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Zhou L, Lin J, Zhuang M, Wang Y, Weng Q, Zhang H. Heliox ventilation in elderly, hypertensive ICU patients improves microcirculation: A randomized controlled study. J Crit Care 2024; 84:154897. [PMID: 39137689 DOI: 10.1016/j.jcrc.2024.154897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 07/30/2024] [Accepted: 08/02/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Conventional mechanical ventilation has adverse impacts on the hemodynamics of elderly, hypertensive ICU patients. Limited studies have addressed ways to ameliorate these negative effects. This study aimed to determine whether heliox ventilation could improve the hemodynamics, especially microcirculation, of elderly, hypertensive patients undergoing mechanical ventilation. METHODS Thirty-eight patients, over the age of 65 with essential hypertension who underwent invasive mechanical ventilation treatment, were divided into two groups: a control group of nitrogen‑oxygen ventilation (n = 19) and an experimental group of heliox ventilation (n = 19). The control group received conventional room air ventilation and the experimental group adopted the innovative, closed heliox ventilation technique. Changes in blood pressure, heart rate (HR), peripheral oxygen saturation (SpO2), central venous oxygen saturation (ScvO2), regional cerebral oxygen saturation (rSO2), lactic acid (Lac) and airway pressure were measured at 0,1,2,3 h under volume-controlled ventilation (VCV) mode throughout the study. Sublingual microcirculation parameters were additionally measured at 0 h and 3 h of ventilation treatment. RESULTS SpO2 in both groups increased after 1 h of ventilation compared with 0 h (p < 0.001), subsequently remaining stable. Compared with the control group, the experimental group showed a decrease in airway pressure and Lac, while blood pressure, ScvO2, and rSO2 increased (p < 0.05). Moreover, the sublingual microcirculation indexes in the experimental group improved compared with the control group (p < 0.05). CONCLUSIONS Heliox ventilation improves blood pressure and microcirculation in elderly hypertensive patients and may resolve the limitations of traditional nitrogen‑oxygen ventilation. TRIAL REGISTRATION This trial was registered. The Chinese trial registration number is ChiCTR2100043945. The date of registration is 6-3-2021.
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Affiliation(s)
- Lili Zhou
- Department of Geriatrics, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, PR China; Department of Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, PR China.
| | - Jing Lin
- Department of Geriatrics, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, PR China; Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, PR China
| | - Mingkai Zhuang
- Department of Geriatrics, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, PR China; Department of Digestive Medicine, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, PR China.
| | - Yue Wang
- Department of Geriatrics, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, PR China; Department of Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, PR China
| | - Qinyong Weng
- Department of Geriatrics, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, PR China; Department of Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, PR China.
| | - Hui Zhang
- Department of Geriatrics, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, PR China; Department of Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, PR China.
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Joseph A, Evrard B, Petit M, Goudelin M, Prat G, Slama M, Charron C, Vignon P, Vieillard-Baron A. Fluid responsiveness in acute respiratory distress syndrome patients: a post hoc analysis of the HEMOPRED study. Intensive Care Med 2024:10.1007/s00134-024-07639-6. [PMID: 39254736 DOI: 10.1007/s00134-024-07639-6] [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: 05/30/2024] [Accepted: 08/24/2024] [Indexed: 09/11/2024]
Abstract
PURPOSE Optimal fluid management in patients with acute respiratory distress syndrome (ARDS) is challenging due to risks associated with both circulatory failure and fluid overload. The performance of dynamic indices to predict fluid responsiveness (FR) in ARDS patients is uncertain. METHODS This post hoc analysis of the HEMOPRED study compared the performance of dynamic indices in mechanically ventilated patients with shock, with and without ARDS, to predict FR, defined as an increase in aortic velocity time integral (VTI) > 10% after passive leg raising (PLR). RESULTS Among 540 patients, 117 (22%) had ARDS and were ventilated with a median tidal volume of 7.6 mL/kg [6.9-8.4] and a median positive end-expiratory pressure of 7 cmH2O [5-9]. FR was observed in 45 ARDS patients (39% vs 44% in non-ARDS patients, p = 0.384). Reliability of dynamic indices to predict FR remained consistent in ARDS patients, though with different thresholds. Collapsibility index of the superior vena cava (ΔSVC) showed the best predictive performance in both ARDS (area under the curve [AUC] = 0.763 [0.659-0.868]) and non-ARDS (AUC = 0.750 [0.698-0.802]) patients. A right to left ventricle end-diastolic area ratio > 0.8 or paradoxical septal motion were strongly linked to the absence of FR (> 80% specificity). FR was not associated with intensive care unit (ICU) mortality (47% vs. 46%, p = 1). However, hypovolemia, defined as an aortic VTI increase > 32% during PLR (median increase in patients with a partial SVC collapse) was independently associated with ICU mortality (odds ratio [OR] = 1.355 [1.077-1.705], p = 0.011), as well as pulse pressure variation (OR = 1.014 [1.001-1.026], p = 0.034). CONCLUSION Performance of dynamic indices to predict FR appears preserved in ARDS patients, albeit with distinct thresholds. Hypovolemia, indicated by a > 32% increase in aortic VTI during PLR, rather than FR, was associated with ICU mortality in this population.
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Affiliation(s)
- Adrien Joseph
- Medical and Surgical intensive care unit, University Hospital Ambroise Paré, GHU Paris-Saclay, Assistance Publique Hôpitaux de Paris, Boulogne-Billancourt, France.
- Inserm U1173, Laboratory of Infection & Inflammation, University Versailles Saint Quentin - University Paris Saclay, Guyancourt, France.
| | - Bruno Evrard
- Medical-Surgical Intensive Care Unit, INSERM CIC 1435 and Faculty of Medicine, University of Limoges, Limoges, France
| | - Matthieu Petit
- Medical and Surgical intensive care unit, University Hospital Ambroise Paré, GHU Paris-Saclay, Assistance Publique Hôpitaux de Paris, Boulogne-Billancourt, France
- Inserm U1018, CESP, University Versailles Saint Quentin - University Paris Saclay, Guyancourt, France
| | - Marine Goudelin
- Medical-Surgical Intensive Care Unit, INSERM CIC 1435 and Faculty of Medicine, University of Limoges, Limoges, France
| | - Gwenaël Prat
- Medical Intensive Care Unit, Brest University Hospital, Brest, France
| | - Michel Slama
- Medical Intensive Care Unit, Amiens University Hospital, Amiens, France
| | - Cyril Charron
- Medical and Surgical intensive care unit, University Hospital Ambroise Paré, GHU Paris-Saclay, Assistance Publique Hôpitaux de Paris, Boulogne-Billancourt, France
| | - Philippe Vignon
- Medical-Surgical Intensive Care Unit, INSERM CIC 1435 and Faculty of Medicine, University of Limoges, Limoges, France
| | - Antoine Vieillard-Baron
- Medical and Surgical intensive care unit, University Hospital Ambroise Paré, GHU Paris-Saclay, Assistance Publique Hôpitaux de Paris, Boulogne-Billancourt, France
- Inserm U1018, CESP, University Versailles Saint Quentin - University Paris Saclay, Guyancourt, France
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Boesing C, Rocco PRM, Luecke T, Krebs J. Positive end-expiratory pressure management in patients with severe ARDS: implications of prone positioning and extracorporeal membrane oxygenation. Crit Care 2024; 28:277. [PMID: 39187853 PMCID: PMC11348554 DOI: 10.1186/s13054-024-05059-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 08/06/2024] [Indexed: 08/28/2024] Open
Abstract
The optimal strategy for positive end-expiratory pressure (PEEP) titration in the management of severe acute respiratory distress syndrome (ARDS) patients remains unclear. Current guidelines emphasize the importance of a careful risk-benefit assessment for PEEP titration in terms of cardiopulmonary function in these patients. Over the last few decades, the primary goal of PEEP usage has shifted from merely improving oxygenation to emphasizing lung protection, with a growing focus on the individual pattern of lung injury, lung and chest wall mechanics, and the hemodynamic consequences of PEEP. In moderate-to-severe ARDS patients, prone positioning (PP) is recommended as part of a lung protective ventilation strategy to reduce mortality. However, the physiologic changes in respiratory mechanics and hemodynamics during PP may require careful re-assessment of the ventilation strategy, including PEEP. For the most severe ARDS patients with refractory gas exchange impairment, where lung protective ventilation is not possible, veno-venous extracorporeal membrane oxygenation (V-V ECMO) facilitates gas exchange and allows for a "lung rest" strategy using "ultraprotective" ventilation. Consequently, the importance of lung recruitment to improve oxygenation and homogenize ventilation with adequate PEEP may differ in severe ARDS patients treated with V-V ECMO compared to those managed conservatively. This review discusses PEEP management in severe ARDS patients and the implications of management with PP or V-V ECMO with respect to respiratory mechanics and hemodynamic function.
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão, Rio de Janeiro, Brazil
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Choi YJ, Park MJ, Cho Y, Kim J, Lee E, Son D, Kim SY, Soh MS. Screening for RV Dysfunction Using Smartphone ECG Analysis App: Validation Study with Acute Pulmonary Embolism Patients. J Clin Med 2024; 13:4792. [PMID: 39200934 PMCID: PMC11355826 DOI: 10.3390/jcm13164792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Revised: 08/09/2024] [Accepted: 08/13/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Acute pulmonary embolism (PE) is a critical condition where the timely and accurate assessment of right ventricular (RV) dysfunction is important for patient management. Given the limited availability of echocardiography in emergency departments (EDs), an artificial intelligence (AI) application that can identify RV dysfunction from electrocardiograms (ECGs) could improve the treatment of acute PE. Methods: This retrospective study analyzed adult acute PE patients in an ED from January 2021 to December 2023. We evaluated a smartphone application which analyzes printed ECGs to generate digital biomarkers for various conditions, including RV dysfunction (QCG-RVDys). The biomarker's performance was compared with that of cardiologists and emergency physicians. Results: Among 116 included patients, 35 (30.2%) were diagnosed with RV dysfunction. The QCG-RVDys score demonstrated significant effectiveness in identifying RV dysfunction, with a receiver operating characteristic-area under the curve (AUC) of 0.895 (95% CI, 0.829-0.960), surpassing traditional biomarkers such as Troponin I (AUC: 0.692, 95% CI: 0.536-0.847) and ProBNP (AUC: 0.655, 95% CI: 0.532-0.778). Binarized based on the Youden Index, QCG-RVDys achieved an AUC of 0.845 (95% CI: 0.778-0.911), with a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 91.2% (95% CI: 82.4-100%), 77.8% (95% CI: 69.1-86.4%), 63.3% (95% CI: 54.4-73.9%), and 95.5% (95% CI: 90.8-100%), respectively, significantly outperforming all the expert clinicians, with their AUCs ranging from 0.628 to 0.683. Conclusions: The application demonstrates promise in rapidly assessing RV dysfunction in acute PE patients. Its high NPV could streamline patient management, potentially reducing the reliance on echocardiography in emergency settings.
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Affiliation(s)
- Yoo Jin Choi
- Department of Emergency Medicine, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si 16499, Gyeonggi-do, Republic of Korea; (Y.J.C.); (M.J.P.); (S.-Y.K.)
| | - Min Ji Park
- Department of Emergency Medicine, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si 16499, Gyeonggi-do, Republic of Korea; (Y.J.C.); (M.J.P.); (S.-Y.K.)
| | - Youngjin Cho
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si 13620, Gyeonggi-do, Republic of Korea;
- ARPI Inc., Room 12 Startup Incubation Center, 172, Dolma-ro, Bundang-gu, Seongnam-si 13605, Gyeonggi-do, Republic of Korea; (J.K.); (E.L.); (D.S.)
| | - Joonghee Kim
- ARPI Inc., Room 12 Startup Incubation Center, 172, Dolma-ro, Bundang-gu, Seongnam-si 13605, Gyeonggi-do, Republic of Korea; (J.K.); (E.L.); (D.S.)
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 82, 166 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si 13620, Gyeonggi-do, Republic of Korea
| | - Eunkyoung Lee
- ARPI Inc., Room 12 Startup Incubation Center, 172, Dolma-ro, Bundang-gu, Seongnam-si 13605, Gyeonggi-do, Republic of Korea; (J.K.); (E.L.); (D.S.)
| | - Dahyeon Son
- ARPI Inc., Room 12 Startup Incubation Center, 172, Dolma-ro, Bundang-gu, Seongnam-si 13605, Gyeonggi-do, Republic of Korea; (J.K.); (E.L.); (D.S.)
| | - Seo-Yoon Kim
- Department of Emergency Medicine, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si 16499, Gyeonggi-do, Republic of Korea; (Y.J.C.); (M.J.P.); (S.-Y.K.)
| | - Moon Seung Soh
- Department of Cardiology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si 16499, Gyeonggi-do, Republic of Korea
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Jozwiak M, Teboul JL. Heart-Lungs interactions: the basics and clinical implications. Ann Intensive Care 2024; 14:122. [PMID: 39133379 PMCID: PMC11319696 DOI: 10.1186/s13613-024-01356-5] [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: 05/02/2024] [Accepted: 07/24/2024] [Indexed: 08/13/2024] Open
Abstract
Heart-lungs interactions are related to the interplay between the cardiovascular and the respiratory system. They result from the respiratory-induced changes in intrathoracic pressure, which are transmitted to the cardiac cavities and to the changes in alveolar pressure, which may impact the lung microvessels. In spontaneously breathing patients, consequences of heart-lungs interactions are during inspiration an increase in right ventricular preload and afterload, a decrease in left ventricular preload and an increase in left ventricular afterload. In mechanically ventilated patients, consequences of heart-lungs interactions are during mechanical insufflation a decrease in right ventricular preload, an increase in right ventricular afterload, an increase in left ventricular preload and a decrease in left ventricular afterload. Physiologically and during normal breathing, heart-lungs interactions do not lead to significant hemodynamic consequences. Nevertheless, in some clinical settings such as acute exacerbation of chronic obstructive pulmonary disease, acute left heart failure or acute respiratory distress syndrome, heart-lungs interactions may lead to significant hemodynamic consequences. These are linked to complex pathophysiological mechanisms, including a marked inspiratory negativity of intrathoracic pressure, a marked inspiratory increase in transpulmonary pressure and an increase in intra-abdominal pressure. The most recent application of heart-lungs interactions is the prediction of fluid responsiveness in mechanically ventilated patients. The first test to be developed using heart-lungs interactions was the respiratory variation of pulse pressure. Subsequently, many other dynamic fluid responsiveness tests using heart-lungs interactions have been developed, such as the respiratory variations of pulse contour-based stroke volume or the respiratory variations of the inferior or superior vena cava diameters. All these tests share the same limitations, the most frequent being low tidal volume ventilation, persistent spontaneous breathing activity and cardiac arrhythmia. Nevertheless, when their main limitations are properly addressed, all these tests can help intensivists in the decision-making process regarding fluid administration and fluid removal in critically ill patients.
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Affiliation(s)
- Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, CHU de Nice Hôpital Archet 1, 151 Route Saint Antoine de Ginestière, 06200, Nice, France.
- UR2CA, Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, 06200, Nice, France.
| | - Jean-Louis Teboul
- Faculté de Médecine Paris-Saclay, Université Paris-Saclay, 94270, Le Kremlin-Bicêtre, France
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Xingzheng L, Weiguang G, Quanqiu Y, Huifen Z, Zijun Z, Qiming Z, Suhua Y, Fu Z, Zhigang J. The impact of positive end-expiratory pressure on right ventricular function in patients with moderate-to-severe ARDS: a prospective paired-design study. Front Med (Lausanne) 2024; 11:1424090. [PMID: 39015782 PMCID: PMC11250698 DOI: 10.3389/fmed.2024.1424090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 06/14/2024] [Indexed: 07/18/2024] Open
Abstract
Objective To determine the effects of varying positive end-expiratory pressures (PEEPs) on right ventricular function, hemodynamics, oxygenation, and the incidence of acute cor pulmonale (ACP) in patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Methods This prospective paired-design study involved patients with moderate-to-severe ARDS in the ICU. Participants received lung-protective ventilation and hemodynamic monitoring. During the study, mechanical ventilation was administered with PEEPs of 5 cmH2O, 10 cmH2O, and 15 cmH2O, while maintaining an end-inspiratory plateau pressure ≤ 30 cmH2O. Various assessments, including transthoracic echocardiography, cardiac output measurement, and blood gas analysis, were conducted at baseline and after 1 h of ventilation at each PEEP. Subsequently, variations in ventilation oxygenation, echocardiographic parameters, and hemodynamic indicators under different PEEPs were analyzed to explore the potential effects of PEEP on right ventricular function and hemodynamics, as well as the incidence of ACP. Results A total of 317 ARDS patients were screened. Among them, 104 met the diagnostic criteria for moderate-to-severe ARDS, and 52 completed the study. The baseline PEEP of these 52 participants, acquired before commencement, was 11.5 ± 1.7 cmH2O, and the incidence of ACP was 25.0% (13/52). Intensive care unit mortality, overall hospital mortality, and 28-day mortality rates were 19.2% (10/52), 21.2% (11/52), and 32.7% (17/52), respectively. During the study, ACP incidences at PEEPs of 5 cmH2O, 10 cmH2O, and 15 cmH2O were 17.3% (9/52), 21.2% (11/52), and 38.5% (20/52), respectively. Meanwhile, the PaO2/FiO2 ratio improved with increasing PEEP, reaching 162.0 (140.9, 174.0), 171.0 (144.0, 182.0), and 176.5 (151.0, 196) mmHg at PEEPs of 5 cmH2O, 10 cmH2O, and 15 cmH2O, respectively. In addition, higher PEEPs were associated with a slight increase in PaCO2, showing statistically significant differences compared to moderate and low PEEPs. Compared to a PEEP of 5 cmH2O or 10 cmH2O, right ventricular function exhibited substantial changes at 15 cmH2O PEEP, manifested as increased pulmonary artery systolic pressure, enlarged right ventricular end-diastolic area, and decreased tricuspid annular plane systolic excursion, all with significant differences. Conversely, variations in left ventricular end-diastolic area and ejection fraction were not statistically significant. In terms of hemodynamics, increasing PEEP resulted in a decline in cardiac index (CI), with statistically significant differences between different PEEPs. Specifically, compared to the value at a PEEP of 5 cmH2O, the CI at a PEEP of 15 cmH2O decreased by 14.3% (2.63 [2.20, 2.95] vs. 3.07 [2.69, 3.67], p < 0.001). The decline in the stroke volume index with PEEP was more obvious (22.1 [18.4, 27.1] vs. 27.0 [24.2, 33.0], p < 0.001), reaching 18.1%. Additionally, both end-diastolic volume index and extravascular lung water index decreased significantly with increasing PEEP, while the pulmonary vascular permeability index remained unaffected. Conclusion Different PEEPs can affect the incidence of ACP in patients with moderate-to-severe ARDS. High PEEP improves oxygenation and reduces extravascular lung water without significantly affecting the pulmonary vascular permeability index and left ventricular systolic function. Nevertheless, it can cause right ventricular dilation, as well as substantial declines in right ventricular systolic function and CI, thereby causing ACP.
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Affiliation(s)
- Luo Xingzheng
- Department of Critical Care Medicine, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Gu Weiguang
- Department of Critical Care Medicine, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Ye Quanqiu
- Department of Critical Care Medicine, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Zhou Huifen
- Department of Critical Care Medicine, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Zheng Zijun
- Department of Critical Care Medicine, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Zou Qiming
- Department of Critical Care Medicine, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Yuan Suhua
- Department of Medical Records, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Zhang Fu
- Department of Ultrasound, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Jian Zhigang
- Department of Critical Care Medicine, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
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Alwakeel M, Wang Y, Torbic H, Sacha GL, Wang X, Abi Fadel F, Duggal A. Impact of Sedation Practices on Mortality in COVID-19-Associated Adult Respiratory Distress Syndrome Patients: A Multicenter Retrospective Descriptive Study. J Intensive Care Med 2024; 39:646-654. [PMID: 38193291 DOI: 10.1177/08850666231224395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Background: Reduction in sedation exposure is an important metric in intensive care unit (ICU) patients. However, challenges arose during the coronavirus disease-2019 (COVID-19) pandemic in adhering to this practice, driven by concerns on transmission and disease severity issues. Accordingly, diverse sedation approaches emerged, although the effect on mortality has not been studied thoroughly. Methods: Retrospective cohort study in the medical ICU of seven hospitals within a major Health System in Northeast Ohio. We included all adult patients admitted with COVID-19 requiring invasive mechanical ventilation (IMV) from March 2020 to December 2021. Results: Study included 2394 COVID-19 patients requiring IMV. Across waves, sample included 55-63% male subjects, with an average age of 61-68 years (P < 0.001), Acute Physiologic and Chronic Health Evaluation (APACHE)-III score 65.8-68.9 (P = 0.37), median IMV duration 8-10 days (P = 0.14), and median ICU duration 9.8-11.6 days (P = 0.084). Propofol remained the primary sedative (84-92%; P = 0.089). Ketamine use increased from the first (9.7%) to fourth (19%) wave (P = 0.002). Midazolam use decreased from the first (27.4%) to third (9.4%) wave (P = 0.001). Dexmedetomidine use declined from 35% to 27-28% (P = 0.002) after the first wave. A multivariable regression analysis indicated clinical variables explained 34% of the variation in hospital mortality (R2). Factors associated with higher mortality included age [aOR = 1.059 (95% CI 1.049-1.069); P < 0.001], COVID-19 wave, especially fourth wave [aOR = 2.147, (95% CI 1.370-3.365); P = 0.001], and higher number of vasopressors [aOR = 31.636, (95% CI 17.603-56.856); P < 0.001]. Addition of sedative medications to a second model led to an increase in the R2 by only 1.6% to 35.6% [aOR = 1 (95% CI 1-1); P > 0.05] for propofol, ketamine, and midazolam. Dexmedetomidine demonstrated a decrease in the odds of mortality [aOR = 0.96 (95% CI 0.94-0.97); P < 0.001]. Conclusion: Mortality in critical COVID-19 patients was mostly driven by illness severity, and the choice of sedation might have minimal impact when other factors are controlled.
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Affiliation(s)
- Mahmoud Alwakeel
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yan Wang
- Department of Anesthesiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Xiaofeng Wang
- Qualitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francois Abi Fadel
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Abhijit Duggal
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Berger D, Stanger EJ, Jenni H, Fried PD, Bachmann KF. Modified Thermodilution for Simultaneous Cardiac Output and Recirculation Assessment in Veno-venous Extracorporeal Membrane Oxygenation: A Prospective Diagnostic Accuracy Study. Anesthesiology 2024; 140:1002-1015. [PMID: 38157435 DOI: 10.1097/aln.0000000000004895] [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: 01/03/2024]
Abstract
BACKGROUND Thermodilution is unreliable in veno-venous extracorporeal membrane oxygenation (VV-ECMO). Systemic oxygenation depends on recirculation fractions and ratios of extracorporeal membrane oxygenation (ECMO) flow to cardiac output. In a prospective in vitro simulation, this study assessed the diagnostic accuracy of a modified thermodilution technique for recirculation and cardiac output. The hypothesis was that this method provided clinically acceptable precision and accuracy for cardiac output and recirculation. METHODS Two ECMO circuits ran in parallel: one representing a VV-ECMO and the second representing native heart, lung, and circulation. Both circuits shared the right atrium. Extra limbs for recirculation and pulmonary shunt were added. This study simulated ECMO flows from 1 to 2.5 l/min and cardiac outputs from 2.5 to 3.5 l/min with recirculation fractions (0 to 80%) and pulmonary shunts. Thermistors in both ECMO limbs and the pulmonary artery measured the temperature changes induced by cold bolus injections into the arterial ECMO limb. Recirculation fractions were calculated from the ratio of the areas under the temperature curve (AUCs) in the ECMO limbs and from partitioning of the bolus volume (flow based). With known partitioning of bolus volumes between ECMO and pulmonary artery, cardiac output was calculated. High-precision ultrasonic flow probes served as reference for Bland-Altman plots and linear mixed-effect models. RESULTS Accuracy and precision for both the recirculation fraction based on AUC (bias, -5.4%; limits of agreement, -18.6 to 7.9%) and flow based (bias, -5.9%; limits of agreement, -18.8 to 7.0%) are clinically acceptable. Calculated cardiac output for all recirculation fractions was accurate but imprecise (RecirculationAUC: bias 0.56 l/min; limits of agreement, -2.27 to 3.4 l/min; and RecirculationFLOW: bias 0.48 l/min; limits of agreement, -2.22 to 3.19 l/min). Recirculation fraction increased bias and decreased precision. CONCLUSIONS Adapted thermodilution for VV-ECMO allows simultaneous measurement of recirculation fraction and cardiac output and may help optimize patient management with severe respiratory failure. EDITOR’S PERSPECTIVE
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Elia J Stanger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hansjörg Jenni
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philipp D Fried
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kaspar F Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Tomarchio E, Momigliano F, Giosa L, Collins PD, Barrett NA, Camporota L. The intricate physiology of veno-venous extracorporeal membrane oxygenation: an overview for clinicians. Perfusion 2024; 39:49S-65S. [PMID: 38654449 DOI: 10.1177/02676591241238156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
During veno-venous extracorporeal membrane oxygenation (V-V ECMO), blood is drained from the central venous circulation to be oxygenated and decarbonated by an artificial lung. It is then reinfused into the right heart and pulmonary circulation where further gas-exchange occurs. Each of these steps is characterized by a peculiar physiology that this manuscript analyses, with the aim of providing bedside tools for clinical care: we begin by describing the factors that affect the efficiency of blood drainage, such as patient and cannulae position, fluid status, cardiac output and ventilatory strategies. We then dig into the complexity of extracorporeal gas-exchange, with particular reference to the effects of extracorporeal blood-flow (ECBF), fraction of delivered oxygen (FdO2) and sweep gas-flow (SGF) on oxygenation and decarbonation. Subsequently, we focus on the reinfusion of arterialized blood into the right heart, highlighting the effects on recirculation and, more importantly, on right ventricular function. The importance and challenges of haemodynamic monitoring during V-V ECMO are also analysed. Finally, we detail the interdependence between extracorporeal circulation, native lung function and mechanical ventilation in providing adequate arterial blood gases while allowing lung rest. In the absence of evidence-based strategies to care for this particular group of patients, clinical practice is underpinned by a sound knowledge of the intricate physiology of V-V ECMO.
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Affiliation(s)
- Emilia Tomarchio
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Francesca Momigliano
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Lorenzo Giosa
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Patrick Duncan Collins
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Nicholas A Barrett
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Luigi Camporota
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
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10
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Patsalis N, Kreutz J, Chatzis G, Fichera CF, Syntila S, Choukeir M, Griewing S, Schieffer B, Markus B. Discussion of hemodynamic optimization strategies and the canonical understanding of hemodynamics during biventricular mechanical support in cardiogenic shock: does the flow balance make the difference? Clin Res Cardiol 2024; 113:602-611. [PMID: 38261027 PMCID: PMC10954998 DOI: 10.1007/s00392-024-02377-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/10/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Mechanical circulatory support (MCS) devices may stabilize patients with severe cardiogenic shock (CS) following myocardial infarction (MI). However, the canonical understanding of hemodynamics related to the determination of the native cardiac output (CO) does not explain or support the understanding of combined left and right MCS. To ensure the most optimal therapy control, the current principles of hemodynamic measurements during biventricular support should be re-evaluated. METHODS Here we report a protocol of hemodynamic optimization strategy during biventricular MCS (VA-ECMO and left ventricular Impella) in a case series of 10 consecutive patients with severe cardiogenic shock complicating myocardial infarction. During the protocol, the flow rates of both devices were switched in opposing directions (+ / - 0.7 l/min) for specified times. To address the limitations of existing hemodynamic measurement strategies during biventricular support, different measurement techniques (thermodilution, Fick principle, mixed venous oxygen saturation) were performed by pulmonary artery catheterization. Additionally, Doppler ultrasound was performed to determine the renal resistive index (RRI) as an indicator of renal perfusion. RESULTS The comparison between condition 1 (ECMO flow > Impella flow) and condition 2 (Impella flow > VA-ECMO flow) revealed significant changes in hemodynamics. In detail, compared to condition 1, condition 2 results in a significant increase in cardiac output (3.86 ± 1.11 vs. 5.44 ± 1.13 l/min, p = 0.005) and cardiac index (2.04 ± 0.64 vs. 2.85 ± 0.69, p = 0.013), and mixed venous oxygen saturation (56.44 ± 6.97% vs. 62.02 ± 5.64% p = 0.049), whereas systemic vascular resistance decreased from 1618 ± 337 to 1086 ± 306 s*cm-5 (p = 0.002). Similarly, RRI decreased in condition 2 (0.662 ± 0.05 vs. 0.578 ± 0.06, p = 0.003). CONCLUSIONS To monitor and optimize MCS in CS, PA catheterization for hemodynamic measurement is applicable. Higher Impella flow is superior to higher VA-ECMO flow resulting in a more profound increase in CO with subsequent improvement of organ perfusion.
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Affiliation(s)
- Nikolaos Patsalis
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Julian Kreutz
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Giorgos Chatzis
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Carlo-Federico Fichera
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Styliani Syntila
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Maryana Choukeir
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Sebastian Griewing
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Bernhard Schieffer
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Birgit Markus
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany.
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11
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Wang C, Zheng J, Zhao Y, Liu T, Zhang Y. Sequential respiratory support in septic patients undergoing continuous renal replacement therapy: A study based on MIMIC-III database. Heliyon 2024; 10:e27563. [PMID: 38524548 PMCID: PMC10958208 DOI: 10.1016/j.heliyon.2024.e27563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 03/26/2024] Open
Abstract
Objective Oxygen and hemodynamic management are important for providing a sufficient adequate oxygen-containing blood to the organs for septic patients. In present study, we aimed to explore the application of sequential respiratory support (SRS) and the association of SRS with the outcome of septic patients who needed continuous renal replacement therapy (CRRT). Methods We extracted the medical information of septic patients who received CRRT within 24 h of intensive care unit (ICU) admission from the MIMIC-III v1.4. SRS was defined as receiving firstly oxygen therapy followed by mechanical ventilation (MV) within 24 h of admission to ICU. The propensity score matching (PSM) was performed to compare the differences in clinical characteristics and outcomes of patients with or without SRS. Finally, we developed logistic regression models to analyze the effects of SRS on hospital mortality. Results A total of 181 patients entered in this study, and there were 80 patients undergoing MV including SRS group (n = 61) and non-SRS group (n = 19). In the multivariate logistic regression, the value of SRS was associated with the lower risk of hospital mortality adjusted by minimum systolic BP (SBP), maximum lactate, vasopressor use, and sequential organ failure assessment (SOFA) score or Logistic Organ Dysfunction System (LODS) scores within the first 24 h of ICU stay. After PSM adjusted by SBP, maximum lactate, vasopressor use, SOFA, and LODS, there were 31 patients in SRS group with a and 18 cases in non-SRS group, displaying a significantly lower hospital mortality in SRS group than that in patients without SRS (19.4 % vs. 83.3 %, P < 0.001). In addition, age, qSOFA, necessitating the administration of vasopressor, and duration of vasopressor were significantly correlated with the hospital mortality in septic patients undergoing CRRT and SRS. Conclusions Receiving SRS within the first 24 h upon admission to the ICU was independently associated with the hospital mortality in patient with sepsis undergoing CRRT, and patients who were directly received MV had a high risk of death.
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Affiliation(s)
- Chunxia Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062, Shanghai, China
- Laboratory of Critical Care Translational Medicine, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062, Shanghai, China
- Institute of Pediatric Critical Care, Shanghai Children's Hospital, Shanghai Jiao Tong University, 200062, Shanghai, China
| | - Jianli Zheng
- Institute of Medical Information Engineering, University of Shanghai for Science and Technology, 200093, Shanghai, China
| | - Yilin Zhao
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062, Shanghai, China
- Laboratory of Critical Care Translational Medicine, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062, Shanghai, China
| | - Tiantian Liu
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062, Shanghai, China
- Laboratory of Critical Care Translational Medicine, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062, Shanghai, China
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062, Shanghai, China
- Laboratory of Critical Care Translational Medicine, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062, Shanghai, China
- Institute of Pediatric Critical Care, Shanghai Children's Hospital, Shanghai Jiao Tong University, 200062, Shanghai, China
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12
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Boesing C, Krebs J, Conrad AM, Otto M, Beck G, Thiel M, Rocco PRM, Luecke T, Schaefer L. Effects of prone positioning on lung mechanical power components in patients with acute respiratory distress syndrome: a physiologic study. Crit Care 2024; 28:82. [PMID: 38491457 PMCID: PMC10941550 DOI: 10.1186/s13054-024-04867-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/10/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Prone positioning (PP) homogenizes ventilation distribution and may limit ventilator-induced lung injury (VILI) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The static and dynamic components of ventilation that may cause VILI have been aggregated in mechanical power, considered a unifying driver of VILI. PP may affect mechanical power components differently due to changes in respiratory mechanics; however, the effects of PP on lung mechanical power components are unclear. This study aimed to compare the following parameters during supine positioning (SP) and PP: lung total elastic power and its components (elastic static power and elastic dynamic power) and these variables normalized to end-expiratory lung volume (EELV). METHODS This prospective physiologic study included 55 patients with moderate to severe ARDS. Lung total elastic power and its static and dynamic components were compared during SP and PP using an esophageal pressure-guided ventilation strategy. In SP, the esophageal pressure-guided ventilation strategy was further compared with an oxygenation-guided ventilation strategy defined as baseline SP. The primary endpoint was the effect of PP on lung total elastic power non-normalized and normalized to EELV. Secondary endpoints were the effects of PP and ventilation strategies on lung elastic static and dynamic power components non-normalized and normalized to EELV, respiratory mechanics, gas exchange, and hemodynamic parameters. RESULTS Lung total elastic power (median [interquartile range]) was lower during PP compared with SP (6.7 [4.9-10.6] versus 11.0 [6.6-14.8] J/min; P < 0.001) non-normalized and normalized to EELV (3.2 [2.1-5.0] versus 5.3 [3.3-7.5] J/min/L; P < 0.001). Comparing PP with SP, transpulmonary pressures and EELV did not significantly differ despite lower positive end-expiratory pressure and plateau airway pressure, thereby reducing non-normalized and normalized lung elastic static power in PP. PP improved gas exchange, cardiac output, and increased oxygen delivery compared with SP. CONCLUSIONS In patients with moderate to severe ARDS, PP reduced lung total elastic and elastic static power compared with SP regardless of EELV normalization because comparable transpulmonary pressures and EELV were achieved at lower airway pressures. This resulted in improved gas exchange, hemodynamics, and oxygen delivery. TRIAL REGISTRATION German Clinical Trials Register (DRKS00017449). Registered June 27, 2019. https://drks.de/search/en/trial/DRKS00017449.
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Alice Marguerite Conrad
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Matthias Otto
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Grietje Beck
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Manfred Thiel
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, Brazil
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Laura Schaefer
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Jing HD, Tian JY, Li W, He BL, Li HC, Jian FX, Shang C, Shen F. Predictive performance of the variation rate of the driving pressure on the outcome of invasive mechanical ventilation in patients with acute respiratory distress syndrome. Chin J Traumatol 2024; 27:107-113. [PMID: 38326140 DOI: 10.1016/j.cjtee.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/06/2023] [Accepted: 12/18/2023] [Indexed: 02/09/2024] Open
Abstract
PURPOSE To assess the value of the driving pressure variation rate (ΔP%) in predicting the outcome of weaning from invasive mechanical ventilation in patients with acute respiratory distress syndrome. METHODS In this case-control study, a total of 35 patients with moderate-severe acute respiratory distress syndrome were admitted to the intensive care unit between January 2022 and December 2022 and received invasive mechanical ventilation for at least 48 h were enrolled. Patients were divided into successful weaning group and failed weaning group depending on whether they could be removed from ventilator support within 14 days. Outcome measures including driving pressure, PaO2:FiO2, and positive end-expiratory pressure, etc. were assessed every 24 h from day 0 to day 14 until successful weaning was achieved. The measurement data of non-normal distribution were presented as median (Q1, Q3), and the differences between groups were compared by Wilcoxon rank sum test. And categorical data use the Chi-square test or Fisher's exact test to compare. The predictive value of ΔP% in predicting the outcome of weaning from the ventilator was analyzed using receiver operating characteristic curves. RESULTS Of the total 35 patients included in the study, 17 were successful vs. 18 failed in weaning from a ventilator after 14 days of mechanical ventilation. The cut-off values of the median ΔP% measured by Operator 1 vs. Operator 2 in the first 4 days were ≥ 4.17% and 4.55%, respectively (p < 0.001), with the area under curve of 0.804 (sensitivity of 88.2%, specificity of 64.7%) and 0.770 (sensitivity of 88.2%, specificity of 64.7%), respectively. There was a significant difference in mechanical ventilation duration between the successful weaning group and the failure weaning group (8 (6, 13) vs. 12 (7.5, 17.3), p = 0.043). The incidence of ventilator-associated pneumonia in the successful weaning group was significantly lower than in the failed weaning group (0.2‰ vs. 2.3‰, p = 0.001). There was a significant difference noted between these 2 groups in the 28-day mortality (11.8% vs. 66.7%, p = 0.003). CONCLUSION The median ΔP% in the first 4 days of mechanical ventilation showed good predictive performance in predicting the outcome of weaning from mechanical ventilation within 14 days. Further study is needed to confirm this finding.
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Affiliation(s)
- Hui-Dan Jing
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China; Department of Intensive Care Unit, Army Medical Center of PLA, Chongqing, 400042, China
| | - Jun-Ying Tian
- College of Foreign Languages, Chongqing Medical University, Chongqing, 400016, China
| | - Wei Li
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Bing-Ling He
- Department of Intensive Care Unit, Army Medical Center of PLA, Chongqing, 400042, China
| | - Hong-Chao Li
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Fu-Xia Jian
- Department of Intensive Care Unit, Army Medical Center of PLA, Chongqing, 400042, China
| | - Cui Shang
- Department of Intensive Care Unit, Army Medical Center of PLA, Chongqing, 400042, China
| | - Feng Shen
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China.
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Chen H, Huang L, Xing B, Gao Y, Zhang J, Zhang B. Prognostic value of right ventricular free wall strain in patients with sepsis. Front Cardiovasc Med 2024; 11:1334759. [PMID: 38450378 PMCID: PMC10915020 DOI: 10.3389/fcvm.2024.1334759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/05/2024] [Indexed: 03/08/2024] Open
Abstract
Background Right ventricular systolic dysfunction (RVSD) in patients with sepsis is an area of growing interest, but its prognostic significance remains unclear and additional tools are needed to improve our understanding. Right ventricular free wall strain (RV-FWS) is a relatively new parameter to assess RV function. This study aimed to investigate the potential correlation between impaired RV-FWS and prognostic outcomes in patients with sepsis. Methods We prospectively assessed right ventricular function in patients with sepsis within the initial 24 h of their hospital admission. RV-FWS, right ventricular global strain (RV-GS), fractional area change (FAC), and tricuspid annular plane systolic excursion (TAPSE) were examined. RVSD was defined as impaired RV-FWS. Moreover, the association between RVSD and 30-day mortality rate was assessed. Results This study included 89 patients. Among them, 27 (30.3%) succumbed to their illness within 30 days. The nonsurviving patients demonstrated significantly lower absolute RV-FWS (-19.7% ± 2.4% vs. -21.1% ± 2.1%, P = 0.008) and RV-GS (-17.7% ± 1.2% vs. -18.4% ± 1.4%, P = 0.032) values than the surviving patients. However, TAPSE and FAC values were not significantly different between the two groups. The optimal cutoff values for RV-FWS, RV-GS, FAC, and TAPSE were -19.0%, -17.9%, 36.5%, and 1.55 cm, respectively. Kaplan-Meier survival curves revealed that patients with impaired RV-FWS and RV-GS demonstrated lower 30-day survival rates, and the predictive performance of RV-FWS (hazard ratio [HR]: 3.97, 95% confidence interval [CI]: 1.85-8.51, P < 0.001) was slightly higher than FAC and TAPSE. However, multivariable Cox regression analysis revealed no association between impaired RV-FWS and mortality outcomes (HR: 1.85, 95% CI: 0.56-6.14, P = 0.316). Conclusions Impaired RV-FWS is not associated with short-term mortality outcomes, and RV strain imaging is of limited value in assessing the prognosis of sepsis.
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Affiliation(s)
- Hongmin Chen
- Department of Ultrasound, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People’s Hospital, Yichang, China
| | - Lei Huang
- Department of Critical Care Medicine, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People’s Hospital, Yichang, China
| | - Boyuan Xing
- Department of Ultrasound, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People’s Hospital, Yichang, China
| | - Yang Gao
- Department of Ultrasound, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People’s Hospital, Yichang, China
| | - Jie Zhang
- Department of Ultrasound, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People’s Hospital, Yichang, China
| | - Bingyi Zhang
- Department of Ultrasound, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People’s Hospital, Yichang, China
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15
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Falk L, Lidegran M, Diaz Ruiz S, Hultman J, Broman LM. Severe Lung Dysfunction and Pulmonary Blood Flow during Extracorporeal Membrane Oxygenation. J Clin Med 2024; 13:1113. [PMID: 38398425 PMCID: PMC10889439 DOI: 10.3390/jcm13041113] [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: 01/10/2024] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is indicated for patients with severe respiratory and/or circulatory failure. The standard technique to visualize the extent of pulmonary damage during ECMO is computed tomography (CT). PURPOSE This single-center, retrospective study investigated whether pulmonary blood flow (PBF) measured with echocardiography can assist in assessing the extent of pulmonary damage and whether echocardiography and CT findings are associated with patient outcomes. METHODS All patients (>15 years) commenced on ECMO between 2011 and 2017 with septic shock of pulmonary origin and a treatment time >28 days were screened. Of 277 eligible patients, 9 were identified where both CT and echocardiography had been consecutively performed. RESULTS CT failed to indicate any differences in viable lung parenchyma within or between survivors and non-survivors at any time during ECMO treatment. Upon initiation of ECMO, the survivors (n = 5) and non-survivors (n = 4) had similar PBF. During a full course of ECMO support, survivors showed no change in PBF (3.8 ± 2.1 at ECMO start vs. 7.9 ± 4.3 L/min, p = 0.12), whereas non-survivors significantly deteriorated in PBF from 3.5 ± 1.0 to 1.0 ± 1.1 L/min (p = 0.029). Tidal volumes were significantly lower over time among the non-survivors, p = 0.047. CONCLUSIONS In prolonged ECMO for pulmonary septic shock, CT was not found to be effective for the evaluation of pulmonary viability or recovery. This hypothesis-generating investigation supports echocardiography as a tool to predict pulmonary recovery via the assessment of PBF at the early to later stages of ECMO support.
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Affiliation(s)
- Lars Falk
- ECMO Centre Karolinska, ME Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Akademiska Straket 14, 171 76 Stockholm, Sweden; (J.H.); (L.M.B.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Marika Lidegran
- Department of Pediatric Radiology, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, 171 76 Stockholm, Sweden; (M.L.); (S.D.R.)
| | - Sandra Diaz Ruiz
- Department of Pediatric Radiology, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, 171 76 Stockholm, Sweden; (M.L.); (S.D.R.)
- Department of Women’s and Children’s Health, Karolinska Institutet, 171 76 Stockholm, Sweden
- Department of Radiology, Lund University, 221 00 Lund, Sweden
| | - Jan Hultman
- ECMO Centre Karolinska, ME Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Akademiska Straket 14, 171 76 Stockholm, Sweden; (J.H.); (L.M.B.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, ME Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Akademiska Straket 14, 171 76 Stockholm, Sweden; (J.H.); (L.M.B.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 76 Stockholm, Sweden
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Joseph A, Petit M, Vieillard-Baron A. Hemodynamic effects of positive end-expiratory pressure. Curr Opin Crit Care 2024; 30:10-19. [PMID: 38085886 DOI: 10.1097/mcc.0000000000001124] [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: 01/03/2024]
Abstract
PURPOSE OF REVIEW Positive end-expiratory pressure (PEEP) is required in the Berlin definition of acute respiratory distress syndrome and is a cornerstone of its treatment. Application of PEEP increases airway pressure and modifies pleural and transpulmonary pressures according to respiratory mechanics, resulting in blood volume alteration into the pulmonary circulation. This can in turn affect right ventricular preload, afterload and function. At the opposite, PEEP may improve left ventricular function, providing no deleterious effect occurs on the right ventricle. RECENT FINDINGS This review examines the impact of PEEP on cardiac function with regards to heart-lung interactions, and describes its consequences on organs perfusion and function, including the kidney, gut, liver and the brain. PEEP in itself is not beneficious nor detrimental on end-organ hemodynamics, but its hemodynamic effects vary according to both respiratory mechanics and association with other hemodynamic variables such as central venous or mean arterial pressure. There are parallels in the means of preventing deleterious impact of PEEP on the lungs, heart, kidney, liver and central nervous system. SUMMARY The quest for optimal PEEP settings has been a prominent goal in ARDS research for the last decades. Intensive care physician must maintain a high degree of vigilance towards hemodynamic effects of PEEP on cardiac function and end-organs circulation.
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Affiliation(s)
- Adrien Joseph
- Medical Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt
| | - Matthieu Petit
- Medical Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt
- Inserm, CESP, Paris-Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, Villejuif, France
| | - Antoine Vieillard-Baron
- Medical Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt
- Inserm, CESP, Paris-Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, Villejuif, France
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Thornton LT, Kummer RL, Marini JJ. The place of positive end expiratory pressure in ventilator-induced lung injury generation. Curr Opin Crit Care 2024; 30:4-9. [PMID: 38085885 DOI: 10.1097/mcc.0000000000001118] [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: 01/03/2024]
Abstract
PURPOSE OF REVIEW Describe the rationale for concern and accumulating pathophysiologic evidence regarding the adverse effects of high-level positive end expiratory pressure (PEEP) on excessive mechanical stress and ventilator-induced lung injury (VILI). RECENT FINDINGS Although the inclusion of PEEP in numerical estimates of mechanical power may be theoretically debated, its potential to increase stress, strain, and mean airway pressure are not. Recent laboratory data in a variety of animal models demonstrate that higher levels of PEEP coupled with additional fluids needed to offset its impediment of hemodynamic function are associated with increased VILI. Moreover, counteracting end-tidal hyperinflation by external chest wall pressure may paradoxically improve respiratory mechanics, indicating that lower PEEP helps protect the small 'baby lung' of advanced acute respiratory distress syndrome (ARDS). SUMMARY The potentially adverse effects of PEEP on VILI can be considered in three broad categories. First, the contribution of PEEP to total mechanical energy expressed through mechanical power, raised mean airway pressure, and end-tidal hyperinflation; second, the hemodynamic consequences of altered cardiac loading, heightened pulmonary vascular stress and total lung water; and third, the ventilatory consequences of compromised carbon dioxide eliminating efficiency. Minimizing ventilation demands, optimized body positioning and care to avoid unnecessary PEEP are central to lung protection in all stages of ARDS.
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Affiliation(s)
- Lauren T Thornton
- University of Minnesota, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Minneapolis, St. Paul, Minnesota, USA
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18
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Boesing C, Schaefer L, Graf PT, Pelosi P, Rocco PRM, Luecke T, Krebs J. Effects of different positive end-expiratory pressure titration strategies on mechanical power during ultraprotective ventilation in ARDS patients treated with veno-venous extracorporeal membrane oxygenation: A prospective interventional study. J Crit Care 2024; 79:154406. [PMID: 37690365 DOI: 10.1016/j.jcrc.2023.154406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 05/13/2023] [Accepted: 07/09/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Ultraprotective ventilation in acute respiratory distress syndrome (ARDS) patients with veno-venous extracorporeal membrane oxygenation (VV ECMO) reduces mechanical power (MP) through changes in positive end-expiratory pressure (PEEP); however, the optimal approach to titrate PEEP is unknown. This study assesses the effects of three PEEP titration strategies on MP, hemodynamic parameters, and oxygen delivery in twenty ARDS patients with VV ECMO. MATERIAL AND METHODS PEEP was titrated according to: (A) a PEEP of 10 cmH2O representing the lowest recommendation by the Extracorporeal Life Support Organization (PEEPELSO), (B) the highest static compliance of the respiratory system (PEEPCstat,RS), and (C) a target end-expiratory transpulmonary pressure of 0 cmH2O (PEEPPtpexp). RESULTS PEEPELSO was lower compared to PEEPCstat,RS and PEEPPtpexp (10.0 ± 0.0 vs. 16.2 ± 4.7 cmH2O and 17.3 ± 4.0 cmH2O, p < 0.001 each, respectively). PEEPELSO reduced MP compared to PEEPCstat,RS and PEEPPtpexp (5.3 ± 1.3 vs. 6.8 ± 2.0 and 6.9 ± 2.3 J/min, p < 0.001 each, respectively). PEEPELSO resulted in less lung stress compared to PEEPCstat,RS (p = 0.011) and PEEPPtpexp (p < 0.001) and increased cardiac output and oxygen delivery (p < 0.001 each). CONCLUSIONS An empirical PEEP of 10 cmH2O minimized MP, provided favorable hemodynamics, and increased oxygen delivery in ARDS patients treated with VV ECMO. TRIAL REGISTRATION German Clinical Trials Register (DRKS00013967). Registered 02/09/2018https://drks.de/search/en/trial/DRKS00013967.
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Laura Schaefer
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Peter T Graf
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Anesthesiology and Critical Care - San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão, Rio de Janeiro, Brazil.
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
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Gong S, Ding X, Wang X. Assessment of Pulmonary Circulation of Critically Ill Patients Based on Critical Care Ultrasound. J Clin Med 2024; 13:722. [PMID: 38337417 PMCID: PMC10856787 DOI: 10.3390/jcm13030722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/01/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Pulmonary circulation is crucial in the human circulatory system, facilitating the oxygenation of blood as it moves from the right heart to the lungs and then to the left heart. However, during critical illness, pulmonary microcirculation can be vulnerable to both intrapulmonary and extrapulmonary injuries. To assess these potential injuries in critically ill patients, critical point-of-care ultrasound can be used to quantitatively and qualitatively evaluate the right atrium, right ventricle, pulmonary artery, lung, pulmonary vein, and left atrium along the direction of blood flow. This assessment is particularly valuable for common ICU diseases such as acute respiratory distress syndrome (ARDS), sepsis, pulmonary hypertension, and cardiogenic pulmonary edema. It has significant potential for diagnosing and treating these conditions in critical care medicine.
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Affiliation(s)
| | - Xin Ding
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing 100730, China;
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing 100730, China;
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20
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Guo Z, Su Z, Wei Y, Zhang X, Hong X. Pyroptosis in glioma: Current management and future application. Immunol Rev 2024; 321:152-168. [PMID: 38063042 DOI: 10.1111/imr.13294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Glioma, the predominant form of central nervous system (CNS) malignancies, presents a significant challenge due to its high prevalence and low 5-year survival rate. The efficacy of current treatment methods is limited by the presence of the blood-brain barrier, the immunosuppressive microenvironment, and other factors. Immunotherapy has emerged as a promising approach, as it can overcome the blood-brain barrier. A tumor's immune privilege, which is induced by an immunosuppressive environment, constricts immunotherapy's clinical impact in glioma. Pyroptosis, a programmed cell death mechanism facilitated by gasdermins, plays a significant role in the management of glioma. Its ability to initiate and regulate tumor occurrence, progression, and metastasis is well-established. However, it is crucial to note that uncontrolled or excessive cell death can result in tissue damage, acute inflammation, and cytokine release syndrome, thereby potentially promoting tumor advancement or recurrence. This paper aims to elucidate the molecular pathways involved in pyroptosis and subsequently discuss its induction in cancer therapy. In addition, the current treatment methods of glioma and the use of pyroptosis in these treatments are introduced. It is hoped to provide more ideas for the treatment of glioma.
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Affiliation(s)
- Zeshang Guo
- Department of Neurosurgery, The First Bethune Hospital of Jilin University, Changchun, China
| | - Zhenjin Su
- Department of Neurosurgery, The First Bethune Hospital of Jilin University, Changchun, China
| | - Ying Wei
- Department of Radiology, The First Bethune Hospital of Jilin University, Changchun, China
| | - Xingmei Zhang
- College of Medical Technology, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xinyu Hong
- Department of Neurosurgery, The First Bethune Hospital of Jilin University, Changchun, China
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21
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Silva PL, Scharffenberg M, Rocco PRM. Understanding the mechanisms of ventilator-induced lung injury using animal models. Intensive Care Med Exp 2023; 11:82. [PMID: 38010595 PMCID: PMC10682329 DOI: 10.1186/s40635-023-00569-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023] Open
Abstract
Mechanical ventilation is a life-saving therapy in several clinical situations, promoting gas exchange and providing rest to the respiratory muscles. However, mechanical ventilation may cause hemodynamic instability and pulmonary structural damage, which is known as ventilator-induced lung injury (VILI). The four main injury mechanisms associated with VILI are as follows: barotrauma/volutrauma caused by overstretching the lung tissues; atelectrauma, caused by repeated opening and closing of the alveoli resulting in shear stress; and biotrauma, the resulting biological response to tissue damage, which leads to lung and multi-organ failure. This narrative review elucidates the mechanisms underlying the pathogenesis, progression, and resolution of VILI and discusses the strategies that can mitigate VILI. Different static variables (peak, plateau, and driving pressures, positive end-expiratory pressure, and tidal volume) and dynamic variables (respiratory rate, airflow amplitude, and inspiratory time fraction) can contribute to VILI. Moreover, the potential for lung injury depends on tissue vulnerability, mechanical power (energy applied per unit of time), and the duration of that exposure. According to the current evidence based on models of acute respiratory distress syndrome and VILI, the following strategies are proposed to provide lung protection: keep the lungs partially collapsed (SaO2 > 88%), avoid opening and closing of collapsed alveoli, and gently ventilate aerated regions while keeping collapsed and consolidated areas at rest. Additional mechanisms, such as subject-ventilator asynchrony, cumulative power, and intensity, as well as the damaging threshold (stress-strain level at which tidal damage is initiated), are under experimental investigation and may enhance the understanding of VILI.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Martin Scharffenberg
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.
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22
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Villar J, Szakmany T, Grasselli G, Camporota L. Redefining ARDS: a paradigm shift. Crit Care 2023; 27:416. [PMID: 37907946 PMCID: PMC10619227 DOI: 10.1186/s13054-023-04699-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 11/02/2023] Open
Abstract
Although the defining elements of "acute respiratory distress syndrome" (ARDS) have been known for over a century, the syndrome was first described in 1967. Since then, despite several revisions of its conceptual definition, it remains a matter of debate whether ARDS is a discrete nosological entity. After almost 60 years, it is appropriate to examine how critical care has modeled this fascinating syndrome and affected patient's outcome. Given that the diagnostic criteria of ARDS (e.g., increased pulmonary vascular permeability and diffuse alveolar damage) are difficult to ascertain in clinical practice, we believe that a step forward would be to standardize the assessment of pulmonary and extrapulmonary involvement in ARDS to ensure that each patient can receive the most appropriate and effective treatment. The selection of treatments based on arbitrary ranges of PaO2/FiO2 lacks sufficient sensitivity to individualize patient care.
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Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029, Madrid, Spain.
- Research Unit, Hospital Universitario Dr. Negrin, Barranco de La Ballena S/N, 4Th Floor-South Wing, 35019, Las Palmas de Gran Canaria, Spain.
- Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada.
| | - Tamas Szakmany
- Department of Intensive Care Medicine & Anesthesia, Aneurin Bevan University Health Board, Newport, NP20 2UB, Wales, UK
- Honorary Professor in Intensive Care, Cardiff University, Cardiff, CF14 4XW, Wales, UK
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
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23
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Pan L, Yang L, Gao L, Zhao Z, Zhang J. Individualized PEEP without Recruitment Maneuvers Improves Intraoperative Oxygenation: A Randomized Controlled Study. Bioengineering (Basel) 2023; 10:1172. [PMID: 37892902 PMCID: PMC10604161 DOI: 10.3390/bioengineering10101172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
Individualized positive end-expiratory pressure (PEEP) combined with recruitment maneuvers improves intraoperative oxygenation in individuals undergoing robot-assisted prostatectomy. However, whether electrical impedance tomography (EIT)-guided individualized PEEP without recruitment maneuvers can also improve intraoperative oxygenation is unknown. To test this, fifty-six male patients undergoing elective robot-assisted laparoscopic prostatectomy were randomly assigned to either individualized PEEP (Group PEEPIND, n = 28) or a control with a fixed PEEP of 5 cm H2O (Group PEEP5, n = 28). Individualized PEEP was guided by EIT after placing the patients in the Trendelenburg position and performing intraperitoneal insufflation. Patients in Group PEEPIND maintained individualized PEEP without intermittent recruitment maneuvers, and those in Group PEEP5 maintained a PEEP of 5 cm H2O intraoperatively. Both groups were extubated in a semi-sitting position once the extubation criteria were met. The primary outcome was arterial oxygen partial pressure (PaO2)/inspiratory oxygen fraction (FiO2) prior to extubation. Other outcomes included intraoperative driving pressure, plateau pressure and dynamic, respiratory system compliance, and the incidence of postoperative hypoxemia in the post-operative care unit (PACU). Our results showed that the intraoperative median for PEEPIND was 16 cm H2O (ranging from 12 to 18 cm H2O). EIT-guided PEEPIND was associated with higher PaO2/FiO2 before extubation compared to PEEP5 (71.6 ± 10.7 vs. 56.8 ± 14.1 kPa, p = 0.003). Improved oxygenation extended into the PACU with a lower incidence of postoperative hypoxemia (3.8% vs. 26.9%, p = 0.021). Additionally, PEEPIND was associated with lower driving pressures (12.0 ± 3.0 vs. 15.0 ± 4.4 cm H2O, p = 0.044) and better compliance (44.5 ± 12.8 vs. 33.6 ± 9.1 mL/cm H2O, p = 0.017). Our data indicated that individualized PEEP guided by EIT without intraoperative recruitment maneuvers also improved perioperative oxygenation in patients undergoing robot-assisted laparoscopic radical prostatectomy, which could benefit patients with the risk of intraoperative hemodynamic instability caused by recruitment maneuvers. Trial registration: China Clinical Trial Registration Center Identifier: ChiCTR2100053839. This study was registered on 1 December 2021. The first patient was recruited on 15 December 2021.
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Affiliation(s)
- Lili Pan
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China; (L.P.); (L.Y.); (L.G.)
| | - Li Yang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China; (L.P.); (L.Y.); (L.G.)
| | - Lingling Gao
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China; (L.P.); (L.Y.); (L.G.)
| | - Zhanqi Zhao
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou 511436, China
- Institute of Technical Medicine, Furtwangen University, 78054 Villingen-Schwenningen, Germany
| | - Jun Zhang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China; (L.P.); (L.Y.); (L.G.)
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24
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Hamahata N, Pinsky MR. Heart-Lung Interactions. Semin Respir Crit Care Med 2023; 44:650-660. [PMID: 37541314 DOI: 10.1055/s-0043-1770062] [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: 08/06/2023]
Abstract
The pulmonary and cardiovascular systems have profound effects on each other. Overall cardiac function is determined by heart rate, preload, contractility, and afterload. Changes in lung volume, intrathoracic pressure (ITP), and hypoxemia can simultaneously change all of these four hemodynamic determinants for both ventricles and can even lead to cardiovascular collapse. Intubation using sedation depresses vasomotor tone. Also, the interdependence between right and left ventricles can be affected by lung volume-induced changes in pulmonary vascular resistance and the rise in ITP. An increase in venous return due to negative ITP during spontaneous inspiration can shift the septum to the left and cause a decrease in left ventricle compliance. During positive pressure ventilation, the increase in ITP causes a decrease in venous return (preload), minimizing ventricular interdependence and will decrease left ventricle afterload augmenting cardiac output. Thus, positive pressure ventilation is beneficial in acute heart failure patients and detrimental in hypovolemic patients where it can cause a significant decrease in venous return and cardiac output. Recently, this phenomenon has been used to assess patient's volume responsiveness to fluid by measuring pulse pressure variation and stroke volume variation. Heart-lung interaction is very dynamic and changes in lung volume, ITP, and oxygen level can have various effects on the cardiovascular system depending on preexisting cardiovascular function and volume status. Heart failure and either hypo or hypervolemia predispose to greater effects of ventilation of cardiovascular function and gas exchange. This review is an overview of the basics of heart-lung interaction.
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Affiliation(s)
- Natsumi Hamahata
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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25
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Xu Y, Zhang Y, Zhang J, Liang W, Wang Y, Zeng Z, Liang Z, Ling Z, Chen Y, Deng X, Huang Y, Liu X, Zhang H, Li Y. High driving pressure ventilation induces pulmonary hypertension in a rabbit model of acute lung injury. J Intensive Care 2023; 11:42. [PMID: 37749622 PMCID: PMC10518953 DOI: 10.1186/s40560-023-00689-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/04/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Mechanical ventilation may cause pulmonary hypertension in patients with acute lung injury (ALI), but the underlying mechanism remains elucidated. METHODS ALI was induced in rabbits by a two-hit injury, i.e., hydrochloric acid aspiration followed by mechanical ventilation for 1 h. Rabbits were then ventilated with driving pressure of 10, 15, 20, or 25 cmH2O for 7 h. Clinicopathological parameters were measured at baseline and different timepoints of ventilation. RNA sequencing was conducted to identify the differentially expressed genes in high driving pressure ventilated lung tissue. RESULTS The two-hit injury induced ALI in rabbits was evidenced by dramatically decreased PaO2/FiO2 in the ALI group compared with that in the control group (144.5 ± 23.8 mmHg vs. 391.6 ± 26.6 mmHg, P < 0.001). High driving pressure ventilation (20 and 25 cmH2O) significantly elevated the parameters of acute pulmonary hypertension at different timepoints compared with low driving pressure (10 and 15 cmH2O), along with significant increases in lung wet/dry ratios, total protein contents in bronchoalveolar lavage fluid, and lung injury scores. The high driving pressure groups showed more pronounced histopathological abnormalities in the lung compared with the low driving pressure groups, accompanied by significant increases in the cross-sectional areas of myocytes, right ventricular weight/body weight value, and Fulton's index. Furthermore, the expression of the genes related to ferroptosis induction was generally upregulated in high driving pressure groups compared with those in low driving pressure groups. CONCLUSIONS A rabbit model of ventilation-induced pulmonary hypertension in ALI was successfully established. Our results open a new research direction investigating the exact role of ferroptosis in ventilation-induced pulmonary hypertension in ALI.
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Affiliation(s)
- Yonghao Xu
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China
| | - Yu Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China
| | - Jie Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China
| | - Weibo Liang
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China
| | - Ya Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China
| | - Zitao Zeng
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China
| | - Zhenting Liang
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China
| | - Zhaoyi Ling
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China
| | - Yubiao Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China
| | - Xiumei Deng
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China
| | - Yongbo Huang
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China
| | - Xiaoqing Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China
| | - Haibo Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China.
- The Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, M5B1W8, Canada.
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Yimin Li
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, 510120, China.
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Bachmann KF, Berger D, Moller PW. Interactions between extracorporeal support and the cardiopulmonary system. Front Physiol 2023; 14:1231016. [PMID: 37772062 PMCID: PMC10523013 DOI: 10.3389/fphys.2023.1231016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023] Open
Abstract
This review describes the intricate physiological interactions involved in the application of extracorporeal therapy, with specific focus on cardiopulmonary relationships. Extracorporeal therapy significantly influences cardiovascular and pulmonary physiology, highlighting the necessity for clinicians to understand these interactions for improved patient care. Veno-arterial extracorporeal membrane oxygenation (veno-arterial ECMO) unloads the right ventricle and increases left ventricular (LV) afterload, potentially exacerbating LV failure and pulmonary edema. Veno-venous (VV) ECMO presents different challenges, where optimal device and ventilator settings remain unknown. Influences on right heart function and native gas exchange as well as end-expiratory lung volumes are important concepts that should be incorporated into daily practice. Future studies should not be limited to large clinical trials focused on mortality but rather address physiological questions to advance the understanding of extracorporeal therapies. This includes exploring optimal device and ventilator settings in VV ECMO, standardizing cardiopulmonary function monitoring strategies, and developing better strategies for device management throughout their use. In this regard, small human or animal studies and computational physiological modeling may contribute valuable insights into optimizing the management of extracorporeal therapies.
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Affiliation(s)
- Kaspar F. Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Per Werner Moller
- Department of Anaesthesia, SV Hospital Group, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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27
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Berger D, Werner Moller P, Bachmann KF. Cardiopulmonary interactions-which monitoring tools to use? Front Physiol 2023; 14:1234915. [PMID: 37621761 PMCID: PMC10445648 DOI: 10.3389/fphys.2023.1234915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/18/2023] [Indexed: 08/26/2023] Open
Abstract
Heart-lung interactions occur due to the mechanical influence of intrathoracic pressure and lung volume changes on cardiac and circulatory function. These interactions manifest as respiratory fluctuations in venous, pulmonary, and arterial pressures, potentially affecting stroke volume. In the context of functional hemodynamic monitoring, pulse or stroke volume variation (pulse pressure variation or stroke volume variability) are commonly employed to assess volume or preload responsiveness. However, correct interpretation of these parameters requires a comprehensive understanding of the physiological factors that determine pulse pressure and stroke volume. These factors include pleural pressure, venous return, pulmonary vessel function, lung mechanics, gas exchange, and specific cardiac factors. A comprehensive knowledge of heart-lung physiology is vital to avoid clinical misjudgments, particularly in cases of right ventricular (RV) failure or diastolic dysfunction. Therefore, when selecting monitoring devices or technologies, these factors must be considered. Invasive arterial pressure measurements of variations in breath-to-breath pressure swings are commonly used to monitor heart-lung interactions. Echocardiography or pulmonary artery catheters are valuable tools for differentiating preload responsiveness from right ventricular failure, while changes in diastolic function should be assessed alongside alterations in airway or pleural pressure, which can be approximated by esophageal pressure. In complex clinical scenarios like ARDS, combined forms of shock or right heart failure, additional information on gas exchange and pulmonary mechanics aids in the interpretation of heart-lung interactions. This review aims to describe monitoring techniques that provide clinicians with an integrative understanding of a patient's condition, enabling accurate assessment and patient care.
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Per Werner Moller
- Department of Anaesthesia, SV Hospital Group, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kaspar F. Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
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Alvarado AC, Pinsky MR. Cardiopulmonary interactions in left heart failure. Front Physiol 2023; 14:1237741. [PMID: 37614756 PMCID: PMC10442533 DOI: 10.3389/fphys.2023.1237741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/25/2023] [Indexed: 08/25/2023] Open
Abstract
The primary impact of ventilation and ventilatory efforts on left ventricular (LV) function in left ventricular dysfunction relate to how changes in intrathoracic pressure (ITP) alter the pressure gradients for venous return into the chest and LV ejection out of the chest. Spontaneous inspiratory efforts by decreasing ITP increase both of these pressure gradients increasing venous blood flow and impeding LV ejection resulting in increased intrathoracic blood volume. In severe heart failure states when lung compliance is reduced, or airway resistance is increased these negative swings in ITP can be exacerbated leading to LV failure and acute cardiogenic pulmonary edema. By merely reversing these negative swings in ITP by the use of non-invasive continuous positive airway pressure (CPAP), these profoundly detrimental forces can be immediately reversed, and cardiovascular stability can be restored in moments. This forms the clinical rationale for the immediate use of CPAP for the treatment of acute cardiogenic pulmonary edema. Increasing ITP during positive pressure ventilation decreases the pressure gradients for venous return and LV ejection decreasing intrathoracic blood volume. In a hypovolemic patient even with LV dysfunction this can result in hypotension due to inadequate LV preload. Minor increases in ITP as occur using pressure-limited positive-pressure ventilation primarily reverse the increased LV afterload of negative swings in ITP and if fluid overload was already present, minimally alter cardiac output. The effect of changes in lung volume on LV function are related primarily to its effects on right ventricular (RV) function through changes in pulmonary vascular resistance and overdistention (hyperinflation). In acute lung injury with alveolar collapse, positive pressure ventilation may reduce pulmonary vascular resistance if alveolar recruitment predominates. Hyperinflation, however, impedes diastolic filling while simultaneously increasing pulmonary vascular resistance. Thus, increasing lung volume can reduce RV afterload by reversing hypoxic pulmonary vasoconstriction or increase afterload by overdistention. Hyperinflation can also impede RV filling. All of these processes can be readily identified at the bedside using echocardiography.
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Affiliation(s)
| | - Michael R. Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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29
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Duncan CF, Bowcock E, Pathan F, Orde SR. Mitral regurgitation in the critically ill: the devil is in the detail. Ann Intensive Care 2023; 13:67. [PMID: 37530859 PMCID: PMC10397171 DOI: 10.1186/s13613-023-01163-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/03/2023] [Indexed: 08/03/2023] Open
Abstract
Mitral regurgitation (MR) is common in the critically unwell and encompasses a heterogenous group of conditions with diverging therapeutic strategies. MR may present acutely with haemodynamic instability or more insidiously with failure to wean from mechanical ventilation. Critical illness is associated with marked physiological stress and haemodynamic changes that dynamically influence the severity and implication of MR. The expanding role of critical care echocardiography uniquely positions the intensivist to apply advanced bedside valvular assessment to recognise haemodynanically significant MR, manipulate and optimise cardiopulmonary physiology and identify patients requiring urgent cardiology and surgical referral. This review will consider common clinical scenarios, therapeutic strategies and the pearls and pitfalls of echocardiographic assessment and quantification in the critically unwell.
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Affiliation(s)
- Chris F Duncan
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia.
| | - Emma Bowcock
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
| | - Faraz Pathan
- Department of Cardiology, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
- Nepean Clinical School of Medicine, Charles Perkin Centre Nepean, University of Sydney, Kingswood, Sydney, NSW, 2747, Australia
| | - Sam R Orde
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
- University of Sydney, Camperdown, Sydney, NSW, 2006, Australia
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30
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de Carvalho EB, Battaglini D, Robba C, Malbrain MLNG, Pelosi P, Rocco PRM, Silva PL. Fluid management strategies and their interaction with mechanical ventilation: from experimental studies to clinical practice. Intensive Care Med Exp 2023; 11:44. [PMID: 37474816 PMCID: PMC10359242 DOI: 10.1186/s40635-023-00526-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/31/2023] [Indexed: 07/22/2023] Open
Abstract
Patients on mechanical ventilation may receive intravenous fluids via restrictive or liberal fluid management. A clear and objective differentiation between restrictive and liberal fluid management strategies is lacking in the literature. The liberal approach has been described as involving fluid rates ranging from 1.2 to 12 times higher than the restrictive approach. A restrictive fluid management may lead to hypoperfusion and distal organ damage, and a liberal fluid strategy may result in endothelial shear stress and glycocalyx damage, cardiovascular complications, lung edema, and distal organ dysfunction. The association between fluid and mechanical ventilation strategies and how they interact toward ventilator-induced lung injury (VILI) could potentiate the damage. For instance, the combination of a liberal fluids and pressure-support ventilation, but not pressure control ventilation, may lead to further lung damage in experimental models of acute lung injury. Moreover, under liberal fluid management, the application of high positive end-expiratory pressure (PEEP) or an abrupt decrease in PEEP yielded higher endothelial cell damage in the lungs. Nevertheless, the translational aspects of these findings are scarce. The aim of this narrative review is to provide better understanding of the interaction between different fluid and ventilation strategies and how these interactions may affect lung and distal organs. The weaning phase of mechanical ventilation and the deresuscitation phase are not explored in this review.
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Affiliation(s)
- Eduardo Butturini de Carvalho
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- University of Vassouras, Rio de Janeiro, Brazil
| | | | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Manu L. N. G. Malbrain
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
- International Fluid Academy, Lovenjoel, Belgium
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Shah N, Katira BH. Role of cardiopulmonary interactions in development of ventilator-induced lung injury-Experimental evidence and clinical Implications. Front Physiol 2023; 14:1228476. [PMID: 37534365 PMCID: PMC10391157 DOI: 10.3389/fphys.2023.1228476] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/07/2023] [Indexed: 08/04/2023] Open
Abstract
Ventilator-induced lung injury (VILI) impacts outcomes in ARDS and optimization of ventilatory strategies improves survival. Decades of research has identified various mechanisms of VILI, largely focusing on airspace forces of plateau pressure, tidal volume and driving pressure. Experimental evidence indicates the role of adverse cardiopulmonary interaction during mechanical ventilation, contributing to VILI genesis mostly by modulating pulmonary vascular dynamics. Under passive mechanical ventilation, high transpulmonary pressure increases afterload on right heart while high pleural pressure reduces the RV preload. Together, they can result in swings of pulmonary vascular flow and pressure. Altered vascular flow and pressure result in increased vascular shearing and wall tension, in turn causing direct microvascular injury accompanied with permeability to water, proteins and cells. Moreover, abrupt decreases in airway pressure, may result in sudden overperfusion of the lung and result in similar microvascular injury, especially when the endothelium is stretched or primed at high positive end-expiratory pressure. Microvascular injury is universal in VILI models and presumed in the diagnosis of ARDS; preventing such microvascular injury can reduce VILI and impact outcomes in ARDS. Consequently, developing cardiovascular targets to reduce macro and microvascular stressors in the pulmonary circulation can potentially reduce VILI. This paper reviews the role of cardiopulmonary interaction in VILI genesis.
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Ding P, Yang R, Li C, Fu HL, Ren GL, Wang P, Zheng DY, Chen W, Yang LY, Mao YF, Yuan HB, Li YH. Fibroblast growth factor 21 attenuates ventilator-induced lung injury by inhibiting the NLRP3/caspase-1/GSDMD pyroptotic pathway. Crit Care 2023; 27:196. [PMID: 37218012 DOI: 10.1186/s13054-023-04488-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 05/13/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Ventilator-induced lung injury (VILI) is caused by overdistension of the alveoli by the repetitive recruitment and derecruitment of alveolar units. This study aims to investigate the potential role and mechanism of fibroblast growth factor 21 (FGF21), a metabolic regulator secreted by the liver, in VILI development. METHODS Serum FGF21 concentrations were determined in patients undergoing mechanical ventilation during general anesthesia and in a mouse VILI model. Lung injury was compared between FGF21-knockout (KO) mice and wild-type (WT) mice. Recombinant FGF21 was administrated in vivo and in vitro to determine its therapeutic effect. RESULTS Serum FGF21 levels in patients and mice with VILI were significantly higher than in those without VILI. Additionally, the increment of serum FGF21 in anesthesia patients was positively correlated with the duration of ventilation. VILI was aggravated in FGF21-KO mice compared with WT mice. Conversely, the administration of FGF21 alleviated VILI in both mouse and cell models. FGF21 reduced Caspase-1 activity, suppressed the mRNA levels of Nlrp3, Asc, Il-1β, Il-18, Hmgb1 and Nf-κb, and decreased the protein levels of NLRP3, ASC, IL-1β, IL-18, HMGB1 and the cleaved form of GSDMD. CONCLUSIONS Our findings reveal that endogenous FGF21 signaling is triggered in response to VILI, which protects against VILI by inhibiting the NLRP3/Caspase-1/GSDMD pyroptosis pathway. These results suggest that boosting endogenous FGF21 or the administration of recombinant FGF21 could be promising therapeutic strategies for the treatment of VILI during anesthesia or critical care.
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Affiliation(s)
- Peng Ding
- Department of Anesthesiology, Changzheng Hospital, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
- Department of Anesthesiology, PLA No.983 Hospital, Tianjin, China
| | - Rui Yang
- Department of Anesthesiology, Changzheng Hospital, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Cheng Li
- Department of Anesthesiology, Changzheng Hospital, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Hai-Long Fu
- Department of Anesthesiology, Changzheng Hospital, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Guang-Li Ren
- Department of Anesthesiology, PLA No.983 Hospital, Tianjin, China
| | - Pei Wang
- Department of Pharmacology, College of Pharmacy, Naval Medical University, Shanghai, China
| | - Dong-Yu Zheng
- Department of Anesthesiology, Changzheng Hospital, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Wei Chen
- Department of Anesthesiology, Changzheng Hospital, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Li-Ye Yang
- Department of Anesthesiology, Changzheng Hospital, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Yan-Fei Mao
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Hong-Bin Yuan
- Department of Anesthesiology, Changzheng Hospital, The Second Affiliated Hospital of Naval Medical University, Shanghai, China.
| | - Yong-Hua Li
- Department of Anesthesiology, Changzheng Hospital, The Second Affiliated Hospital of Naval Medical University, Shanghai, China.
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Stanger EJ, Berger DC, Jenni H, Bachmann KF. Behaviour and stability of thermodilution signals in a closed extracorporeal circuit: a bench study. J Clin Monit Comput 2023:10.1007/s10877-023-01018-0. [PMID: 37166694 PMCID: PMC10371883 DOI: 10.1007/s10877-023-01018-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/14/2023] [Indexed: 05/12/2023]
Abstract
Thermodilution is the gold standard for cardiac output measurement in critically ill patients. Its application in extracorporeal therapy is limited, as a portion of the thermal indicator is drawn into the extracorporeal circuit. The behaviour of thermodilution signals in extracorporeal circuits is unknown. We investigated thermodilution curves within a closed-circuit and assessed the impact of injection volume, flow and distance on the behaviour of the thermodilution signals and catheter constants. We injected 3, 5, 7 and 10 ml of thermal indicator into a heated closed circuit. Thermistors at distances of 40, 60, 80, and 100 cm from the injection port recorded the thermodilution signals (at flow settings of 0.5, 1, 1.5, and 2 L/min). Area under the curve (AUC), rise time, exponential decay and catheter constants were analysed. Linear mixed-effects models were used to evaluate the impact of circuit flow, distance and injection volume. Catheter positioning did not influence AUC (78 injections). Catheter constants were independent of flow, injection volume or distance to the injection port. The distance to the injection port increased peak temperature and rise time and decreased exponential time constant significantly. The distance to the injection port did not influence catheter constants, but the properties of the thermodilution signal itself. This may influence measurements that depend on the exponential decay of the thermodilution signal such as right ventricular ejection fraction.
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Affiliation(s)
- Elia J Stanger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 3000, Bern, Switzerland
| | - David C Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 3000, Bern, Switzerland
| | - Hansjörg Jenni
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kaspar F Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 3000, Bern, Switzerland.
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de Forcrand C, Cassara CM, Dollerschell JT, Kopanczyk R, Long MT. Refractory Hypoxemia on VV-ECMO: Repetition of a Structured Approach Is Paramount: A Case Report. A A Pract 2023; 17:e01677. [PMID: 37146223 DOI: 10.1213/xaa.0000000000001677] [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: 05/07/2023]
Abstract
Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is increasingly used to manage severe respiratory failure. Unfortunately, refractory hypoxemia often complicates VV-ECMO support. Both circuit- and patient-related etiologies can drive this, and a structured approach is necessary to diagnose and treat the condition. We present the case of a patient on VV-ECMO for acute respiratory distress syndrome who suffered from several distinct etiologies of refractory hypoxemia over a short timeframe. Frequent recalculation of cardiac output and oxygen delivery enabled early diagnosis and treatment of these conditions. We highlight the need for a structured and oft-repeated approach to this complex problem.
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Affiliation(s)
- Claire de Forcrand
- From the Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Chris M Cassara
- Department of Anesthesiology, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - John T Dollerschell
- Department of Anesthesiology, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Rafal Kopanczyk
- Department of Anesthesiology, Division of Critical Care Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Micah T Long
- Department of Anesthesiology, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
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Messina A, Alicino V, Cecconi M. Transpulmonary thermodilution. Curr Opin Crit Care 2023; 29:223-230. [PMID: 37083621 DOI: 10.1097/mcc.0000000000001047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
PURPOSE OF REVIEW The purpose of this article is to systematically review and critically assess the existing data regarding the use of transpulmonary thermodilution (TPTD), by providing a detailed description of technical aspects of TPTD techniques, appraising the use of TPTD-derived parameters in specific clinical settings, and exploring the limits of this technique. RECENT FINDINGS The aim of hemodynamic monitoring is to optimize cardiac output (CO) and therefore improve oxygen delivery to the tissues. Hemodynamic monitoring plays a fundamental role in the management of acutely ill patients. TPTD is a reliable, multiparametric, advanced cardiopulmonary monitoring technique providing not only hemodynamic parameters related to cardiac function, but also to the redistribution of the extravascular water in the thorax. The hemodynamic monitors available in the market usually couple the intermittent measurement of the CO by TPTD with the arterial pulse contour analysis, offering automatic calibration of continuous CO and an accurate assessment of cardiac preload and fluid responsiveness. SUMMARY The TPTD is an invasive but well tolerated, multiparametric, advanced cardiopulmonary monitoring technique, allowing a comprehensive assessment of cardiopulmonary condition. Beyond the CO estimation, TPTD provides several indices that help answering questions that clinicians ask themselves during hemodynamic management. TPTD-guided algorithm obtained by pulse contour analysis may be useful to optimize fluid resuscitation by titrating fluid therapy according to functional hemodynamic monitoring and to define safety criteria to avoid fluid overload by following the changes in the extravascular lung water (EVLW) and pulmonary vascular permeability index (PVPI).
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Via Manzoni, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | | | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Via Manzoni, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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Magder S, Slobod D, Assanangkornchai N. Right Ventricular Limitation: A Tale of Two Elastances. Am J Respir Crit Care Med 2023; 207:678-692. [PMID: 36257049 DOI: 10.1164/rccm.202106-1564so] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Right ventricular (RV) dysfunction is a commonly considered cause of low cardiac output in critically ill patients. Its management can be difficult and requires an understanding of how the RV limits cardiac output. We explain that RV stroke output is caught between the passive elastance of the RV walls during diastolic filling and the active elastance produced by the RV in systole. These two elastances limit RV filling and stroke volume and consequently limit left ventricular stroke volume. We emphasize the use of the term "RV limitation" and argue that limitation of RV filling is the primary pathophysiological process by which the RV causes hemodynamic instability. Importantly, RV limitation can be present even when RV function is normal. We use the term "RV dysfunction" to indicate that RV end-systolic elastance is depressed or diastolic elastance is increased. When RV dysfunction is present, RV limitation occurs at lowerpulmonary valve opening pressures and lower stroke volume, but stroke volume and cardiac output still can be maintained until RV filling is limited. We use the term "RV failure" to indicate the condition in which RV output is insufficient for tissue needs. We discuss the physiological underpinnings of these terms and implications for clinical management.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Nawaporn Assanangkornchai
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
- Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand
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Aragona CO, Bagnato G, Tomeo S, Rosa DL, Chiappalone M, Tringali MC, Singh EB, Versace AG. Echocardiography in Coronavirus Disease 2019 Era: A Single Tool for Diagnosis and Prognosis. J Cardiovasc Echogr 2023; 33:10-16. [PMID: 37426709 PMCID: PMC10328134 DOI: 10.4103/jcecho.jcecho_11_23] [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: 02/04/2023] [Revised: 03/07/2023] [Accepted: 03/18/2023] [Indexed: 07/11/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is characterized by multi-organ involvement, including respiratory and cardiac events. Echocardiography is widely considered the first-choice tool for the evaluation of cardiac structures and function because of its reproducibility, feasibility, easy to use at bedside, and for good cost-effectiveness. The aim of our literature review is to define the utility of echocardiography in the prediction of prognosis and mortality in COVID-19 patients with mild to critical respiratory illness, with or without known cardiovascular disease. Moreover, we focused our attention on classical echocardiographic parameters and the use of speckle tracking to predict the evolution of respiratory involvement. Finally, we tried to explore the possible relationship between pulmonary disease and cardiac manifestations.
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Affiliation(s)
- Caterina Oriana Aragona
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
| | - Gianluca Bagnato
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
| | - Simona Tomeo
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
| | - Daniela La Rosa
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
| | - Marianna Chiappalone
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
| | - Maria Concetta Tringali
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
| | - Emanuele Balwinder Singh
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
| | - Antonio Giovanni Versace
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
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Wang X, Zhang T, Gao X, Cai H, Guo M, Liu Q, Guo S, Ji W. Early human albumin administration is associated with reduced mortality in septic shock patients with acute respiratory distress syndrome: A retrospective study from the MIMIC-III database. Front Physiol 2023; 14:1142329. [PMID: 37089426 PMCID: PMC10119420 DOI: 10.3389/fphys.2023.1142329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/27/2023] [Indexed: 04/25/2023] Open
Abstract
Background: Sepsis-induced acute respiratory distress syndrome (ARDS) was associated with higher mortality. It is unclear whether albumin supplementation early in the course of ARDS can affect the prognostic outcomes of septic shock (SS) patients with ARDS. Methods: The MIMIC-III database was employed to identify SS patients with ARDS. The effect of early application (<24 h after ICU admission) of human albumin on 28-day mortality in SS patients with ARDS was explored. The propensity score matching was used to minimize the bias between the non-albumin and early albumin treatment groups. Results: The analysis for all eligible patients who received human albumin showed significantly lower 28-hospital mortality rates than the non-albumin group (37% versus 47%, p = 0.018). After propensity matching, the difference between the two groups also significantly (34.8% versus 48.1%, p = 0.031). Moreover, we found that the relationship between albumin use and reduced 28-day mortality was inconsistent across SOFA score subgroups (Pinteraction = 0.004, non-adjustment for multiple testing). Conclusion: Early human albumin administration in SS patients with ARDS was independently associated with a reduction of 28-day mortality. Furthermore, the benefit of human albumin treatment appeared to be more pronounced in patients with a SOFA score of ≤ 10.
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Affiliation(s)
- Xiya Wang
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
| | - Tianqian Zhang
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
| | - Xinzhen Gao
- LIANREN Digital Health Co., Ltd., Beijing, China
| | - Hongbo Cai
- LIANREN Digital Health Co., Ltd., Beijing, China
| | - Mengke Guo
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
| | - Qi Liu
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
| | - Shubin Guo
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
- *Correspondence: Shubin Guo, ; Wenqing Ji,
| | - Wenqing Ji
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
- *Correspondence: Shubin Guo, ; Wenqing Ji,
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Palikova YA, Palikov VA, Novikova NI, Slashcheva GA, Rasskazova EA, Tukhovskaya EA, Danilkovich AV, Dyachenko IA, Belogurov Jr. AA, Kudriaeva AA, Bugrimov DY, Krasnorutskaya ON, Murashev AN. Derinat ® has an immunomodulatory and anti-inflammatory effect on the model of acute lung injury in male SD rats. Front Pharmacol 2022; 13:1111340. [PMID: 36642990 PMCID: PMC9837527 DOI: 10.3389/fphar.2022.1111340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/16/2022] [Indexed: 12/31/2022] Open
Abstract
To simulate acute lung injury (ALI) in SD male rats they we administered intratracheally with lipopolysaccharide (LPS) followed by hyperventilation of the lungs (HVL), which lead to functional changes in the respiratory system and an increase in the blood serum concentration of inflammatory cytokines. LPS + HVL after 4 h lead to pronounced histological signs of lung damage. We have studied the effectiveness of Derinat® when administered intramuscularly at dose of 7.5 mg/kg for 8 days in the ALI model. Derinat® administration lead to an increase in the concentration of most of the studied cytokines in a day. In the ALI model the administration of Derinat® returned the concentration of cytokines to its original values already 48 h after LPS + HVL, and also normalized the parameters of pulmonary respiration in comparison with animals without treatment. By the eighth day after LPS + HVL, respiratory parameters and cytokine levels, as well as biochemical and hematological parameters did not differ between groups, while histological signs of residual effects of lung damage were found in all animals, and were more pronounced in Derinat® group, which may indicate stimulation of the local immune response. Thus, the administration of Derinat® stimulates the immune response, has a pronounced protective effect against cytokinemia and respiratory failure caused by ALI, has immunomodulatory effect, and also stimulates a local immune response in lung tissues. Thus, Derinat® is a promising treatment for ALI.
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Affiliation(s)
- Yulia A. Palikova
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia
| | - Victor A. Palikov
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia
| | - Nadezhda I. Novikova
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia
| | - Gulsara A. Slashcheva
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia
| | - Ekaterina A. Rasskazova
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia
| | - Elena A. Tukhovskaya
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia,*Correspondence: Elena A. Tukhovskaya,
| | - Alexey V. Danilkovich
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia
| | - Igor A. Dyachenko
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia
| | - Alexey A. Belogurov Jr.
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (IBCh RAS), 16/10 Miklukho-Maklay Str, Moscow, Russia,Department of Biological Chemistry, Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Anna A. Kudriaeva
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (IBCh RAS), 16/10 Miklukho-Maklay Str, Moscow, Russia
| | - Daniil Y Bugrimov
- Voronezh State Medical University Named After N. N. Burdenko, 10 Studencheskaya Str, Voronezh, Russia
| | - Olga N. Krasnorutskaya
- Voronezh State Medical University Named After N. N. Burdenko, 10 Studencheskaya Str, Voronezh, Russia
| | - Arkady N. Murashev
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia,*Correspondence: Elena A. Tukhovskaya,
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Ma A, Wang B, Cheng J, Dong M, Li Y, Wei C, Zhou Y, Xue Y, Gao H, Zhao L, Li S, Qin Y, Zhang M, Wu Q, Yang J, Kang Y. Effects of airway pressure release ventilation on multi-organ injuries in severe acute respiratory distress syndrome pig models. BMC Pulm Med 2022; 22:468. [PMID: 36476475 PMCID: PMC9730639 DOI: 10.1186/s12890-022-02238-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Extra-pulmonary multi-organ failure in patients with severe acute respiratory distress syndrome (ARDS) is a major cause of high mortality. Our purpose is to assess whether airway pressure release ventilation (APRV) causes more multi-organ damage than low tidal volume ventilation (LTV). METHODS Twenty one pigs were randomized into control group (n = 3), ARDS group (n = 3), LTV group (n = 8) and APRV group (n = 7). Severe ARDS model was induced by repeated bronchial saline lavages. Pigs were ventilated and monitored continuously for 48 h. Respiratory data, hemodynamic data, serum inflammatory cytokines were collected throughout the study. Histological injury and apoptosis were assessed by two pathologists. RESULTS After severe ARDS modeling, pigs in ARDS, LTV and APRV groups experienced significant hypoxemia and reduced lung static compliance (Cstat). Oxygenation recovered progressively after 16 h mechanical ventilation (MV) in LTV and APRV group. The results of the repeated measures ANOVA showed no statistical difference in the PaO2/FiO2 ratio between the APRV and LTV groups (p = 0.54). The Cstat showed a considerable improvement in APRV group with statistical significance (p < 0.01), which was significantly higher than in the LTV group since 16 h (p = 0.04). Histological injury scores showed a significantly lower injury score in the middle and lower lobes of the right lung in the APRV group compared to LTV (pmiddle = 0.04, plower = 0.01), and no significant increase in injury scores for extra-pulmonary organs, including kidney (p = 0.10), small intestine (p = 1.0), liver (p = 0.14, p = 0.13) and heart (p = 0.20). There were no significant differences in serum inflammatory cytokines between the two groups. CONCLUSION In conclusion, in the experimental pig models of severe ARDS induced by repetitive saline lavage, APRV improved lung compliance with reduced lung injury of middle and lower lobes, and did not demonstrate more extra-pulmonary organ injuries as compared with LTV.
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Affiliation(s)
- Aijia Ma
- grid.412901.f0000 0004 1770 1022Department of Critical Care Medicine, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Bo Wang
- grid.412901.f0000 0004 1770 1022Department of Critical Care Medicine, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Jiangli Cheng
- grid.412901.f0000 0004 1770 1022Department of Critical Care Medicine, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Meiling Dong
- grid.412901.f0000 0004 1770 1022Department of Critical Care Medicine, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Yang Li
- grid.412901.f0000 0004 1770 1022Department of Critical Care Medicine, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Canzheng Wei
- grid.412901.f0000 0004 1770 1022Department of Critical Care Medicine, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Yongfang Zhou
- grid.412901.f0000 0004 1770 1022Department of Critical Care Medicine, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Yang Xue
- grid.412901.f0000 0004 1770 1022Department of Critical Care Medicine, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Hui Gao
- grid.412901.f0000 0004 1770 1022Department of Nursing, West China Hospital of Sichuan University, Chengdu, Sichuan Province China
| | - Lican Zhao
- grid.412901.f0000 0004 1770 1022Department of Nursing, West China Hospital of Sichuan University, Chengdu, Sichuan Province China
| | - Siyu Li
- grid.412901.f0000 0004 1770 1022Department of Nursing, West China Hospital of Sichuan University, Chengdu, Sichuan Province China
| | - Yiwei Qin
- grid.414880.1Department of Critical Care Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan Province China
| | - Mengni Zhang
- grid.412901.f0000 0004 1770 1022Department of Pathology, West China Hospital of Sichuan University, Chengdu, Sichuan Province China
| | - Qin Wu
- grid.412901.f0000 0004 1770 1022Department of Critical Care Medicine, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Jing Yang
- grid.412901.f0000 0004 1770 1022Department of Critical Care Medicine, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Yan Kang
- grid.412901.f0000 0004 1770 1022Department of Critical Care Medicine, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041 Sichuan Province China
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Comprehensive Monitoring in Patients With Dual Lumen Right Atrium to Pulmonary Artery Right Ventricular Assist Device. ASAIO J 2022; 68:1461-1469. [PMID: 35239539 PMCID: PMC9579997 DOI: 10.1097/mat.0000000000001684] [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: 02/04/2023] Open
Abstract
Right ventricular assist devices (RVADs) can be used in patients with acute right heart failure. A novel device that has recently been deployed is the right atrium to pulmonary artery (RA-PA) dual lumen single cannula (DLSC). One of the limitations is that it occupies a large proportion of the right ventricular outflow tract and PA; therefore, standard continuous hemodynamic monitoring with a pulmonary artery catheter is commonly not used. Serial echocardiography is pivotal for device deployment, monitoring device position, assessing RV readiness for decannulation, and surveilling for short-term complications. We performed a retrospective case series of 24 patients with RA-PA DLSC RVAD assessing echocardiographic RV progression and vasoactive infusion requirements. The overall survival was 66.6%. The average vasoactive infusion score at the time of cannulation was 24.9 ± 43.9, at decannulation in survivors 4.6 ± 4.9 vs . 25.4 ± 21.5 in nonsurvivors, and 2.7 ± 4.9 at 48 hours post decannulation. On echocardiography, the average visual estimate of RV systolic function encoded (0 = none and 5 = severe) in survivors was 3.9 ± 1.2, 2.8 ± 1.6, 2.5 ± 1.7, and 2.8 ± 1.9, respectively, and in nonsurvivors 3.8 ± 1.6 and 3.4 ± 1.8, respectively. This demonstrated an RV systolic function improvement over time in survivors as opposed to nonsurvivors. This was also demonstrated in RV size visual estimate, respectively. Quantitatively, at the predefined four timepoints, the RV:LV, tricuspid annular plane systolic excursion, and fractional area change all improve over time and there is statistically significant difference in survivors versus nonsurvivors. In this study, we describe a cohort of patients treated with RA-PA DLSC RVAD. We illustrate the critical nature of echocardiographic measures to rate the progression of RV function, improvement in vasoactive infusion requirements, and ventilator parameters with the RA-PA DLSC.
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Shi R, Ayed S, Moretto F, Azzolina D, De Vita N, Gavelli F, Carelli S, Pavot A, Lai C, Monnet X, Teboul JL. Tidal volume challenge to predict preload responsiveness in patients with acute respiratory distress syndrome under prone position. Crit Care 2022; 26:219. [PMID: 35850771 PMCID: PMC9294836 DOI: 10.1186/s13054-022-04087-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/29/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Prone position is frequently used in patients with acute respiratory distress syndrome (ARDS), especially during the Coronavirus disease 2019 pandemic. Our study investigated the ability of pulse pressure variation (PPV) and its changes during a tidal volume challenge (TVC) to assess preload responsiveness in ARDS patients under prone position.
Methods
This was a prospective study conducted in a 25-bed intensive care unit at a university hospital. We included patients with ARDS under prone position, ventilated with 6 mL/kg tidal volume and monitored by a transpulmonary thermodilution device. We measured PPV and its changes during a TVC (ΔPPV TVC6–8) after increasing the tidal volume from 6 to 8 mL/kg for one minute. Changes in cardiac index (CI) during a Trendelenburg maneuver (ΔCITREND) and during end-expiratory occlusion (EEO) at 8 mL/kg tidal volume (ΔCI EEO8) were recorded. Preload responsiveness was defined by both ΔCITREND ≥ 8% and ΔCI EEO8 ≥ 5%. Preload unresponsiveness was defined by both ΔCITREND < 8% and ΔCI EEO8 < 5%.
Results
Eighty-four sets of measurements were analyzed in 58 patients. Before prone positioning, the ratio of partial pressure of arterial oxygen to fraction of inspired oxygen was 104 ± 27 mmHg. At the inclusion time, patients were under prone position for 11 (2–14) hours. Norepinephrine was administered in 83% of cases with a dose of 0.25 (0.15–0.42) µg/kg/min. The positive end-expiratory pressure was 14 (11–16) cmH2O. The driving pressure was 12 (10–17) cmH2O, and the respiratory system compliance was 32 (22–40) mL/cmH2O. Preload responsiveness was detected in 42 cases. An absolute change in PPV ≥ 3.5% during a TVC assessed preload responsiveness with an area under the receiver operating characteristics (AUROC) curve of 0.94 ± 0.03 (sensitivity: 98%, specificity: 86%) better than that of baseline PPV (0.85 ± 0.05; p = 0.047). In the 56 cases where baseline PPV was inconclusive (≥ 4% and < 11%), ΔPPV TVC6–8 ≥ 3.5% still enabled to reliably assess preload responsiveness (AUROC: 0.91 ± 0.05, sensitivity: 97%, specificity: 81%; p < 0.01 vs. baseline PPV).
Conclusion
In patients with ARDS under low tidal volume ventilation during prone position, the changes in PPV during a TVC can reliably assess preload responsiveness without the need for cardiac output measurements.
Trial registration: ClinicalTrials.gov (NCT04457739). Registered 30 June 2020 —Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT04457739
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Cheng Z, Zhu Q, Chen J, Sun Y, Liang Z. Analysis of clinical characteristics and prognostic factors of ARDS caused by community-acquired pneumonia in people with different immune status. Expert Rev Anti Infect Ther 2022; 20:1643-1650. [PMID: 36306191 DOI: 10.1080/14787210.2022.2142116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The purpose of this study is to describe the clinical characteristics and prognostic risk factors of acute respiratory distress syndrome (ARDS) caused by community-acquired pneumonia under different immune states. METHODS The patients were divided into immunocompetent and immunocompromised groups according to their immune status. The basic clinical data of the two groups were collected and statistically analyzed, and the clinical characteristics and prognostic factors of ARDS caused by community-acquired pneumonia under different immune states were summarized. RESULTS 128 patients with ARDS caused by community-acquired pneumonia were enrolled. The chest High-Resolution Computed Tomography (HRCT) scores of patients with immunosuppression were higher (236.0 ± 55.0 vs. 207.5 ± 49.6, p < 0.05) and the score of APACHE II was higher (17.3 ± 4.8 vs. 15.1 ± 5.4, p < 0.05). The 28-day intensive care unit (ICU) mortality was higher in the immunocompromised group (54.5% vs. 34.7%, p = 0.045). The 28-day in-hospital mortality in the immunocompetent group was mainly related to NLR and the oxygenation index. The 28-day in-hospital mortality in the immunocompromised group was mainly related to LDH and APACHE II. CONCLUSION There are differences in clinical characteristics and mortality of ARDS patients caused by community-acquired pneumonia under different immune states.
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Affiliation(s)
- Zhipeng Cheng
- Department of Respiratory and Critical Care Medicine, First Medical Center, PLA General Hospital, Beijing, China
| | - Qiang Zhu
- Department of Respiratory and Critical Care Medicine, First Medical Center, PLA General Hospital, Beijing, China
| | - Jingyi Chen
- Department of Respiratory and Critical Care Medicine, First Medical Center, PLA General Hospital, Beijing, China
| | - Yanan Sun
- Department of Respiratory and Critical Care Medicine, First Medical Center, PLA General Hospital, Beijing, China
| | - Zhixin Liang
- Department of Respiratory and Critical Care Medicine, First Medical Center, PLA General Hospital, Beijing, China
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Bronicki RA, Benitz WE, Buckley JR, Yarlagadda VV, Porta NFM, Agana DO, Kim M, Costello JM. Respiratory Care for Neonates With Congenital Heart Disease. Pediatrics 2022; 150:189881. [PMID: 36317970 DOI: 10.1542/peds.2022-056415h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Ronald A Bronicki
- Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas
| | - William E Benitz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California
| | - Jason R Buckley
- Medical University of South Carolina, Divison of Pediatric Cardiology, Shawn Jenkins Children's Hospital, Charleston, South Carolina
| | - Vamsi V Yarlagadda
- Stanford School of Medicine, Division of Cardiology, Lucile Packard Children's Hospital, Palo Alto, California
| | - Nicolas F M Porta
- Northwestern University Feinberg School of Medicine, Division of Neonatology, Pediatric Pulmonary Hypertension Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Devon O Agana
- Mayo Clinic College of Medicine and Science, Department of Anesthesiology and Pediatric Critical Care Medicine, Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota
| | - Minso Kim
- University of California San Francisco School of Medicine, Division of Critical Care, University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | - John M Costello
- Medical University of South Carolina, Divison of Pediatric Cardiology, Shawn Jenkins Children's Hospital, Charleston, South Carolina
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Zhang H, Liu Z, Shu H, Yu Y, Yang X, Li R, Xu J, Zou X, Shang Y. Prone positioning in ARDS patients supported with VV ECMO, what we should explore? J Intensive Care 2022; 10:46. [PMID: 36195935 PMCID: PMC9531855 DOI: 10.1186/s40560-022-00640-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS), a prevalent cause of admittance to intensive care units, is associated with high mortality. Prone positioning has been proven to improve the outcomes of moderate to severe ARDS patients owing to its physiological effects. Venovenous extracorporeal membrane oxygenation (VV ECMO) will be considered in patients with severe hypoxemia. However, for patients with severe hypoxemia supported with VV ECMO, the potential effects and optimal strategies of prone positioning remain unclear. This review aimed to present these controversial questions and highlight directions for future research. Main body The clinically significant benefit of prone positioning and early VV ECMO alone was confirmed in patients with severe ARDS. However, a number of questions regarding the combination of VV ECMO and prone positioning remain unanswered. We discussed the potential effects of prone positioning on gas exchange, respiratory mechanics, hemodynamics, and outcomes. Strategies to achieve optimal outcomes, including indications, timing, duration, and frequency of prone positioning, as well as the management of respiratory drive during prone positioning sessions in ARDS patients receiving VV ECMO, are challenging and controversial. Additionally, whether and how to implement prone positioning according to ARDS phenotypes should be evaluated. Lung morphology monitored by computed tomography, lung ultrasound, or electrical impedance tomography might be a potential indication to make an individualized plan for prone positioning therapy in patients supported with VV ECMO. Conclusion For patients with ARDS supported with VV ECMO, the potential effects of prone positioning have yet to be clarified. Ensuring an optimal strategy, especially an individualized plan for prone positioning therapy during VV ECMO, is particularly challenging and requires further research.
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Affiliation(s)
- Hongling Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, 237000, China
| | - Zhengdong Liu
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, 237000, China
| | - Huaqing Shu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yuan Yu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ruiting Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Rissel R, Renz M, Mohnke K, Riedel J, Ritter K, Ziebart A, Ruemmler R, Hartmann EK, Kamuf J. Comparison of two porcine acute lung injury models: a post-hoc analysis. Intensive Care Med Exp 2022; 10:37. [PMID: 36058954 PMCID: PMC9441218 DOI: 10.1186/s40635-022-00466-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/25/2022] [Indexed: 11/21/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is a common disease in intensive care medicine. Despite intensive research, mortality rates are high, not even in COVID-19 ARDS. Thereby, pigs offer some advantages to study the characteristics of ARDS. Many different ARDS models exist. Most of the articles published focused on histopathological and microscopic lung alterations to identify the most suitable animal ARDS model. “Macroscopic” observations and descriptions are often missing. Therefore, we performed a post-hoc comparison of two common ARDS models for pigs: lipopolysaccharide (LPS) vs. a double-hit model (bronchoalveolar lavage + oleic acid infusion). We investigated hemodynamic, spirometric and laboratory changes as another main clinical part of ARDS. Results The groups were compared by two-way analysis of variance (ANOVA) with a post-hoc Student–Newman–Keuls test. A p value lower than 0.05 was accepted as significant. All animals (n = 8 double-hit ARDS; n = 8 LPS ARDS) survived the observation period of 8 h. ARDS induction with reduced oxygen indices was successful performed in both models (76 ± 35/225 ± 54/212 ± 79 vs. 367 ± 64; T0/T4/T8 vs. BLH for double-hit; 238 ± 57/144 ± 59 vs. 509 ± 41; T4/T8 vs. BLH for LPS; p < 0.05). ARDS induced with LPS leads to more hemodynamic (mean arterial pulmonary pressure 35 ± 3/30 ± 3 vs. 28 ± 4/23 ± 4; T4/T8 LPS vs. double-hit; p < 0.05; doses of norepinephrine 1.18 ± 1.05 vs. 0.11 ± 0.16; LPS vs. double-hit for T8; p < 0.05) and inflammatory (pulmonary IL-6 expression: 2.41e−04 ± 1.08e−04 vs. 1.45e−05 ± 7.26e−06; LPS vs. double-hit; p < 0.05) alterations. ARDS induced by double-hit requires a more invasive ventilator strategy to maintain a sufficient oxygenation (PEEP at T4: 8 ± 3 vs. 6 ± 2; double-hit vs. LPS; p < 0.05). Conclusions Both animal ARDS models are feasible and are similar to human presentation of ARDS. If your respiratory research focus on hemodynamic/inflammation variables, the LPS-induced ARDS is a feasible model. Studying different ventilator strategies, the double-hit ARDS model offers a suitable approach.
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Affiliation(s)
- René Rissel
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Miriam Renz
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Katja Mohnke
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Julian Riedel
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Katharina Ritter
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Alexander Ziebart
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Robert Ruemmler
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Erik K Hartmann
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Jens Kamuf
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
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de Carvalho EB, Fonseca ACF, Magalhães R, Pinto EF, Samary CDS, Antunes MA, Baldavira CM, da Silveira LKR, Teodoro WR, de Abreu MG, Capelozzi VL, Felix NS, Pelosi P, Rocco PRM, Silva PL. Effects of different fluid management on lung and kidney during pressure-controlled and pressure-support ventilation in experimental acute lung injury. Physiol Rep 2022; 10:e15429. [PMID: 36065867 PMCID: PMC9446390 DOI: 10.14814/phy2.15429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 07/22/2022] [Accepted: 07/29/2022] [Indexed: 04/24/2023] Open
Abstract
Optimal fluid management is critical during mechanical ventilation to mitigate lung damage. Under normovolemia and protective ventilation, pulmonary tensile stress during pressure-support ventilation (PSV) results in comparable lung protection to compressive stress during pressure-controlled ventilation (PCV) in experimental acute lung injury (ALI). It is not yet known whether tensile stress can lead to comparable protection to compressive stress in ALI under a liberal fluid strategy (LF). A conservative fluid strategy (CF) was compared with LF during PSV and PCV on lungs and kidneys in an established model of ALI. Twenty-eight male Wistar rats received endotoxin intratracheally. After 24 h, they were treated with CF (minimum volume of Ringer's lactate to maintain normovolemia and mean arterial pressure ≥70 mmHg) or LF (~4 times higher than CF) combined with PSV or PCV (VT = 6 ml/kg, PEEP = 3 cmH2 O) for 1 h. Nonventilated animals (n = 4) were used for molecular biology analyses. CF-PSV compared with LF-PSV: (1) decreased the diffuse alveolar damage score (10 [7.8-12] vs. 25 [23-31.5], p = 0.006), mainly due to edema in axial and alveolar parenchyma; (2) increased birefringence for occludin and claudin-4 in lung tissue and expression of zonula-occludens-1 and metalloproteinase-9 in lung. LF compared with CF reduced neutrophil gelatinase-associated lipocalin and interleukin-6 expression in the kidneys in PSV and PCV. In conclusion, CF compared with LF combined with PSV yielded less lung epithelial cell damage in the current model of ALI. However, LF compared with CF resulted in less kidney injury markers, regardless of the ventilatory strategy.
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Affiliation(s)
- Eduardo Butturini de Carvalho
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
- University of VassourasVassourasRJBrazil
| | - Ana Carolina Fernandes Fonseca
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
| | - Raquel Ferreira Magalhães
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
| | - Eliete Ferreira Pinto
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
| | - Cynthia dos Santos Samary
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
| | - Mariana Alves Antunes
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
| | | | | | | | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Therapy, Technische Universität DresdenUniversity Hospital Carl Gustav CarusDresdenGermany
- Department of Intensive Care and Resuscitation, Anesthesiology InstituteCleveland ClinicClevelandOhioUSA
- Department of Outcomes Research, Anesthesiology InstituteCleveland ClinicClevelandOhioUSA
| | - Vera Luiza Capelozzi
- Department of Pathology, School of MedicineUniversity of São PauloSão PauloBrazil
| | - Nathane Santanna Felix
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated DiagnosticsUniversity of GenoaGenoaItaly
- Anesthesia and Critical Care, San Martino Policlinico HospitalIRCCS for Oncology and NeurosciencesGenoaItaly
| | - Patrícia Rieken Macêdo Rocco
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
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Ziaka M, Exadaktylos A. ARDS associated acute brain injury: from the lung to the brain. Eur J Med Res 2022; 27:150. [PMID: 35964069 PMCID: PMC9375183 DOI: 10.1186/s40001-022-00780-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 07/29/2022] [Indexed: 01/10/2023] Open
Abstract
A complex interrelation between lung and brain in patients with acute lung injury (ALI) has been established by experimental and clinical studies during the last decades. Although, acute brain injury represents one of the most common insufficiencies in patients with ALI and acute respiratory distress syndrome (ARDS), the underlying pathophysiology of the observed crosstalk remains poorly understood due to its complexity. Specifically, it involves numerous pathophysiological parameters such as hypoxemia, neurological adverse events of lung protective ventilation, hypotension, disruption of the BBB, and neuroinflammation in such a manner that the brain of ARDS patients-especially hippocampus-becomes very vulnerable to develop secondary lung-mediated acute brain injury. A protective ventilator strategy could reduce or even minimize further systemic release of inflammatory mediators and thus maintain brain homeostasis. On the other hand, mechanical ventilation with low tidal volumes may lead to self-inflicted lung injury, hypercapnia and subsequent cerebral vasodilatation, increased cerebral blood flow, and intracranial hypertension. Therefore, by describing the pathophysiology of ARDS-associated acute brain injury we aim to highlight and discuss the possible influence of mechanical ventilation on ALI-associated acute brain injury.
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Affiliation(s)
- Mairi Ziaka
- Department of Internal Medicine, Thun General Hospital, Thun, Switzerland
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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A computational evaluation of FDA medicines’ ability to inhibit hypoxia-inducible factor prolyl hydroxylase-2 (PHD-2) for acute respiratory distress syndrome. Struct Chem 2022; 33:1391-1407. [PMID: 35855326 PMCID: PMC9282623 DOI: 10.1007/s11224-022-02012-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/30/2022] [Indexed: 11/30/2022]
Abstract
COVID-19 infection is associated with a significant fatality rate in individuals suffering from severe acute respiratory distress syndrome (ARDS). Among the several possibilities, inhibition of hypoxia-inducible factor prolyl hydroxylase-2 or prolyl hydroxylase domain-containing protein 2 (PHD2) in a hypoxia-independent way is a prospective therapeutic target for the treatment of ARDS. Vadadustat, Roxadustat, Daprodustat, Desidustat, and Enarudustat are the available clinical trial inhibitors. This study is proposed to focus on the repurposing of FDA-approved drugs as effective PHD2 inhibitors. This computational study utilises e-pharmacophore hypothesis generation from the native ligand–protein complex (PDB ID: 5OX6) based on XP visualiser information. The hypothesis containing five essential features (AAANR) was incorporated for FDA database screening, followed by Glide XP molecular docking and Prime MM-GBSA binding free energy calculations. Top scored ligands were investigated and Fenbufen was identified as an effective PHD-2 inhibitor by comparing with the native co-crystal ligand (Vadadustat). The manual lead optimisation of the Fenbufen structure was adopted to improve inhibitory potency, by increasing the binding affinity and protein–ligand stability. The newly designed compounds B and C showed additional binding interactions, excellent docking scores, binding free energy, and an acceptable range of ADME properties. Also, Fenbufen and compound C owned preferable protein–ligand stability during MD simulation when compared with the co-crystallised clinical trial ligand. Based on our findings, we deduce that Fenbufen can be proposed as an effective repurposable candidate as its structural modification showed a remarkable improvement in PHD2 inhibition.
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McGlothlin D, Granton J, Klepetko W, Beghetti M, Rosenzweig EB, Corris P, Horn E, Kanwar M, McRae K, Roman A, Tedford R, Badagliacca R, Bartolome S, Benza R, Caccamo M, Cogswell R, Dewachter C, Donahoe L, Fadel E, Farber HW, Feinstein J, Franco V, Frantz R, Gatzoulis M, Hwa (Anne) Goh C, Guazzi M, Hansmann G, Hastings S, Heerdt P, Hemnes A, Herpain A, Hsu CH, Kerr K, Kolaitis N, Kukreja J, Madani M, McCluskey S, McCulloch M, Moser B, Navaratnam M, Radegran G, Reimer C, Savale L, Shlobin O, Svetlichnaya J, Swetz K, Tashjian J, Thenappan T, Vizza CD, West S, Zuckerman W, Zuckermann A, De Marco T. ISHLT CONSENSUS STATEMENT: Peri-operative Management of Patients with Pulmonary Hypertension and Right Heart Failure Undergoing Surgery. J Heart Lung Transplant 2022; 41:1135-1194. [DOI: 10.1016/j.healun.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022] Open
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