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Dushianthan A, Grocott MPW, Murugan GS, Wilkinson TMA, Postle AD. Pulmonary Surfactant in Adult ARDS: Current Perspectives and Future Directions. Diagnostics (Basel) 2023; 13:2964. [PMID: 37761330 PMCID: PMC10528901 DOI: 10.3390/diagnostics13182964] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/10/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a major cause of hypoxemic respiratory failure in adults, leading to the requirement for mechanical ventilation and poorer outcomes. Dysregulated surfactant metabolism and function are characteristic of ARDS. A combination of alveolar epithelial damage leading to altered surfactant synthesis, secretion, and breakdown with increased functional inhibition from overt alveolar inflammation contributes to the clinical features of poor alveolar compliance and alveolar collapse. Quantitative and qualitative alterations in the bronchoalveolar lavage and tracheal aspirate surfactant composition contribute to ARDS pathogenesis. Compared to neonatal respiratory distress syndrome (nRDS), replacement studies of exogenous surfactants in adult ARDS suggest no survival benefit. However, these studies are limited by disease heterogeneity, variations in surfactant preparations, doses, and delivery methods. More importantly, the lack of mechanistic understanding of the exact reasons for dysregulated surfactant remains a significant issue. Moreover, studies suggest an extremely short half-life of replaced surfactant, implying increased catabolism. Refining surfactant preparations and delivery methods with additional co-interventions to counteract surfactant inhibition and degradation has the potential to enhance the biophysical characteristics of surfactant in vivo.
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Affiliation(s)
- Ahilanandan Dushianthan
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton National Health System Foundation Trust, Southampton SO16 6YD, UK; (M.P.W.G.); (T.M.A.W.); (A.D.P.)
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Michael P. W. Grocott
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton National Health System Foundation Trust, Southampton SO16 6YD, UK; (M.P.W.G.); (T.M.A.W.); (A.D.P.)
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | | | - Tom M. A. Wilkinson
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton National Health System Foundation Trust, Southampton SO16 6YD, UK; (M.P.W.G.); (T.M.A.W.); (A.D.P.)
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Anthony D. Postle
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton National Health System Foundation Trust, Southampton SO16 6YD, UK; (M.P.W.G.); (T.M.A.W.); (A.D.P.)
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
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Battaglini D, Robba C, Pelosi P, Rocco PRM. Treatment for acute respiratory distress syndrome in adults: A narrative review of phase 2 and 3 trials. Expert Opin Emerg Drugs 2022; 27:187-209. [PMID: 35868654 DOI: 10.1080/14728214.2022.2105833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Ventilatory management and general supportive care of acute respiratory distress syndrome (ARDS) in the adult population have led to significant clinical improvements, but morbidity and mortality remain high. Pharmacologic strategies acting on the coagulation cascade, inflammation, oxidative stress, and endothelial cell injury have been targeted in the last decade for patients with ARDS, but only a few of these have shown potential benefits with a meaningful clinical response and improved patient outcomes. The lack of availability of specific pharmacologic treatments for ARDS can be attributed to its complex pathophysiology, different risk factors, huge heterogeneity, and difficult classification into specific biological phenotypes and genotypes. AREAS COVERED In this narrative review, we briefly discuss the relevance and current advances in pharmacologic treatments for ARDS in adults and the need for the development of new pharmacological strategies. EXPERT OPINION Identification of ARDS phenotypes, risk factors, heterogeneity, and pathophysiology may help to design clinical trials personalized according to ARDS-specific features, thus hopefully decreasing the rate of failed clinical pharmacologic trials. This concept is still under clinical investigation and needs further development.
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Affiliation(s)
- Denise Battaglini
- Dipartimento di Anestesia e Rianimazione, Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - Chiara Robba
- Dipartimento di Anestesia e Rianimazione, Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Largo Rosanna Benzi, 10, 16132, Genoa, Italy.,Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - Paolo Pelosi
- Dipartimento di Anestesia e Rianimazione, Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Largo Rosanna Benzi, 10, 16132, Genoa, Italy.,Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, RJ 21941-902, Brazil.,COVID-19 Virus Network from Ministry of Science, Technology, and Innovation, Brazilian Council for Scientific and Technological Development, and Foundation Carlos Chagas Filho Research Support of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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Bhatt RM, Clark HW, Girardis M, Busani S. Exogenous pulmonary surfactant in COVID-19 ARDS. The similarities to neonatal RDS suggest a new scenario for an 'old' strategy. BMJ Open Respir Res 2021; 8:e000867. [PMID: 34521648 PMCID: PMC8441217 DOI: 10.1136/bmjresp-2020-000867] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 08/24/2021] [Indexed: 12/15/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) related to SARS-CoV-2 infection has some unusual characteristics that differentiate it from the pathophysiology described in the more 'typical' ARDS. Among multiple hypotheses, a close similarity has been suggested between COVID-19 ARDS and neonatal respiratory distress syndrome (RDS). With this opinion paper, we investigated the pathophysiological similarities between infant respiratory diseases (RDS and direct neonatal ARDS (NARDS)) and COVID-19 in adults. We also analysed, for the first time, similarities in the response to exogenous surfactant administration in terms of improved static compliance in RDS and direct NARDS, and adult COVID-19 ARDS. In conclusion, we believe that if the pathological processes are similar both from the pathophysiological point of view and from the response in respiratory mechanics to a recruitment treatment such as surfactant, perhaps the latter could be considered a plausible option and lead to recruitment in clinical trials currently ongoing on patients with COVID-19.
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Affiliation(s)
- Reena M Bhatt
- Department of Neonatal Medicine, University College London, London, UK
- Department of Neonatal Medicine, University College Hospital, London, UK
| | - Howard W Clark
- Department of Neonatal Medicine, University College London, London, UK
- Department of Neonatal Medicine, University College Hospital, London, UK
| | - Massimo Girardis
- Surgical, Medical and Dental Department of Morphological Sciences Related to Transplants Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Busani
- Department of Anesthesia and Intensive Care, Policlinico di Modena, Modena, Italy
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Saha R, Assouline B, Mason G, Douiri A, Summers C, Shankar-Hari M. Impact of differences in acute respiratory distress syndrome randomised controlled trial inclusion and exclusion criteria: systematic review and meta-analysis. Br J Anaesth 2021; 127:85-101. [PMID: 33812666 PMCID: PMC9768208 DOI: 10.1016/j.bja.2021.02.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/31/2021] [Accepted: 02/21/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Control-arm mortality varies between acute respiratory distress syndrome (ARDS) RCTs. METHODS We systematically reviewed ARDS RCTs that commenced recruitment after publication of the American-European Consensus (AECC) definition (MEDLINE, Embase, and Cochrane central register of controlled trials; January 1994 to October 2020). We assessed concordance of RCT inclusion criteria to ARDS consensus definitions and whether exclusion criteria are strongly or poorly justified. We estimated the proportion of between-trial difference in control-arm 28-day mortality explained by the inclusion criteria and RCT design characteristics using meta-regression. RESULTS A literature search identified 43 709 records. One hundred and fifty ARDS RCTs were included; 146/150 (97.3%) RCTs defined ARDS inclusion criteria using AECC/Berlin definitions. Deviations from consensus definitions, primarily aimed at improving ARDS diagnostic certainty, frequently related to duration of hypoxaemia (117/146; 80.1%). Exclusion criteria could be grouped by rationale for selection into strongly or poorly justified criteria. Common poorly justified exclusions included pregnancy related, age, and comorbidities (infectious/immunosuppression, hepatic, renal, and human immunodeficiency virus/acquired immunodeficiency syndrome). Control-arm 28-day mortality varied between ARDS RCTs (mean: 29.8% [95% confidence interval: 27.0-32.7%; I2=88.8%; τ2=0.02; P<0.01]), and differed significantly between RCTs with different Pao2:FiO2 ratio inclusion thresholds (26.6-39.9 kPa vs <26.6 kPa; P<0.01). In a meta-regression model, inclusion criteria and RCT design characteristics accounted for 30.6% of between-trial difference (P<0.01). CONCLUSIONS In most ARDS RCTs, consensus definitions are modified to use as inclusion criteria. Between-RCT mortality differences are mostly explained by the Pao2:FiO2 ratio threshold within the consensus definitions. An exclusion criteria framework can be applied when designing and reporting exclusion criteria in future ARDS RCTs.
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Affiliation(s)
- Rohit Saha
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Georgina Mason
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, King's College London, London, UK; National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Manu Shankar-Hari
- Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Immunology & Microbial Sciences, King's College London, London, UK.
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Qaqish R, Watanabe Y, Galasso M, Summers C, Ali AA, Takahashi M, Gazzalle A, Liu M, Keshavjee S, Cypel M, Del Sorbo L. Veno-venous ECMO as a platform to evaluate lung lavage and surfactant replacement therapy in an animal model of severe ARDS. Intensive Care Med Exp 2020; 8:63. [PMID: 33108583 PMCID: PMC7591687 DOI: 10.1186/s40635-020-00352-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are limited therapeutic options directed at the underlying pathological processes in acute respiratory distress syndrome (ARDS). Experimental therapeutic strategies have targeted the protective systems that become deranged in ARDS such as surfactant. Although results of surfactant replacement therapy (SRT) in ARDS have been mixed, questions remain incompletely answered regarding timing and dosing strategies of surfactant. Furthermore, there are only few truly clinically relevant ARDS models in the literature. The primary aim of our study was to create a clinically relevant, reproducible model of severe ARDS requiring extracorporeal membrane oxygenation (ECMO). Secondly, we sought to use this model as a platform to evaluate a bronchoscopic intervention that involved saline lavage and SRT. METHODS Yorkshire pigs were tracheostomized and cannulated for veno-venous ECMO support, then subsequently given lung injury using gastric juice via bronchoscopy. Animals were randomized post-injury to either receive bronchoscopic saline lavage combined with SRT and recruitment maneuvers (treatment, n = 5) or recruitment maneuvers alone (control, n = 5) during ECMO. RESULTS PaO2/FiO2 after aspiration injury was 62.6 ± 8 mmHg and 60.9 ± 9.6 mmHg in the control and treatment group, respectively (p = 0.95) satisfying criteria for severe ARDS. ECMO reversed the severe hypoxemia. After treatment with saline lavage and SRT during ECMO, lung physiologic and hemodynamic parameters were not significantly different between treatment and controls. CONCLUSIONS A clinically relevant severe ARDS pig model requiring ECMO was established. Bronchoscopic saline lavage and SRT during ECMO did not provide a significant physiologic benefit compared to controls.
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Affiliation(s)
- Robert Qaqish
- Latner Thoracic Surgery Research Laboratories, Toronto, Canada.,University of Toronto, Toronto, ON, Canada
| | - Yui Watanabe
- Latner Thoracic Surgery Research Laboratories, Toronto, Canada.,University of Toronto, Toronto, ON, Canada
| | - Marcos Galasso
- Latner Thoracic Surgery Research Laboratories, Toronto, Canada.,University of Toronto, Toronto, ON, Canada
| | - Cara Summers
- Latner Thoracic Surgery Research Laboratories, Toronto, Canada.,University of Toronto, Toronto, ON, Canada
| | - A Adil Ali
- Latner Thoracic Surgery Research Laboratories, Toronto, Canada.,University of Toronto, Toronto, ON, Canada
| | - Mamoru Takahashi
- Latner Thoracic Surgery Research Laboratories, Toronto, Canada.,University of Toronto, Toronto, ON, Canada
| | - Anajara Gazzalle
- Latner Thoracic Surgery Research Laboratories, Toronto, Canada.,University of Toronto, Toronto, ON, Canada
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, Toronto, Canada.,University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, Toronto, Canada.,University of Toronto, Toronto, ON, Canada
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, Toronto, Canada.,University of Toronto, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Latner Thoracic Surgery Research Laboratories, Toronto, Canada. .,Interdepartmental Division of Critical Care Medicine, University Health Network, Toronto General Hospital, 585 University Avenue, PMB 11-122, Toronto, ON, M5G 2N2, Canada. .,University of Toronto, Toronto, ON, Canada.
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Lewis SR, Pritchard MW, Thomas CM, Smith AF. Pharmacological agents for adults with acute respiratory distress syndrome. Cochrane Database Syst Rev 2019; 7:CD004477. [PMID: 31334568 PMCID: PMC6646953 DOI: 10.1002/14651858.cd004477.pub3] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a life-threatening condition caused by direct or indirect injury to the lungs. Despite improvements in clinical management (for example, lung protection strategies), mortality in this patient group is at approximately 40%. This is an update of a previous version of this review, last published in 2004. OBJECTIVES To evaluate the effectiveness of pharmacological agents in adults with ARDS on mortality, mechanical ventilation, and fitness to return to work at 12 months. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and CINAHL on 10 December 2018. We searched clinical trials registers and grey literature, and handsearched reference lists of included studies and related reviews. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing pharmacological agents with control (placebo or standard therapy) to treat adults with established ARDS. We excluded trials of nitric oxide, inhaled prostacyclins, partial liquid ventilation, neuromuscular blocking agents, fluid and nutritional interventions and medical oxygen. We excluded studies published earlier than 2000, because of changes to lung protection strategies for people with ARDS since this date. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We assessed the certainty of evidence with GRADE. MAIN RESULTS We included 48 RCTs with 6299 participants who had ARDS; two included only participants with mild ARDS (also called acute lung injury). Most studies included causes of ARDS that were both direct and indirect injuries. We noted differences between studies, for example the time of administration or the size of dose, and because of unclear reporting we were uncertain whether all studies had used equivalent lung protection strategies.We included five types of agents as the primary comparisons in the review: corticosteroids, surfactants, N-acetylcysteine, statins, and beta-agonists. We included 15 additional agents (sivelestat, mesenchymal stem cells, ulinastatin, anisodimine, angiotensin-converting enzyme (ACE) inhibitor, recombinant human ACE2 (palifermin), AP301, granulocyte-macrophage colony stimulating factor (GM-CSF), levosimendan, prostacyclins, lisofylline, ketaconazole, nitroglycerins, L-2-oxothiazolidine-4-carboxylic acid (OTZ), and penehyclidine hydrochloride).We used GRADE to downgrade outcomes for imprecision (because of few studies and few participants), for study limitations (e.g. high risks of bias) and for inconsistency (e.g. differences between study data).Corticosteroids versus placebo or standard therapyCorticosteroids may reduce all-cause mortality within three months by 86 per 1000 patients (with as many as 161 fewer to 19 more deaths); however, the 95% confidence interval (CI) includes the possibility of both increased and reduced deaths (risk ratio (RR) 0.77, 95% CI 0.57 to 1.05; 6 studies, 574 participants; low-certainty evidence). Due to the very low-certainty evidence, we are uncertain whether corticosteroids make little or no difference to late all-cause mortality (later than three months) (RR 0.99, 95% CI 0.64 to 1.52; 1 study, 180 participants), or to the duration of mechanical ventilation (mean difference (MD) -4.30, 95% CI -9.72 to 1.12; 3 studies, 277 participants). We found that ventilator-free days up to day 28 (VFD) may be improved with corticosteroids (MD 4.09, 95% CI 1.74 to 6.44; 4 studies, 494 participants; low-certainty evidence). No studies reported adverse events leading to discontinuation of study medication, or fitness to return to work at 12 months (FTR).Surfactants versus placebo or standard therapyWe are uncertain whether surfactants make little or no difference to early mortality (RR 1.08, 95% CI 0.91 to 1.29; 9 studies, 1338 participants), or whether they reduce late all-cause mortality (RR 1.28, 95% CI 1.01 to 1.61; 1 study, 418 participants). Similarly, we are uncertain whether surfactants reduce the duration of mechanical ventilation (MD -2.50, 95% CI -4.95 to -0.05; 1 study, 16 participants), make little or no difference to VFD (MD -0.39, 95% CI -2.49 to 1.72; 2 studies, 344 participants), or to adverse events leading to discontinuation of study medication (RR 0.50, 95% CI 0.17 to 1.44; 2 studies, 88 participants). We are uncertain of these effects because we assessed them as very low-certainty. No studies reported FTR.N-aceytylcysteine versus placeboWe are uncertain whether N-acetylcysteine makes little or no difference to early mortality, because we assessed this as very low-certainty evidence (RR 0.64, 95% CI 0.32 to 1.30; 1 study, 36 participants). No studies reported late all-cause mortality, duration of mechanical ventilation, VFD, adverse events leading to study drug discontinuation, or FTR.Statins versus placeboStatins probably make little or no difference to early mortality (RR 0.99, 95% CI 0.78 to 1.26; 3 studies, 1344 participants; moderate-certainty evidence) or to VFD (MD 0.40, 95% CI -0.71 to 1.52; 3 studies, 1342 participants; moderate-certainty evidence). Statins may make little or no difference to duration of mechanical ventilation (MD 2.70, 95% CI -3.55 to 8.95; 1 study, 60 participants; low-certainty evidence). We could not include data for adverse events leading to study drug discontinuation in one study because it was unclearly reported. No studies reported late all-cause mortality or FTR.Beta-agonists versus placebo controlBeta-blockers probably slightly increase early mortality by 40 per 1000 patients (with as many as 119 more or 25 fewer deaths); however, the 95% CI includes the possibility of an increase as well as a reduction in mortality (RR 1.14, 95% CI 0.91 to 1.42; 3 studies, 646 participants; moderate-certainty evidence). Due to the very low-certainty evidence, we are uncertain whether beta-agonists increase VFD (MD -2.20, 95% CI -3.68 to -0.71; 3 studies, 646 participants), or make little or no difference to adverse events leading to study drug discontinuation (one study reported little or no difference between groups, and one study reported more events in the beta-agonist group). No studies reported late all-cause mortality, duration of mechanical ventilation, or FTR. AUTHORS' CONCLUSIONS We found insufficient evidence to determine with certainty whether corticosteroids, surfactants, N-acetylcysteine, statins, or beta-agonists were effective at reducing mortality in people with ARDS, or duration of mechanical ventilation, or increasing ventilator-free days. Three studies awaiting classification may alter the conclusions of this review. As the potential long-term consequences of ARDS are important to survivors, future research should incorporate a longer follow-up to measure the impacts on quality of life.
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Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Michael W Pritchard
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Carmel M Thomas
- Greater Manchester Mental Health NHS Foundation TrustDepartment of Research and InnovationHarrop HousePrestwichManchesterUKM25 3BL
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
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Effect of surfactant administration on outcomes of adult patients in acute respiratory distress syndrome: a meta-analysis of randomized controlled trials. BMC Pulm Med 2019; 19:9. [PMID: 30626363 PMCID: PMC6325713 DOI: 10.1186/s12890-018-0761-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 12/07/2018] [Indexed: 11/29/2022] Open
Abstract
Introduction Surfactant is usually deficiency in adult acute respiratory distress syndrome(ARDS) patients and surfactant administration may be a useful therapy. The aim of this study was to perform a meta-analysis of the effect of surfactant administration on outcomes of adult patients with acute respiratory distress syndrome. Methods PubMed, EMBASE, Medline, Cochrane database, Elsevier, Web of Science and http://clinicaltrials.gov were searched and investigated until December 2017. Randomized controlled trials(RCTs) comparing surfactant administration with general therapy in adult patients with ARDS were enrolled. The primary outcome was mortality (7–10-day, 28–30-day and 90–180-day). Secondary outcome included oxygenation (PaO2/FiO2 ratio). Demographic variables, surfactant administration, and outcomes were retrieved. Sensitivity analyses were used to evaluate the impact of study quality issues on the overall effect. Funnel plot inspection, Egger’s and Begger’s test were applied to investigate the publication bias. Internal validity was assessed with the risk of bias tool. Random errors were evaluated with trial sequential analysis(TSA). Quality levels were assessed by Grading of Recommendations Assessment, Development, and Evaluation methodology(GRADE). Results Eleven RCTs with 3038 patients were identified. Surfactant administration could not improve mortality of adult patients [Risk ratio (RR) (95%CI)) = 1.02(0.93–1.12), p = 0.65]. Subgroup analysis revealed no difference of 7–10-day mortality [RR(95%CI)) = 0.89(0.54–1.49), p = 0.66], 28–30-day mortality[RR(95%CI) = 1.00(0.89–1.12), p = 0.98] and 90–180-day mortality [RR(95%CI) = 1.11(0.94–1.32), p = 0.22] between surfactant group and control group. The change of the PaO2/FiO2 ratio in adult ARDS patients had no difference [MD(95%CI) = 0.06(− 0.12–0.24), p = 0.5] after surfactant administration. Finally, TSA and GRADE indicated lack of firm evidence for a beneficial effect. Conclusions Surfactant administration has not been shown to improve mortality and improve oxygenation for adult ARDS patients. Large rigorous randomized trials are needed to explore the effect of surfactant to adult ARDS patients. Electronic supplementary material The online version of this article (10.1186/s12890-018-0761-y) contains supplementary material, which is available to authorized users.
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Exogenous surfactant as a bridge to prolonged "total lung rest" in severely injured patient during extracorporeal membrane oxygenation. J Artif Organs 2018; 21:374-377. [PMID: 29582175 DOI: 10.1007/s10047-018-1037-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 03/20/2018] [Indexed: 10/17/2022]
Abstract
We report a case of a 20-year-old male patient suffering from motorcycle accident complicated by rapid development of severe refractory hypoxemia and hypercapnia due to serious bilateral lung contusions and lacerations. Positive pressure mechanical ventilation induced pressure-dependent massive air leak from disrupted pulmonary tissue. Simultaneous implementation of veno-venous extracorporeal membrane oxygenation together with surfactant application allowed prolonged disconnection of patient from mechanical ventilation ("total lung rest" mode). Despite considerable areas of nonaerated tissue on computed tomography prior to the disconnection from mechanical ventilation, almost total functional recovery of lungs was eventually achieved.
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Hashimoto S, Sanui M, Egi M, Ohshimo S, Shiotsuka J, Seo R, Tanaka R, Tanaka Y, Norisue Y, Hayashi Y, Nango E. The clinical practice guideline for the management of ARDS in Japan. J Intensive Care 2017; 5:50. [PMID: 28770093 PMCID: PMC5526253 DOI: 10.1186/s40560-017-0222-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 04/19/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The Japanese Society of Respiratory Care Medicine and the Japanese Society of Intensive Care Medicine provide here a clinical practice guideline for the management of adult patients with ARDS in the ICU. METHOD The guideline was developed applying the GRADE system for performing robust systematic reviews with plausible recommendations. The guideline consists of 13 clinical questions mainly regarding ventilator settings and drug therapies (the last question includes 11 medications that are not approved for clinical use in Japan). RESULTS The recommendations for adult patients with ARDS include: we suggest against early tracheostomy (GRADE 2C), we suggest using NPPV for early respiratory management (GRADE 2C), we recommend the use of low tidal volumes at 6-8 mL/kg (GRADE 1B), we suggest setting the plateau pressure at 30cmH20 or less (GRADE2B), we suggest using PEEP within the range of plateau pressures less than or equal to 30cmH2O, without compromising hemodynamics (Grade 2B), and using higher PEEP levels in patients with moderate to severe ARDS (Grade 2B), we suggest using protocolized methods for liberation from mechanical ventilation (Grade 2D), we suggest prone positioning especially in patients with moderate to severe respiratory dysfunction (GRADE 2C), we suggest against the use of high frequency oscillation (GRADE 2C), we suggest the use of neuromuscular blocking agents in patients requiring mechanical ventilation under certain circumstances (GRADE 2B), we suggest fluid restriction in the management of ARDS (GRADE 2A), we do not suggest the use of neutrophil elastase inhibitors (GRADE 2D), we suggest the administration of steroids, equivalent to methylprednisolone 1-2mg/kg/ day (GRADE 2A), and we do not recommend other medications for the treatment of adult patients with ARDS (GRADE1B; inhaled/intravenous β2 stimulants, prostaglandin E1, activated protein C, ketoconazole, and lisofylline, GRADE 1C; inhaled nitric oxide, GRADE 1D; surfactant, GRADE 2B; granulocyte macrophage colony-stimulating factor, N-acetylcysteine, GRADE 2C; Statin.). CONCLUSIONS This article was translated from the Japanese version originally published as the ARDS clinical practice guidelines 2016 by the committee of ARDS clinical practice guideline (Tokyo, 2016, 293p, available from http://www.jsicm.org/ARDSGL/ARDSGL2016.pdf). The original article, written for Japanese healthcare providers, provides points of view that are different from those in other countries.
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Affiliation(s)
- Satoru Hashimoto
- Department of Anesthesiology and Intensive Care, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Moritoki Egi
- Department of anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Hiroshima University, Hiroshima, Japan
| | - Junji Shiotsuka
- Division of Critical Care Medicine, Okinawa Chubu Hospital, Okinawa, Japan
| | - Ryutaro Seo
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ryoma Tanaka
- Pulmonary & Critical Care Medicine, LDS Hospital, Salt Lake City, USA
| | - Yu Tanaka
- Department of Anesthesiology, Nara Medical University, Nara, Japan
| | - Yasuhiro Norisue
- Department of Emergency and Critical Care Medicine, Tokyo Bay Medical Center, Tokyo, Japan
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
| | - Eishu Nango
- Department of General Medicine, Tokyo kita Social Insurance Hospital, Tokyo, Japan
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Abstract
Surfactant replacement therapy (SRT) involves instillation of a liquid-surfactant mixture directly into the lung airway tree. It is widely successful for treating surfactant deficiency in premature neonates who develop neonatal respiratory distress syndrome (NRDS). However, when applied to adults with acute respiratory distress syndrome (ARDS), early successes were followed by failures. This unexpected and puzzling situation is a vexing issue in the pulmonary community. A pressing question is whether the instilled surfactant mixture actually reaches the adult alveoli/acinus in therapeutic amounts. In this study, to our knowledge, we present the first mathematical model of SRT in a 3D lung structure to provide insight into answering this and other questions. The delivery is computed from fluid mechanical principals for 3D models of the lung airway tree for neonates and adults. A liquid plug propagates through the tree from forced inspiration. In two separate modeling steps, the plug deposits a coating film on the airway wall and then splits unevenly at the bifurcation due to gravity. The model generates 3D images of the resulting acinar distribution and calculates two global indexes, efficiency and homogeneity. Simulating published procedural methods, we show the neonatal lung is a well-mixed compartment, whereas the adult lung is not. The earlier, successful adult SRT studies show comparatively good index values implying adequate delivery. The later, failed studies used different protocols resulting in very low values of both indexes, consistent with inadequate acinar delivery. Reasons for these differences and the evolution of failure from success are outlined and potential remedies discussed.
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12
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Tidal volume and plateau pressure use for acute lung injury from 2000 to present: a systematic literature review. Crit Care Med 2014; 42:2278-89. [PMID: 25098333 DOI: 10.1097/ccm.0000000000000504] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Since publication of the Respiratory Management of Acute Lung Injury and Acute Respiratory Distress Syndrome (ARMA) trial in 2000, use of tidal volume (VT) less than or equal to 6 mL/kg predicted body weight with corresponding plateau airway pressures (PPlat) less than or equal to 30 cm H2O has been advocated for acute lung injury. However, compliance with these recommendations is unknown. We therefore investigated VT (mL/kg predicted body weight) and PPlat (cm H2O) practices reported in studies of acute lung injury since ARMA using a systematic literature review (i.e., not a meta-analysis). DATA SOURCES PubMed, Scopus, and EMBASE. STUDY SELECTION Randomized controlled trials and nonrandomized studies enrolling patients with acute lung injury from May 2000 to June 2013 and reporting VT. DATA EXTRACTION Whether the study was a randomized controlled trial or a nonrandomized study and performed or not at an Acute Respiratory Distress Syndrome Network center; in randomized controlled trials, the pre- and postrandomization VT (mL/kg predicted body weight) and PPlat (cm H2O) and whether a VT protocol was used postrandomization; in nonrandomized studies, baseline VT and PPlat. DATA SYNTHESIS Twenty-two randomized controlled trials and 71 nonrandomized studies were included. Since 2000 at acute respiratory distress syndrome Network centers, routine VT was similar comparing randomized controlled trials and nonrandomized studies (p = 0.25) and unchanged over time (p = 0.75) with a mean value of 6.81 (95% CI, 6.45, 7.18). At non-acute respiratory distress syndrome Network centers, routine VT was also similar when comparing randomized controlled trials and nonrandomized studies (p = 0.71), but decreased (p = 0.001); the most recent estimate for it was 6.77 (6.22, 7.32). All VT estimates were significantly greater than 6 (p ≤ 0.02). In randomized controlled trials employing VT protocols, routine VT was reduced in both acute respiratory distress syndrome Network (n = 4) and non-acute respiratory distress syndrome Network (n = 11) trials (p ≤ 0.01 for both), but even postrandomization was greater than 6 (6.47 [6.29, 6.65] and 6.80 [6.42, 7.17], respectively; p ≤ 0.0001 for both). In 59 studies providing data, routine PPlat, averaged across acute respiratory distress syndrome Network or non-acute respiratory distress syndrome Network centers, was significantly less than 30 (p ≤ 0.02). CONCLUSIONS For clinicians treating acute lung injury since 2000, achieving VT less than or equal to 6 mL/kg predicted body weight may not have been as attainable or important as PPlat less than or equal to 30 cm H2O. If so, there may be equipoise to test if VT less than or equal to 6 mL/kg predicted body weight are necessary to improve acute lung injury outcome.
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Blackwood B, Clarke M, McAuley DF, McGuigan PJ, Marshall JC, Rose L. How outcomes are defined in clinical trials of mechanically ventilated adults and children. Am J Respir Crit Care Med 2014; 189:886-93. [PMID: 24512505 DOI: 10.1164/rccm.201309-1645pp] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Systematic reviews have considerable potential to provide evidence-based data to aid clinical decision-making. However, there is growing recognition that trials involving mechanical ventilation lack consistency in the definition and measurement of ventilation outcomes, creating difficulties in combining data for meta-analyses. To address the inconsistency in outcome definitions, international standards for trial registration and clinical trial protocols published recommendations, effectively setting the "gold standard" for reporting trial outcomes. In this Critical Care Perspective, we review the problems resulting from inconsistent outcome definitions and inconsistent reporting of outcomes (outcome sets). We present data highlighting the variability of the most commonly reported ventilation outcome definitions. Ventilation outcomes reported in trials over the last 6 years typically fall into four domains: measures of ventilator dependence; adverse outcomes; mortality; and resource use. We highlight the need, first, for agreement on outcome definitions and, second, for a minimum core outcome set for trials involving mechanical ventilation. A minimum core outcome set would not restrict trialists from measuring additional outcomes, but would overcome problems of variability in outcome selection, measurement, and reporting, thereby enhancing comparisons across trials.
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14
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Akdemir HU, Güzel A, Katı C, Duran L, Alaçam H, Gacar A, Güvenç T, Murat N, Sişman B. The evaluation of different treatment protocols for trauma-induced lung injury in rats. J Thorac Dis 2014; 6:66-73. [PMID: 24605218 DOI: 10.3978/j.issn.2072-1439.2013.12.54] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 12/30/2013] [Indexed: 11/14/2022]
Abstract
BACKGROUND Lung contusion is an important factor that affects mortality and morbidity of lung injury after blunt chest trauma (BCT). The present study aims to evaluate the effectiveness of different treatment regimens on BCT-induced lung injury. METHODS A total of 35 Sprague Dawley rats were divided into five experimental groups (n=7): sham, control; BCT; BCT + MP, BCT group treated with methylprednisolone (MP; 30 mg/kg on first day and 3 mg/kg/d on the following days); BCT + Q, BCT group treated with quercetin (Q; 50 mg/kg/d for seven days); and BCT + MP + Q, BCT group treated with the same doses of MP and Q. Serum Clara Cell Protein-16 (CC-16), thiobarbituric acid reactive substances (TBARS), and superoxide dismutase (SOD) levels were analyzed to determine histopathological changes in the lung tissues. RESULTS Elevated serum CC-16 and TBARS levels and reduced serum SOD levels were found in the BCT group compared to the Sham group. There was a significant change in the serum CC-16 levels in the BCT + MP group compared to the Sham group. Serum TBARS levels were significantly lower in the BCT + MP and BCT + Q group compared to the BCT group. The combined therapy regimen yielded significantly decreased CC-16 levels and increased serum SOD levels compared to the individual treatment groups. Serum TBARS levels did not significantly differ between the BCT + MP + Q group and the other treatment groups. Compared to the BCT + MP + Q group, the BCT + MP group showed significantly lower alveolar edema (AED) and alveolar exudate (AEX) scores, while the BCT + Q group showed significantly lower peribronchial inflammatory cell infiltration (PICI) and AED scores. CONCLUSIONS The combined usage of quercetin and low dose MP treatment after initial high dose MP at the early stage of lung injury after BCT is more effective.
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Affiliation(s)
- Hızır Ufuk Akdemir
- 1 Faculty of Medicine, Department of Emergency Medicine, 2 Faculty of Medicine, Department of Chest Diseases, 3 Faculty of Medicine, Department of Medical Biochemistry, 4 Faculty of Veterinary Medicine, Department of Pathology, 5 Department of Industrial Engineering, Ondokuz Mayıs University, Samsun, Turkey
| | - Aygül Güzel
- 1 Faculty of Medicine, Department of Emergency Medicine, 2 Faculty of Medicine, Department of Chest Diseases, 3 Faculty of Medicine, Department of Medical Biochemistry, 4 Faculty of Veterinary Medicine, Department of Pathology, 5 Department of Industrial Engineering, Ondokuz Mayıs University, Samsun, Turkey
| | - Celal Katı
- 1 Faculty of Medicine, Department of Emergency Medicine, 2 Faculty of Medicine, Department of Chest Diseases, 3 Faculty of Medicine, Department of Medical Biochemistry, 4 Faculty of Veterinary Medicine, Department of Pathology, 5 Department of Industrial Engineering, Ondokuz Mayıs University, Samsun, Turkey
| | - Latif Duran
- 1 Faculty of Medicine, Department of Emergency Medicine, 2 Faculty of Medicine, Department of Chest Diseases, 3 Faculty of Medicine, Department of Medical Biochemistry, 4 Faculty of Veterinary Medicine, Department of Pathology, 5 Department of Industrial Engineering, Ondokuz Mayıs University, Samsun, Turkey
| | - Hasan Alaçam
- 1 Faculty of Medicine, Department of Emergency Medicine, 2 Faculty of Medicine, Department of Chest Diseases, 3 Faculty of Medicine, Department of Medical Biochemistry, 4 Faculty of Veterinary Medicine, Department of Pathology, 5 Department of Industrial Engineering, Ondokuz Mayıs University, Samsun, Turkey
| | - Ayhan Gacar
- 1 Faculty of Medicine, Department of Emergency Medicine, 2 Faculty of Medicine, Department of Chest Diseases, 3 Faculty of Medicine, Department of Medical Biochemistry, 4 Faculty of Veterinary Medicine, Department of Pathology, 5 Department of Industrial Engineering, Ondokuz Mayıs University, Samsun, Turkey
| | - Tolga Güvenç
- 1 Faculty of Medicine, Department of Emergency Medicine, 2 Faculty of Medicine, Department of Chest Diseases, 3 Faculty of Medicine, Department of Medical Biochemistry, 4 Faculty of Veterinary Medicine, Department of Pathology, 5 Department of Industrial Engineering, Ondokuz Mayıs University, Samsun, Turkey
| | - Naci Murat
- 1 Faculty of Medicine, Department of Emergency Medicine, 2 Faculty of Medicine, Department of Chest Diseases, 3 Faculty of Medicine, Department of Medical Biochemistry, 4 Faculty of Veterinary Medicine, Department of Pathology, 5 Department of Industrial Engineering, Ondokuz Mayıs University, Samsun, Turkey
| | - Bülent Sişman
- 1 Faculty of Medicine, Department of Emergency Medicine, 2 Faculty of Medicine, Department of Chest Diseases, 3 Faculty of Medicine, Department of Medical Biochemistry, 4 Faculty of Veterinary Medicine, Department of Pathology, 5 Department of Industrial Engineering, Ondokuz Mayıs University, Samsun, Turkey
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15
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Meng H, Sun Y, Lu J, Fu S, Meng Z, Scott M, Li Q. Exogenous surfactant may improve oxygenation but not mortality in adult patients with acute lung injury/acute respiratory distress syndrome: a meta-analysis of 9 clinical trials. J Cardiothorac Vasc Anesth 2012; 26:849-56. [PMID: 22265270 PMCID: PMC9942513 DOI: 10.1053/j.jvca.2011.11.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate whether exogenous surfactant therapy may be useful in adult patients with acute lung injury or acute respiratory distress syndrome, using a meta-analysis of published clinical trials. DESIGN A comprehensive literature search was performed to identify all randomized clinical trials examining the effects of the treatment of acute lung injury/acute respiratory distress syndrome with exogenous surfactant in adults. The primary outcome measurement was mortality 28 or 30 days after randomization. Secondary outcome measurements included a change in the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen in the first 24 hours or after 120 hours, the number of ventilation-free days, and any adverse effects. The meta-analysis was performed using the Review Manager 5.0.0 system. PARTICIPANTS Randomized clinical trials. INTERVENTION Meta-analysis of 9 trials. MEASUREMENTS AND MAIN RESULTS Nine trials involving 2,575 patients were included in the meta-analysis. The analysis showed that treatment with exogenous pulmonary surfactant does not decrease mortality significantly. There was a significant effect of exogenous surfactant treatment on the change in the partial pressure of arterial oxygen/fraction of inspired oxygen ratio in the first 24 hours but this was lost by 120 hours. The duration of ventilation trended lower in surfactant-treated patients but this was not significant. In addition, surfactant-treated patients had a significantly higher risk of adverse effects. CONCLUSIONS An exogenous surfactant may improve oxygenation over the first 24 hours after administration. However, treatment does not improve mortality and oxygenation over ≥120 hours after administration and results in a high rate of adverse effects. Therefore, the present data suggest that an exogenous surfactant cannot be considered an effective adjunctive therapy in patients with acute lung injury/acute respiratory distress syndrome.
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Affiliation(s)
- Haoyu Meng
- Department of Anesthesiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China,First Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Ying Sun
- First Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Jun Lu
- Department of Anesthesiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shukun Fu
- Department of Anesthesiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhaoyi Meng
- Department of Surgery, Xinyi People's Hospital, Xinyi, Jiangsu Province, China
| | - Melanie Scott
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Quan Li
- Department of Anesthesiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China,Address reprint requests to Quan Li, MD, PhD, Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang-zhong Road, Shanghai 200072, China
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16
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Busani S, Girardis M, Biagioni E, Pasetto A, Sambri V. Surfactant therapy and intravenous zanamivir in severe respiratory failure due to persistent influenza A/H1N1 2009 virus infection. Am J Respir Crit Care Med 2010; 182:1334. [PMID: 21079271 DOI: 10.1164/ajrccm.182.10.1334] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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17
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Cohn SM, Dubose JJ. Pulmonary contusion: an update on recent advances in clinical management. World J Surg 2010; 34:1959-70. [PMID: 20407767 DOI: 10.1007/s00268-010-0599-9] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pulmonary contusion is a common finding after blunt chest trauma. The physiologic consequences of alveolar hemorrhage and pulmonary parenchymal destruction typically manifest themselves within hours of injury and usually resolve within approximately 7 days. Clinical symptoms, including respiratory distress with hypoxemia and hypercarbia, peak at about 72 h after injury. The timely diagnosis of pulmonary contusion requires a high degree of clinical suspicion when a patient presents with trauma caused by an appropriate mechanism of injury. The clinical diagnosis of acute parenchymal lung injury is usually confirmed by thoracic computed tomography, which is both highly sensitive in identifying pulmonary contusion and highly predictive of the need for subsequent mechanical ventilation. Management of pulmonary contusion is primarily supportive. Associated complications such as pneumonia, acute respiratory distress syndrome, and long-term pulmonary disability, however, are frequent sequelae of these injuries.
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Affiliation(s)
- Stephen M Cohn
- Department of Surgery, University of Texas Health Sciences Center, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
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Marraro GA, Denaro C, Spada C, Luchetti M, Giansiracusa C. Selective medicated (saline + natural surfactant) bronchoalveolar lavage in unilateral lung contusion. A clinical randomized controlled trial. J Clin Monit Comput 2009; 24:73-81. [PMID: 20012912 DOI: 10.1007/s10877-009-9213-9] [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] [Received: 07/03/2009] [Accepted: 11/25/2009] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Open lung and low tidal volume ventilation appear to be a promising ventilation for chest trauma as it can reduce ARDS and improve outcome. Local therapy (e.g. BAL) can be synergic to remove from the lung the debris, mitigate inflammatory cascade and avoid damage spreading to not compromised lung areas. MATERIALS AND METHODS 44 pulmonary contused patients were randomized to receive broncho-suction and volume controlled low tidal volume ventilation-VCLTVV (Control Group) or the same ventilation plus medicated (saline + surfactant) BAL (Treatment Group). Tidal volume <10 ml/kg, PEEP of 10-12 cm H(2)O and PaO(2) 60-100 mm Hg and PaCO(2) 35-45 mm Hg were used in both groups. BAL was performed using a fiberscope. 4 boluses of 25 ml saline with 2.4 mg/ml of surfactant were introduced into each contused lobe in which, subsequently, 240 mg of surfactant was instilled. RESULTS All patients survived. In the Control Group 18 patients developed pneumonia, 5 ARDS and days of intubation were 11.50 (3.83) compared to 5.05 (1.21) of Treatment Group in which OI and PaO(2)/FiO(2) significantly improved from 36 h. CONCLUSIONS VCLTVV alone was not able to prevent ARDS and infection in the Control Group as the reduction of intubation. In the Treatment Group, VCLTVV and medicated BAL facilitated the removal of degradated lung material and recruited the contused lung regions, enabling the healing of the lung pathology.
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Affiliation(s)
- Giuseppe A Marraro
- Anesthesia and Intensive Care Department, A.O. Fatebenefratelli and Ophthalmiatric Hospital, Milan, Italy.
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Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Groeneveld J, Hedenstierna G, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Metnitz P, Pugin J, Wernerman J, Zhang H. Year in review in Intensive Care Medicine, 2007. II. Haemodynamics, pneumonia, infections and sepsis, invasive and non-invasive mechanical ventilation, acute respiratory distress syndrome. Intensive Care Med 2008; 34:405-22. [PMID: 18236026 DOI: 10.1007/s00134-008-1009-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 01/07/2008] [Indexed: 01/14/2023]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anaesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168 Rome, Italy.
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