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Martin TR, Zemans RL, Ware LB, Schmidt EP, Riches DWH, Bastarache L, Calfee CS, Desai TJ, Herold S, Hough CL, Looney MR, Matthay MA, Meyer N, Parikh SM, Stevens T, Thompson BT. New Insights into Clinical and Mechanistic Heterogeneity of the Acute Respiratory Distress Syndrome: Summary of the Aspen Lung Conference 2021. Am J Respir Cell Mol Biol 2022; 67:284-308. [PMID: 35679511 PMCID: PMC9447141 DOI: 10.1165/rcmb.2022-0089ws] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/09/2022] [Indexed: 12/15/2022] Open
Abstract
Clinical and molecular heterogeneity are common features of human disease. Understanding the basis for heterogeneity has led to major advances in therapy for many cancers and pulmonary diseases such as cystic fibrosis and asthma. Although heterogeneity of risk factors, disease severity, and outcomes in survivors are common features of the acute respiratory distress syndrome (ARDS), many challenges exist in understanding the clinical and molecular basis for disease heterogeneity and using heterogeneity to tailor therapy for individual patients. This report summarizes the proceedings of the 2021 Aspen Lung Conference, which was organized to review key issues related to understanding clinical and molecular heterogeneity in ARDS. The goals were to review new information about ARDS phenotypes, to explore multicellular and multisystem mechanisms responsible for heterogeneity, and to review how best to account for clinical and molecular heterogeneity in clinical trial design and assessment of outcomes. The report concludes with recommendations for future research to understand the clinical and basic mechanisms underlying heterogeneity in ARDS to advance the development of new treatments for this life-threatening critical illness.
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Affiliation(s)
- Thomas R. Martin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Rachel L. Zemans
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Program in Cellular and Molecular Biology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine and
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eric P. Schmidt
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - David W. H. Riches
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Program in Cell Biology, Department of Pediatrics, National Jewish Health, Denver, Colorado
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carolyn S. Calfee
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Anesthesia
| | - Tushar J. Desai
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Stem Cell Institute, Stanford University School of Medicine, Stanford, California
| | - Susanne Herold
- Department of Internal Medicine VI and Cardio-Pulmonary Institute (CPI), Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Catherine L. Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Michael A. Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | - Nuala Meyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samir M. Parikh
- Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Division of Nephrology, University of Texas Southwestern, Dallas, Texas
| | - Troy Stevens
- Department of Physiology and Cell Biology, College of Medicine, Center for Lung Biology, University of South Alabama, Mobile, Alabama; and
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Rebetz J, Semple JW, Kapur R. The Pathogenic Involvement of Neutrophils in Acute Respiratory Distress Syndrome and Transfusion-Related Acute Lung Injury. Transfus Med Hemother 2018; 45:290-298. [PMID: 30498407 PMCID: PMC6257140 DOI: 10.1159/000492950] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 08/16/2018] [Indexed: 12/19/2022] Open
Abstract
The acute respiratory distress syndrome (ARDS) is a serious and common complication of multiple medical and surgical interventions, with sepsis, pneumonia, and aspiration of gastric contents being common risk factors. ARDS develops within 1 week of a known clinical insult or presents with new/worsening respiratory symptoms if the clinical insult is unknown. Approximately 40% of the ARDS cases have a fatal outcome. Transfusion-related acute lung injury (TRALI), on the other hand, is characterized by the occurrence of respiratory distress and acute lung injury, which presents within 6 h after administration of a blood transfusion. In contrast to ARDS, acute lung injury in TRALI is not attributable to another risk factor for acute lung injury. 'Possible TRALI', however, may have a clear temporal relationship to an alternative risk factor for acute lung injury. Risk factors for TRALI include chronic alcohol abuse and systemic inflammation. TRALI is the leading cause of transfusion-related fatalities. There are no specific therapies available for ARDS or TRALI as both have a complex and incompletely understood pathogenesis. Neutrophils (polymorphonuclear leukocytes; PMNs) have been suggested to be key effector cells in the pathogenesis of both syndromes. In the present paper, we summarize the literature with regard to PMN involvement in the pathogenesis of both ARDS and TRALI based on both human data as well as on animal models. The evidence generally supports a strong role for PMNs in both ARDS and TRALI. More research is required to shed light on the pathogenesis of these respiratory syndromes and to more thoroughly establish the nature of the PMN involvement, especially considering the heterogeneous etiologies of ARDS.
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Affiliation(s)
| | - John W. Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
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Ando M, Miyazaki E, Abe T, Ehara C, Goto A, Masuda T, Nishio S, Fujisaki H, Yamasue M, Ishii T, Mukai Y, Ito T, Nureki SI, Kumamoto T, Kadota J. Angiopoietin-2 expression in patients with an acute exacerbation of idiopathic interstitial pneumonias. Respir Med 2016; 117:27-32. [PMID: 27492510 DOI: 10.1016/j.rmed.2016.05.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/10/2016] [Accepted: 05/12/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVE We hypothesized that increased pulmonary vascular permeability may play a role in the pathogenesis of an acute exacerbation of the idiopathic interstitial pneumonias (AE-IIPs). Angiopoietin-2 (Ang-2) promotes endothelial activation, destabilization, and inflammation. The purpose of this study was to examine whether Ang-2 expression was associated with the pathogenesis of AE-IIPs. METHODS Twenty-three patients with AE-IIP patients, 18 acute lung injury/acute respiratory distress syndrome (ALI/ARDS) patients, 37 idiopathic pulmonary fibrosis (IPF) patients, and 33 healthy volunteers (HVs) were enrolled. The serum level of Ang-2 was measured by an enzyme-linked immunosorbent assay. RESULTS The serum levels of Ang-2 were higher in AE-IIPs and ALI/ARDS patients than in IPF patients and HVs; the BALF levels of Ang-2 were also higher than in IPF patients. There was a positive correlation between the serum level of Ang-2 and the CRP in patients with AE-IIP patients, whereas a significant positive correlation was found between the serum Ang-2 level and the CRP or SOFA scores of the ALI/ARDS patients. Although the baseline Ang-2 level was not related to survival, the Ang-2 levels significantly declined in survivors during treatment, while they did not change in non-survivors. CONCLUSIONS Increased pulmonary vascular permeability and inflammation due to Ang-2 may play a role in the pathogenesis of AE-IIPs.
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Affiliation(s)
- Masaru Ando
- Department of Respiratory Medicine, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan.
| | - Eishi Miyazaki
- Center for Community Medicine, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan
| | - Tetsutaro Abe
- Internal Medicine 3, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan
| | - Chihiro Ehara
- Department of Respiratory Medicine, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan
| | - Akihiro Goto
- Department of Respiratory Medicine, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan
| | - Taiki Masuda
- Department of Respiratory Medicine, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan
| | - Suehiro Nishio
- Department of Respiratory Medicine, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan
| | - Hideaki Fujisaki
- Department of Respiratory Medicine, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan
| | - Mari Yamasue
- Department of Respiratory Medicine, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan
| | - Toshihiro Ishii
- Center for Community Medicine, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan
| | - Yutaka Mukai
- Department of Respiratory Medicine, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan
| | - Takeo Ito
- Department of Respiratory Medicine, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan
| | - Shin-Ich Nureki
- Department of Respiratory Medicine, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan
| | - Toshihide Kumamoto
- Internal Medicine 3, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan
| | - Junichi Kadota
- Department of Respiratory Medicine, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593, Japan
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Paola RD, Cuzzocrea S. Peroxisome proliferator-activated receptors and acute lung injury. PPAR Res 2011; 2007:63745. [PMID: 17710233 PMCID: PMC1940050 DOI: 10.1155/2007/63745] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Revised: 02/08/2007] [Accepted: 05/02/2007] [Indexed: 01/11/2023] Open
Abstract
Peroxisome proliferator-activated receptors are ligand-activated transcription factors belonging to the nuclear hormone receptor superfamily. PPARs regulate several metabolic pathways by binding to sequence-specific PPAR response elements in the promoter region of target genes, including lipid biosynthesis and glucose metabolism. Recently, PPARs and their respective ligands have been implicated as regulators of cellular inflammatory and immune responses. These molecules are thought to exert anti-inflammatory effects by negatively regulating the expression of proinflammatory genes. Several studies have demonstrated that PPAR ligands possess anti-inflammatory properties and that these properties may prove helpful in the treatment of inflammatory diseases of the lung. This review will outline the anti-inflammatory effects of PPARs and PPAR ligands and discuss their potential therapeutic effects in animal models of inflammatory lung disease.
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Affiliation(s)
- Rosanna Di Paola
- Department of Clinical, Experimental Medicine and Pharmacology, School of Medicine, University of Messina, Via C. Valeria,
Torre Biologica, Policlinico Universitario, 98123 Messina, Italy
- Institute of Pharmacology, School of Medicine, University of Messina, Via C. Valeria, Torre Biologica, Policlinico Universitario,
98123 Messina, Italy
| | - Salvatore Cuzzocrea
- Department of Clinical, Experimental Medicine and Pharmacology, School of Medicine, University of Messina, Via C. Valeria,
Torre Biologica, Policlinico Universitario, 98123 Messina, Italy
- Institute of Pharmacology, School of Medicine, University of Messina, Via C. Valeria, Torre Biologica, Policlinico Universitario,
98123 Messina, Italy
- *Salvatore Cuzzocrea:
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Grommes J, Soehnlein O. Contribution of neutrophils to acute lung injury. Mol Med 2010; 17:293-307. [PMID: 21046059 DOI: 10.2119/molmed.2010.00138] [Citation(s) in RCA: 961] [Impact Index Per Article: 68.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Accepted: 10/18/2010] [Indexed: 12/27/2022] Open
Abstract
Treatment of acute lung injury (ALI) and its most severe form, acute respiratory distress syndrome (ARDS), remain unsolved problems of intensive care medicine. ALI/ARDS are characterized by lung edema due to increased permeability of the alveolar-capillary barrier and subsequent impairment of arterial oxygenation. Lung edema, endothelial and epithelial injury are accompanied by an influx of neutrophils into the interstitium and broncheoalveolar space. Hence, activation and recruitment of neutrophils are regarded to play a key role in progression of ALI/ARDS. Neutrophils are the first cells to be recruited to the site of inflammation and have a potent antimicrobial armour that includes oxidants, proteinases and cationic peptides. Under pathological circumstances, however, unregulated release of these microbicidal compounds into the extracellular space paradoxically can damage host tissues. This review focuses on the mechanisms of neutrophil recruitment into the lung and on the contribution of neutrophils to tissue damage in ALI.
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Affiliation(s)
- Jochen Grommes
- Department of Vascular Surgery, University Hospital, RWTH Aachen, Germany.
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von Wulffen W, Steinmueller M, Herold S, Marsh LM, Bulau P, Seeger W, Welte T, Lohmeyer J, Maus UA. Lung dendritic cells elicited by Fms-like tyrosine 3-kinase ligand amplify the lung inflammatory response to lipopolysaccharide. Am J Respir Crit Care Med 2007; 176:892-901. [PMID: 17690334 DOI: 10.1164/rccm.200608-1068oc] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Strategically located beneath the alveolar epithelial barrier, dendritic cells (DCs) of the lung are centrally involved in the sampling and processing of inhaled antigens. However, the contribution of DCs to acute lung inflammation induced by inhaled bacterial toxins is largely unknown. OBJECTIVES To determine the effect of increased lung DC numbers elicited by Fms-like tyrosine kinase-3 ligand (Flt3L) on the acute lung inflammatory response to Escherichia coli lipopolysaccharide (LPS) and Klebsiella pneumoniae infection. METHODS Mice were pretreated with Flt3L either in the absence or presence of anti-CD11a antibodies to block the Flt3L-elicited lung DC accumulation or were made transiently neutropenic and then challenged with E. coli LPS or K. pneumoniae. MEASUREMENTS AND MAIN RESULTS Flt3L-pretreated mice challenged with LPS responded with drastically increased numbers of both lung parenchymal and alveolar DCs together with an aggravated neutrophilic alveolitis, elevated tumor necrosis factor-alpha and IL-12 levels, and a strongly increased lung permeability compared with LPS- or Flt3L-only-treated mice. Anti-CD11a-mediated blockade of lung DC accumulation significantly attenuated the lung permeability developing in response to LPS, whereas transient neutropenia did not affect lung permeability changes. Finally, Flt3L-pretreated mice responded with increased lung permeability and decreased survival upon infection with K. pneumoniae. CONCLUSIONS Lung DCs actively participate in the early inflammatory response to both inhaled bacterial toxins and live bacteria and play a yet unrecognized role in regulating lung barrier integrity.
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Affiliation(s)
- Werner von Wulffen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Giessen Lung Center, Giessen, Germany
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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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Abstract
Pediatric acute respiratory distress syndrome (ARDS) is a severe lung injury caused by pneumonia, sepsis, and trauma. ARDS results from inflammation and pulmonary capillary leak causing major changes in lung architecture and function. It has a low incidence, but its severity and duration cause major morbidity, mortality, and use of resources. Any organism can cause ARDS. Susceptible populations develop the syndrome more often and have worse outcomes. Aggressive diagnosis and intensive treatment are essential to good outcomes in ARDS caused by infection. The prognosis for survival is good, but morbidity after the syndrome is a major burden.
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Flori HR, Glidden DV, Rutherford GW, Matthay MA. Pediatric acute lung injury: prospective evaluation of risk factors associated with mortality. Am J Respir Crit Care Med 2004; 171:995-1001. [PMID: 15618461 DOI: 10.1164/rccm.200404-544oc] [Citation(s) in RCA: 274] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The 1994 American European Consensus Committee definitions of acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) have not been applied systematically in the pediatric population. OBJECTIVES The purpose of this study was to evaluate prospectively the epidemiology and clinical risk factors associated with death and prolonged mechanical ventilation in all pediatric patients admitted to two large, pediatric intensive care units with ALI/ARDS using Consensus criteria. METHODS All pediatric patients meeting Consensus Committee definitions for ALI were prospectively identified and included in a relational database. MEASUREMENTS AND MAIN RESULTS There were 328 admissions for ALI/ARDS with a mortality of 22%. Multivariate logistic regression analyses revealed (1) the initial severity of oxygenation defect, as measured by the Pa(O2)/FI(O2) ratio; (2) the presence of nonpulmonary and non-central nervous system (CNS) organ dysfunction; and (3) the presence of CNS dysfunction were independently associated with mortality and prolonged mechanical ventilation. A substantial fraction of patients (28%) did not require mechanical ventilation at the onset of ALI; 46% of these patients eventually required intubation for worsening ALI. CONCLUSIONS Mortality in pediatric ALI/ARDS is high and several risk factors have major prognostic value. In contrast to ALI/ARDS in adults, the initial severity of arterial hypoxemia in children correlates well with mortality. A significant fraction of patients with pediatric ALI/ARDS can be identified before endotracheal intubation is required. These patients provide a valuable group in whom new therapies can be tested.
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Affiliation(s)
- Heidi R Flori
- Department of Critical Care, Children's Hospital and Research Center at Oakland, PICU Offices, 747 52nd Street, Oakland, CA 94609, USA.
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Bandi VD, Munnur U, Matthay MA. Acute lung injury and acute respiratory distress syndrome in pregnancy. Crit Care Clin 2004; 20:577-607. [PMID: 15388190 DOI: 10.1016/j.ccc.2004.05.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Acute respiratory failure can be the result of a variety of clinical conditions, such as congestive heart failure, pneumonia, pulmonary embolism, exacerbation of obstructive lung diseases, and acute respiratory distress syndrome (ARDS). This article focuses on developments related to acute lung injury and ARDS and reviews epidemiology, pathogenesis and therapeutic advances with an emphasis on the obstetric population. A brief discussion of tocolytic-induced pulmonary edema, preeclampsia, venous air embolism, and aspiration-related ARDS is included. Management of pregnant women with ARDS is outlined.
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Affiliation(s)
- Venkata D Bandi
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
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11
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Flori HR, Ware LB, Glidden D, Matthay MA. Early elevation of plasma soluble intercellular adhesion molecule-1 in pediatric acute lung injury identifies patients at increased risk of death and prolonged mechanical ventilation. Pediatr Crit Care Med 2003; 4:315-21. [PMID: 12831413 DOI: 10.1097/01.pcc.0000074583.27727.8e] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine whether soluble intercellular adhesion molecule (sICAM)-1, a biological marker of alveolar epithelial and lung endothelial injury and alveolar macrophage activation, is elevated in the plasma of pediatric patients with acute lung injury and to examine whether elevated plasma sICAM-1 levels correlate with two clinically relevant outcomes, mortality and the duration of mechanical ventilation. DESIGN Prospective cohort study. SETTING Pediatric intensive care units at an urban children's hospital and a tertiary university medical center. PATIENTS Eighty-three pediatric patients with acute lung injury and five intubated controls. INTERVENTIONS Plasma sICAM-1 levels were measured on days 1 and 2 of acute lung injury in pediatric patients and on day 1 of mechanical ventilation in control patients. MEASUREMENTS AND MAIN RESULTS Plasma sICAM-1 levels were significantly higher in patients with acute lung injury compared with controls (966 +/- 830 vs. 251 +/- 168 ng/mL, p <.05). Levels of sICAM-1 were also significantly higher on days 1 and 2 of acute lung injury in nonsurvivors and in patients requiring prolonged duration of mechanical ventilation. Also, plasma sICAM-1 levels >1000 ng/mL had a high specificity for identifying nonsurvivors of acute lung injury. CONCLUSIONS Early elevation of sICAM-1 in the plasma of pediatric patients with acute lung injury is associated with increased risk of death or prolonged duration of mechanical ventilation.
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Affiliation(s)
- Heidi R Flori
- Department of Pediatric Critical Care, Children's Hospital and Research Center, Oakland, Oakland, CA 94609, USA.
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Wang E, Simard M, Ouellet N, Bergeron Y, Beauchamp D, Bergeron MG. Pathogenesis of pneumococcal pneumonia in cyclophosphamide-induced leukopenia in mice. Infect Immun 2002; 70:4226-38. [PMID: 12117931 PMCID: PMC128150 DOI: 10.1128/iai.70.8.4226-4238.2002] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Streptococcus pneumoniae pneumonia frequently occurs in leukopenic hosts, and most patients subsequently develop lung injury and septicemia. However, few correlations have been made so far between microbial growth, inflammation, and histopathology of pneumonia in specific leukopenic states. In the present study, the pathogenesis of pneumococcal pneumonia was investigated in mice rendered leukopenic by the immunosuppressor antineoplastic drug cyclophosphamide. Compared to the immunocompetent state, cyclophosphamide-induced leukopenia did not hamper interleukin-1 (IL-1), IL-6, macrophage inflammatory protein-1 (MIP-1), MIP-2, and monocyte chemotactic protein-1 secretion in infected lungs. Leukopenia did not facilitate bacterial dissemination into the bloodstream despite enhanced bacterial proliferation into lung tissues. Pulmonary capillary permeability and edema as well as lung injury were enhanced in leukopenic mice despite the absence of neutrophilic and monocytic infiltration into their lungs, suggesting an important role for bacterial virulence factors and making obvious the fact that neutrophils are ultimately not required for lung injury in this model. Scanning and transmission electron microscopy revealed extensive disruption of alveolar epithelium and a defect in surfactant production, which were associated with alveolar collapse, hemorrhage, and fibrin deposits in alveoli. These results contrast with those observed in immunocompetent animals and indicate that leukopenic hosts suffering from pneumococcal pneumonia are at a higher risk of developing diffuse alveolar damage.
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Affiliation(s)
- Erjian Wang
- Infectious Diseases Research Center, Laval University, Quebec City, Canada G1V 4G2
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Wang E, Ouellet N, Simard M, Fillion I, Bergeron Y, Beauchamp D, Bergeron MG. Pulmonary and systemic host response to Streptococcus pneumoniae and Klebsiella pneumoniae bacteremia in normal and immunosuppressed mice. Infect Immun 2001; 69:5294-304. [PMID: 11500398 PMCID: PMC98638 DOI: 10.1128/iai.69.9.5294-5304.2001] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Mortality related to bacteremic pneumonia remains high, and the role of sepsis in inflammation, pulmonary injury, and death remains unclear, mostly in leukopenic states. In the present study, the microbiology, histopathology, and host response to Streptococcus pneumoniae and Klebsiella pneumoniae infection were determined in an experimental model of bacteremia in immunocompetent and leukopenic mice. Leukocyte depletion by cyclophosphamide did not impair the early clearance of pneumococci from blood but facilitated growth in lungs. By contrast, klebsiellae rapidly grew in blood of leukopenic mice. These observations suggest that tissue-based phagocytes and circulating leukocytes, respectively, play prominent roles in S. pneumoniae and K. pneumoniae eradication. The kinetics of leukocyte recruitment in lungs during S. pneumoniae bacteremia suggested early strong inflammation in immunocompetent mice that is associated with tumor necrosis factor alpha release and histological disorders, including cell debris and surfactant in alveolar spaces. Leukocyte depletion further stimulated pulmonary capillary leakage both in S. pneumoniae and K. pneumoniae bacteremia, which seemed attributable to bacterial virulence factors. Nitric oxide production did not differ significantly among groups. Leukopenia and low platelet counts characterized the late stage of bacteremia for both strains, but only K. pneumoniae altered renal function. Understanding the pathogenesis of bacteremia will help establish beneficial therapies for both sepsis and pneumonia.
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Affiliation(s)
- E Wang
- Centre de Recherche en Infectiologie, Université Laval, Québec, Québec, Canada
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14
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Abstract
The clinical course of acute lung injury (ALI) is a complex and variable process accompanied by severe lung dysfunction, which persists for a long period of time with variable recovery of pulmonary function. The extent and severity of the lung disease associated with ALI varies with those patients having the most severe manifestations of lung disease being grouped as acute respiratory distress syndrome (ARDS). The pathological injury associated with this disease process, termed diffuse alveolar damage (DAD), has three overlapping phases (exudative, proliferative and fibrotic) which are the consequences of severe injury to the alveolar-capillary unit. There is no uniformity to the progression and length of each stage. This review explores those cellular mechanisms and derangements involved in the progression of ARDS. Those areas that demonstrate the major advances within the field are highlighted because of the diverse and vast nature of the cellular components involved in the process of ALI. We are beginning to identify those processes that contribute to the cellular derangements which are the hallmark of ALI. By expanding our understanding of those factors, we should in the future be able to construct therapeutic interventions that address the aetiology of ALI.
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Affiliation(s)
- M A Schwarz
- Pediatrics, Children's Hospital Los Angeles, 4650 Sunset Boulevard, MS # 66, Los Angeles, CA 90027, USA
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15
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Derelle J. [Pulmonary complications in immunosuppressed children]. Arch Pediatr 2000; 7 Suppl 1:77S-81S. [PMID: 10793954 DOI: 10.1016/s0929-693x(00)88825-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Pulmonary complications, which are dominated by opportunistic infections, can be first manifestations of inherited or acquired pediatric immune deficiencies. Prompt diagnosis is essential. The epidemiology and natural history of these complications have changed as a result of major advances in prevention, diagnosis and treatment.
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Affiliation(s)
- J Derelle
- Service de pédiatrie 1, Hôpital d'Enfants, Vandoeuvre-lès-Nancy, France
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Kiehl MG, Ostermann H, Thomas M, Birkfellner T, Kienast J. Inflammatory mediators in BAL fluid as markers of evolving pneumonia in leukocytopenic patients. Chest 1997; 112:1214-20. [PMID: 9367460 DOI: 10.1378/chest.112.5.1214] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
STUDY OBJECTIVES Pneumonia during chemotherapy-induced leukocytopenia is a major cause of overall treatment failure in patients with hematologic malignancies. To improve outcome in these high-risk patients, early diagnosis of pulmonary infiltrates and institution of adequate antimicrobial treatment are mandatory. To identify patients with evolving pneumonia, we have prospectively studied the prognostic value of cytokine and complement measurements in early BAL samples from febrile leukocytopenic patients. DESIGN Prospective, comparative study. SETTING Hematology/oncology section of a university hospital. PATIENTS Twenty-one patients with leukocytopenia (WBC count < 1.000/microL) following cytoreductive chemotherapy for malignant disorders. INTERVENTION Early BAL sampling primarily for microbiologic diagnostic purposes. MEASUREMENTS AND RESULTS Proinflammatory cytokines and activated complement components were measured in the BAL aspirates and the results were related to the prevalence or subsequent evolution of overt pneumonia. Of the 21 patients studied, 10 patients presented with overt pneumonia at BAL sampling (group A), 5 patients developed objective signs of pneumonia 3 to 5 days after BAL (group B), and 6 patients remained free of pneumonia during follow-up (group C). In comparison with group C, patients in groups A and B both had distinctly elevated bronchoalveolar levels of tumor necrosis factor-alpha, interleukin-6, granulocyte colony-stimulating factor, C3a, and C5a. CONCLUSIONS Cytokine and complement determinations in early BAL samples may aid in the identification of febrile leukocytopenic patients with evolving pneumonia 3 to 5 days prior to the manifestation of diagnostic clinical and radiographic signs.
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Affiliation(s)
- M G Kiehl
- Department of Internal Medicine, Hematology/Oncology Section, University of Muenster, Germany
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DiScipio AW, Burchard KW. Continuous arteriovenous hemofiltration attenuates polymorphonuclear leukocyte phagocytosis in porcine intra-abdominal sepsis. Am J Surg 1997; 173:174-80. [PMID: 9124621 DOI: 10.1016/s0002-9610(97)89590-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Activation of circulating polymorphonuclear leukocytes (PMN) is a characteristic of systemic inflammation and may contribute to organ malfunction. Continuous arteriovenous hemofiltration (CAVH) has been reported to improve organ malfunction during severe systemic inflammation. This study postulates that the CAVH effects may be linked to alterations in PMN activation. METHODS Sixteen pigs that underwent cecal ligation and rupture were randomized to receive CAVH or no CAVH for 24 hours. The PMN phagocytosis of Candida was measured prior to the insult and at 24, 48, and 72 hours. Temperature, total leukocyte count (WBC), hemodynamic, blood gas, microbiologic, and ionized calcium data were also collected. RESULTS All animals developed increased temperature, heart rate, and WBC, and positive blood and peritoneal cultures. Hemodynamic, pulmonary, and ionized calcium changes were not different between the CAVH and no CAVH groups. Phagocytosis of PMN increased in the no CAVH group at 24 hours, but not in the CAVH group. After discontinuing CAVH, phagocytosis increased to the no CAVH rate at 48 and 72 hours. CONCLUSIONS Continuous arteriovenous hemofiltration attenuates the upregulation of PMN phagocytosis of Candida; this effect disappears after CAVH is discontinued. Hemofiltration does not affect many other manifestations of sepsis, which implies that these manifestations may not be related to PMN phagocytosis capacity.
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Affiliation(s)
- A W DiScipio
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756-0001, USA
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Sculier JP. Indications for intensive care in the management of infections in cancer patients. Cancer Treat Res 1995; 79:233-44. [PMID: 8746657 DOI: 10.1007/978-1-4613-1239-0_11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- J P Sculier
- Service de Medicine Interne et Laboratoire d'Investigation, Centre des Tumeurs de L'Universite, Libre de Bruxelles, Belgium
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Abstract
Viridans streptococci have long been considered, with the exception of the ability to cause endocarditis, as minor pathogenic agents. More recently, however, these bacteria have become a major concern in neutropenic patients undergoing a chemotherapeutic treatment. In this high-risk population, they can be responsible for up to 39% of bacteremia cases and are the most frequent cause of this type of infection. The most frequently isolated species in blood cultures are Streptococcus mitis and Streptococcus sanguis II. Viridans streptococcus bacteremia can be accompanied by serious complications, like adult respiratory distress syndrome (ARDS) (3% to 33%), shock (7% to 18%) or endocarditis (7% to 8%). Mortality rates range from 6% to 30%. Case-control studies have identified the following risk factors: severe neutropenia (< 100 neutrophils/mm3), prophylactic antibiotic treatments with quinolone or co-trimoxazole, absence of intravenous antibiotics at the time of bacteremia, high doses of cytosine arabinoside, oropharyngeal mucositis, and heavy colonization by viridans streptococci. The introduction of penicillin in prophylactic antibiotic treatments has reduced the incidence of these infections, but the long-term use of penicillin could be compromised by the emergence of resistant strains.
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Affiliation(s)
- P Y Bochud
- Division Autonome de Médecine Préventive Hospitalière, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Abstract
In spite of modern technological advances, ARDS continues to be an important cause of morbidity and mortality from a diverse group of disorders such as sepsis, trauma, and aspiration. ARDS represents a target organ injury resulting from activation of the host's inflammatory cells and uncontrolled liberation of inflammatory mediators. In most instances, therefore, ARDS is a localized manifestation of a widespread onslaught characteristic of SIRS. At this time, there are no proven interventions to prevent ARDS, and the management is mainly supportive. Modulation of the host's inflammatory response seems to hold the most promise for prevention and treatment of ARDS. Such strategies need to be explored with well-controlled clinical trials.
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Affiliation(s)
- A P Sarnaik
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan
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Larsen GL, Presley DM, Graves JP, Giclas PC. The effect of intravascular complement activation and brief episodes of hypoxia on protein in bronchoalveolar lavage fluid in C5 sufficient and deficient mice. Pediatr Pulmonol 1991; 11:302-9. [PMID: 1758754 DOI: 10.1002/ppul.1950110406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Our earlier investigations indicated that systemic complement activation with iv cobra venom factor (CVF) or infused zymosan-activated rabbit plasma or rabbit C5a does not significantly increase bronchoalveolar lavage albumin in rabbits (Am Rev Respir Dis 1982; 125:335-340); but that complement activation due to CVF combined with a brief episode of hypoxia increases lavage albumin and is associated with the presence of neutrophils for its expression (J Clin Invest 1985; 75:902-910). In order to determine if intravenous CVF and hypoxia cause similar alterations in mice, and to investigate the time course of the response as well as the importance of C5 fragments to the process, we challenged the B10.D2/nSn strain of C5 sufficient mice (C5+) and the congenic B10.D2/oSn strain of C5 deficient mice (C5-) with intravenous CVF, 15 min of 12% oxygen, or CVF followed by hypoxia. Neither C5+ nor C5- mice had significant increases in lavage protein after either CVF or hypoxia. However, the combined insults significantly increased lavage protein in C5+ but not C5- mice; polyacrylamide gel electrophoresis showed increased amounts of proteins of low and high molecular weights in lavage fluid from the C5+ strain. While the time course of abnormalities in mice was different from that in rabbits, both meclofenamate pretreatment and neutrophil depletion attenuated the increases in lavage protein after the combined insults in both animal species. Infusion of prostaglandin E2 (PGE2) with CVF in the C5+ mice also led to significant increases in lavage protein. We conclude that in mice, intravenous complement activation, as an isolated event, does not cause a significant increase in lavage protein.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- G L Larsen
- Department of Pediatrics, National Jewish Center for Immunology and Respiratory Medicine, Denver, CO 80206
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