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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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252
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Lalwani LK, Sharma V, Chaudhry D, Singh PK. Indications for Proning in Acute Respiratory Distress Syndrome: Expanding the Horizon! Indian J Crit Care Med 2020; 24:589-591. [PMID: 32963446 PMCID: PMC7482358 DOI: 10.5005/jp-journals-10071-23480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Previously prone positioning (PP) was described in addition to invasive mechanical ventilation and it has been known to reduced mortality and improve oxygenation in patients of ARDS. Recently novel timing of prone positioning was described with the use of high-frequency nasal cannula (HFNC) and noninvasive ventilation (NIV) in patients of acute respiratory distress syndrome (ARDS) to avoid the intubation. Here we would like to share a case of severe ARDS where prone positioning was used in a step further ahead. Case description A 38-year-old gentleman presented with the complaints of progressive breathlessness, dry cough and fever for 7 days. Patient was diagnosed as a case of H1N1 pneumonia with severe ARDS. Patient was initially managed with invasive mechanical ventilation according to ARDS-Net protocol. Despite persistent hypoxia he was put on prone positioning for consecutive 4 days. Patient was extubated after 10 days of mechanical ventilation and put on HFNC in view of persistent high oxygen requirement. At this point of time, we attempted prone positioning in addition to HFNC. Patient was comfortable on prone position and put himself in the same condition for prolonged periods. His oxygenation showed a remarkable improvement from PaO2 of 63 (before prone positioning) to 136 mm Hg (after prone positioning). Oxygen supplementation was later tapered off and subsequently, he improved and was shifted to ward. Conclusion Prone positioning is a harmless and still extremely effective intervention which can and should be utilized at all steps of ARDS-management. How to cite this article Lalwani LK, Sharma V, Chaudhry D, Singh PK. Indications for Proning in Acute Respiratory Distress Syndrome: Expanding the Horizon! Indian J Crit Care Med 2020;24(7):589-591.
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Affiliation(s)
- Lokesh K Lalwani
- Department of Pulmonary and Critical Care Medicine, Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Vinod Sharma
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Pawan K Singh
- Department of Pulmonary and Critical Care Medicine, Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
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Alhazzani W, Al-Suwaidan F, Al Aseri Z, Al Mutair A, Alghamdi G, Rabaan A, Algamdi M, Alohali A, Asiri A, Alshahrani M, Al-Subaie M, Alayed T, Bafaqih H, Alkoraisi S, Alharthi S, Alenezi F, Al Gahtani A, Amr A, Shamsan A, Al Duhailib Z, Al-Omari A. The saudi critical care society clinical practice guidelines on the management of COVID-19 patients in the intensive care unit. ACTA ACUST UNITED AC 2020. [DOI: 10.4103/sccj.sccj_15_20] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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254
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Silva PL, Pelosi P, Rocco PRM. Personalized pharmacological therapy for ARDS: a light at the end of the tunnel. Expert Opin Investig Drugs 2019; 29:49-61. [PMID: 31778609 DOI: 10.1080/13543784.2020.1699531] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Pharmacotherapy for the acute respiratory distress syndrome (ARDS) has been tested in preclinical and clinical studies. However, to date, no pharmacological interventions have proven effective. This may be attributed to lack of proper identification of different ARDS phenotypes.Areas covered: We designed inclusive search strings and searched four bibliographic databases (Cochrane Database of Systematic Reviews, PubMed, Web of Science, and clinicaltrials.gov) to identify relevant research. Search results were mainly restricted to papers published from 2009 through 2019. ARDS is a heterogeneous syndrome, and its different phenotypes - defined according to clinical, radiological, and biological parameters - may affect response to therapy. The most promising pharmacological approaches to date have been based on ARDS pathophysiology. They focus on reducing inflammation and pulmonary edema, promoting selective vasodilation, and repairing alveolar epithelial and endothelial cells.Expert opinion: Pharmacotherapeutic approaches targeting ARDS pathophysiology have failed to exert beneficial effects. Personalized medicine targeting the different ARDS phenotypes has emerged as an option to improve survival. Identification of specific ARDS patient phenotypes that respond to specific therapies seems to be the most important challenge for the next decade. Additional research is warranted before personalized medicine approaches can be applied at bedside for ARDS patients.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Rio de Janeiro, Brazil
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255
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Abstract
The acute respiratory distress syndrome (ARDS) remains a common and highly morbid condition despite advances in the understanding and management of this complex critical illness. Recent work has illuminated the heterogeneity within ARDS and demonstrated the likely impact of heterogeneity on the identification of effective therapeutic interventions. Despite these challenges, new data have also informed the standard of care for ARDS and have resulted in the re-evaluation of previously established therapies, including ventilation strategies, pharmacologic interventions, and rescue therapies. As the field of ARDS continues to evolve, innovative approaches will be needed to further define phenotypes within ARDS and design targeted clinical trials.
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Affiliation(s)
- Tyler J Peck
- Division of Pulmonary and Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Kathryn A Hibbert
- Division of Pulmonary and Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
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256
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Boehm O, Rohner M, Ehrentraut H, Guenther U, Meyer R, Knuefermann P, Baumgarten G, Duerr GD, Velten M. Low-tidal-volume prevent ventilation induced inflammation in a mouse model of sepsis. Life Sci 2019; 240:117081. [PMID: 31756342 DOI: 10.1016/j.lfs.2019.117081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/12/2019] [Accepted: 11/14/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND GOAL OF THE STUDY Pulmonary inflammation, increased vascular permeability, and pulmonary edema, occur in response to primary pulmonary infections like pneumonia but are also evident in endotoxemia or sepsis. Mechanical ventilation augments pre-existing lung injury and inflammation resulting from exposure to microbial products. The objective of this study was to test the hypothesis that low-tidal-volume prevent ventilation induced lung injury in sepsis. MATERIALS AND METHODS 10-12-week-old male C57BL/6N-mice received an intraperitoneal (i.p.) injection with equipotent dosages of LPS, 1668-thioate, 1612-thioate, or PBS. 120 min after injection, mice were randomized to low- (LV, 7 ± 1 ml/kg) or high-tidal-volume (HV, 25 ± 1 ml/kg) ventilation. Hemodynamic and ventilatory parameters were recorded and inflammatory markers were analyzed form BAL that was generated after 90 minute ventilation. RESULTS AND DISCUSSION Arterial blood pressures declined during mechanical ventilation in all groups. pO2 decreased in LPS injected and CO2 increased in sham, LPS, and 1612-thioate administered mice at 45 min and in 1668-thioate injected mice after 90 minute LV ventilation compared to respective HV groups. BAL protein concentrations increased in HV ventilated and 1668- or 1612-thioat pre-treated mice. BAL TNF-α protein concentrations increased in both LPS- and 1668-thioate-injected and IL-1β protein concentrations only in LPS-injected and HV ventilated mice. Most notably, no increased protein concentrations were observed in any of the LV ventilated groups. CONCLUSION We conclude that low-tidal-volume ventilation may be a potential strategy for the prevention of ventilator induced lung injury in a murine model of systemic TLR agonist induced lung injury.
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Affiliation(s)
- Olaf Boehm
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University Medical Center, Bonn, Germany
| | - Marc Rohner
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University Medical Center, Bonn, Germany
| | - Heidi Ehrentraut
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University Medical Center, Bonn, Germany
| | - Ulf Guenther
- Department of Anesthesiology, Critical Care, Emergency Medicine and Pain Therapy, Klinikum Oldenburg, Medical Campus University of Oldenburg, Germany
| | - Rainer Meyer
- Institute of Physiology, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | | | | | - Georg Daniel Duerr
- Department of Cardiac Surgery, Rheinische Friedrich-Wilhelms-University Medical Center, Bonn, Germany
| | - Markus Velten
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University Medical Center, Bonn, Germany.
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257
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Bhakta P, Karim HMR, O'Brien B, Esquinas A. Letter to the editor: Aeration changes induced by high flow nasal cannula are more homogeneous than those generated by non-invasive ventilation in healthy subjects. J Crit Care 2019; 57:275-276. [PMID: 31757577 DOI: 10.1016/j.jcrc.2019.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/17/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Pradipta Bhakta
- Department of Anaesthesia and Intensive Care, Temple Street Children's University Hospital, Dublin, Ireland.
| | - Habib Md Reazaul Karim
- Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, Raipur, India
| | - Brian O'Brien
- Department of Anaesthesia and Intensive Care, Cork University Hospital, Cork, Ireland
| | - Antonio Esquinas
- Department of Cardiac Anesthesia and Intensive Care, Intensive Care Unit; Hospital Morales Meseguer, Murcia, Spain
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258
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Abraham A, Krasnodembskaya A. Mesenchymal stem cell-derived extracellular vesicles for the treatment of acute respiratory distress syndrome. Stem Cells Transl Med 2019; 9:28-38. [PMID: 31647191 PMCID: PMC6954712 DOI: 10.1002/sctm.19-0205] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/26/2019] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a serious and potentially fatal acute inflammatory lung condition which currently has no specific treatments targeting its pathophysiology. However, mesenchymal stem cells have been shown to have very promising therapeutic potential, and recently, it has been established that their effect is largely due to the transfer of extracellular vesicles (EVs). EVs have been shown to transfer a variety of substances such as mRNA, miRNA, and even organelles such as mitochondria in order to ameliorate ARDS in preclinical models. In addition, the fact that they have been proven to have the same effect as their parent cells combined with their numerous advantages over whole cell administration means that they are a promising candidate for clinical application that merits further research.
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Affiliation(s)
- Aswin Abraham
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University of Belfast, Belfast, United Kingdom
| | - Anna Krasnodembskaya
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University of Belfast, Belfast, United Kingdom
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259
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Griffiths M, Fan E, Baudouin SV. New UK guidelines for the management of adult patients with ARDS. Thorax 2019; 74:931-933. [PMID: 31481634 DOI: 10.1136/thoraxjnl-2018-212885] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Mark Griffiths
- Barts Heart Centre, St Bartholomews Hospital, London, UK .,NHLI, Imperial College London, London, UK
| | - Eddy Fan
- Toronto General Hospital, Toronto, Ontario, Canada
| | - Simon V Baudouin
- Department of Medicine, Newcastle University, Newcastle upon Tyne, UK
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260
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Abstract
BACKGROUND Acute hypoxaemia de novo or on a background of chronic hypoxaemia is a common reason for admission to intensive care and for provision of mechanical ventilation. Various refinements of mechanical ventilation or adjuncts are employed to improve patient outcomes. Mortality from acute respiratory distress syndrome, one of the main contributors to the need for mechanical ventilation for hypoxaemia, remains approximately 40%. Ventilation in the prone position may improve lung mechanics and gas exchange and could improve outcomes. OBJECTIVES The objectives of this review are (1) to ascertain whether prone ventilation offers a mortality advantage when compared with traditional supine or semi recumbent ventilation in patients with severe acute respiratory failure requiring conventional invasive artificial ventilation, and (2) to supplement previous systematic reviews on prone ventilation for hypoxaemic respiratory failure in an adult population. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 1), Ovid MEDLINE (1950 to 31 January 2014), EMBASE (1980 to 31 January 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 31 January 2014) and Latin American Caribbean Health Sciences Literature (LILACS) (1992 to 31 January 2014) in Ovid MEDLINE for eligible randomized controlled trials. We also searched for studies by handsearching reference lists of relevant articles, by contacting colleagues and by handsearching published proceedings of relevant journals. We applied no language constraints, and we reran the searches in CENTRAL, MEDLINE, EMBASE, CINAHL and LILACS in June 2015. We added five new studies of potential interest to the list of "Studies awaiting classification" and will incorporate them into formal review findings during the review update. SELECTION CRITERIA We included randomized controlled trials (RCTs) that examined the effects of prone position versus supine/semi recumbent position during conventional mechanical ventilation in adult participants with acute hypoxaemia. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed all trials identified by the search and assessed them for suitability, methods and quality. Two review authors extracted data, and three review authors reviewed the data extracted. We analysed data using Review Manager software and pooled included studies to determine the risk ratio (RR) for mortality and the risk ratio or mean difference (MD) for secondary outcomes; we also performed subgroup analyses and sensitivity analyses. MAIN RESULTS We identified nine relevant RCTs, which enrolled a total of 2165 participants (10 publications). All recruited participants suffered from disorders of lung function causing moderate to severe hypoxaemia and requiring mechanical ventilation, so they were fairly comparable, given the heterogeneity of specific disease diagnoses in intensive care. Risk of bias, although acceptable in the view of the review authors, was inevitable: Blinding of participants and carers to treatment allocation was not possible (face-up vs face-down).Primary analyses of short- and longer-term mortality pooled from six trials demonstrated an RR of 0.84 to 0.86 in favour of the prone position (PP), but findings were not statistically significant: In the short term, mortality for those ventilated prone was 33.4% (363/1086) and supine 38.3% (395/1031). This resulted in an RR of 0.84 (95% confidence interval (CI) 0.69 to 1.02) marginally in favour of PP. For longer-term mortality, results showed 41.7% (462/1107) for prone and 47.1% (490/1041) for supine positions, with an RR of 0.86 (95% CI 0.72 to 1.03). The quality of the evidence for both outcomes was rated as low as a result of important potential bias and serious inconsistency.Subgroup analyses for mortality identified three groups consistently favouring PP: those recruited within 48 hours of meeting entry criteria (five trials; 1024 participants showed an RR of 0.75 (95% CI 0.59 to 94)); those treated in the PP for 16 or more hours per day (five trials; 1005 participants showed an RR of 0.77 (95% CI 0.61 to 0.99)); and participants with more severe hypoxaemia at trial entry (six trials; 1108 participants showed an RR of 0.77 (95% CI 0.65 to 0.92)). The quality of the evidence for these outcomes was rated as moderate as a result of potentially important bias.Prone positioning appeared to influence adverse effects: Pressure sores (three trials; 366 participants) with an RR of 1.37 (95% CI 1.05 to 1.79) and tracheal tube obstruction with an RR of 1.78 (95% CI 1.22 to 2.60) were increased with prone ventilation. Reporting of arrhythmias was reduced with PP, with an RR of 0.64 (95% CI 0.47 to 0.87). AUTHORS' CONCLUSIONS We found no convincing evidence of benefit nor harm from universal application of PP in adults with hypoxaemia mechanically ventilated in intensive care units (ICUs). Three subgroups (early implementation of PP, prolonged adoption of PP and severe hypoxaemia at study entry) suggested that prone positioning may confer a statistically significant mortality advantage. Additional adequately powered studies would be required to confirm or refute these possibilities of subgroup benefit but are unlikely, given results of the most recent study and recommendations derived from several published subgroup analyses. Meta-analysis of individual patient data could be useful for further data exploration in this regard. Complications such as tracheal obstruction are increased with use of prone ventilation. Long-term mortality data (12 months and beyond), as well as functional, neuro-psychological and quality of life data, are required if future studies are to better inform the role of PP in the management of hypoxaemic respiratory failure in the ICU.
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Affiliation(s)
- Roxanna Bloomfield
- Intensive Care Unit and Department of Anaesthesia, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZN
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