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Brown CJ, Rubel N, Lai J, Ward C, McLean J, Wheelock M, Steuerwald M, Cathers A. Initiation of Inhaled Nitric Oxide by Air Transport Team in Adult COVID-19 Respiratory Failure. Air Med J 2022; 41:406-410. [PMID: 35750450 PMCID: PMC8907015 DOI: 10.1016/j.amj.2022.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/28/2022] [Accepted: 03/02/2022] [Indexed: 11/19/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has caused a significant increase in the volume of critical care flight transports between outlying referral hospitals and tertiary care facilities. Because of the tropism of severe acute respiratory syndrome coronavirus 2, flight crews are often asked to transport mechanically ventilated patients in refractory hypoxemic respiratory failure. The authors present a case series of 5 patients with COVID-19 acute respiratory distress syndrome (ARDS) who were initiated on inhaled nitric oxide (iNO) by the transport team before rotor wing transport and survived the journey in stable or improved condition upon arrival. Previously, no case reports have described adults with COVID-19 ARDS transported after iNO initiation by the transport team. This case series shows the feasibility of iNO initiation by trained air medical transport teams and suggests a short-term stabilizing effect of iNO in patients with ARDS from COVID-19.
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Affiliation(s)
- Connor J Brown
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI.
| | - Nicolas Rubel
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Jason Lai
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Christen Ward
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Justin McLean
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Martin Wheelock
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Michael Steuerwald
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Andrew Cathers
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
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Hao GW, Tu GW, Yu SJ, Luo JC, Liu K, Wang H, Ma GG, Su Y, Hou JY, Lai H, Fang Y, Luo Z. Inhaled nitric oxide reduces the intrapulmonary shunt to ameliorate severe hypoxemia after acute type A aortic dissection surgery. Nitric Oxide 2021; 109-110:26-32. [PMID: 33667622 DOI: 10.1016/j.niox.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND To assess the relationship between the intrapulmonary shunt and PaO2/FiO2 in severe hypoxemic patients after acute type A aortic dissection (ATAAD) surgery and to evaluate the effect of inhaled nitric oxide (iNO) on intrapulmonary shunt. METHODS Postoperative ATAAD patients with PaO2/FiO2 ≤ 150 mmHg were enrolled. Intrapulmonary shunt was calculated from oxygen content of different sites (artery [CaO2], mixed venous [CvO2], and alveolar capillary [CcO2]) using the Fick equation, where intrapulmonary shunt = (CcO2-CaO2)/(CcO2-CvO2). Related variables were measured at baseline (positive end expiratory pressure [PEEP] 5 cm H2O), 30 min after increasing PEEP (PEEP 10 cm H2O), 30 min after 5 ppm iNO therapy (PEEP 10 cm H2O + iNO), and 30 min after decreasing PEEP (PEEP 5 cm H2O + iNO). RESULTS A total of 20 patients were enrolled between April 2019 and December 2019. Intrapulmonary shunt and PaO2/FiO2 were correlated in severe hypoxemic, postoperative ATAAD patients (adjusted R2 = 0.467, p < 0.001). A mixed model for repeated measures revealed that iNO, rather than increasing PEEP, significantly decreased the intrapulmonary shunt (by 15% at a PEEP of 5 cm H2O and 16% at a PEEP of 10 cm H2O, p < 0.001 each) and increased PaO2/FiO2 (by 63% at a PEEP of 5 cm H2O and 65% at a PEEP of 10 cm H2O, p < 0.001 each). After iNO therapy, the decrement of intrapulmonary shunt and the increment of PaO2/FiO2 were also correlated (adjusted R2 = 0.375, p < 0.001). CONCLUSIONS This study showed that intrapulmonary shunt and PaO2/FiO2 were correlated in severe hypoxemic, postoperative ATAAD patients. Furthermore, iNO, rather than increasing PEEP, significantly decreased the intrapulmonary shunt to improve severe hypoxemic conditions.
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Affiliation(s)
- Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Shen-Ji Yu
- Department of Nursing, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Guo-Guang Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Jun-Yi Hou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Hao Lai
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yan Fang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China; Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital Fudan University, No. 668 Jinghu Road, Huli District, Xiamen, 361015, China.
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Patterns of Use of Adjunctive Therapies in Patients With Early Moderate to Severe ARDS: Insights From the LUNG SAFE Study. Chest 2020; 157:1497-1505. [PMID: 32088180 DOI: 10.1016/j.chest.2020.01.041] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/04/2019] [Accepted: 01/13/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Adjunctive strategies are an important part of the management of ARDS. However, their application in clinical practice remains inconsistent. RESEARCH QUESTION We wished to determine the frequency and patterns of use of adjunctive strategies in patients with moderate to severe ARDS (Pao2/Fio2 [P/F ratio] < 150) enrolled into the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. STUDY DESIGN AND METHODS The LUNG SAFE study was an international, multicenter, prospective cohort study of patients with severe respiratory failure, conducted in 2014 in 459 ICUs from 50 countries. The primary objective of this substudy was to determine the frequency of use of widely available (neuromuscular blockade, prone position) adjuncts vs adjuncts requiring specialized equipment (extracorporeal membrane oxygenation, inhaled vasodilators, high-frequency ventilation) in patients in the first 48 h of moderate to severe ARDS (P/F ratio < 150). RESULTS Of 1,146 patients on invasive ventilation with moderate to severe ARDS, 811 patients (71%) received no adjunct within 48 h of ARDS onset. Of 335 (29%) that received adjunctive strategies, 252 (75%) received a single strategy, and 83 (25%) receiving more than one adjunct. Of ARDS nonsurvivors, 67% did not receive any adjunctive strategy in the first 48 h. Most patients (67%) receiving specialized adjuncts did not receive prone positioning or neuromuscular blockade. Patients that received adjuncts were more likely to have their ARDS recognized, be younger and sicker, have pneumonia, be more difficult to ventilate, and be in a European high-income country than those that did not receive adjuncts. INTERPRETATION Three in 10 patients with moderate to severe ARDS, and only one-third of nonsurvivors, received adjunctive strategies over the first 48 h of ARDS. A more consistent and evidence-driven approach to adjunct use may reduce costs and improve outcomes in patients with moderate to severe ARDS. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02010073; URL: www.clinicaltrials.gov.
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Carlotti APDCP, de Carvalho WB, Johnston C, Rodriguez IS, Delgado AF. COVID-19 Diagnostic and Management Protocol for Pediatric Patients. Clinics (Sao Paulo) 2020; 75:e1894. [PMID: 32321116 PMCID: PMC7153362 DOI: 10.6061/clinics/2020/e1894] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 12/18/2022] Open
Abstract
This review aims to verify the main epidemiologic, clinical, laboratory-related, and therapeutic aspects of coronavirus disease 2019 (COVID-19) in critically ill pediatric patients. An extensive review of the medical literature on COVID-19 was performed, mainly focusing on the critical care of pediatric patients, considering expert opinions and recent reports related to this new disease. Experts from a large Brazilian public university analyzed all recently published material to produce a report aiming to standardize the care of critically ill children and adolescents. The report emphasizes on the clinical presentations of the disease and ventilatory support in pediatric patients with COVID-19. It establishes a flowchart to guide health practitioners on triaging critical cases. COVID-19 is essentially an unknown clinical condition for the majority of pediatric intensive care professionals. Guidelines developed by experts can help all practitioners standardize their attitudes and improve the treatment of COVID-19.
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Affiliation(s)
| | - Werther Brunow de Carvalho
- Instituto da Crianca e do Adolescente (Icr), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding author. E-mail:
| | - Cíntia Johnston
- Instituto da Crianca e do Adolescente (Icr), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Isadora Souza Rodriguez
- Instituto da Crianca e do Adolescente (Icr), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Artur Figueiredo Delgado
- Instituto da Crianca e do Adolescente (Icr), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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De Jong A, Jaber S, Ferguson ND. Focus on ventilation and ARDS: recent insights. Intensive Care Med 2019; 45:1635-1638. [PMID: 31620833 DOI: 10.1007/s00134-019-05804-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 09/25/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Audrey De Jong
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR, 9214, St-Eloi Hospital, Montpellier, France.
| | - Samir Jaber
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR, 9214, St-Eloi Hospital, Montpellier, France
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, 585 University Avenue, PMB 11-120, Toronto, ON, M5G 2N2, Canada.,Toronto General Hospital Research Institute, Toronto, Canada
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Ma GG, Hao GW, Lai H, Yang XM, Liu L, Wang CS, Tu GW, Luo Z. Initial clinical impact of inhaled nitric oxide therapy for refractory hypoxemia following type A acute aortic dissection surgery. J Thorac Dis 2019; 11:495-504. [PMID: 30962993 PMCID: PMC6409278 DOI: 10.21037/jtd.2019.01.42] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND To evaluate the effect of inhaled nitric oxide (iNO) therapy on oxygenation and clinical outcomes in patients with refractory hypoxemia after surgical reconstruction for acute type A aortic dissection (TAAD). METHODS A before-and-after interventional study was conducted in patients with refractory hypoxemia after surgical reconstruction for TAAD. Postoperative refractory hypoxemia was defined as a persistent PaO2/FiO2 ratio ≤100 mmHg despite conventional therapy. From January to November 2016, conventional treatment was carried out for refractory hypoxemia. From December 2016 to October 2017, on the basis of conventional therapy, we explored the use of iNO to treat refractory hypoxemia. RESULTS Fifty-three TAAD patients with refractory hypoxemia were enrolled in this study. Twenty-seven patients received conventional treatment (conventional group), while the remaining 26 patients received iNO therapy. The PaO2/FiO2 ratio was significantly higher in the iNO group after treatment than in the conventional group when analyzed over the entire 72 hours. The duration of invasive mechanical ventilation was significantly reduced in the iNO group (69.19 vs. 104.56 hours; P=0.003). Other outcomes, such as mortality (3.85% vs. 7.41%, P=1.000), intensive care unit (ICU) duration (9.88 vs. 12.36 days, P=0.059) and hospital stay (16.88 vs. 20.76 days, P=0.060), were not significantly different between the two groups. CONCLUSIONS iNO therapy might play an ameliorative role in patients with refractory hypoxemia after surgical reconstruction for TAAD. This therapy may lead to sustained improvement in oxygenation and reduce the duration of invasive mechanical ventilation.
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Affiliation(s)
- Guo-Guang Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Hao Lai
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Xiao-Mei Yang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Lan Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Chun-Sheng Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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Dalmedico M, Ramos D, Hinata P, Alves W, Carvalho C, Avila J. Prone position and extracorporeal membrane oxygenation in acute respiratory distress syndrome. FISIOTERAPIA EM MOVIMENTO 2019. [DOI: 10.1590/1980-5918.032.ao35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Introduction: The acute respiratory distress syndrome is an inflammatory process originated by some pulmonary diseases, resulting in non-hydrostatic protein edema of the pulmonary parenchyma. The loss of the lung ability to eliminate carbon dioxide generates complications such as refractory hypoxemia, decreased alveolar dysplasia, increased complacency and hypercarbia. The treatment of acute respiratory distress syndrome, consist in measures to prevent lung diseases progression and optimize oxygenation. Objective: To identify, in the international scientific literature, cases or series of cases reporting the combined application of prone position and extracorporeal membrane oxygenation in patients with severe acute respiratory distress syndrome, as well as the benefit of these rescue therapies. Method: This is a systematic review of case reports that show the benefit of combined therapies in the treatment of patients with acute respiratory distress syndrome. Results: From the research strategy and selection criteria were included 8 studies reporting 19 cases of patients with acute respiratory distress syndrome who received the combination of the two rescue therapies. All studies showed that extracorporeal membrane oxygenation was the primary intervention. There were no reports of adverse events. Conclusion: The combinations of therapies positively interfere on the prognosis of patients with acute respiratory distress syndrome, in addition to presenting no additional risks in terms of the occurrence of adverse events; however, the prone position should precede the extracorporeal membrane oxygenation as first-line intervention. PROSPERO Registration No. CRD42018093076
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