respiratory distress syndrome is a common disorder associated with significant mortality and morbidity. The aim of this article is to critically evaluate the definition of acute respiratory distress syndrome and examine the impact the definition has on clinical practice and research. DATA SOURCES Articles from a MEDLINE search (1950 to August 2007) using the Medical Subject Heading respiratory distress syndrome, adult, diagnosis, limited to the English language and human subjects, their relevant bibliographies, and personal collections, were reviewed. DATA SYNTHESIS The definition of acute respiratory distress syndrome is important to researchers, clinicians, and administrators alike. It has evolved significantly over the last 40 years, culminating in the American-European Consensus Conference definition, which was published in 1994. Although the American-European Consensus Conference definition is widely used, it has some important limitations that may impact on the conduct of clinical research, on resource allocation, and ultimately on the bedside management of such patients. These limitations stem partially from the fact that as defined, acute respiratory distress syndrome is a heterogeneous entity and also involve the reliability and validity of the criteria used in the definition. This article critically evaluates the American-European Consensus Conference definition and its limitations. Importantly, it highlights how these limitations may contribute to clinical trials that have failed to detect a potential true treatment effect. Finally, recommendations are made that could be considered in future definition modifications with an emphasis on the significance of accurately identifying the target population in future trials and subsequently in clinical care. CONCLUSION How acute respiratory distress syndrome is defined has a significant impact on the results of randomized, controlled trials and epidemiologic studies. Changes to the current American-European Consensus Conference definition are likely to have an important role in advancing the understanding and management of acute respiratory distress syndrome.
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209
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Kralt D, Light B, Cheang M, MacNair T, Wiebe L, Limerick B, Sarsfield P, Hammond G, MacDonald K, Trepman E, Embil JM. Clinical characteristics and outcomes in patients with pulmonary blastomycosis. Mycopathologia 2008; 167:115-24. [PMID: 18931937 DOI: 10.1007/s11046-008-9163-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Accepted: 10/02/2008] [Indexed: 12/22/2022]
Abstract
BACKGROUND Blastomycosis is an uncommon granulomatous infection caused by the thermally dimorphic fungus Blastomyces dermatitidis. The most frequent clinical infections involve the lung, skin, and bone. Pulmonary manifestations range from asymptomatic self-limited infection to severe diffuse pneumonia causing respiratory failure. OBJECTIVES To establish the clinical characteristics and outcomes of patients with pulmonary blastomycosis diagnosed at hospitals in Manitoba and northwestern Ontario, Canada. METHODS A retrospective review of medical records was done for 318 patients with blastomycosis in these regions. RESULTS The majority of patients were Caucasian (198 (62.5%) patients), male (193 (61%) patients), and residents of Ontario (209 (65.7%) patients). Most patients were treated in an inpatient hospital ward (266 (84%) patients) and survived (294 (92%) patients). Pulmonary involvement, either alone or associated with other sites, was present in 296 (93%) of the 318 patients; 22 (7%) patients had no evidence of pulmonary blastomycosis. The majority of patients had localized lung disease (1-3 quadrants on chest radiograph involved; 225 (82%) patients). Of 294 (92%) patients requiring hospitalization, 266 (90%) patients received all inpatient care on a general medical ward; 28 (10%) patients received some care in the intensive care unit (ICU). Factors associated with ICU admission included diffuse pulmonary disease (four quadrants involved on chest radiograph), diabetes, and prior use of antimicrobial therapy. Twenty-four (8%) patients died, and multivariate analysis showed that older age and Aboriginal ethnicity were the significant risk factors for death from blastomycosis. CONCLUSION Blastomycosis is a cause of serious, potentially life-threatening pulmonary infection in this geographic region.
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Affiliation(s)
- Doug Kralt
- Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
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210
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Taut FJ, Rippin G, Schenk P, Findlay G, Wurst W, Häfner D, Lewis JF, Seeger W, Günther A, Spragg RG. A Search for Subgroups of Patients With ARDS Who May Benefit From Surfactant Replacement Therapy. Chest 2008; 134:724-732. [DOI: 10.1378/chest.08-0362] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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211
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Currier PF, Gong MN, Zhai R, Pothier LJ, Boyce PD, Xu L, Yu CL, Thompson BT, Christiani DC. Surfactant protein-B polymorphisms and mortality in the acute respiratory distress syndrome. Crit Care Med 2008; 36:2511-6. [PMID: 18679120 PMCID: PMC3090262 DOI: 10.1097/ccm.0b013e318183f608] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether polymorphisms of the surfactant protein B gene may be associated with increased mortality in patients with the acute respiratory distress syndrome. DESIGN A prospective cohort study. SETTING Four adult intensive care units at a tertiary academic medical center. PATIENTS Two hundred fourteen white patients who had met criteria for acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were genotyped for a variable nuclear tandem repeat polymorphism in intron 4 of the surfactant protein B gene and the surfactant protein B gene +1580 polymorphism. For the variable nuclear tandem repeat surfactant protein B gene polymorphism, patients were found to have either a homozygous wild-type genotype or a variant genotype consisting of either a heterozygous insertion or deletion polymorphism. Logistic regression was performed to analyze the relationship of the polymorphisms to mortality in patients with acute respiratory distress syndrome. In multivariate analysis, the presence of variable nuclear tandem repeat surfactant protein B gene polymorphism was associated with a 3.51 greater odds of death at 60 days in patients with acute respiratory distress syndrome as compared to those patients with the wild-type genotype (95% confidence interval 1.39-8.88, p = 0.008). There was no association found between the +1580 variant and outcome (p = 0.15). CONCLUSIONS In this study, the variable nuclear tandem repeat surfactant protein B gene polymorphism in intron 4 is associated with an increased 60 day mortality in acute respiratory distress syndrome after adjusting for age, severity of illness, and other potential confounders. Additional studies in other populations are needed to confirm this finding.
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Affiliation(s)
- Paul F Currier
- Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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212
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Gullberg N, Kalzén H, Luhr O, Göthberg S, Winsö O, Markström A, Olsson AK, Frostell C. Immediate and 5-year cumulative outcome after paediatric intensive care in Sweden. Acta Anaesthesiol Scand 2008; 52:1086-95. [PMID: 18840109 DOI: 10.1111/j.1399-6576.2008.01711.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Little has been reported about intensive care of children in Sweden. The aims of this study are to (I) assess the number of admissions, types of diagnoses and length-of-stay (LOS) for all Swedish children admitted to intensive care during the years 1998-2001, and compare paediatric intensive care units (PICUs) with other intensive care units (adult ICUs) (II) assess immediate (ICU) and cumulative 5-year mortality and (III) determine the actual consumption of paediatric intensive care for the defined age group in Sweden. METHODS Children between 6 months and 16 years of age admitted to intensive care in Sweden were included in a national multicentre, ambidirectional cohort study. In PICUs, data were also collected for infants aged 1-6 months. Survival data were retrieved from the National Files of Registration, 5 years after admission. RESULTS Eight-thousand sixty-three admissions for a total of 6661 patients were identified, corresponding to an admission rate of 1.59/1000 children per year. Median LOS was 1 day. ICU mortality was 2.1% and cumulative 5-year mortality rate was 5.6%. Forty-four per cent of all admissions were to a PICU. CONCLUSIONS This study has shown that Sweden has a low immediate ICU mortality, similar in adult ICU and PICU. Patients discharged alive from an ICU had a 20-fold increased mortality risk, compared with a control cohort for the 5-year period. Less than half of the paediatric patients admitted for intensive care in Sweden were cared for in a PICU. Studies are needed to evaluate whether a centralization of paediatric intensive care in Sweden would be beneficial to the paediatric population.
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Affiliation(s)
- N Gullberg
- Department of Paediatric Anaesthesia and Intensive Care, Karolinska Institutet, Astrid Lindgren Children's Hospital, Stockholm, Sweden
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213
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Quartin AA, Campos MA, Maldonado DA, Ashkin D, Cely CM, Schein RMH. Acute lung injury outside of the ICU: incidence in respiratory isolation on a general ward. Chest 2008; 135:261-268. [PMID: 18689600 DOI: 10.1378/chest.08-0280] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Epidemiologic investigations of acute lung injury (ALI) and ARDS have focused on mechanically ventilated patients in ICUs, and have reported high mortality rates. We sought to determine the incidence and lethality of these syndromes in the respiratory isolation areas of general wards, a non-ICU setting that often serves patients with acute lung processes. METHODS We prospectively studied all patients who were admitted to respiratory isolation rooms on the general wards of a large tertiary care hospital over a 1-year period. Patients were classified as having ALI or ARDS if they met consensus definitions for the syndromes. Characteristics and outcomes were compared to those of other patients who had been admitted to a respiratory isolation room with infiltrating lung disease but lacking bilateral infiltrates, hypoxemia, or both. RESULTS Of 715 patients admitted to respiratory isolation rooms on general wards, 474 (66%) had acute infiltrates. ALI criteria were met by 9% of patients (62 of 715 patients), with 2% of patients (15 of 715) satisfying the criteria for ARDS. Respiratory distress was present in 71% of ALI patients (44 of 62 patients) and 32% of patients (130 of 412 patients) with acute infiltrates who did not have ALI (p < 0.001). However, the 90-day survival rates (ALI patients, 88%; patients with acute infiltrates who did not have ALI, 90%) was similar between the two groups (p > 0.50). CONCLUSIONS ALI and ARDS may be frequent among patients who are admitted to respiratory isolation beds outside of ICUs. Mortality rates are substantially lower than those typically reported from surveys of ventilated ICU patients with ALI and ARDS.
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Affiliation(s)
- Andrew A Quartin
- Division of Pulmonary and Critical Care Medicine, University of Miami Miller School of Medicine, Miami, FL.
| | - Michael A Campos
- Division of Pulmonary and Critical Care Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Diego A Maldonado
- Division of Pulmonary and Critical Care Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - David Ashkin
- Division of Pulmonary and Critical Care Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Cynthia M Cely
- Division of Pulmonary and Critical Care Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Roland M H Schein
- Division of Pulmonary and Critical Care Medicine, University of Miami Miller School of Medicine, Miami, FL
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214
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Siau C, Stewart TE. Current role of high frequency oscillatory ventilation and airway pressure release ventilation in acute lung injury and acute respiratory distress syndrome. Clin Chest Med 2008; 29:265-75, vi. [PMID: 18440436 DOI: 10.1016/j.ccm.2008.02.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Lung protective ventilatory strategies using conventional ventilators have resulted in decreased mortality in adult patients who have acute lung injury and acute respiratory distress syndrome. Conceptually, high frequency oscillatory ventilation and airway pressure release ventilation appear not only able to fulfill the goals of lung protection, but also to offer some additional advantages over conventional ventilation. Although early data for each of these modes in adults have been encouraging, their widespread use--particularly outside of a rescue situation--cannot be recommended without further evidence.
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Affiliation(s)
- Chuin Siau
- Interdepartmental Division of Critical Care Medicine, University of Toronto, 220 Victoria Street, Suite 1807, Toronto, Ontario, Canada M5B 2R6
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215
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Kárason S, Söndergaard S, Lundin S, Wiklund J, Stenqvist O. Reply. Acta Anaesthesiol Scand 2008. [DOI: 10.1111/j.1399-6576.2001.450822-2.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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216
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Seeley E, McAuley DF, Eisner M, Miletin M, Matthay MA, Kallet RH. Predictors of mortality in acute lung injury during the era of lung protective ventilation. Thorax 2008; 63:994-8. [PMID: 18566110 DOI: 10.1136/thx.2007.093658] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Lung protective ventilation has been widely adopted for the management of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Consequently, ventilator associated lung injury and mortality have decreased. It is not known if this ventilation strategy changes the prognostic value of previously identified demographic and pulmonary predictors of mortality, such as respiratory compliance and the arterial oxygen tension to inspired oxygen fraction ratio (Pao(2)/Fio(2)). METHODS Demographic, clinical, laboratory and pulmonary variables were recorded in 149 patients with ALI/ARDS. Significant predictors of mortality were identified in bivariate analysis and these were entered into multivariate analysis to identify independent predictors of mortality. RESULTS Hospital mortality was 41%. In the bivariate analysis, 17 variables were significantly correlated with mortality, including age, APACHE II score and the presence of cirrhosis. Pulmonary parameters associated with death included Pao(2)/Fio(2) and oxygenation index ((mean airway pressurexFio(2)x100)/Pao(2)). In unadjusted analysis, the odds ratio (OR) of death for Pao(2)/Fio(2) was 1.57 (CI 1.12 to 3.04) per standard deviation decrease. However, in adjusted analysis, Pao(2)/Fio(2) was not a statistically significant predictor of death, with an OR of 1.29 (CI 0.82 to 2.02). In contrast, oxygenation index (OI) was a statistically significant predictor of death in both unadjusted analysis (OR 1.89 (CI 1.28 to 2.78)) and in adjusted analysis (OR 1.84 (CI 1.13 to 2.99)). CONCLUSIONS In this cohort of patients with ALI/ARDS, OI was an independent predictor of mortality, whereas Pao(2)/Fio(2) was not. OI may be a superior predictor because it integrates both airway pressure and oxygenation into a single variable.
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Affiliation(s)
- E Seeley
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California, USA.
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217
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Li T, Zhao B, Wang C, Wang H, Liu Z, Li W, Jin H, Tang C, Du J. Regulatory effects of hydrogen sulfide on IL-6, IL-8 and IL-10 levels in the plasma and pulmonary tissue of rats with acute lung injury. Exp Biol Med (Maywood) 2008; 233:1081-7. [PMID: 18535161 DOI: 10.3181/0712-rm-354] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
We examined the possible role of hydrogen sulfide (H2S) in the pathogenesis of oleic acid (OA)-induced acute lung injury (ALI) and its regulatory effects on the inflammatory response. Compared to control rats, the OA-treated rats had decreased partial pressure of oxygen in the arterial blood (PaO2) levels, an increased pulmonary wet/dry weight (W/D) ratio, increased index of quantitative assessment (IQA) score and increased frequency of polymorphonuclear (PMN) cells in the lung 2, 4 or 6 h after OA injection (0.1 ml/kg, intravenous injection). In addition, significantly increased IL-6, IL-8 and IL-10 levels together with decreased H2S levels were observed in the plasma and lung tissue of OA-treated rats compared to controls. Administration of the H2S donor sodium hydrosulfide (NaHS, 56 micromol/L, intraperitoneal injection) into OA-treated rats increased the PaO2 level, reduced the lung W/D ratio and infiltration of PMN cells, and alleviated the degree of ALI (measured by the IQA score). In addition, NaHS decreased IL-6 and IL-8 levels but increased IL-10 levels in the plasma and lung tissues, suggesting that H2S may regulate the inflammatory response during ALI via regulation of IL-6, IL-8 and IL-10. Thus, the down-regulation of endogenous H2S production might be involved in the pathogenesis of OA-induced ALI in rats.
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Affiliation(s)
- Tianshui Li
- Department of Pediatrics, Peking University First Hospital, West District, Beijing 100034, China
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218
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Predictors of hospital mortality in a population-based cohort of patients with acute lung injury. Crit Care Med 2008; 36:1412-20. [PMID: 18434894 DOI: 10.1097/ccm.0b013e318170a375] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Studies describing predictors of mortality in patients with acute lung injury were primarily derived from selected academic centers. We sought to determine the predictors of mortality in a population-based cohort of patients with acute lung injury and to characterize the performance of current severity of illness scores in this population. DESIGN Secondary analysis of a prospective, multicenter, population-based cohort. SETTING Twenty-one hospitals in Washington State. PATIENTS The cohort included 1,113 patients with acute lung injury identified during the year 1999-2000. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We evaluated physiology, comorbidities, risk factors for acute lung injury, and other variables for their association with death at hospital discharge. Bivariate predictors of death were entered into a multiple logistic regression model. We compared Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, and Simplified Acute Physiology Score II to the multivariable model using area under the receiver operating characteristic curve. The model was validated in an independent cohort of 886 patients with acute lung injury. Modified acute physiology score, age, comorbidities, arterial pH, minute ventilation, PaCO2, PaO2/FiO2 ratio, intensive care unit admission source, and intensive care unit days before onset of acute lung injury were independently predictive of in-hospital death (p < .05). The area under the receiver operating characteristic curve for the multivariable model was superior to that of APACHE III (.81 vs. .77, p < .001) but was no different after external validation (.71 vs. .70, p = .64). CONCLUSIONS The predictors of mortality in patients with acute lung injury are similar to those predictive of mortality in the general intensive care unit population, indicating disease heterogeneity within this cohort. Accordingly, APACHE III predicts mortality in acute lung injury as well as a model using variables selected specifically for patients with acute lung injury.
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Ferguson ND, Frutos-Vivar F, Esteban A, Gordo F, Honrubia T, Peñuelas O, Algora A, García G, Bustos A, Rodríguez I. Clinical risk conditions for acute lung injury in the intensive care unit and hospital ward: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:R96. [PMID: 17784960 PMCID: PMC2556739 DOI: 10.1186/cc6113] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 08/23/2007] [Accepted: 09/04/2007] [Indexed: 12/22/2022]
Abstract
BACKGROUND Little is known about the development of acute lung injury outside the intensive care unit. We set out to document the following: the association between predefined clinical conditions and the development of acute lung injury by using the American-European consensus definition; the frequency of lung injury development outside the intensive care unit; and the temporal relationship between antecedent clinical risk conditions, intensive care admission, and diagnosis of lung injury. METHODS We conducted a 4-month prospective observational study in three Spanish teaching hospitals, enrolling consecutive patients who developed clinical conditions previously linked to lung injury, both inside and outside the intensive care unit. Patients were followed prospectively for outcomes, including the diagnosis of acute lung injury or acute respiratory distress syndrome. RESULTS A total 815 patients were identified with at least one clinical insult; the most common were sepsis, pneumonia, and pancreatitis. Pulmonary risk conditions were observed in 30% of cases. Fifty-three patients (6.5%) developed acute lung injury; 33 of these (4.0%) met criteria for acute respiratory distress syndrome. Lung injury occurred most commonly in the setting of sepsis (46/53; 86.7%), but shock (21/59; 36%) and pneumonia (20/211; 9.5%) portended the highest proportional risk; this risk was higher in patients with increasing numbers of clinical risk conditions (2.2%, 14%, and 21% (P < 0.001) in patients with one, two, and three conditions, respectively). Median days (interquartile range) from risk condition to diagnosis of lung injury was shorter with pulmonary (0 (0 to 2)) versus extrapulmonary (3 (1 to 5)) (P = 0.029) risk conditions. Admission to the intensive care unit was provided to 9/20 (45%) patients with acute lung injury and to 29/33 (88%) of those with acute respiratory distress syndrome. Lung injury patients had higher mortality than others (acute lung injury 25.0%; acute respiratory distress syndrome 45.5%; others 10.3%; P < 0.001). CONCLUSION The time course from clinical insult to diagnosis of lung injury was rapid, but may be longer for extrapulmonary cases. Some patients with lung injury receive care and die outside the intensive care unit; this observation needs further study.
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Affiliation(s)
- Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, and Department of Medicine, Division of Respirology, University Health Network, University of Toronto, 399 Bathurst Street, F2-150, Toronto, Ontario M5T 2S8, Canada
| | - Fernando Frutos-Vivar
- Intensive Care Unit, Hospital Universitario de Getafe, CIBER de Enfermades Respiratorios, Carretera de Toledo Km 12,500, 28905 Madrid, Spain
| | - Andrés Esteban
- Intensive Care Unit, Hospital Universitario de Getafe, CIBER de Enfermades Respiratorios, Carretera de Toledo Km 12,500, 28905 Madrid, Spain
| | - Federico Gordo
- Intensive Care Unit, Fundacíon Hospital de Alcorcón, c/Budapest 1, 28922 Alcorcón, Madrid, Spain
| | - Teresa Honrubia
- Intensive Care Unit, Hospital de Móstoles, c/Río Jucar, 28935 Móstoles, Madrid, Spain
| | - Oscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, CIBER de Enfermades Respiratorios, Carretera de Toledo Km 12,500, 28905 Madrid, Spain
| | - Alejandro Algora
- Intensive Care Unit, Fundacíon Hospital de Alcorcón, c/Budapest 1, 28922 Alcorcón, Madrid, Spain
| | - Gema García
- Intensive Care Unit, Hospital de Móstoles, c/Río Jucar, 28935 Móstoles, Madrid, Spain
| | - Alejandra Bustos
- Intensive Care Unit, Hospital Universitario de Getafe, CIBER de Enfermades Respiratorios, Carretera de Toledo Km 12,500, 28905 Madrid, Spain
| | - Inmaculada Rodríguez
- Intensive Care Unit, Hospital Universitario de Getafe, CIBER de Enfermades Respiratorios, Carretera de Toledo Km 12,500, 28905 Madrid, Spain
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Borba A, Lourenço S, Marcelino P, Marum S, Fernandes AP. Prevalência e caracterização clínica dos doentes com insuficiência respiratória parcial grave internados numa UCI. REVISTA PORTUGUESA DE PNEUMOLOGIA 2008. [DOI: 10.1016/s0873-2159(15)30242-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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221
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Schuster KM, Alouidor R, Barquist ES. Nonventilatory interventions in the acute respiratory distress syndrome. J Intensive Care Med 2008; 23:19-32. [PMID: 18230633 DOI: 10.1177/0885066607310166] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Acute respiratory distress syndrome was first described in 1967. Acute respiratory distress syndrome and acute lung injury are diseases the busy intensivist treats almost daily. The etiologies of acute respiratory distress syndrome are many. A significant distinction is based on whether the insult to the lung was direct, such as in pneumonia, or indirect, such as trauma or sepsis. Strategies for managing patients with acute respiratory distress syndrome/acute lung injury can be subdivided into 2 large groups, those based in manipulation of mechanical ventilation and those based in nonventilatory modalities. This review focuses on the nonventlilatory strategies and includes fluid restriction, exogenous surfactant, inhaled nitric oxide, manipulation of production, or administration of eicosanoids, neuromuscular blocking agents, prone position ventilation, glucocorticoids, extracorporeal membrane oxygenation, and administration of beta-agonists. Most of these therapies either have not been studied in large trials or have failed to show a benefit in terms of long-term patient mortality. Many of these therapies have shown promise in terms of improved oxygenation and may therefore be beneficial as rescue therapy for severely hypoxic patients. Recommendations regarding the use of each of these strategies are made, and an algorithm for implementing these strategies is suggested.
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Affiliation(s)
- Kevin M Schuster
- Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale University School of Medicine, New Haven, Connecticut, USA
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222
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Zambon M, Vincent JL. Mortality rates for patients with acute lung injury/ARDS have decreased over time. Chest 2008; 133:1120-7. [PMID: 18263687 DOI: 10.1378/chest.07-2134] [Citation(s) in RCA: 372] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Over the last decade, several studies have suggested that survival rates for patients with acute lung injury (ALI) or ARDS may have improved. We performed a systematic analysis of the ALI/ARDS literature to document possible trends in mortality between 1994 and 2006. METHODS We used the Medline database to select studies with the key words "acute lung injury," "ARDS," "acute respiratory failure," and "mechanical ventilation." All studies that reported mortality rates for patients with ALI/ARDS defined according to the criteria of the American European Consensus Conference were selected. We excluded studies with < 30 patients and studies limited to specific subgroups of ARDS patients such as sepsis, trauma, burns, or transfusion-related ARDS. RESULTS Seventy-two studies were included in the analysis. There was a wide variation in mortality rates among the studies (15 to 72%). The overall pooled mortality rate for all studies was 43% (95% confidence interval, 40 to 46%). Metaregression analysis suggested a significant decrease in overall mortality rates of approximately 1.1%/yr over the period analyzed (1994 to 2006). The mortality reduction was also observed for hospital but not for ICU or 28-day mortality rates. CONCLUSIONS In this literature review, the data are consistent with a reduction in mortality rates in general populations of patients with ALI/ARDS over the last 10 years.
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Affiliation(s)
- Massimo Zambon
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070 Brussels, Belgium
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223
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Ventilator-induced lung injury: another sign of aging? Intensive Care Med 2008; 34:796-9. [PMID: 18180904 DOI: 10.1007/s00134-007-0961-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Accepted: 11/20/2007] [Indexed: 01/11/2023]
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224
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Suri HS, Li G, Gajic O. Epidemiology of Acute Respiratory Failure and Mechanical Ventilation. Intensive Care Med 2008. [PMCID: PMC7121586 DOI: 10.1007/978-0-387-77383-4_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Acute respiratory failure, and the need for mechanical ventilation, remains one of the most common reasons for admission to the intensive care unit (ICU). The burden of acute respiratory failure is high in terms of mortality and morbidity as well as the cost of its principal treatment, mechanical ventilation. Very few epidemiologic studies have evaluated the prevalence and outcome of acute respiratory failure and mechanical ventilation in general. Most of the published literature has focused on specific forms of acute respiratory failure, particularly acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). In this chapter, we provide a brief review of the pathophysiology of acute respiratory failure, its definition and classification, and then present the incidence and outcomes of specific forms of acute respiratory failure from epidemiologic studies.
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225
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Song JW, Choi CM, Hong SB, Oh YM, Shim TS, Lim CM, Lee SD, Kim WS, Kim DS, Kim WD, Koh Y. Analysis of Characteristics and Prognostic Factors in Adult Patients Receiving Mechanical Ventilation in the Medical Intensive Care Unit of a University Hospital. Tuberc Respir Dis (Seoul) 2008. [DOI: 10.4046/trd.2008.65.4.292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jin Woo Song
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang-Min Choi
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon-Mok Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Sun Shim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Do Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo Sung Kim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Soon Kim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Dong Kim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Acute Lung Injury: Acute Respiratory Distress Syndrome. MECHANICAL VENTILATION 2008. [PMCID: PMC7149661 DOI: 10.1016/b978-0-7216-0186-1.50008-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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227
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Epidemiology of Acute Respiratory Failure and Mechanical Ventilation. YEARBOOK OF INTENSIVE CARE AND EMERGENCY MEDICINE 2008. [PMCID: PMC7123201 DOI: 10.1007/978-3-540-77290-3_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute respiratory failure, and the need for mechanical ventilation, remains one of the most common reasons for admission to the intensive care unit (ICU). The burden of acute respiratory failure is high in terms of mortality and morbidity as well as the cost of its principal treatment, mechanical ventilation. Very few epidemiologic studies have evaluated the prevalence and outcome of acute respiratory failure and mechanical ventilation in general. Most of the published literature has focused on specific forms of acute respiratory failure, particularly acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). In this chapter, we provide a brief review of the pathophysiology of acute respiratory failure, its definition and classification, and then present the incidence and outcomes of specific forms of acute respiratory failure from epidemiologic studies.
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228
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Abstract
Among ventilated children, the incidence of acute lung injury (ALI) was 9%; of that latter group 80% developed the acute respiratory distress syndrome (ARDS). The population-based prevalence of pediatric ARDS was 5.5 cases/100.000 inhabitants. Underlying diseases in children were septic shock (34%), respiratory syncytial virus infections (16%), bacterial pneumonia (15%), near-drowning 9%, and others. Mortality ranged from 18% to 27% for ALI (including ALI-non ARDS and ARDS) and from 29% to 50% for ARDS. Mortality was only 3%-11% in children with ALI-non ARDS. As risk factors, oxygenation indices and multi-organ failure have been identified. New insights into the pathophysiology (for example the interplay between intraalveolar coagulation/fibrinolysis and inflammation and the genetic polymorphism for the angiotensin-converting enzyme) offer new therapeutic options. Lung protective mechanical ventilation with optimal lung recruitment is the mainstay of supportive therapy. New therapeutic modalities refer to corticosteroid and surfactant treatment. Well-designed follow up studies are needed.
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229
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Wind J, Versteegt J, Twisk J, van der Werf TS, Bindels AJGH, Spijkstra JJ, Girbes ARJ, Groeneveld ABJ. Epidemiology of acute lung injury and acute respiratory distress syndrome in The Netherlands: A survey. Respir Med 2007; 101:2091-8. [PMID: 17616453 DOI: 10.1016/j.rmed.2007.05.021] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Revised: 05/21/2007] [Accepted: 05/25/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND The characteristics, incidence and risk factors for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) may depend on definitions and geography. METHODS A prospective, 3-day point-prevalence study was performed by a survey of all intensive care units (ICU) in the Netherlands (n=96). Thirty-six ICU's responded (37%), reporting on 266 patients, of whom 151 were mechanically ventilated. The questionnaire included criteria and potential risk factors for ALI/ARDS, according to the North American-European Consensus Conference (NAECC) or the lung injury score (LIS>or=2.5). RESULTS Agreement between definitions was fair (kappa 0.31-0.42, P=0.001). ALI/ARDS was characterized, regardless of definition, by radiographic densities, low oxygenation ratios, high inspiratory O(2) and airway pressure requirements. Depending on definitions, ALI and ARDS accounted for about 12-33% and 7-9% of ICU admissions per year, respectively, constituting 21-58% (ALI) and 13-16% (ARDS) of all mechanically ventilated patients. The annual incidences of ALI and ARDS are 29.3 (95%CI 18.4-40.1) and 24.0 (95%CI 14.2-33.8) by NAECC, respectively, and are, respectively, 83.6 (95%CI 65.3-101.9) and 20.9 (95%CI 11.7-30.1) by LIS per 100,000. Risk factors for ALI/ARDS were aspiration, pneumonia, sepsis and chronic alcohol abuse (the latter only by NAECC). CONCLUSION The effect of definitions of ALI/ARDS on mechanical ventilation in the Netherlands is small. Nevertheless, the incidence of ALI/ARDS may be higher than in other European countries but lower than in the USA, and the incidence of ALI by LIS may overestimate compared to that by NAECC. Aspiration, pneumonia, sepsis and chronic alcohol abuse are major risk factors, largely independent of definitions.
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Affiliation(s)
- Jan Wind
- Department of Intensive Care, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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231
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Sato H, Griffith GW, Hall CM, Toomasian JM, Hirschl RB, Bartlett RH, Cook KE. Seven-Day Artificial Lung Testing in an In-Parallel Configuration. Ann Thorac Surg 2007; 84:988-94. [PMID: 17720415 DOI: 10.1016/j.athoracsur.2007.03.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Revised: 03/01/2007] [Accepted: 03/05/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND A thoracic artificial lung, the MC3 Biolung, is being developed as a bridge to lung transplantation or as a treatment for acute respiratory insufficiency. METHODS The thoracic artificial lung was tested in 10 sheep with the goal of 7 days of respiratory support. The sheep were recovered from surgery and monitored awake for 7 days. Hemodynamics, blood gases, blood cell counts, and organ function were recorded, and after 7 days, all sheep were euthanized and necropsied. RESULTS Seven sheep survived the full duration. Cardiac output and mean arterial blood pressure were unchanged, averaging 4.7 +/- 0.8 L/min and 98 +/- 10 mm Hg, respectively. Arterial oxygen tension and device oxygen transfer rate were also unchanged, averaging 110 +/- 26 mm Hg and 97.7 +/- 35 mL/min, respectively. Arterial carbon dioxide tension was within normal ranges during the entire experiment, averaging 37.4 +/- 3.8 mm Hg. Artificial lung blood flow decreased from 51% +/- 14% of cardiac output on day 1 to 30% +/- 16% by day 7 because of changes in natural and artificial lung resistance. White blood cell counts were significantly elevated on days 5 and 7, and lastly, kidney and liver function remained normal, although signs of kidney infarction or hemorrhage were noted. CONCLUSIONS The thoracic artificial lung is suitable for 7-day attachment, but improvements in blood biocompatibility are warranted.
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Affiliation(s)
- Hitoshi Sato
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Kostopanagiotou G, Avgerinos E, Costopanagiotou C, Arkadopoulos N, Andreadou I, Diamantopoulou K, Lekka M, Smyrniotis V, Nakos G. Acute lung injury in a rat model of intestinal ischemia-reperfusion: the potential time depended role of phospholipases A(2). J Surg Res 2007; 147:108-16. [PMID: 17981297 DOI: 10.1016/j.jss.2007.07.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2007] [Revised: 07/03/2007] [Accepted: 07/17/2007] [Indexed: 01/14/2023]
Abstract
BACKGROUND A pivotal role of phospholipase A(2) (PLA(2)) and platelet-activating factor-acetylhydrolase (PAF-AcH) as enzymes involved in lung inflammation has recently been suggested. The objective of this study was to elucidate the role and the time dependence of PLA(2) and PAF-AcH fluctuations in the lung relative to the evolution of intestinal ischemia-reperfusion (IIR). MATERIALS AND METHODS Rats were randomly allocated to five groups of IIR induced by occlusion of the superior mesenteric artery for 45 min followed by 1 min, 2, 4, and 8 h of reperfusion (expGroups) and five corresponding sham groups (sGroups). Bronchoalveolar lavage fluid was obtained from the right lung and its biochemical (protein, PLA(2), PAF-AcH) and cytological characteristics were determined. Plasma malonyldialdehyde was measured as a marker of lipid peroxidation. The 4 and 8 h reperfusion expGroups had significantly (P < 0.05) elevated alveolar-arterial O(2) gradient values compared with the corresponding controls. Total protein, PLA(2) and PAF-AcH levels significantly (P < 0.05) increased in expGroups compared with the corresponding shams after 4 h of reperfusion. Total bronchoalveolar lavage fluid cells and plasma malonyldialdehyde were significantly (P < 0.05) elevated in expGroups compared with the sGroups after 2 h of reperfusion. CONCLUSIONS PLA(2) could act synergistically or parallel with the reactive oxygen species produced during IIR, resulting in the induction or even in the exacerbation of the inflammatory reaction in acute respiratory distress syndrome. PAF-AcH could play an anti-inflammatory role by reducing the concentration of PAF.
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Affiliation(s)
- Georgia Kostopanagiotou
- 2nd Department of Anesthesiology, Medical School, University of Athens, Attikon Hospital, Chaidari, Greece
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Rega FR, Evrard V, Bollen H, Peeters G, Vercaemst L, Meuris B, Herijgers P, Sergeant P, Hermans G, Vlasselaers D, Meyns B. pH 48 h after onset of extracorporeal membrane oxygenation is an independent predictor of survival in patients with respiratory failure. Artif Organs 2007; 31:384-9. [PMID: 17470208 DOI: 10.1111/j.1525-1594.2007.00396.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving procedure in patients with severe respiratory failure, unresponsive to conventional therapy. We reviewed our series of 70 ECMO runs (April 1997 to December 2005) in patients with respiratory distress, refractory to standard ventilation. Survival at 90 days was 42.7%. Besides age, we found no statistical significant difference in patient demographics or preoperative patient data between survivors and nonsurvivors. Univariate analyses indicated that pH values at 24 and 48 h after onset of ECMO were significantly higher in survivors. In multivariate analysis, age and pH at 48 h remained independent predictors of survival. ECMO in respiratory failure saves lives. No other demographic or preoperative, patient-related parameter than age was identified as predictor of survival. Although there was no difference in pH at onset of ECMO, blood gas analysis at 48 h revealed pH as an independent predictor of survival.
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Affiliation(s)
- Filip R Rega
- Department of Cardiac Surgery, University Hospital Gasthuisberg, Leuven, Belgium
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Kahn J, Müller H, Marte W, Rehak P, Wasler A, Prenner G, Tscheliessnigg K. Establishing Extracorporeal Membrane Oxygenation in a University Clinic: Case Series. J Cardiothorac Vasc Anesth 2007; 21:384-7. [PMID: 17544891 DOI: 10.1053/j.jvca.2006.12.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2006] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Although extracorporeal membrane oxygenation (ECMO) is well established for respiratory failure in neonates, application in adults is still considered controversial. The survival of patients with acute respiratory distress syndrome and ECMO therapy is 50% to 70%. DESIGN A retrospective analysis of 10 patients, who were placed on ECMO from September 2004 to December 2005, was performed. SETTING University clinic. INTERVENTIONS Venoarterial ECMO was established in 7 patients, venovenous ECMO in 2 patients, and combined venoarterial and venovenous ECMO in 1 patient. MEASUREMENTS AND MAIN RESULTS Indications were pneumonia, acute respiratory distress syndrome, near drowning, pericardial tamponade with shock lung, right-heart failure after heart transplantation, shock lung after cardiopulmonary resuscitation, and right-heart failure in chronic thromboembolic pulmonary hypertension. Median maintenance of ECMO therapy was 56.5 hours (range, 36-240). The median Murray score was 3.3 for survivors and 4 for nonsurvivors. Overall mortality was 30%; 70% were weaned from ECMO and survived until discharge. Median pre-ECMO risk for fatal outcome according to Hemmila was 0.43 for survivors and 0.92 for nonsurvivors (p < 0.02). In 2 cases, surgical reintervention was necessary because of bleeding in one, and a side switch of the cannulae had to be performed because of femoral venous thrombosis in the other. CONCLUSIONS ECMO has been shown to be a successful therapy for acute respiratory distress syndrome when conventional strategies have failed. Pre-ECMO risk assessment may be useful in the evaluation of patients.
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Affiliation(s)
- Judith Kahn
- Department of Transplant Surgery, Division of Surgery, Medical University of Graz, Graz, Austria.
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Abstract
Acute respiratory distress syndrome and acute lung injury are well defined and readily recognised clinical disorders caused by many clinical insults to the lung or because of predispositions to lung injury. That this process is common in intensive care is well established. The mainstay of treatment for this disorder is provision of excellent supportive care since these patients are critically ill and frequently have coexisting conditions including sepsis and multiple organ failure. Refinements in ventilator and fluid management supported by data from prospective randomised trials have increased the methods available to effectively manage this disorder.
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Affiliation(s)
- Arthur P Wheeler
- Medical Intensive Care Unit, Vanderbilt University Medical Center, Nashville, TN 37232-2650, USA
| | - Gordon R Bernard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN 37232-2650, USA.
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Abstract
Mechanical ventilation, although essential in taking care of acute lung injury and widely used during surgical procedures worldwide, remains a highly debated field. Clinical trials in the last decade have shown convincingly that mechanical ventilation can result in additional mortality in patients with acute lung injury. This understanding has resulted in a resurged interest in mechanical ventilation, and especially in techniques and strategies to further improve mechanical ventilation. This article discusses physiological principles to improve the understanding of mechanical ventilation.
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Affiliation(s)
- Jack J Haitsma
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Saint Michael's Hospital, 30 Bond Street, Queen wing 4-042, Toronto, Ontario, Canada M5B 1W8.
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Luh SP, Chiang CH. Acute lung injury/acute respiratory distress syndrome (ALI/ARDS): the mechanism, present strategies and future perspectives of therapies. J Zhejiang Univ Sci B 2007; 8:60-9. [PMID: 17173364 PMCID: PMC1764923 DOI: 10.1631/jzus.2007.b0060] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Acute lung injury/acute respiratory distress syndrome (ALI/ARDS), which manifests as non-cardiogenic pulmonary edema, respiratory distress and hypoxemia, could be resulted from various processes that directly or indirectly injure the lung. Extensive investigations in experimental models and humans with ALI/ARDS have revealed many molecular mechanisms that offer therapeutic opportunities for cell or gene therapy. Herein the present strategies and future perspectives of the treatment for ALI/ARDS, include the ventilatory, pharmacological, as well as cell therapies.
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Affiliation(s)
- Shi-ping Luh
- Department of Surgery, Chung-Shan Medical University Hospital, 402 Taichung, Taiwan, China
- †E-mail:
| | - Chi-huei Chiang
- Division of Pulmonary Immunology and Infectious Diseases, Taipei Veterans General Hospital, 112 Taipei, Taiwan, China
- †E-mail:
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238
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Abstract
Acute lung injury (ALI) and its presentation with more severe hypoxemia, the ARDS, is a challenging entity for clinical investigation because, like many critical illness syndromes, it lacks an accepted diagnostic test and relies on a constellation of clinical findings for diagnosis. Despite these barriers, there have been important advances in the clinical and population epidemiology of ALI. This article will review recent studies of the incidence, diagnosis, etiologic and prognostic factors, relevant disease subsets, mortality, and long-term outcomes of ALI. A detailed understanding of the epidemiology and outcomes of ALI is essential for future research on mechanisms of both the acute presentation and long-term sequelae, for designing studies to identify genetic risk factors for developing ALI, and to develop strategies to treat or prevent the morbidity encountered by survivors.
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Affiliation(s)
- Gordon D Rubenfeld
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, 325 Ninth Ave, Seattle WA 98104, USA.
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239
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Hopper K, Haskins SC, Kass PH, Rezende ML, Aldrich J. Indications, management, and outcome of long-term positive-pressure ventilation in dogs and cats: 148 cases (1990-2001). J Am Vet Med Assoc 2007; 230:64-75. [PMID: 17199495 DOI: 10.2460/javma.230.1.64] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine outcome of positive-pressure ventilation (PPV) for 24 hours or longer and identify factors associated with successful weaning from PPV and survival to hospital discharge in dogs and cats. DESIGN Retrospective case series. ANIMALS 124 dogs and 24 cats that received PPV for 24 hours or longer. PROCEDURES Medical records were reviewed for signalment, primary diagnosis, reason for initiating PPV, measures of oxygenation and ventilation before and during PPV, ventilator settings, complications, duration of PPV, and outcome. Animals were categorized into 1 of 3 groups on the basis of the reason for PPV. RESULTS Group 1 patients received PPV for inadequate oxygenation (67 dogs and 6 cats), group 2 for inadequate ventilation (46 dogs and 16 cats), and group 3 for inadequate oxygenation and ventilation (11 dogs and 2 cats). Of the group 1 animals, 36% (26/73) were weaned from PPV and 22% (16/73) survived to hospital discharge. In group 2, 50% (31/62) were weaned from PPV and 39% (24/62) survived to hospital discharge. In group 3, 3 of 13 were weaned from PPV and 1 of 13 survived to hospital discharge. Likelihood of successful weaning and survival to hospital discharge were significantly higher for group 2 animals, and cats had a significantly lower likelihood of successful weaning from PPV, compared with dogs. Median duration of PPV was 48 hours (range, 24 to 356 hours) and was not associated with outcome. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that long-term PPV is practical and successful in dogs and cats.
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Affiliation(s)
- Kate Hopper
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, CA 95616, USA
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240
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Da J, Chen L, Hedenstierna G. Nitric oxide up-regulates the glucocorticoid receptor and blunts the inflammatory reaction in porcine endotoxin sepsis. Crit Care Med 2007; 35:26-32. [PMID: 17095945 DOI: 10.1097/01.ccm.0000250319.91575.bb] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Nitric oxide inhibits the expression of many genes involved in inflammatory diseases. Glucocorticoids inhibit similar transcription factors. We hypothesized that there may be an interaction between nitric oxide and glucocorticoids, with the potential to enhance the anti-inflammatory effect when administered simultaneously. DESIGN Prospective, randomized, controlled study. SETTING Animal research laboratory. SUBJECTS A total of 45 anesthetized and mechanically ventilated pigs. INTERVENTIONS Lung and systemic injury was induced by intravenous infusion of endotoxin (lipopolysaccharide) for 6 hrs. After 2.5 hrs, one group received 3.5 mg/kg hydrocortisone, another group inhaled nitric oxide (30 ppm), and still another group received both steroid and nitric oxide. Control groups of healthy and endotoxin-exposed piglets were also studied. MEASUREMENTS AND MAIN RESULTS Central hemodynamics and gas exchange were measured. Detection of the glucocorticoid receptor and inflammatory markers in lung, liver, and kidney tissue were made by immunohistochemistry, and morphology was studied with light microscopy. Endotoxin infusion markedly reduced glucocorticoid receptor expression in lung, liver, and kidney and up-regulated activator protein-1 and the inflammatory markers nuclear factor-kappaB and tumor necrosis factor-alpha. When administered separately, steroids and nitric oxide had modest effect on the inflammatory response. However, nitric oxide up-regulated the glucocorticoid receptor expression. Simultaneous administration of steroids and nitric oxide attenuated the inflammatory response and almost preserved or restored normal histology of both lung and systemic organs. When the glucocorticoid receptor was blocked by a receptor antagonist (mifepristone, 600 mg) and inhaled nitric oxide was subsequently administered, no increase in the expression of the glucocorticoid receptor was seen. CONCLUSION We suggest that up-regulation of glucocorticoid receptor expression by nitric oxide made steroid therapy more effective.
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Affiliation(s)
- Jiping Da
- Department of Medical Sciences, Clinical Physiology, University Hospital, Uppsala University, Sweden
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241
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Vincent JL, Zambon M. Why do patients who have acute lung injury/acute respiratory distress syndrome die from multiple organ dysfunction syndrome? Implications for management. Clin Chest Med 2007; 27:725-31; abstract x-xi. [PMID: 17085258 DOI: 10.1016/j.ccm.2006.06.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Acute respiratory distress syndrome (ARDS) affects some 10% to 15% of ICU patients and is associated with mortality rates of 40% to 50%. Although ARDS is the most severe form of acute respiratory failure, refractory hypoxia is an uncommon cause of death in these patients. The majority of patients who have ARDS die from multiple-organ dysfunction syndrome (MODS), and ARDS should, therefore, be seen as a systemic disease. Improved understanding of the systemic factors involved in the development and evolution of ARDS and MODS should facilitate the development of new therapeutic agents that will improve outcomes in these patients.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Free University of Brussels, Route de Lennik 808, Brussels, Belgium.
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242
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Abstract
Prolonged hypoxemic respiratory failure and evidence of lung organization and fibrosis are features of an ARDS subgroup that is variably identified as "late," "persistent," or "fibroproliferative" ARDS. Early reports suggested that patients with late ARDS had a high mortality unless treated with corticosteroids. A large recent study with improved methodology has demonstrated that despite improvements of pulmonary physiology, corticosteroids do not change mortality of patients who continue to meet ARDS criteria 7 to 28 days after onset of acute lung injury. Additionally, there is no compelling evidence that persistent ARDS confers a higher mortality than that of ALI/ARDS. Observational and interventional studies are needed to increase understanding of the incidence, best management, and outcomes of patients with persistent ARDS.
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Affiliation(s)
- Leonard D Hudson
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98122, USA.
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243
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Avecillas JF, Freire AX, Arroliga AC. Clinical epidemiology of acute lung injury and acute respiratory distress syndrome: incidence, diagnosis, and outcomes. Clin Chest Med 2007; 27:549-57; abstract vii. [PMID: 17085244 DOI: 10.1016/j.ccm.2006.06.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) are clinical syndromes characterized by the sudden onset of severe hypoxemia and diffuse bilateral pulmonary infiltrates in the absence of left atrial hypertension. Although advances have been made in the understanding of the etiology, pathophysiology, and epidemiology of both entities, many questions remain regarding their incidence, diagnosis, and outcomes. This article reviews the currently used definition of ARDS and ALI, different studies that have advanced the understanding of the epidemiology and outcomes of these entities, and several diagnostic issues that are important for both clinicians and researchers.
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Affiliation(s)
- Jaime F Avecillas
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Tennessee Health Science Center at Memphis, Memphis, TN 38163, USA
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244
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George I, Xydas S, Topkara VK, Ferdinando C, Barnwell EC, Gableman L, Sladen RN, Naka Y, Oz MC. Clinical indication for use and outcomes after inhaled nitric oxide therapy. Ann Thorac Surg 2006; 82:2161-9. [PMID: 17126129 DOI: 10.1016/j.athoracsur.2006.06.081] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Revised: 06/26/2006] [Accepted: 06/28/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) use is widespread, but the long-term outcomes after therapy in adult patients remain unknown. METHODS All 376 patients receiving perioperative iNO (excluding pediatric and interventional cardiology procedures) at Columbia University Medical Center were prospectively followed from 2000 to 2003. Survival data were collected from chart review. RESULTS Inhaled nitric oxide was used to treat pulmonary and right ventricular failure in patients undergoing orthotopic heart transplantation (OHT, n = 67), orthotopic lung transplantation (n = 45), cardiac surgery (n = 105), and ventricular assist device placement (n = 66), and for hypoxemia in other surgery (n = 34) and medical patients (n = 59). Average follow-up was 2.9 +/- 1.0 years. Overall mortality was lowest when iNO was used after OHT (25.4%) and orthotopic lung transplantation (37.8%), intermediately after cardiac surgery (61%), ventricular assist device (62%), and other surgery patients (75%), and highest among medical patients (90%; all p < 0.005). The cost of iNO therapy was lower in transplantation versus medical patients, with a trend toward shorter duration of use. In multivariate analysis, respiratory failure and use in non-OHT were independent predictors of mortality (both p = 0.001). A risk score greater than 1 (score = non-OHT use 1, plus right ventricular failure 1) predicted a mortality of 76.5% versus 37.2% (p < 0.001). CONCLUSIONS Use of iNO for pulmonary hypertension in patients undergoing OHT and orthotopic lung transplantation was associated with a significantly lower overall mortality rate compared with its use after cardiac surgery or for hypoxemia in medical patients. Inhaled nitric oxide does not appear to be cost effective when treating hypoxemia in medical patients with high-risk scores and irreversible disease.
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Affiliation(s)
- Isaac George
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA.
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245
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Lobo SM, Lobo FRM, Lopes-Ferreira F, Bota DP, Melot C, Vincent JL. Initial and delayed onset of acute respiratory failure: factors associated with development and outcome. Anesth Analg 2006; 103:1219-23. [PMID: 17056958 DOI: 10.1213/01.ane.0000237433.00877.5a] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
In a prospective observational study of 1038 adult admissions to a 31-bed medical/surgical intensive care unit (ICU), acute respiratory failure (ARF, defined as a Pao(2)/Fio(2) ratio <or=200 mm Hg and the need for respiratory support) occurred in 182 (58%) of the 313 admissions with an ICU stay of more than 48 h. Initial ARF (onset within 48 h of ICU admission) occurred in 133 (42%) patients, and delayed onset ARF (onset >48 h after ICU admission) in 49 (16%). On admission, the cardiovascular sequential organ failure assessment (SOFA) score was higher in initial than in delayed onset ARF (1.1 +/- 1.5 vs 0.6 +/- 1.2, P < 0.05). High admission serum C-reactive protein concentrations (OR 1.08, 95% CI 1.04-1.12, P = 0.0001) and SOFA scores (OR 1.20, 95% CI 1.08-1.33, P = 0.0007) were the factors independently associated with initial ARF, and a low Glasgow coma scale (GCS) score (OR 1.13, 95% CI 1.04-1.21, P = 0.0018) was associated with delayed onset ARF. In initial ARF, a high SOFA score (OR 1.24, 95% CI 1.12-1.38, P = 0.0001) and a low GCS score (OR 0.89, 95% CI 0.83-0.96, P = 0.0013) on admission, and in delayed onset ARF, a low GCS score at 48 h (OR 0.67, 95% CI 0.54-0.84, P = 0.0011) were independently associated with death. The mortality rate was similar for initial and delayed onset ARF.
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Affiliation(s)
- Suzana M Lobo
- Department of Intensive Care Medicine, Erasme University Hospital, Route de Lennik 808, 1070 Brussels, Belgium
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Martínez-Escobar S, Ruiz-Bailén M, Lorente-Acosta MJ, Vicente-Rull JR, Martínez-Coronel JF, Rodríguez-Cuartero A. Pleurodesis using autologous blood: a new concept in the management of persistent air leak in acute respiratory distress syndrome. J Crit Care 2006; 21:209-16. [PMID: 16769470 DOI: 10.1016/j.jcrc.2005.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2004] [Revised: 08/10/2005] [Accepted: 10/07/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Pneumothorax is present as a frequent complication in acute respiratory distress syndrome (ARDS). Persistent air leak (PAL) prolongs pneumothorax in 2% of cases of ARDS, increasing the rate of mortality by 26%. Pleurodesis using autologous blood (PAB) is an effective method in cases of oncological pulmonary surgery. The goal of this study was to compare PAB with the conventional drain and water seal in the management of PAL in patients with ARDS and pneumothorax. DESIGN The study was a case-control, prospective, nonrandomized one comparing 2 groups subjected to artificial pairing (1:1). SETTING The study took place at the Torrecardenas Hospital (Andalusian Health Service, Almería, Spain). PATIENTS Participants were 2 groups of 27 patients, all with ARDS, pneumothorax, and PAL. INTERVENTIONS One group received conventional treatment whereas the other received PAB. MAIN RESULTS The severity of the conditions of both groups is homogeneous, shown by sex; age; Murray, Marshall, and Acute Physiology and Chronic Health Evaluation II scores; and etiology of ARDS. The patients in the PAB group had a shorter stay in the ICU, shorter weaning time (WT), and lower death rate. The average differences between the groups were 11 days less WT (adjusted odds ratio [OR] = 0.1) and 9 days less on average time spent in the ICU (adjusted OR = 0.24). The death rates in the PAB group and the control group were 3.7% and 29.6%, respectively (adjusted OR = 0.6). CONCLUSIONS The use of PAB makes possible a decrease in ventilator WT and a shorter stay in the ICU, with a resulting increase in functional recuperation and decrease in patient mortality.
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247
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Rimeika D, Wiklund NP, Lindahl SGE, Wiklund CU. Regional differences in nitric oxide-mediated vasorelaxation in porcine pulmonary arteries. Acta Anaesthesiol Scand 2006; 50:947-53. [PMID: 16923089 DOI: 10.1111/j.1399-6576.2006.01060.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Several previous investigations have shown improved oxygenation when ventilator-treated patients with acute lung injury are turned prone. In a previous human study, we demonstrated higher Ca(2+)-dependent nitric oxide synthase (NOS) activity in dorsal than in ventral parts of the lung. The current investigation was designed to determine whether Ca(2+)-dependent NOS activity was different in dorsal and ventral porcine lung regions. In addition, possible differences in vascular responses to nitroprusside or secondary to acetylcholine- or bradykinin-stimulated NO production were studied in dorsal and ventral pulmonary arteries. METHODS In the study, 20 pigs were used. Lung biopsies and pulmonary arterial rings were harvested from ventral and dorsal lung regions. NOS activity was determined by citrulline assay in the presence and absence of the calcium chelator ethyleneglycol-bis(beta-aminoethylether)-N,N'-tetraacetic acid (EDTA) to discriminate between Ca(2+)-dependent and Ca(2+)-independent NOS activity. In organ baths, in submaximally contracted arterial rings, vasorelaxation induced by acetylcholine, bradykinin and nitroprusside was measured. RESULTS Ca(2+)-dependent NOS activity was higher in dorsal parts (87.2 +/- 9.1 citrulline units) than in ventral parts (62.2 +/- 10.1 citrulline units, P < 0.05) of porcine lung. There was a greater relaxation in dorsal than in ventral pulmonary arterial rings induced by both acetylcholine and bradykinin. Nitroprusside relaxed both sites equally. CONCLUSIONS Our results show that endothelial-derived NO is an important factor influencing the differences between dorsal and ventral lung regions in vasorelaxing activity in porcine pulmonary arteries. This finding provides an explanation for the improved oxygenation when patients with severe acute lung insufficiency are turned prone.
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Affiliation(s)
- D Rimeika
- Department of Anaesthesiology and Intensive Care Medicine, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden.
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248
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Manteiga Riestra E, Martínez González Ó, Frutos Vivar F. [Epidemiology of acute pulmonary injury and acute respiratory distress syndrome]. Med Intensiva 2006; 30:151-61. [PMID: 16750078 PMCID: PMC7130804 DOI: 10.1016/s0210-5691(06)74496-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | | | - F. Frutos Vivar
- Correspondencia: Dr. F. Frutos Vivar. Unidad de Cuidados Intensivos. Hospital Universitario de Getafe. Cra. de Toledo, km. 12,500. 28905 Getafe, Madrid. España.
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Sobottke R, Friese J, Ozokyay L, Muhr G, Wick M. [Polytrauma with severe lung contusion. Early use of extracorporeal membrane oxygenation]. Unfallchirurg 2006; 109:805-8. [PMID: 16924442 DOI: 10.1007/s00113-006-1117-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a technique for sustaining body oxygenation in case of respiratory failure. Since ECMO technology has undergone improvements resulting in better hemo-compatibility and reduced side effects, venovenous ECMO is a mostly accepted treatment of adult respiratory distress syndrome (ARDS). One should discuss the early initiation of ECMO therapy for post-traumatic respiratory failure. We report about a 23-year-old male and a 15-year-old female patient, who suffered polytrauma and received early treatment with ECMO because of severe lung contusion.
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Affiliation(s)
- R Sobottke
- Klinik und Poliklinik für Orthopädie der Universität zu Köln, 50924 Köln, Deutschland.
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Cepkova M, Matthay MA. Pharmacotherapy of acute lung injury and the acute respiratory distress syndrome. J Intensive Care Med 2006; 21:119-43. [PMID: 16672636 PMCID: PMC2765330 DOI: 10.1177/0885066606287045] [Citation(s) in RCA: 140] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Acute lung injury and the acute respiratory distress syndrome are common syndromes with a high mortality rate that affect both medical and surgical patients. Better understanding of the pathophysiology of acute lung injury and the acute respiratory distress syndrome and advances in supportive care and mechanical ventilation have led to improved clinical outcomes since the syndrome was first described in 1967. Although several promising pharmacological therapies, including surfactant, nitric oxide, glucocorticoids and lysofylline, have been studied in patients with acute lung injury and the acute respiratory distress syndrome, none of these pharmacological treatments reduced mortality. This article provides an overview of pharmacological therapies of acute lung injury and the acute respiratory distress syndrome tested in clinical trials and current recommendations for their use as well as a discussion of potential future pharmacological therapies including beta(2)-adrenergic agonist therapy, keratinocyte growth factor, and activated protein C.
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Affiliation(s)
- Magda Cepkova
- Cardiovascular Research Institute, University of California San Francisco, CA 94143-0130, USA.
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