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Lou Q. Neutrophil-to-Lymphocyte Ratio: A Promising Predictor of Mortality in Patients With Acute Respiratory Distress Syndrome. A Retrospective Analysis of a Single Hospital Center. J Cardiothorac Vasc Anesth 2024; 38:1716-1726. [PMID: 38821730 DOI: 10.1053/j.jvca.2024.03.027] [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: 08/14/2023] [Revised: 02/29/2024] [Accepted: 03/20/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVES To examine how the neutrophil-to-lymphocyte ratio (NLR) affects both short-term and long-term mortality in individuals with acute respiratory distress syndrome (ARDS). DESIGN A retrospective study. SETTING Critical care unit. PARTICIPANTS A total of 785 patients with ARDS. INTERVENTIONS There were three groups in the NLR study. A Cox proportional hazards regression model was used to calculate the hazard ratio (HR) between the NLR and 30-day, 90-day, and 1-year mortality. MEASUREMENTS AND MAIN RESULTS The 785 patients included 329 women (41.9%) and 456 men (58.1%), with a mean age of 63.4 ± 16.7 years and a mean NLR of 14.2 ± 9.8. The study population was divided into 3 groups based on NLR value. In the unadjusted model, compared to group 1 (NLR <6.0), group 2 (NLR 6.0-11.3) and group 3 (NLR >11.3) had HR values of 1.12 (95% confidence interval [CI], 0.83-1.52) and 2.39 (95% CI, 1.87-3.04), respectively, for 30-day all-cause mortality. This association remained significant after adjusting for potential confounding variables (HR, 1.54; 95% CI, 1.18-2.02), with a statistically significant trend (p = 0.0004) in group 3 (NLR >11.3). A similar effect was seen on both 90-day and 1-year all-cause mortality. The R2 value in a 2-piecewise linear regression was 1.25 (95% CI, 1.06-1.48; p < 0.0001) on the left side of the inflection point (NLR 17.1). CONCLUSIONS In this retrospective single-center study, the NLR was a potential predictor of both short- and long-term mortality in patients with ARDS and may aid risk stratification.
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Affiliation(s)
- Qiyan Lou
- Department of Respiratory Medicine, Zhuji People's Hospital Affiliated to Shaoxing University of Arts and Sciences, Shaoxing, China.
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Hsu PC, Lin YT, Kao KC, Peng CK, Sheu CC, Liang SJ, Chan MC, Wang HC, Chen YM, Chen WC, Yang KY. Risk factors for prolonged mechanical ventilation in critically ill patients with influenza-related acute respiratory distress syndrome. Respir Res 2024; 25:9. [PMID: 38178147 PMCID: PMC10765923 DOI: 10.1186/s12931-023-02648-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/20/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Patients with influenza-related acute respiratory distress syndrome (ARDS) are critically ill and require mechanical ventilation (MV) support. Prolonged mechanical ventilation (PMV) is often seen in these cases and the optimal management strategy is not established. This study aimed to investigate risk factors for PMV and factors related to weaning failure in these patients. METHODS This retrospective cohort study was conducted by eight medical centers in Taiwan. All patients in the intensive care unit with virology-proven influenza-related ARDS requiring invasive MV from January 1 to March 31, 2016, were included. Demographic data, critical illness data and clinical outcomes were collected and analyzed. PMV is defined as mechanical ventilation use for more than 21 days. RESULTS There were 263 patients with influenza-related ARDS requiring invasive MV enrolled during the study period. Seventy-eight patients had PMV. The final weaning rate was 68.8% during 60 days of observation. The mortality rate in PMV group was 39.7%. Risk factors for PMV were body mass index (BMI) > 25 (kg/m2) [odds ratio (OR) 2.087; 95% confidence interval (CI) 1.006-4.329], extracorporeal membrane oxygenation (ECMO) use (OR 6.181; 95% CI 2.338-16.336), combined bacterial pneumonia (OR 4.115; 95% CI 2.002-8.456) and neuromuscular blockade use over 48 h (OR 2.8; 95% CI 1.334-5.879). In addition, risk factors for weaning failure in PMV patients were ECMO (OR 5.05; 95% CI 1.75-14.58) use and bacteremia (OR 3.91; 95% CI 1.20-12.69). CONCLUSIONS Patients with influenza-related ARDS and PMV have a high mortality rate. Risk factors for PMV include BMI > 25, ECMO use, combined bacterial pneumonia and neuromuscular blockade use over 48 h. In addition, ECMO use and bacteremia predict unsuccessful weaning in PMV patients.
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Affiliation(s)
- Pai-Chi Hsu
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Respiratory Therapy, Sijhih Cathay General Hospital, New Taipei, Taiwan
| | - Yi-Tsung Lin
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, 112, Taiwan
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chung-Kan Peng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, Taipei, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Shinn-Jye Liang
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Ming-Cheng Chan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hao-Chien Wang
- Division of Chest Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Mu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wei-Chih Chen
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, 112, Taiwan
- Department of Chest Medicine, Taipei Veterans General Hospital, # 201 Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Kuang-Yao Yang
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, 112, Taiwan.
- Department of Chest Medicine, Taipei Veterans General Hospital, # 201 Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.
- Cancer Progression Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Suarez-Pajes E, Tosco-Herrera E, Ramirez-Falcon M, Gonzalez-Barbuzano S, Hernandez-Beeftink T, Guillen-Guio B, Villar J, Flores C. Genetic Determinants of the Acute Respiratory Distress Syndrome. J Clin Med 2023; 12:3713. [PMID: 37297908 PMCID: PMC10253474 DOI: 10.3390/jcm12113713] [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: 04/17/2023] [Revised: 05/18/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition that arises from multiple causes, including sepsis, pneumonia, trauma, and severe coronavirus disease 2019 (COVID-19). Given the heterogeneity of causes and the lack of specific therapeutic options, it is crucial to understand the genetic and molecular mechanisms that underlie this condition. The identification of genetic risks and pharmacogenetic loci, which are involved in determining drug responses, could help enhance early patient diagnosis, assist in risk stratification of patients, and reveal novel targets for pharmacological interventions, including possibilities for drug repositioning. Here, we highlight the basis and importance of the most common genetic approaches to understanding the pathogenesis of ARDS and its critical triggers. We summarize the findings of screening common genetic variation via genome-wide association studies and analyses based on other approaches, such as polygenic risk scores, multi-trait analyses, or Mendelian randomization studies. We also provide an overview of results from rare genetic variation studies using Next-Generation Sequencing techniques and their links with inborn errors of immunity. Lastly, we discuss the genetic overlap between severe COVID-19 and ARDS by other causes.
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Affiliation(s)
- Eva Suarez-Pajes
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain
| | - Eva Tosco-Herrera
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain
| | - Melody Ramirez-Falcon
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain
| | - Silvia Gonzalez-Barbuzano
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain
| | - Tamara Hernandez-Beeftink
- Department of Population Health Sciences, University of Leicester, Leicester LE1 7RH, UK
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester LE1 7RH, UK
| | - Beatriz Guillen-Guio
- Department of Population Health Sciences, University of Leicester, Leicester LE1 7RH, UK
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester LE1 7RH, UK
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Research Unit, Hospital Universitario de Gran Canaria Dr. Negrín, 35019 Las Palmas de Gran Canaria, Spain
| | - Carlos Flores
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Genomics Division, Instituto Tecnológico y de Energías Renovables (ITER), 38600 Santa Cruz de Tenerife, Spain
- Faculty of Health Sciences, University of Fernando Pessoa Canarias, 35450 Las Palmas de Gran Canaria, Spain
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Fu LX, Yu H, Lan L, Luo FM, Ni YN. Association between ventilatory ratio and ICU mortality in interstitial lung disease patients on mechanical ventilation: A retrospective study. Heart Lung 2023; 58:223-228. [PMID: 36638763 DOI: 10.1016/j.hrtlng.2023.01.001] [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: 07/20/2022] [Revised: 01/03/2023] [Accepted: 01/03/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND Ventilatory ratio (VR) is a simple bedside index of ventilatory efficiency. Interstitial lung disease (ILD) is a diverse group of diseases that causes fibrosis or inflammation of the pulmonary parenchyma, and the main clinical manifestation is hypoxemia. To date, no study has explored ventilation efficiency in patients with ILD. OBJECTIVES This study aimed to explore the features of VR in mechanically ventilated patients with ILD and their relationship with intensive care unit (ICU) mortality. METHODS In this retrospective analysis, we included mechanically ventilated patients with ILD in the ICU of West China Hospital, Sichuan University, from 2013 to 2021. Demographic data and mechanical ventilation (MV) parameters within 24 h of intubation were collected. The characteristics of VR and their relationships with ICU mortality were also analyzed. RESULTS 224 patients were included in the final analysis. There were 146 males (53.9%), and the median age was 65 years (interquartile range [IQR]54∼74). The mean value of VR was 2.22, and VR was significantly higher in nonsurvivors than in survivors (1.79 vs 2.32, P < 0.001). A high VR value was an independent risk factor for ICU mortality (odds ratio=1.602, P = 0.038) after adjustment. A high value of VR was associated with a shorter survival time after admission to ICU (hazard ratio=1.485, P = 0.006) CONCLUSIONS: VR in patients with ILD on MV was increased, and the VR of nonsurvivors within 24 h of intubation was higher than that of survivors. The high VR value within 24 h of intubation was an independent risk factor for ICU mortality after adjusting for other factors.
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Affiliation(s)
- Lin-Xi Fu
- Department of Pulmonary and Critical Care Medicine, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 China
| | - He Yu
- Department of Pulmonary and Critical Care Medicine, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 China
| | - Lan Lan
- Department of Pulmonary and Critical Care Medicine, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 China
| | - Feng-Ming Luo
- Department of Pulmonary and Critical Care Medicine, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 China.
| | - Yue-Nan Ni
- Department of Pulmonary and Critical Care Medicine, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 China.
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Poole G, Shetty S, Greenough A. The use of neurally-adjusted ventilatory assist (NAVA) for infants with congenital diaphragmatic hernia (CDH). J Perinat Med 2022; 50:1163-1167. [PMID: 35795983 DOI: 10.1515/jpm-2022-0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/08/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Newborns with congenital diaphragmatic hernia (CDH) can have complex respiratory problems which are worsened by ventilatory induced lung injury. Neurally adjusted ventilator assist (NAVA) is a potentially promising ventilation mode for this population, as it can result in improved patient-ventilator interactions and provision of adequate gas exchange at lower airway pressures. CONTENT A literature review was undertaken to provide an overview of NAVA and examine its role in the management of infants with CDH. SUMMARY NAVA in neonates has been used in CDH infants who were stable on ventilatory support or being weaned from mechanical ventilation and was associated with a reduction in the level of respiratory support. OUTLOOK There is, however, limited evidence regarding the efficacy of NAVA in infants with CDH, with only short-term benefits being investigated. A prospective, multicentre study with long term follow-up is required to appropriately assess NAVA in this population.
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Affiliation(s)
- Grace Poole
- Department of Child Health, Kings College Hospital NHS Foundation Trust, London, UK
| | - Sandeep Shetty
- Neonatal Unit, St George's Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,National institute for Health Research (NIHR) Biomedical Research Centre at Guy's and St Thomas' National Health Service (NHS) Foundation Trust and King's College London, London, UK
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Usefulness of low tidal volume ventilation strategy for patients with acute respiratory distress syndrome: a systematic review and meta-analysis. Sci Rep 2022; 12:9331. [PMID: 35660756 PMCID: PMC9167294 DOI: 10.1038/s41598-022-13224-y] [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: 01/11/2021] [Accepted: 05/23/2022] [Indexed: 11/24/2022] Open
Abstract
The effects of lower tidal volume ventilation (LTV) were controversial for patients with acute respiratory distress syndrome (ARDS). This systematic review and meta-analysis aimed to evaluate the use of LTV strategy in patients with ARDS. We performed a literature search on MEDLINE, CENTRAL, EMBASE, CINAHL, “Igaku-Chuo-Zasshi”, clinical trial registration sites, and the reference of recent guidelines. We included randomized controlled trials (RCTs) to compare the LTV strategy with the higher tidal volume ventilation (HTV) strategy in patients with ARDS. Two authors independently evaluated the eligibility of studies and extracted the data. The primary outcomes were 28-day mortality. We used the GRADE methodology to assess the certainty of evidence. Among the 19,864 records screened, 13 RCTs that recruited 1874 patients were included in our meta-analysis. When comparing LTV (4–8 ml/kg) versus HTV (> 8 ml/kg), the pooled risk ratio for 28-day mortality was 0.79 (11 studies, 95% confidence interval [CI] 0.66–0.94, I2 = 43%, n = 1795, moderate certainty of evidence). Subgroup-analysis by combined high positive end-expiratory pressure with LTV showed interaction (P = 0.01). Our study indicated that ventilation with LTV was associated with reduced risk of mortality in patients with ARDS when compared with HTV.
Trial registration: UMIN-CTR (UMIN000041071).
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Kalikkot Thekkeveedu R, El-Saie A, Prakash V, Katakam L, Shivanna B. Ventilation-Induced Lung Injury (VILI) in Neonates: Evidence-Based Concepts and Lung-Protective Strategies. J Clin Med 2022; 11:jcm11030557. [PMID: 35160009 PMCID: PMC8836835 DOI: 10.3390/jcm11030557] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/05/2022] [Accepted: 01/19/2022] [Indexed: 02/04/2023] Open
Abstract
Supportive care with mechanical ventilation continues to be an essential strategy for managing severe neonatal respiratory failure; however, it is well known to cause and accentuate neonatal lung injury. The pathogenesis of ventilator-induced lung injury (VILI) is multifactorial and complex, resulting predominantly from interactions between ventilator-related factors and patient-related factors. Importantly, VILI is a significant risk factor for developing bronchopulmonary dysplasia (BPD), the most common chronic respiratory morbidity of preterm infants that lacks specific therapies, causes life-long morbidities, and imposes psychosocial and economic burdens. Studies of older children and adults suggest that understanding how and why VILI occurs is essential to developing strategies for mitigating VILI and its consequences. This article reviews the preclinical and clinical evidence on the pathogenesis and pathophysiology of VILI in neonates. We also highlight the evidence behind various lung-protective strategies to guide clinicians in preventing and attenuating VILI and, by extension, BPD in neonates. Further, we provide a snapshot of future directions that may help minimize neonatal VILI.
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Affiliation(s)
| | - Ahmed El-Saie
- Section of Neonatology, Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO 64106, USA;
- Department of Pediatrics, Cairo University, Cairo 11956, Egypt
| | - Varsha Prakash
- Department of Pathology, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Lakshmi Katakam
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Binoy Shivanna
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA;
- Correspondence: ; Tel.: +832-824-6474; Fax: +832-825-3204
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Schmid B, Kredel M, Ullrich R, Krenn K, Lucas R, Markstaller K, Fischer B, Kranke P, Meybohm P, Zwißler B, Frank S. Safety and preliminary efficacy of sequential multiple ascending doses of solnatide to treat pulmonary permeability edema in patients with moderate-to-severe ARDS-a randomized, placebo-controlled, double-blind trial. Trials 2021; 22:643. [PMID: 34544463 PMCID: PMC8450703 DOI: 10.1186/s13063-021-05588-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is a complex clinical diagnosis with various possible etiologies. One common feature, however, is pulmonary permeability edema, which leads to an increased alveolar diffusion pathway and, subsequently, impaired oxygenation and decarboxylation. A novel inhaled peptide agent (AP301, solnatide) was shown to markedly reduce pulmonary edema in animal models of ARDS and to be safe to administer to healthy humans in a Phase I clinical trial. Here, we present the protocol for a Phase IIB clinical trial investigating the safety and possible future efficacy endpoints in ARDS patients. Methods This is a randomized, placebo-controlled, double-blind intervention study. Patients with moderate to severe ARDS in need of mechanical ventilation will be randomized to parallel groups receiving escalating doses of solnatide or placebo, respectively. Before advancing to a higher dose, a data safety monitoring board will investigate the data from previous patients for any indication of patient safety violations. The intervention (application of the investigational drug) takes places twice daily over the course of 7 days, ensued by a follow-up period of another 21 days. Discussion The patients to be included in this trial will be severely sick and in need of mechanical ventilation. The amount of data to be collected upon screening and during the course of the intervention phase is substantial and the potential timeframe for inclusion of any given patient is short. However, when prepared properly, adherence to this protocol will make for the acquisition of reliable data. Particular diligence needs to be exercised with respect to informed consent, because eligible patients will most likely be comatose and/or deeply sedated at the time of inclusion. Trial registration This trial was prospectively registered with the EU Clinical trials register (clinicaltrialsregister.eu). EudraCT Number: 2017-003855-47.
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Affiliation(s)
- Benedikt Schmid
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Markus Kredel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Roman Ullrich
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Katharina Krenn
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Rudolf Lucas
- Vascular Biology Center, Division of Pulmonary Medicine, Medical College of Georgia, Augusta University, Augusta, USA
| | - Klaus Markstaller
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Bernhard Zwißler
- Department of Anesthesiology, University Hospital of Ludwig-Maximilians-University (LMU), Munich, Germany.,Comprehensive Pulmonary Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Sandra Frank
- Department of Anesthesiology, University Hospital of Ludwig-Maximilians-University (LMU), Munich, Germany
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Barr J, Paulson SS, Kamdar B, Ervin JN, Lane-Fall M, Liu V, Kleinpell R. The Coming of Age of Implementation Science and Research in Critical Care Medicine. Crit Care Med 2021; 49:1254-1275. [PMID: 34261925 PMCID: PMC8549627 DOI: 10.1097/ccm.0000000000005131] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Juliana Barr
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Shirley S Paulson
- Regional Adult Patient Care Services, Kaiser Permanente, Northern California, Oakland, CA
| | - Biren Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego School of Medicine, La Jolla, CA
| | - Jennifer N Ervin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Meghan Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Vincent Liu
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
- Regional Adult Patient Care Services, Kaiser Permanente, Northern California, Oakland, CA
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego School of Medicine, La Jolla, CA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Division of Research, Kaiser Permanente Northern California, Santa Clara, CA
- Kaiser Permanente Medical Center, Santa Clara, CA
- Stanford University, Stanford, CA
- Hospital Advanced Analytics, Kaiser Permanente Northern California, Santa Clara, CA
- Vanderbilt University School of Nursing, Nashville, TN
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Early prediction of extubation failure in patients with severe pneumonia: a retrospective cohort study. Biosci Rep 2021; 40:221958. [PMID: 31990295 PMCID: PMC7007404 DOI: 10.1042/bsr20192435] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 01/03/2020] [Accepted: 01/28/2020] [Indexed: 02/05/2023] Open
Abstract
Backgroud: Severe pneumonia is one of the most common causes for mechanical ventilation. We aimed to early identify severe pneumonia patients with high risk of extubation failure in order to improve prognosis. Methods: From April 2014 to December 2015, medical records of intubated patients with severe pneumonia in intensive care unit were retrieved from database. Patients were divided into extubation success and failure groups, and multivariate logistic regressions were performed to identify independent predictors for extubation failure. Results: A total of 125 eligible patients were included, of which 82 and 43 patients had extubation success and failure, respectively. APACHE II score (odds ratio (OR) 1.141, 95% confident interval (CI) 1.022–1.273, P = 0.019, cutoff at 17.5), blood glucose (OR 1.122, 95%CI 1.008–1.249, P = 0.035, cutoff at 9.87 mmol/l), dose of fentanyl (OR 3.010, 95%CI 1.100–8.237, P = 0.032, cutoff at 1.135 mg/d), and the need for red blood cell (RBC) transfusion (OR 2.774, 95%CI 1.062–7.252, P = 0.037) were independent risk factors for extubation failure. Conclusion: In patients with severe pneumonia, APACHE II score > 17.5, blood glucose > 9.87 mmol/l, fentanyl usage > 1.135 mg/d, and the need for RBC transfusion might be associated with higher risk of extubation failure.
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Acute and Chronic Respiratory Failure in Cancer Patients. ONCOLOGIC CRITICAL CARE 2020. [PMCID: PMC7123817 DOI: 10.1007/978-3-319-74588-6_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In 2016, there was an estimated 1.8 million new cases of cancer diagnosed in the United States. Remarkable advances have been made in cancer therapy and the 5-year survival has increased for most patients affected by malignancy. There are growing numbers of patients admitted to intensive care units (ICU) and up to 20% of all patients admitted to an ICU carry a diagnosis of malignancy. Respiratory failure remains the most common reason for ICU admission and remains the leading causes of death in oncology patients. There are many causes of respiratory failure in this population. Pneumonia is the most common cause of respiratory failure, yet there are many causes of respiratory insufficiency unique to the cancer patient. These causes are often a result of immunosuppression, chemotherapy, radiation treatment, or hematopoietic stem cell transplant (HCT). Treatment is focused on supportive care and specific therapy for the underlying cause of respiratory failure. Noninvasive modalities of respiratory support are available; however, careful patient selection is paramount as indiscriminate use of noninvasive positive pressure ventilation is associated with a higher mortality if mechanical ventilation is later required. Historically, respiratory failure in the cancer patient had a grim prognosis. Outcomes have improved over the past 20 years. Survivors are often left with significant disability.
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Boiron L, Hopper K, Borchers A. Risk factors, characteristics, and outcomes of acute respiratory distress syndrome in dogs and cats: 54 cases. J Vet Emerg Crit Care (San Antonio) 2019; 29:173-179. [PMID: 30861281 DOI: 10.1111/vec.12819] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 05/04/2017] [Accepted: 06/21/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To characterize the clinical features of the acute respiratory distress syndrome (ARDS), risk factors, and outcome in dogs and cats. The study also aimed to evaluate the current veterinary criteria for the diagnosis of ARDS by comparison of clinical diagnostic criteria with necropsy findings. DESIGN Retrospective study. ANIMALS Fifty-four client-owned animals, 46 dogs and 8 cats. INTERVENTIONS Medical records were reviewed for patients with the diagnosis of ARDS based on previously published clinical criteria or necropsy diagnosis. Signalment, clinical findings, and outcome were recorded. MEASUREMENTS AND MAIN RESULTS Animals were grouped according to a clinical or necropsy diagnosis: 43/54 (80%) were diagnosed with ARDS based on clinical criteria (group 1) and 11/54 (20%) were diagnosed with ARDS based on necropsy only (group 2). In group 1, 22/43 (51%) had a necropsy, which confirmed ARDS in 12/22 (54%). Direct (pulmonary) causes of ARDS were more common than indirect causes in dogs, while cats had a similar occurrence of direct and indirect causes. The most common risk factors identified in dogs were aspiration pneumonia (42%), systemic inflammatory response syndrome (SIRS) (29%), and shock (29%). All cats diagnosed clinically with ARDS had SIRS with or without sepsis. Of the animals with a clinical diagnosis of ARDS, 49% received mechanical ventilation and 58% received treatment (with or without mechanical ventilation) for 24 hours or longer. The overall case fatality rate was 84% in dogs and 100% in cats. CONCLUSIONS AND CLINICAL RELEVANCE As described in human literature, pneumonia was the most common risk factor in dogs with ARDS, whereas it was SIRS for the cat population. The high mortality rate and discrepancy between the clinical diagnosis and necropsy findings may highlight limitations in the clinical criteria for the diagnosis of ARDS and treatment in dogs and cats.
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Affiliation(s)
- Ludivine Boiron
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, CA
| | - Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences and School of Veterinary Medicine, University of California, Davis, Davis, CA
| | - Angela Borchers
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, CA
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Macke C, Sarakintsis M, Winkelmann M, Mommsen P, Omar M, Schröter C, Krettek C, Zeckey C. Influence of Entrapment on Prehospital Management and the Hospital Course in Polytrauma Patients: A Retrospective Analysis in Air Rescue. J Emerg Med 2018; 54:827-834. [PMID: 29680410 DOI: 10.1016/j.jemermed.2018.02.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 01/12/2018] [Accepted: 02/22/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Entrapment is a challenging and crucial factor in the prehospital setting. Few studies have addressed whether entrapment has an influence on on-scene treatment or on the following hospital course. OBJECTIVES Here we aimed to investigate the influence of entrapment on prehospital management and on the hospital course of polytrauma patients. METHODS We performed a retrospective analysis of consecutive patients with an Injury Severity Score ≥16 and aged 16-65 years that were admitted between 2005 and 2013 to a Level I trauma center. Two groups were built: entrapped (E) and nonentrapped patients (nE). These groups were evaluated for multiple prehospital and clinical parameters, including on-scene time, prehospital interventions, and posttraumatic complications. RESULTS There were 310 patients (n = 194 no entrapment [Group nE], n = 116 with entrapment [Group E]) enrolled. The on-scene time was significantly longer in Group E than Group nE. Moreover, this group received a significantly higher volume of colloidal solution. Regarding the Injury Severity Score and Abbreviated Injury Scale (AIS), there were no significant differences between the groups, except for the AISextremities, which was significantly increased in Group E. The overall hospital stay and the initial theater time were significantly longer in Group E than Group nE. No significant differences were present for the occurrence of systemic inflammatory response syndrome, multiple organ dysfunction syndrome, and acute respiratory distress syndrome, nor for Acute Physiology and Chronic Health Evaluation II and estimated and final mortality. CONCLUSION In polytraumatized patients, entrapment has a minor influence on the outcome and treatment in the prehospital and hospital setting when using physician-based air rescue. However, entrapped patients are prone to sustain more severe trauma to the extremities.
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Affiliation(s)
- Christian Macke
- Trauma Department, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Marika Sarakintsis
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Marcel Winkelmann
- Trauma Department, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Philipp Mommsen
- Trauma Department, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Mohamed Omar
- Trauma Department, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | | | - Christian Krettek
- Trauma Department, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Zeckey
- Trauma Department, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany; Department of General, Trauma, and Reconstructive Surgery, Ludwig-Maximilians-Universität München, Munich, Germany
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Automatic regulation of NF-κB by pHSP70/IκBαm to prevent acute lung injury in mice. Arch Biochem Biophys 2017; 634:47-56. [DOI: 10.1016/j.abb.2017.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 07/25/2017] [Accepted: 07/31/2017] [Indexed: 01/23/2023]
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Hashimoto S, Sanui M, Egi M, Ohshimo S, Shiotsuka J, Seo R, Tanaka R, Tanaka Y, Norisue Y, Hayashi Y, Nango E. The clinical practice guideline for the management of ARDS in Japan. J Intensive Care 2017; 5:50. [PMID: 28770093 PMCID: PMC5526253 DOI: 10.1186/s40560-017-0222-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 04/19/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The Japanese Society of Respiratory Care Medicine and the Japanese Society of Intensive Care Medicine provide here a clinical practice guideline for the management of adult patients with ARDS in the ICU. METHOD The guideline was developed applying the GRADE system for performing robust systematic reviews with plausible recommendations. The guideline consists of 13 clinical questions mainly regarding ventilator settings and drug therapies (the last question includes 11 medications that are not approved for clinical use in Japan). RESULTS The recommendations for adult patients with ARDS include: we suggest against early tracheostomy (GRADE 2C), we suggest using NPPV for early respiratory management (GRADE 2C), we recommend the use of low tidal volumes at 6-8 mL/kg (GRADE 1B), we suggest setting the plateau pressure at 30cmH20 or less (GRADE2B), we suggest using PEEP within the range of plateau pressures less than or equal to 30cmH2O, without compromising hemodynamics (Grade 2B), and using higher PEEP levels in patients with moderate to severe ARDS (Grade 2B), we suggest using protocolized methods for liberation from mechanical ventilation (Grade 2D), we suggest prone positioning especially in patients with moderate to severe respiratory dysfunction (GRADE 2C), we suggest against the use of high frequency oscillation (GRADE 2C), we suggest the use of neuromuscular blocking agents in patients requiring mechanical ventilation under certain circumstances (GRADE 2B), we suggest fluid restriction in the management of ARDS (GRADE 2A), we do not suggest the use of neutrophil elastase inhibitors (GRADE 2D), we suggest the administration of steroids, equivalent to methylprednisolone 1-2mg/kg/ day (GRADE 2A), and we do not recommend other medications for the treatment of adult patients with ARDS (GRADE1B; inhaled/intravenous β2 stimulants, prostaglandin E1, activated protein C, ketoconazole, and lisofylline, GRADE 1C; inhaled nitric oxide, GRADE 1D; surfactant, GRADE 2B; granulocyte macrophage colony-stimulating factor, N-acetylcysteine, GRADE 2C; Statin.). CONCLUSIONS This article was translated from the Japanese version originally published as the ARDS clinical practice guidelines 2016 by the committee of ARDS clinical practice guideline (Tokyo, 2016, 293p, available from http://www.jsicm.org/ARDSGL/ARDSGL2016.pdf). The original article, written for Japanese healthcare providers, provides points of view that are different from those in other countries.
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Affiliation(s)
- Satoru Hashimoto
- Department of Anesthesiology and Intensive Care, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Moritoki Egi
- Department of anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Hiroshima University, Hiroshima, Japan
| | - Junji Shiotsuka
- Division of Critical Care Medicine, Okinawa Chubu Hospital, Okinawa, Japan
| | - Ryutaro Seo
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ryoma Tanaka
- Pulmonary & Critical Care Medicine, LDS Hospital, Salt Lake City, USA
| | - Yu Tanaka
- Department of Anesthesiology, Nara Medical University, Nara, Japan
| | - Yasuhiro Norisue
- Department of Emergency and Critical Care Medicine, Tokyo Bay Medical Center, Tokyo, Japan
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
| | - Eishu Nango
- Department of General Medicine, Tokyo kita Social Insurance Hospital, Tokyo, Japan
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Xu Y, Liu L. Curcumin alleviates macrophage activation and lung inflammation induced by influenza virus infection through inhibiting the NF-κB signaling pathway. Influenza Other Respir Viruses 2017. [PMID: 28646616 PMCID: PMC5596526 DOI: 10.1111/irv.12459] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Influenza A viruses (IAV) result in severe public health problems with worldwide each year. Overresponse of immune system to IAV infection leads to complications, and ultimately causing morbidity and mortality. OBJECTIVE Curcumin has been reported to have anti-inflammatory ability. However, its molecular mechanism in immune responses remains unclear. METHODS We detected the pro-inflammatory cytokine secretion and nuclear factor kappa-light-chain-enhancer of activated B cell (NF-κB)-related protein expression in human macrophages or mice infected by IAV with or without curcumin treatment. RESULTS We found that the IAV infection caused a dramatic enhancement of pro-inflammatory cytokine productions of human macrophages and mice immune cells. However, curcumin treatment after IAV infection downregulated these cytokines production in a dose-dependent manner. Moreover, the NF-κB has been activated in human macrophages after IAV infection, while administration of curcumin inhibited NF-κB signaling pathway via promoting the expression of nuclear factor of kappa light polypeptide gene enhancer in B-cells inhibitor, alpha (IκBα), and inhibiting the translocation of p65 from cytoplasm to nucleus. CONCLUSIONS In summary, IAV infection could result in the inflammatory responses of immune cells, especially macrophages. Curcumin has the therapeutic potentials to relieve these inflammatory responses through inhibiting the NF-κB signaling pathway.
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Affiliation(s)
- Yiming Xu
- Department of Respiration Medicine, The Affiliated Wuxi Second People's Hospital of Nanjing Medical University, Wuxi, China
| | - Ling Liu
- Department of Respiration Medicine, The Affiliated Wuxi Second People's Hospital of Nanjing Medical University, Wuxi, China
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Clark PA, Inocencio RC, Lettieri CJ. I-TRACH: Validating A Tool for Predicting Prolonged Mechanical Ventilation. J Intensive Care Med 2016; 33:567-573. [PMID: 27899470 DOI: 10.1177/0885066616679974] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE We previously developed a bedside model (I-TRACH), which used commonly obtained data at the time of intubation to predict the duration of mechanical ventilation (MV). We now sought to validate this in a prospective trial. METHODS A prospective, observational study of 225 consecutive adult medical intensive care unit patients requiring MV. Utilizing the original 6 variables used in the I-TRACH model (Intubation in the ICU, Tachycardia [heart rate > 110], Renal dysfunction [blood urea nitrogen > 25], Acidemia [pH < 7.25], Creatinine [>2.0 or >50% increase from baseline values], and decreased HCO3 [<20]), we (1) confirmed that these were still predictive of length of MV by multivariate analysis and (2) assessed the correlation between the number of criteria met and the subsequent duration of MV. In addition, we compared the performance of I-TRACH to Acute Physiology Age Chronic Health Evaluation-II and III, Sequential Organ Failure Assessment, and Acute Physiology Score as predictors of length of MV. RESULTS Mean age was 62.6 ± 18.7 years, with a mean duration of MV of 5.8 ± 5.7 days. The number of I-TRACH criteria met directly correlated with the duration of MV. Individuals with ≥4 criteria were significantly more likely to require MV >7 and >14 days. Similarly, those who remained on ventilators for both >7 and >14 days met significantly more I-TRACH criteria than those requiring shorter durations of MV (1.7 ± 1.3 vs 2.8 ± 1.3 vs 3.8 ± 1.3 criteria, P < .001). I-TRACH performed better than all other models used to predict the duration of MV. CONCLUSION Similar to our previous retrospective study, these findings validate I-TRACH in determining the subsequent need for MV >7 and >14 days at the time of intubation.
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Affiliation(s)
- Paul A Clark
- 1 Department of Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Ryan C Inocencio
- 1 Department of Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Christopher J Lettieri
- 1 Department of Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA.,2 Department of Medicine, Uniformed Services University, Bethesda, MD, USA
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Notter RH, Gupta R, Schwan AL, Wang Z, Shkoor MG, Walther FJ. Synthetic lung surfactants containing SP-B and SP-C peptides plus novel phospholipase-resistant lipids or glycerophospholipids. PeerJ 2016; 4:e2635. [PMID: 27812430 PMCID: PMC5088750 DOI: 10.7717/peerj.2635] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 09/30/2016] [Indexed: 01/22/2023] Open
Abstract
Background This study examines the biophysical and preclinical pulmonary activity of synthetic lung surfactants containing novel phospholipase-resistant phosphonolipids or synthetic glycerophospholipids combined with Super Mini-B (S-MB) DATK and/or SP-Css ion-lock 1 peptides that replicate the functional biophysics of surfactant proteins (SP)-B and SP-C. Phospholipase-resistant phosphonolipids used in synthetic surfactants are DEPN-8 and PG-1, molecular analogs of dipalmitoyl phosphatidylcholine (DPPC) and palmitoyl-oleoyl phosphatidylglycerol (POPG), while glycerophospholipids used are active lipid components of native surfactant (DPPC:POPC:POPG 5:3:2 by weight). The objective of the work is to test whether these novel lipid/peptide synthetic surfactants have favorable preclinical activity (biophysical, pulmonary) for therapeutic use in reversing surfactant deficiency or dysfunction in lung disease or injury. Methods Surface activity of synthetic lipid/peptide surfactants was assessed in vitro at 37 °C by measuring adsorption in a stirred subphase apparatus and dynamic surface tension lowering in pulsating and captive bubble surfactometers. Shear viscosity was measured as a function of shear rate on a Wells-Brookfield micro-viscometer. In vivo pulmonary activity was determined by measuring lung function (arterial oxygenation, dynamic lung compliance) in ventilated rats and rabbits with surfactant deficiency/dysfunction induced by saline lavage to lower arterial PO2 to <100 mmHg, consistent with clinical acute respiratory distress syndrome (ARDS). Results Synthetic surfactants containing 5:3:2 DPPC:POPC:POPG or 9:1 DEPN-8:PG-1 combined with 3% (by wt) of S-MB DATK, 3% SP-Css ion-lock 1, or 1.5% each of both peptides all adsorbed rapidly to low equilibrium surface tensions and also reduced surface tension to ≤1 mN/m under dynamic compression at 37 °C. However, dual-peptide surfactants containing 1.5% S-MB DATK + 1.5% SP-Css ion-lock 1 combined with 9:1 DEPN-8:PG-1 or 5:3:2 DPPC:POPC:POPG had the greatest in vivo activity in improving arterial oxygenation and dynamic lung compliance in ventilated animals with ARDS. Saline dispersions of these dual-peptide synthetic surfactants were also found to have shear viscosities comparable to or below those of current animal-derived surfactant drugs, supporting their potential ease of deliverability by instillation in future clinical applications. Discussion Our findings support the potential of dual-peptide synthetic lipid/peptide surfactants containing S-MB DATK + SP-Css ion-lock 1 for treating diseases of surfactant deficiency or dysfunction. Moreover, phospholipase-resistant dual-peptide surfactants containing DEPN-8/PG-1 may have particular applications in treating direct forms of ARDS where endogenous phospholipases are present in the lungs.
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Affiliation(s)
- Robert H Notter
- Department of Pediatrics, University of Rochester , Rochester , NY , United States
| | - Rohun Gupta
- Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center , Torrance , CA , United States
| | - Adrian L Schwan
- Department of Chemistry, University of Guelph , Guelph , Ontario , Canada
| | - Zhengdong Wang
- Department of Pediatrics, University of Rochester , Rochester , NY , United States
| | - Mohanad Gh Shkoor
- Department of Chemistry, University of Guelph , Guelph , Ontario , Canada
| | - Frans J Walther
- Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, United States; Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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Abstract
Mechanical ventilation remains the cornerstone in the management of severe acute respiratory failure. Acute respiratory distress syndrome (ARDS) is the most common cause of respiratory failure. It is associated with substantial mortality, and unmanageable refractory hypoxemia remains the most feared clinical possibility. If hypoxemia persists despite application of lung protective ventilation, additional therapies including inhaled vasodilators, prone positioning, recruitment maneuvers, high-frequency oscillatory ventilation, neuromuscular blockade (NMB), and extracorporeal membrane oxygenation may be needed. NMB and prone ventilation are modalities that have been clearly linked to reduced mortality in ARDS. Rescue therapies pose a clinical challenge requiring a precarious balance of risks and benefits, as well as, in-depth knowledge of therapeutic limitations.
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Affiliation(s)
- Chitra Mehta
- Institute of Critical Care and Anaesthesiology, Medanta The Medicity, Gurgaon, Haryana, India
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20
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Bernard GR, Artigas A. The definition of ARDS revisited: 20 years later. Intensive Care Med 2016; 42:640-642. [PMID: 26942447 DOI: 10.1007/s00134-016-4281-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 02/16/2016] [Indexed: 11/26/2022]
Affiliation(s)
| | - Antonio Artigas
- Critical Care Department, CIBER Enfermedades Respiratorias, Corporacion Sanitaria Universitaria Parc Tauli, Parc Tauli 1, Sabadell, Spain
- Autonomous University of Barcelona, Barcelona, Spain
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Jauncey-Cooke J, Schibler A, Bogossian F, Gibbons K, Grant CA, East CE. Lung recruitment manoeuvres in mechanically ventilated children for reducing respiratory morbidity. Hippokratia 2016. [DOI: 10.1002/14651858.cd008866.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Andreas Schibler
- Mater Children’s Hospital; Paediatric Critical Care Research Group; South Brisbane Queensland Australia 4101
| | - Fiona Bogossian
- School of Nursing and Midwifery; The University of Queensland; Herston Australia
| | - Kristen Gibbons
- Mater Research Institute; South Brisbane Queensland Australia 4101
| | - Caroline A Grant
- Mater Children's Hospital; Paediatric Intensive Care Unit; Raymond Terrace South Brisbane Queensland Australia 4001
| | - Christine E East
- Monash University/Monash Health; School of Nursing and Midwifery/Maternity Services; 246 Clayton Road Clayton Victoria Australia 3168
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Notter RH, Wang Z, Walther FJ. Activity and biophysical inhibition resistance of a novel synthetic lung surfactant containing Super-Mini-B DATK peptide. PeerJ 2016; 4:e1528. [PMID: 26793419 PMCID: PMC4715451 DOI: 10.7717/peerj.1528] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 12/02/2015] [Indexed: 12/22/2022] Open
Abstract
Background/objectives. This study examines the surface activity, resistance to biophysical inhibition, and pulmonary efficacy of a synthetic lung surfactant containing glycerophospholipids combined with Super Mini-B (S-MB) DATK, a novel and stable molecular mimic of lung surfactant protein (SP)-B. The objective of the work is to test whether S-MB DATK synthetic surfactant has favorable biophysical and physiological activity for future use in treating surfactant deficiency or dysfunction in lung disease or injury. Methods. The structure of S-MB DATK peptide was analyzed by homology modeling and by FTIR spectroscopy. The in vitro surface activity and inhibition resistance of synthetic S-MB DATK surfactant was assessed in the presence and absence of albumin, lysophosphatidylcholine (lyso-PC), and free fatty acids (palmitoleic and oleic acid). Adsorption and dynamic surface tension lowering were measured with a stirred subphase dish apparatus and a pulsating bubble surfactometer (20 cycles/min, 50% area compression, 37 °C). In vivo pulmonary activity of S-MB DATK surfactant was measured in ventilated rabbits with surfactant deficiency/dysfunction induced by repeated lung lavages that resulted in arterial PO2 values <100 mmHg. Results. S-MB DATK surfactant had very high surface activity in all assessments. The preparation adsorbed rapidly to surface pressures of 46–48 mN/m at 37 °C (low equilibrium surface tensions of 22–24 mN/m), and reduced surface tension to <1 mN/m under dynamic compression on the pulsating bubble surfactometer. S-MB DATK surfactant showed a significant ability to resist inhibition by serum albumin, C16:0 lyso-PC, and free fatty acids, but surfactant inhibition was mitigated by increasing surfactant concentration. S-MB DATK synthetic surfactant quickly improved arterial oxygenation and lung compliance after intratracheal instillation to ventilated rabbits with severe surfactant deficiency. Conclusions. S-MB DATK is an active mimic of native SP-B. Synthetic surfactants containing S-MB DATK (or related peptides) combined with lipids appear to have significant future potential for treating clinical states of surfactant deficiency or dysfunction, such as neonatal and acute respiratory distress syndromes.
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Affiliation(s)
- Robert H Notter
- Department of Pediatrics, University of Rochester , Rochester, NY , United States
| | - Zhengdong Wang
- Department of Pediatrics, University of Rochester , Rochester, NY , United States
| | - Frans J Walther
- Department of Pediatrics, David Geffen School of Medicine, University of California , Los Angeles, CA , United States
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Räsänen J, Nemergut ME, Gavriely N. Effect of PEEP on breath sound power spectra in experimental lung injury. Intensive Care Med Exp 2015; 2:25. [PMID: 26266922 PMCID: PMC4512991 DOI: 10.1186/s40635-014-0025-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 09/09/2014] [Indexed: 11/10/2022] Open
Abstract
Background Acute lung injury (ALI) is known to be associated with the emergence of inspiratory crackles and enhanced transmission of artificial sounds from the airway opening to the chest wall. Recently, we described the effect of ALI on the basic flow-induced breath sounds, separated from the crackles. In this study, we investigated the effects of positive end-expiratory pressure (PEEP) on these noncrackling basic lung sounds augmented during ALI. Methods Lung sounds were recorded in six anesthetized, intubated, and mechanically ventilated pigs at three locations bilaterally on the chest wall. Recordings were obtained before and after induction of lung injury with oleic acid and during application of incremental positive end-expiratory pressure. Results Oleic acid injections caused severe pulmonary edema predominately in the dependent-lung regions. Inspiratory spectral power of breath sounds increased in all lung regions over a frequency band from 150 to 1,200 Hz, with further power augmentation in dependent-lung areas at higher frequencies. Incremental positive end-expiratory pressure reversed the spectral power augmentation seen with ALI, reducing it to pre-injury levels with PEEP of 10 and 15 cmH2O in all lung regions at all frequencies. The application of positive end-expiratory pressure to normal lungs attenuated spectral power slightly and only over a band from 150 to 1,200 Hz. Conclusions We confirm a gravity-related spectral amplitude increase of basic flow-induced breath sounds recorded over lung regions affected by permeability-type pulmonary edema and show that such changes are reversible by alveolar recruitment with PEEP. Electronic supplementary material The online version of this article (doi:10.1186/s40635-014-0025-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jukka Räsänen
- Department of Anesthesiology, H. Lee Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612-9416, USA,
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Chittawatanarat K, Pichaiya T, Chandacham K, Jirapongchareonlap T, Chotirosniramit N. Fluid accumulation threshold measured by acute body weight change after admission in general surgical intensive care units: how much should be concerning? Ther Clin Risk Manag 2015; 11:1097-106. [PMID: 26251605 PMCID: PMC4524471 DOI: 10.2147/tcrm.s86409] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The objective of this study (ClinicalTrials.gov: NCT01351506) was to identify the threshold level of fluid accumulation measured by acute body weight (BW) change during the first week in a general surgical intensive care unit (ICU), which is associated with ICU mortality and other adverse outcomes. Methods Four hundred sixty-five patients were prospectively followed for a 28-day period. The maximum BW change threshold during the first week was evaluated by the maximum percentage change in BW from the ICU admission weight (Max%ΔBW). Daily screening of adverse events in the ICU were recorded. The cutoff point of Max%ΔBW on ICU mortality was defined by considering the area under the receiver operating characteristic (ROC) curve, intersection of the sensitivity and specificity, and the Youden Index. Univariable and multivariable regression analyses were used to demonstrate the associations. Statistical significance was defined as P<0.05. Results The appropriate cutoff value of Max%ΔBW threshold was 5%. Regarding the multivariable regression model, in overall patients, the occurrence of the following adverse events (expressed as adjusted odds ratio [95% confidence interval]) were significantly associated with a Max%ΔBW of >5%: ICU mortality (2.38 [1.25–4.54]) (P=0.008), ICU mortality in patients without renal replacement therapy (RRT) (2.47 [1.21–5.06]) (P=0.013), reintubation within 72 hours (2.51 [1.04–6.00]) (P=0.039), RRT requirement (2.67 [1.13–6.33]) (P=0.026), and delirium (1.97 [1.08–3.57]) (P=0.025). Regarding the postoperative subgroup, a Max%ΔBW value of more than 5% was significantly associated with: ICU mortality (3.87 [1.38–10.85]) (P=0.010), ICU mortality in patients without RRT (6.32 [1.85–21.64]) (P=0.003), reintubation within 72 hours (4.44 [1.30–15.16]) (P=0.017), and vasopressor requirement (2.04 [1.04–4.01]) (P=0.037). Conclusion Fluid accumulation, measured as acute BW change of more than the threshold of 5% during the first week of ICU admission, is associated with adverse outcomes of higher ICU mortality, especially in the patients without RRT, with reintubation within 72 hours, with RRT requirement, with vasopressor requirement, and with delirium. Some of these effects were higher in postoperative patients. This threshold value might be an indicator for caution during fluid management in surgical ICU.
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Affiliation(s)
- Kaweesak Chittawatanarat
- Division of Surgical Critical Care and Trauma, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Todsaporn Pichaiya
- Department of Physical Therapy, Faculty of Associated Medical Science, Chiang Mai University, Chiang Mai, Thailand
| | - Kamtone Chandacham
- Division of Surgical Critical Care and Trauma, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Tidarat Jirapongchareonlap
- Division of Surgical Critical Care and Trauma, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Narain Chotirosniramit
- Division of Surgical Critical Care and Trauma, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Modrykamien AM, Gupta P. The acute respiratory distress syndrome. Proc (Bayl Univ Med Cent) 2015; 28:163-71. [PMID: 25829644 DOI: 10.1080/08998280.2015.11929219] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The acute respiratory distress syndrome (ARDS) is a major cause of acute respiratory failure. Its development leads to high rates of mortality, as well as short- and long-term complications, such as physical and cognitive impairment. Therefore, early recognition of this syndrome and application of demonstrated therapeutic interventions are essential to change the natural course of this devastating entity. In this review article, we describe updated concepts in ARDS. Specifically, we discuss the new definition of ARDS, its risk factors and pathophysiology, and current evidence regarding ventilation management, adjunctive therapies, and intervention required in refractory hypoxemia.
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Affiliation(s)
- Ariel M Modrykamien
- Division of Pulmonary and Critical Care Medicine, Baylor University Medical Center at Dallas, Dallas, Texas (Modrykamien), and the Division of Pulmonary, Sleep, and Critical Care Medicine, Creighton University Medical Center, Omaha, Nebraska (Gupta)
| | - Pooja Gupta
- Division of Pulmonary and Critical Care Medicine, Baylor University Medical Center at Dallas, Dallas, Texas (Modrykamien), and the Division of Pulmonary, Sleep, and Critical Care Medicine, Creighton University Medical Center, Omaha, Nebraska (Gupta)
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Jauncey-Cooke J, East CE, Bogossian F. Paediatric lung recruitment: a review of the clinical evidence. Paediatr Respir Rev 2015; 16:127-32. [PMID: 24680638 DOI: 10.1016/j.prrv.2014.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Revised: 02/13/2014] [Accepted: 02/15/2014] [Indexed: 12/21/2022]
Abstract
Lung recruitment is used as an adjunct to lung protective ventilation strategies. Lung recruitment is a brief, deliberate elevation of transpulmonary pressures beyond what is achieved during tidal ventilation levels. The aim of lung recruitment is to maximise the number of alveoli participating in gas exchange particularly in distal and dependant regions of the lung. This may improve oxygenation and end expiratory levels. Restoration of end expiratory levels and stabilisation of the alveoli may reduce the incidence of ventilator induced lung injury (VILI). Various methods of lung recruitment have been studied in adult and experimental populations. This review aims to establish the evidence for lung recruitment in the pediatric population.
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Affiliation(s)
- Jacqui Jauncey-Cooke
- School of Nursing & Midwifery, The University of Queensland, Australia; Paediatric Critical Care Research Group, PICU, Mater Children's Hospital, Brisbane, Australia.
| | - Chris E East
- School of Nursing and Midwifery/Maternity Services, Monash University/Southern Health, Clayton, Victoria and the School of Nursing & Midwifery, The University of Queensland, Australia.
| | - Fiona Bogossian
- School of Nursing & Midwifery, The University of Queensland, Australia.
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Rimensberger PC. Surfactant. PEDIATRIC AND NEONATAL MECHANICAL VENTILATION 2015. [PMCID: PMC7175631 DOI: 10.1007/978-3-642-01219-8_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Exogenous pulmonary surfactant, widely used in neonatal care, is one of the best-studied treatments in neonatology, and its introduction in the 1990s led to a significant improvement in neonatal outcomes in preterm infants, including a decrease in mortality. This chapter provides an overview of surfactant composition and function in health and disease and summarizes the evidence for its clinical use.
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Affiliation(s)
- Peter C. Rimensberger
- Service of Neonatology and Pediatric Intensive Care, Department of Pediatrics, University Hospital of Geneva, Geneve, Switzerland
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Samalavicius R, Serpytis M, Ringaitiene D, Grazulyte D, Bertasiute R, Rimkus B, Matulionyte R, Ambrazaitiene R, Sipylaite J, Kacergius T, Griskevicius L. Successful use of extracorporeal membrane oxygenation in a human immunodeficiency virus infected patient with severe acute respiratory distress syndrome. AIDS Res Ther 2014; 11:37. [PMID: 25745500 PMCID: PMC4350972 DOI: 10.1186/1742-6405-11-37] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 11/08/2014] [Indexed: 11/24/2022] Open
Abstract
Introduction We report a case of an adult patient with human immunodeficiency virus (HIV), acute respiratory distress syndrome (ARDS) and ventilator associated pneumonia (VAP) caused by multidrug resistant (MDR) bacteria that was successfully managed with veno-venous extracorporeal membrane oxygenation (ECMO). Case report A 25 year old male with no significant past medical history had been admitted to a local hospital due to dyspnea and fever. His pulmonary function subsequently failed necessitating mechanical ventilation (MV) and introduction of ECMO support. The patient was transported for 300 km by road on ECMO to a tertiary medical center. The diagnosis of ARDS, HIV infection and MDR bacterial and fungal VAP was made. Patient was successfully treated with antiretroviral therapy (ART), anti-infective agents and 58 days of veno-venous ECMO support, with complete resolution of the respiratory symptoms. Conclusion HIV infected patients with ARDS and MDR bacterial VAP whose HIV replication is controlled by ART could be successfully managed with ECMO.
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Voelker MT, Fichtner F, Kasper M, Kamprad M, Sack U, Kaisers UX, Laudi S. Characterization of a double-hit murine model of acute respiratory distress syndrome. Clin Exp Pharmacol Physiol 2014; 41:844-53. [DOI: 10.1111/1440-1681.12283] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 06/16/2014] [Accepted: 06/21/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Maria Theresa Voelker
- Department of Anesthesiology and Intensive Care Medicine; University Hospital of Leipzig; Leipzig Germany
| | - Falk Fichtner
- Department of Anesthesiology and Intensive Care Medicine; University Hospital of Leipzig; Leipzig Germany
| | - Michael Kasper
- Institute of Anatomy, Medical Faculty; Dresden University of Technology; Dresden Germany
| | - Manja Kamprad
- Institute of Clinical Immunology; University Hospital of Leipzig; Leipzig Germany
| | - Ulrich Sack
- Institute of Clinical Immunology; University Hospital of Leipzig; Leipzig Germany
| | - Udo X Kaisers
- Department of Anesthesiology and Intensive Care Medicine; University Hospital of Leipzig; Leipzig Germany
| | - Sven Laudi
- Department of Anesthesiology and Intensive Care Medicine; University Hospital of Leipzig; Leipzig Germany
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Räsänen J, Nemergut ME, Gavriely N. Effect of positive end-expiratory pressure on acoustic wave propagation in experimental porcine lung injury. Clin Physiol Funct Imaging 2014; 35:134-41. [DOI: 10.1111/cpf.12138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 01/17/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Jukka Räsänen
- Department of Anesthesiology; H. Lee Moffitt Cancer Center; Tampa FL USA
| | - Michael E. Nemergut
- Departments of Anesthesiology and Pediatrics; Mayo Foundation for Education and Research; Rochester MN USA
| | - Noam Gavriely
- Technion - Israel Institute of Technology; Rappaport Faculty of Medicine; Haifa Israel
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Parekh D, Dancer RCA, Lax S, Cooper MS, Martineau AR, Fraser WD, Tucker O, Alderson D, Perkins GD, Gao-Smith F, Thickett DR. Vitamin D to prevent acute lung injury following oesophagectomy (VINDALOO): study protocol for a randomised placebo controlled trial. Trials 2013; 14:100. [PMID: 23782429 PMCID: PMC3680967 DOI: 10.1186/1745-6215-14-100] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 03/25/2013] [Indexed: 12/22/2022] Open
Abstract
Background Acute lung injury occurs in approximately 25% to 30% of subjects undergoing oesophagectomy. Experimental studies suggest that treatment with vitamin D may prevent the development of acute lung injury by decreasing inflammatory cytokine release, enhancing lung epithelial repair and protecting alveolar capillary barrier function. Methods/Design The ‘Vitamin D to prevent lung injury following oesophagectomy trial’ is a multi-centre, randomised, double-blind, placebo-controlled trial. The aim of the trial is to determine in patients undergoing elective transthoracic oesophagectomy, if pre-treatment with a single oral dose of vitamin D3 (300,000 IU (7.5 mg) cholecalciferol in oily solution administered seven days pre-operatively) compared to placebo affects biomarkers of early acute lung injury and other clinical outcomes. The primary outcome will be change in extravascular lung water index measured by PiCCO® transpulmonary thermodilution catheter at the end of the oesophagectomy. The trial secondary outcomes are clinical markers indicative of lung injury: PaO2:FiO2 ratio, oxygenation index; development of acute lung injury to day 28; duration of ventilation and organ failure; survival; safety and tolerability of vitamin D supplementation; plasma indices of endothelial and alveolar epithelial function/injury, plasma inflammatory response and plasma vitamin D status. The study aims to recruit 80 patients from three UK centres. Discussion This study will ascertain whether vitamin D replacement alters biomarkers of lung damage following oesophagectomy. Trial registration Current Controlled Trials ISRCTN27673620
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Abstract
BACKGROUND Patients with acute respiratory distress syndrome and acute lung injury require mechanical ventilatory support. Acute respiratory distress syndrome and acute lung injury are further complicated by ventilator-induced lung injury. Lung protective ventilation strategies may lead to improved survival. This systematic review is an update of a Cochrane review originally published in 2003 and updated in 2007. OBJECTIVES To assess the effects of ventilation with lower tidal volume on morbidity and mortality in patients aged 16 years or older affected by acute respiratory distress syndrome and acute lung injury. A secondary objective was to determine whether the comparison between low and conventional tidal volume was different if a plateau airway pressure of greater than 30 to 35 cm H20 was used. SEARCH METHODS In our previous 2007 updated review, we searched databases from inception until 2006. In this third updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL and the Web of Science from 2006 to September 2012. We also updated our search of databases of ongoing research and of reference lists from 2006 to September 2012. SELECTION CRITERIA We included randomized controlled trials comparing ventilation using either a lower tidal volume (Vt) or low airway driving pressure (plateau pressure 30 cm H2O or less), resulting in a tidal volume of 7 ml/kg or less, versus ventilation that used Vt in the range of 10 to 15 ml/kg in adults (16 years old or older) with acute respiratory distress syndrome and acute lung injury. DATA COLLECTION AND ANALYSIS We independently assessed trial quality and extracted data. Wherever appropriate, results were pooled. We applied fixed-effect and random-effects models. MAIN RESULTS We did not find any new study which were eligible for inclusion in this update. The total number of studies remained unchanged, six trials involving 1297 patients. Five trials had a low risk of bias. One trial had an unclear risk of bias. Mortality at day 28 was significantly reduced by lung-protective ventilation with a relative risk (RR) of 0.74 (95% confidence interval (CI) 0.61 to 0.88); hospital mortality was reduced with a RR of 0.80 (95% CI 0.69 to 0.92). Overall mortality was not significantly different if a plateau pressure less than or equal to 31 cm H2O in the control group was used (RR 1.13, 95% CI 0.88 to 1.45). There was insufficient evidence for morbidity and long-term outcomes. AUTHORS' CONCLUSIONS Clinical heterogeneity, such as different lengths of follow up and higher plateau pressure in control arms in two trials, makes the interpretation of the combined results difficult. Mortality was significantly reduced at day 28 and at the end of the hospital stay. The effects on long-term mortality are unknown, although the possibility of a clinically relevant benefit cannot be excluded. Ventilation with lower tidal volumes is becoming a routine strategy of treatment of acute respiratory distress syndrome and acute lung injury, stopping investigators from carrying out additional trials.
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Affiliation(s)
- Nicola Petrucci
- Department of Anaesthesia and Intensive Care, Azienda Ospedaliera Desenzano, Desenzano,
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Abstract
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) represent a continuum of a clinical syndrome of respiratory failure due to refractory hypoxia. Acute respiratory distress syndrome is differentiated from ALI by a greater degree of hypoxemia and is associated with higher morbidity and mortality. The mortality for ARDS ranges from 22-41%, with survivors usually requiring long-term rehabilitation to regain normal physiologic function. Numerous pharmacologic therapies have been studied for prevention and treatment of ARDS; however, studies demonstrating clear clinical benefit for ARDS-related mortality and morbidity are limited. In this focused review, controversial pharmacologic therapies that have demonstrated, at minimum, a modest clinical benefit are discussed. Three pharmacologic treatment strategies are reviewed in detail: corticosteroids, fluid management, and neuromuscular blocking agents. Use of corticosteroids to attenuate inflammation remains controversial. Available evidence does not support early administration of corticosteroids. Additionally, administration after 14 days of disease onset is strongly discouraged. A liberal fluid strategy during the early phase of comorbid septic shock, balanced with a conservative fluid strategy in patients with ALI or ARDS during the postresuscitation phase, is the optimum approach for fluid management. Available evidence supports an early, short course of continuous-infusion cisatracurium in patients presenting with severe ARDS. Evidence of safe and effective pharmacologic therapies for ARDS is limited, and clinicians must be knowledgeable about the areas of controversies to determine application to patient care.
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Affiliation(s)
- Hira Shafeeq
- College of Pharmacy and Allied Health Professions, St. John's University, Jamaica, New York, USA
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Defining ARDS: do we need a mandatory waiting period? Intensive Care Med 2013; 39:775-8. [PMID: 23370830 DOI: 10.1007/s00134-013-2834-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 12/19/2012] [Indexed: 01/11/2023]
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Effect of different seated positions on lung volume and oxygenation in acute respiratory distress syndrome. Intensive Care Med 2013; 39:1121-7. [PMID: 23344832 DOI: 10.1007/s00134-013-2827-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 01/07/2013] [Indexed: 10/27/2022]
Abstract
RATIONALE Lung volume available for ventilation is markedly decreased during acute respiratory distress syndrome. Body positioning may contribute to increase lung volume and partial verticalization is simple to perform. This study evaluated whether verticalization had parallel effects on oxygenation and end expiratory lung volume (EELV). METHODS Prospective multicenter study in 40 mechanically ventilated patients with ALI/ARDS in five university hospital MICUs. We evaluated four 45-min successive trunk position epochs (supine slightly elevated at 15°; semi recumbent with trunk elevated at 45°; seated with trunk elevated at 60° and legs down at 45°; back to supine). Arterial blood gases, EELV measured using the nitrogen washin/washout, and static compliance were measured. Responders were defined by a PaO₂/FiO₂ increase >20 % between supine and seated position. Results are median [25th-75th percentiles]. RESULTS With median PEEP = 10 cmH₂O, verticalization increased lung volume but only responders (13 patients, 32 %) had a significant increase in EELV/PBW (predicted body weight) compared to baseline. This increase persisted at least partially when patients were positioned back to supine. Responders had a lower EELV/PBW supine [14 mL/kg (13-15) vs. 18 mL/kg (15-27) (p = 0.005)] and a lower compliance [30 mL/cmH₂O (22-38) vs. 42 (30-46) (p = 0.01)] than non-responders. Strain decreased with verticalization for responders. EELV/PBW increase and PaO₂/FiO₂ increase were not correlated. DISCUSSION Verticalization is easily achieved and improves oxygenation in approximately 32 % of the patients together with an increase in EELV. Nonetheless, effect of verticalization on EELV/PBW is not predictable by PaO₂/FiO₂ increase, its monitoring may be helpful for strain optimization.
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Early stabilizing alveolar ventilation prevents acute respiratory distress syndrome: a novel timing-based ventilatory intervention to avert lung injury. J Trauma Acute Care Surg 2012; 73:391-400. [PMID: 22846945 DOI: 10.1097/ta.0b013e31825c7a82] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Established acute respiratory distress syndrome (ARDS) is often refractory to treatment. Clinical trials have demonstrated modest treatment effects, and mortality remains high. Ventilator strategies must be developed to prevent ARDS. HYPOTHESIS Early ventilatory intervention will block progression to ARDS if the ventilator mode (1) maintains alveolar stability and (2) reduces pulmonary edema formation. METHODS Yorkshire pigs (38-45 kg) were anesthetized and subjected to a "two-hit" ischemia-reperfusion and peritoneal sepsis. After injury, animals were randomized into two groups: early preventative ventilation (airway pressure release ventilation [APRV]) versus nonpreventative ventilation (NPV) and followed for 48 hours. All animals received anesthesia, antibiotics, and fluid or vasopressor therapy as per the Surviving Sepsis Campaign. Titrated for optimal alveolar stability were the following ventilation parameters: (1) NPV group--tidal volume, 10 mL/kg + positive end-expiratory pressure - 5 cm/H2O volume-cycled mode; (2) APRV group--tidal volume, 10 to 15 mL/kg; high pressure, low pressure, time duration of inspiration (Thigh), and time duration of release phase (Tlow). Physiological data and plasma were collected throughout the 48-hour study period, followed by BAL and necropsy. RESULTS APRV prevented the development of ARDS (p < 0.001 vs. NPV) by PaO₂/FIO₂ ratio. Quantitative histological scoring showed that APRV prevented lung tissue injury (p < 0.001 vs. NPV). Bronchoalveolar lavage fluid showed that APRV lowered total protein and interleukin 6 while preserving surfactant proteins A and B (p < 0.05 vs. NPV). APRV significantly lowered lung water (p < 0.001 vs. NPV). Plasma interleukin 6 concentrations were similar between groups. CONCLUSION Early preventative mechanical ventilation with APRV blocked ARDS development, preserved surfactant proteins, and reduced pulmonary inflammation and edema despite systemic inflammation similar to NPV. These data suggest that early preventative ventilation strategies stabilizing alveoli and reducing pulmonary edema can attenuate ARDS after ischemia-reperfusion and sepsis.
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Shafeeq H, Lat I. Pharmacotherapy for Acute Respiratory Distress Syndrome. Pharmacotherapy 2012. [DOI: 10.1002/phar.1115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hira Shafeeq
- College of Pharmacy and Allied Health Professions; St. John's University; Jamaica; New York
| | - Ishaq Lat
- Department of Pharmaceutical Services; University of Chicago Medical Center; Chicago; Illinois
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Jauncey-Cooke J, Bogossian F, Hough JL, Schibler A, Davies MW, Grant CA, Gibbons K, East CE. Lung recruitment manoeuvres for reducing respiratory morbidity in mechanically ventilated neonates. Hippokratia 2012. [DOI: 10.1002/14651858.cd009969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | - Fiona Bogossian
- School of Nursing and Midwifery; The University of Queensland; Herston Australia
| | - Judith L Hough
- Mater Medical Research Institute; South Brisbane Queensland Australia 4101
| | - Andreas Schibler
- Mater Children's Hospital; Paediatric Intensive Care Unit; Raymond Terrace South Brisbane Queensland Australia 4101
| | - Mark W Davies
- Department of Paediatrics & Child Health, The University of Queensland; Grantley Stable Neonatal Unit, Royal Brisbane and Women's Hospital; Butterfield St Herston Brisbane Queensland Australia 4029
| | - Caroline A Grant
- Mater Children's Hospital; Paediatric Intensive Care Unit; Raymond Terrace South Brisbane Queensland Australia 4101
| | - Kristen Gibbons
- Mater Medical Research Institute; Clinical Research Support Unit; Level 3, Quarters Building Raymond Terrace South Brisbane Queensland Australia 4101
| | - Christine E East
- School of Nursing and Midwifery, Monash University / Southern Health; School of Nursing and Midwifery, University of Queensland; 246 Clayton Rd Clayton Victoria Australia 3168
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Sindrome acuta da stress respiratorio (ARDS). LA RESPIRAZIONE ARTIFICIALE 2012. [PMCID: PMC7121832 DOI: 10.1007/978-88-470-2382-6_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
L’esatta incidenza dell’ ARDS non è nota, poiché nella maggior parte delle diagnosi non viene impiegata una definizione univoca. Si può, comunque, affermare che sussiste una frequenza di circa 2–8 casi di malattia per 100.000 abitanti.
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Mabley J, Gordon S, Pacher P. Nicotine exerts an anti-inflammatory effect in a murine model of acute lung injury. Inflammation 2011; 34:231-7. [PMID: 20625922 DOI: 10.1007/s10753-010-9228-x] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Activation of the cholinergic anti-inflammatory pathway through direct activation of nicotinic acetylcholine receptors on immune cells can inhibit pro-inflammatory chemokine and cytokine release and thereby protect in a variety of inflammatory diseases. The aim of this study was to investigate whether nicotine treatment protected against acute lung inflammation. Mice challenged with intratracheal lipopolysaccharide (LPS, 50 μg) were treated with nicotine (0.2 or 0.4 mg/kg, sc). After 24 h, bronchoalveolar lavage fluid (BALF) was obtained to measure leukocyte infiltration, lung edema, and pro-inflammatory chemokine (MIP-1α, MIP-2, and eotaxin) and cytokine (IL-1, IL-6, and TNF-α) levels. Nicotine treatment reduced the LPS-mediated infiltration of leukocytes and edema as evidenced by decreased BALF inflammatory cells, myeloperoxidase, and protein. Nicotine also downregulated lung production of pro-inflammatory chemokines and cytokines. These data support the proposal that activation of the cholinergic anti-inflammatory pathway may represent a useful addition to the therapy of acute respiratory distress syndrome.
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Affiliation(s)
- Jon Mabley
- School of Pharmacy & Biomolecular Sciences, University of Brighton, Brighton BN2 4GJ, UK.
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Eslami S, Abu-Hanna A, Schultz MJ, de Jonge E, de Keizer NF. Evaluation of consulting and critiquing decision support systems: effect on adherence to a lower tidal volume mechanical ventilation strategy. J Crit Care 2011; 27:425.e1-8. [PMID: 22172793 DOI: 10.1016/j.jcrc.2011.07.082] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 07/01/2011] [Accepted: 07/29/2011] [Indexed: 01/22/2023]
Abstract
PURPOSE Our hypothesis was that both styles are effective to decrease tidal volume (V(T)) but that critiquing comprises the most effective strategy. The purpose of this study is to test this hypothesis by measuring the effect of an active computerized decision support system, in 2 communication styles, consulting and critiquing, on adherence to V(T) recommendations. MATERIALS AND METHODS We developed and implemented an active computerized decision support system (CDSS) working in a consulting style that always shows the preferred V(T) and in a critiquing style that shows the preferred V(T) only if V(T) is above the desired threshold. A prospective, off-on-off-on study evaluated the system's performance in a mixed medical-surgical intensive care unit of a university hospital. RESULTS Four thousand seven hundred sixty-four patient-day mechanical ventilation from 757 patients were analyzed. The percentage of ventilation time in excess of 6 and 8 mL/kg predicted body weight decreased significantly after intervening with the consulting style (12% reduction and P < .001; 22% reduction and P < .001) and again increased after stopping the CDSS (11% increase and P < .001; 29% increase and P < .001). With the critiquing CDSS, the percentage of ventilation time in excess of 6 and 8 mL/kg predicted body weight again decreased significantly (6% reduction and P < .001; 15% reduction and P < .001). CONCLUSIONS The use of a CDSS in both communication styles improved the use of lower V(T)s for ventilated patients. When decision support was not sustained, adherence to low V(T) fell back to its original value. Interestingly, the consulting style had a slightly larger effect. This may stem from the high frequency of showing reminders in this style and the relatively simple underlying guideline where its display implies the associated action of lowering V(T). The consulting style, however, was more interruptive for clinicians, calling upon the need to strike a balance between effect and intrusiveness.
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Affiliation(s)
- Saeid Eslami
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands.
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Dellamonica J, Lerolle N, Sargentini C, Beduneau G, Di Marco F, Mercat A, Richard JCM, Diehl JL, Mancebo J, Rouby JJ, Lu Q, Bernardin G, Brochard L. Accuracy and precision of end-expiratory lung-volume measurements by automated nitrogen washout/washin technique in patients with acute respiratory distress syndrome. Crit Care 2011; 15:R294. [PMID: 22166727 PMCID: PMC3388680 DOI: 10.1186/cc10587] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 12/04/2011] [Accepted: 12/07/2011] [Indexed: 11/10/2022] Open
Abstract
Introduction End-expiratory lung volume (EELV) is decreased in acute respiratory distress
syndrome (ARDS), and bedside EELV measurement may help to set positive
end-expiratory pressure (PEEP). Nitrogen washout/washin for EELV measurement is
available at the bedside, but assessments of accuracy and precision in real-life
conditions are scant. Our purpose was to (a) assess EELV measurement precision in
ARDS patients at two PEEP levels (three pairs of measurements), and (b) compare
the changes (Δ) induced by PEEP for total EELV with the PEEP-induced changes
in lung volume above functional residual capacity measured with passive spirometry
(ΔPEEP-volume). The minimal predicted increase in lung volume was calculated
from compliance at low PEEP and ΔPEEP to ensure the validity of lung-volume
changes. Methods Thirty-four patients with ARDS were prospectively included in five
university-hospital intensive care units. ΔEELV and ΔPEEP volumes were
compared between 6 and 15 cm H2O of PEEP. Results After exclusion of three patients, variability of the nitrogen technique was less
than 4%, and the largest difference between measurements was 81 ± 64 ml.
ΔEELV and ΔPEEP-volume were only weakly correlated (r2
= 0.47); 95% confidence interval limits, -414 to 608 ml). In four
patients with the highest PEEP (≥ 16 cm H2O), ΔEELV was
lower than the minimal predicted increase in lung volume, suggesting flawed
measurements, possibly due to leaks. Excluding those from the analysis markedly
strengthened the correlation between ΔEELV and ΔPEEP volume (r2
= 0.80). Conclusions In most patients, the EELV technique has good reproducibility and accuracy, even
at high PEEP. At high pressures, its accuracy may be limited in case of leaks. The
minimal predicted increase in lung volume may help to check for accuracy.
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Affiliation(s)
- Jean Dellamonica
- Réanimation Médicale, AP-HP, Centre Hospitalier Albert Chenevier, Henri Mondor, avenue Marechal de Lattre de Tassigny, Créteil, 94000, France.
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PEEP-induced changes in lung volume in acute respiratory distress syndrome. Two methods to estimate alveolar recruitment. Intensive Care Med 2011; 37:1595-604. [PMID: 21866369 DOI: 10.1007/s00134-011-2333-y] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Accepted: 07/26/2011] [Indexed: 10/17/2022]
Abstract
PURPOSE Lung volumes, especially functional residual capacity (FRC), are decreased in acute respiratory distress syndrome (ARDS). Positive end-expiratory pressure (PEEP) contributes to increased end-expiratory lung volume (EELV) and to improved oxygenation, but differentiating recruitment of previously nonaerated lung units from distension of previously open lung units remains difficult. This study evaluated simple methods derived from bedside EELV measurements to assess PEEP-induced lung recruitment while monitoring strain. METHODS Prospective multicenter study in 30 mechanically ventilated patients with ARDS in five university hospital ICUs. Two PEEP levels were studied, each for 45 min, and EELV (nitrogen washout/washin technique) was measured at both levels, with the difference (Δ) reflecting PEEP-induced lung volume changes. Alveolar recruitment was measured using pressure-volume (PV) curves. High and low recruiters were separated based on median recruitment at high PEEP. Minimum predicted increase in lung volume computed as the product of ΔPEEP by static compliance was subtracted from ΔEELV as an independent estimate of recruitment. Estimated and measured recruitments were compared. Strain induced by PEEP was also calculated from the same measurements. RESULTS FRC was 31 ± 11% of predicted. Median [25th-75th percentiles] PEEP-induced recruitment was 272 [187-355] mL. Estimated recruitment correlated with recruited volume measured on PV curves (ρ = 0.68), with a slope close to identity. The ΔEELV/FRC ratio differentiated high from low recruiters (110 [76-135] vs. 55 [23-70]%, p = 0.001). Strain increase due to PEEP was larger in high recruiters (p = 0.002). CONCLUSION PEEP-induced recruitment and strain can be assessed at the bedside using EELV measurement. We describe two bedside methods for predicting low or high alveolar recruitment during ARDS.
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Deans KJ, Minneci PC, Danner RL, Eichacker PQ, Natanson C. Practice misalignments in randomized controlled trials: Identification, impact, and potential solutions. Anesth Analg 2010; 111:444-50. [PMID: 19820238 DOI: 10.1213/ane.0b013e3181aa8903] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Appropriate control group selection in a randomized controlled trial (RCT) is a critical factor in generating results, which are both interpretable and generalizable. Control groups ideally encompass and realistically reflect prevailing medical practices. This goal can be challenging in investigations of standard therapies that are routinely titrated. To eliminate the heterogeneity in clinical practice from the trial design, recent investigations of titrated therapies have randomized patients to fixed-dose regimens. Although this approach may produce statistically significant differences, the results may not be interpretable or generalizable. In this trial design, randomization disrupts the normal relationship between clinically important characteristics and therapy titration, thereby creating subgroups of patients within each study arm that receive levels of therapy inconsistent with current practices outside of the clinical study. These misaligned subgroups may have worse outcomes than usual care. Practice misalignments can occur in any clinical trial of a preexisting therapy that is typically adjusted based on severity of illness or other patient characteristics. In this study, we review three recent RCTs to demonstrate how practice misalignments can affect the safety, results, and conclusions of RCTs. Furthermore, we discuss methods to prospectively identify potentially important relationships between therapy titration and patient- and disease-specific characteristics. Finally, we review trial design options that may minimize the occurrence and impact of practice misalignments. Because these designs may limit the feasibility of a clinical trial, a thorough characterization of usual care is necessary to determine whether one of these designs should be used to protect patient safety.
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Affiliation(s)
- Katherine J Deans
- Department of Surgery, The Children's Institute for Surgical Science, The Children's Hospital of Philadelphia, Abramson Research Center, Rm 1116, 34th St. and Civic Center Blvd., Philadelphia, PA 19104, USA.
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Zhang XD, Hou JF, Qin XJ, Li WL, Chen HL, Liu R, Liang X, Hai CX. Pentoxifylline inhibits intercellular adhesion molecule-1 (ICAM-1) and lung injury in experimental phosgene-exposure rats. Inhal Toxicol 2010; 22:889-95. [DOI: 10.3109/08958378.2010.493900] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Jauncey-Cooke JI, Bogossian F, East CE. Lung protective ventilation strategies in paediatrics-A review. Aust Crit Care 2010; 23:81-8. [PMID: 20047842 DOI: 10.1016/j.aucc.2009.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Revised: 11/03/2009] [Accepted: 11/10/2009] [Indexed: 10/20/2022] Open
Abstract
Ventilator Associated Lung Injury (VALI) is an iatrogenic phenomena that significantly impacts on the morbidity and mortality of critically ill patients. The hazards associated with mechanical ventilation are becoming increasingly understood courtesy of a large body of research. Barotrauma, volutrauma and biotrauma all play a role in VALI. Concomitant to this growth in understanding is the development of strategies to reduce the deleterious impact of mechanical ventilation. The majority of the research is based upon adult populations but with careful extrapolation this review will focus on paediatrics. This review article describes the physiological basis of VALI and discusses the various lung protective strategies that clinicians can employ to minimise its incidence and optimise outcomes for paediatric patients.
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Affiliation(s)
- Jacqui I Jauncey-Cooke
- The University of Queensland, School of Nursing and Midwifery, Herston, Australia; Clinical Nurse, PICU, Mater Children's Hospital, South Brisbane, Queensland, Australia.
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Ragaller M, Richter T. Acute lung injury and acute respiratory distress syndrome. J Emerg Trauma Shock 2010; 3:43-51. [PMID: 20165721 PMCID: PMC2823143 DOI: 10.4103/0974-2700.58663] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Accepted: 10/30/2009] [Indexed: 01/11/2023] Open
Abstract
Every year, more information accumulates about the possibility of treating patients with acute lung injury or acute respiratory distress syndrome with specially designed mechanical ventilation strategies. Ventilator modes, positive end-expiratory pressure settings, and recruitment maneuvers play a major role in these strategies. However, what can we take from these experimental and clinical data to the clinical practice? In this article, we discuss substantial options of mechanical ventilation together with some adjunctive therapeutic measures, such as prone positioning and inhalation of nitric oxide.
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Affiliation(s)
- Maximillian Ragaller
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Torsten Richter
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
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Mabley JG, Pacher P, Murthy KGK, Williams W, Southan GJ, Salzman AL, Szabo C. The novel inosine analogue INO-2002 exerts an anti-inflammatory effect in a murine model of acute lung injury. Shock 2009; 32:258-62. [PMID: 19174745 DOI: 10.1097/shk.0b013e31819c3414] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Endogenous purines, including inosine, have been shown to exert immunomodulatory and anti-inflammatory effects in a variety of disease models. The dosage of inosine required for these effects has been shown to be between 200 and 600 mg kg(-1) because of the rapid metabolism of inosine in vivo. The aim of this study was to determine whether a metabolic resistant purine analog, INO-2002, exerts anti-inflammatory effects in an animal model of acute respiratory distress syndrome. Mice challenged with intratracheal LPS (50 microg) were treated with INO-2002 (30 or 100 mg kg(-1), i.p.) in divided doses at either 1 and 12 h or at 5 and 16 h. After 24 h, bronchoalveolar lavage fluid was obtained to measure leukocyte infiltration by myeloperoxidase levels, lung edema by protein levels, and proinflammatory chemokine (macrophage inflammatory protein 1alpha) and cytokine (TNF-alpha, IL-1, and IL-6) levels. INO-2002 (30 and 100 mg kg(-1)) reduced the LPS-mediated infiltration of leukocytes and edema as evidenced by bronchoalveolar lavage fluid reduction in levels of myeloperoxidase and protein. INO-2002 also downregulated expression of the proinflammatory mediators macrophage inflammatory protein 1alpha, TNF-alpha, IL-1, and IL-6. Delaying the start of treatment by 5 h after LPS administration affected the potency of INO-2002 protective effects, with 100 but not 30 mg kg(-1) having anti-inflammatory effects. The inosine analog INO-2002 largely suppressed LPS-induced inflammation in vivo at doses lower than those needed for the naturally occurring purine inosine. These data support the proposal that purine analogs, resistant to metabolic breakdown, may represent a useful addition to the therapy of acute respiratory distress syndrome.
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Affiliation(s)
- Jon G Mabley
- School of Pharmacy and Biomolecular Sciences, University of Brighton, Brighton, UK.
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Alcohol consumption and development of acute respiratory distress syndrome: a population-based study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2009; 6:2426-35. [PMID: 19826554 PMCID: PMC2760420 DOI: 10.3390/ijerph6092426] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Accepted: 09/04/2009] [Indexed: 01/08/2023]
Abstract
This retrospective population-based study evaluated the effects of alcohol consumption on the development of acute respiratory distress syndrome (ARDS). Alcohol consumption was quantified based on patient and/or family provided information at the time of hospital admission. ARDS was defined according to American-European consensus conference (AECC). From 1,422 critically ill Olmsted county residents, 1,357 had information about alcohol use in their medical records, 77 (6%) of whom developed ARDS. A history of significant alcohol consumption (more than two drinks per day) was reported in 97 (7%) of patients. When adjusted for underlying ARDS risk factors (aspiration, chemotherapy, high-risk surgery, pancreatitis, sepsis, shock), smoking, cirrhosis and gender, history of significant alcohol consumption was associated with increased risk of ARDS development (odds ratio 2.9, 95% CI 1.3–6.2). This population-based study confirmed that excessive alcohol consumption is associated with higher risk of ARDS.
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