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Pathobiology, Severity, and Risk Stratification of Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S12-S27. [PMID: 36661433 DOI: 10.1097/pcc.0000000000003156] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To review the literature for studies published in children on the pathobiology, severity, and risk stratification of pediatric acute respiratory distress syndrome (PARDS) with the intent of guiding current medical practice and identifying important areas for future research related to severity and risk stratification. DATA SOURCES Electronic searches of PubMed and Embase were conducted from 2013 to March 2022 by using a combination of medical subject heading terms and text words to capture the pathobiology, severity, and comorbidities of PARDS. STUDY SELECTION We included studies of critically ill patients with PARDS that related to the severity and risk stratification of PARDS using characteristics other than the oxygenation defect. Studies using animal models, adult only, and studies with 10 or fewer children were excluded from our review. DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize relevant evidence and develop recommendations for clinical practice. There were 192 studies identified for full-text extraction to address the relevant Patient/Intervention/Comparator/Outcome questions. One clinical recommendation was generated related to the use of dead space fraction for risk stratification. In addition, six research statements were generated about the impact of age on acute respiratory distress syndrome pathobiology and outcomes, addressing PARDS heterogeneity using biomarkers to identify subphenotypes and endotypes, and use of standardized ventilator, physiologic, and nonpulmonary organ failure measurements for future research. CONCLUSIONS Based on an extensive literature review, we propose clinical management and research recommendations related to characterization and risk stratification of PARDS severity.
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Dynamics of acute respiratory distress syndrome development due to smoke inhalation injury: Implications for prolonged field care. J Trauma Acute Care Surg 2020; 87:S91-S100. [PMID: 31246912 DOI: 10.1097/ta.0000000000002227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Smoke inhalation injury (SII) causes 30% to 40% mortality and will increase as a cause of death during prolonged field care. We used a combat relevant model of acute respiratory distress syndrome due to SII to study temporal changes in ventilation-perfusion (V/Q) matching, computed tomography (CT) scan data, and histopathology and hypothesized that SII leads to increase in shunt (Qshunt), V/Q mismatch, lung consolidation, and diffuse alveolar damage. METHODS Swine received severe SII and airway pressure release ventilation (APRV, n = 6), or conventional ARDSNet mechanical ventilation (MV) (CMV, n = 8). A control group without injury received volume controlled MV (CTRL, n = 6), The multiple inert gas elimination technique and CT were performed at baseline (BL), 0.5 hours, 1 hours, 2 hours, 24 hours, and 48 hours after injury. Diffuse alveolar damage scoring was performed post mortem. Significance at p less than 0.05: APRV versus CTRL; CMV versus CTRL; APRV versus CMV*; denotes changes versus BL. RESULTS (1) SII caused increases in Qshunt more so in APRV than CMV group. Qshunt did not change in CTRL. (2) PaO2-to-FIO2 ratio (PFR) was lower in APRV versus CTRL at 2 hours (375 ± 62‡ vs. 549 ± 40) and 24 hours (126 ± 34‡* vs. 445 ± 5) and 48 hours (120 ± 41‡& vs. 430 ± 13). In CMV animals, PFR was lower versus CTRL and BL at 24 hours (238 ± 33) and 48 hours (98 ± 27). Qshunt correlated with PFR (r = 0.75, p < 0.0001, APRV and (r = 0.65, p < 0.0001, CMV). CT showed decrease in normally aerated lung, while poorly and nonaerated lung increased. CONCLUSION Smoke inhalation injury leads to early development of shunt, V/Q mismatch, lung consolidation, and diffuse alveolar damage. These data substantiate the need for new point of injury interventions in the prolonged field care setting. LEVEL OF EVIDENCE Animal research.
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Lin B, Jin Z, Chen X, Zhao L, Weng C, Chen B, Tang Y, Lin L. Necrostatin‑1 protects mice from acute lung injury by suppressing necroptosis and reactive oxygen species. Mol Med Rep 2020; 21:2171-2181. [PMID: 32323764 PMCID: PMC7115190 DOI: 10.3892/mmr.2020.11010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 11/19/2019] [Indexed: 12/18/2022] Open
Abstract
Acute lung injury (ALI) is characterized by tissue damage and inflammatory cytokine secretion; however, the therapeutic options available to treat ALI remain limited. Necrostatin-1 (Nec-1) has the ability to attenuate cell necroptosis in various inflammatory diseases. The present study evaluated the protective effects of Nec-1 on a mouse model of lipopolysaccharide-induced ALI. Histological alterations in the lungs were evaluated through hematoxylin and eosin staining, and the expression levels of cytokines in the bronchoalveolar lavage fluid and lung tissues were determined by ELISA. In addition, accumulated production of reactive oxygen species was determined by staining with DCFH-DA probes, western blotting and immunofluorescence. The results revealed that treatment with the necroptosis inhibitor, Nec-1, exerted significant protective effects on ALI-induced inflammation and necroptosis. The key proteins involved in necroptosis were markedly reduced, including receptor-interacting serine/threonine-protein kinase (RIP)1 and RIP3. Notably, antioxidant proteins were upregulated by Nec-1, which may attenuate oxidative stress. Furthermore, treatment with Nec-1 markedly suppressed necroptosis in the pulmonary alveoli RLE-6TN cell line. Taken together, these data revealed a novel association between ALI and necroptosis, and suggested that necroptosis inhibitors may be used as effective anti-inflammatory drugs to treat ALI.
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Affiliation(s)
- Bi Lin
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Ziyuan Jin
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Xiang Chen
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Li Zhao
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Chengwei Weng
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Baihui Chen
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Yaning Tang
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Lina Lin
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
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Heparin-Free Extracorporeal Life Support Using Tethered Liquid Perfluorocarbon: A Feasibility and Efficacy Study. ASAIO J 2019; 66:809-817. [PMID: 31453831 DOI: 10.1097/mat.0000000000001055] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Coagulation management is the leading challenge during extracorporeal life support (ECLS) due to shear stress and foreign-surface-induced coagulation disturbance during circulation. A nonadhesive, liquid-infused coating called tethered liquid perfluorocarbon (TLP) was developed to prevent adhesion of blood on medical materials. We investigated the novel application of TLP to commercial ECLS circuits compared with standard heparin-coated circuits in vivo in anesthetized swine for 6 hours veno-venous ECLS (1 L/min blood flow) without systemic anticoagulation (n = 3/group). We hypothesized that TLP coating permits heparin-free circulation without untoward effects while reducing thrombus deposition compared with controls. Vital signs, respiration, gas transfer, coagulation, and histology were assessed. Scanning electron microscopy (SEM), elemental mapping, and digital imaging were used to assess thrombus deposition after circulation. There were no group differences in vitals, gas exchange, coagulation, and histology. In both groups, ECLS enabled a decrease in minute volume and end-tidal CO2, with concomitant increase in pH (p < 0.05). Scanning electron microscopy and digital imaging revealed significant thrombus on heparin-coated membranes, which was reduced or absent on TLP-coated materials. Tethered liquid perfluorocarbon permitted heparin-free ECLS without altering device performance and prevented thrombus deposition versus immobilized heparin. Pending multiday in vivo testing, TLP is a promising biomaterial solution to eliminate anticoagulation requirements during ECLS.
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Choi JH, Necsoiu C, Wendorff D, Jordan B, Dixon A, Roberts TR, Beely BM, Cancio LC, Batchinsky AI. Effects of adjunct treatments on end-organ damage and histological injury severity in acute respiratory distress syndrome and multiorgan failure caused by smoke inhalation injury and burns. Burns 2019; 45:1765-1774. [PMID: 31378621 DOI: 10.1016/j.burns.2019.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND We investigated effects of mesenchymal stem cells (MSC) or low-flow extracorporeal life support (ECLS) as adjunctive treatments for acute respiratory distress syndrome (ARDS) due to inhalation injury and burns. We hypothesized that these interventions decrease histological end-organ damage. METHODS Anesthetized female swine underwent smoke inhalation injury and 40% TBSA burns, then critical care for 72h. The following groups were studied: CTR (no injury, n = 4), ICTR (injured untreated, n = 10), Allo (injured treated with allogenic MSC, n = 10), Auto (injured treated with autologous MSC, n = 10), Hemo (injured and treated with the Hemolung low flow ECLS system, n = 9), and Nova (injured and treated with the NovaLung low flow ECLS system, n = 8). Histology scores from lung, kidneys, liver, and jejunum were calculated. Data are presented as means±SEM. RESULTS Survival at 72h was 100% in CTR; 40% in ICTR; 50% in Allo; 90% in Auto; 33% in Hemo; 63% in Nova. ARDS developed in 0/10 CTR; 10/10 ICTR; 8/9 Hemo; 5/8 Nova; 9/10 Allo; 6/10 Auto. Diffuse alveolar damage (DAD) was present in all injured groups. MSC groups had significantly lower DAD scores than ICTR animals (Allo 26.6 ± 3.4 and Auto 18.9 ± 1.5 vs. ICTR 46.8 ± 2.1, p < 0.001). MSC groups also had lower DAD scores than ECLS animals (Allo vs. Nova, p < 0.05, Allo vs. Hemo p < 0.001, Auto vs. Nova p < 0.001, Auto vs. Hemo, p < 0.001). Kidney injury ICTR (p < 0.05) and Hemo (p < 0.01) were higher than in CTR. By logistic regression, a PaO2-to-FiO2 ratio (PFR) < 300 was a function of the DAD score: logit (PFR < 300) = 0.84 + 0.072*DAD Score, odds ratio 1.074 (1.007, 1.147, p < 0.05) with a ROC AUC of 0.76, p < 0.001. CONCLUSION Treatment with Auto MSC followed by Allo and then Nova were most effective in mitigating ARDS and MOF severity in this model. Further studies will elucidate the role of combination therapies of MSC and ECLS as comprehensive treatments for ARDS and MOF.
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Affiliation(s)
- Jae Hyek Choi
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA-Ft. Sam Houston, TX, United States
| | - Corina Necsoiu
- United States Army Institute of Surgical Research, JBSA-Ft. Sam Houston, TX, United States
| | - Daniel Wendorff
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA-Ft. Sam Houston, TX, United States
| | - Bryan Jordan
- United States Army Institute of Surgical Research, JBSA-Ft. Sam Houston, TX, United States
| | - Alexander Dixon
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA-Ft. Sam Houston, TX, United States
| | - Teryn R Roberts
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA-Ft. Sam Houston, TX, United States; Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Brendan M Beely
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA-Ft. Sam Houston, TX, United States
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA-Ft. Sam Houston, TX, United States
| | - Andriy I Batchinsky
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA-Ft. Sam Houston, TX, United States; Morsani College of Medicine, University of South Florida, Tampa, FL, United States.
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Choi JH, Chou LD, Roberts TR, Beely BM, Wendorff DS, Espinoza MD, Sieck K, Dixon AT, Burmeister D, Jordan BS, Brenner M, Chen Z, Necsoiu C, Cancio LC, Batchinsky AI. Point-of-care endoscopic optical coherence tomography detects changes in mucosal thickness in ARDS due to smoke inhalation and burns. Burns 2018; 45:589-597. [PMID: 30482414 DOI: 10.1016/j.burns.2018.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 10/09/2018] [Accepted: 10/15/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND The prevalence of acute respiratory distress syndrome (ARDS) in mechanically ventilated burn patients is 33%, with mortality varying from 11-46% depending on ARDS severity. Despite the new Berlin definition for ARDS, prompt bedside diagnosis is lacking. We developed and tested a bedside technique of fiberoptic-bronchoscopy-based optical coherence tomography (OCT) measurement of airway mucosal thickness (MT) for diagnosis of ARDS following smoke inhalation injury (SII) and burns. METHODS 16 female Yorkshire pigs received SII and 40% thermal burns. OCT MT and PaO2-to-FiO2 ratio (PFR) measurements were taken at baseline, after injury, and at 24, 48, and 72h after injury. RESULTS Injury led to thickening of MT which was sustained in animals that developed ARDS. Significant correlations were found between MT, PFR, peak inspiratory pressure (PIP), and total infused fluid volume. CONCLUSIONS OCT is a useful tool to quantify MT changes in the airway following SII and burns. OCT may be effective as a diagnostic tool in the early stages of SII-induced ARDS and should be tested in humans.
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Affiliation(s)
- Jae Hyek Choi
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States.
| | - Li-Dek Chou
- Beckman Laser Institute, University of California Irvine, Irvine, CA, United States
| | - Teryn R Roberts
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Brendan M Beely
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Daniel S Wendorff
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Mark D Espinoza
- United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Kyle Sieck
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Alexander T Dixon
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - David Burmeister
- United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Bryan S Jordan
- United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Matthew Brenner
- Beckman Laser Institute, University of California Irvine, Irvine, CA, United States
| | - Zhongping Chen
- Beckman Laser Institute, University of California Irvine, Irvine, CA, United States
| | - Corina Necsoiu
- United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Andriy I Batchinsky
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
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Integrity of airway epithelium in pediatric burn autopsies: Association with age and extent of burn injury. Burns 2015; 41:1435-41. [PMID: 26093952 DOI: 10.1016/j.burns.2015.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 05/04/2015] [Accepted: 05/05/2015] [Indexed: 01/24/2023]
Abstract
UNLABELLED This study examines the structural integrity of the airway epithelium in autopsy tissues from pediatric burn subjects. METHODS A semi-quantitative score for the degree of airway epithelial integrity was made for seventy- two pediatric burn autopsies. Multivariate ordinal logistic regression was performed to identify relationships between epithelial integrity and conditions related to tissue fixation, time of death after injury, age, total body surface area burn (TBSA), extent of 3rd degree burn, presence of inhalation injury, ventilator days and pneumonia. RESULTS No significant difference in epithelial integrity scores was identified between burn only cases and those with inhalation injury. Significant correlations with bronchiolar epithelial integrity scores were identified for age, p=0.02, and percent 3rd degree burn, p=0.02. There was no significant relationship between epithelial integrity and time between death and autopsy, p>0.44. CONCLUSIONS Airway epithelial loss seen in autopsy tissue is not simply an artifact of tissue fixation. The degree of compromise correlates most strongly with age and degree of burn. Further studies are needed to identify physiological or critical care factors following burn injury that contribute to compromise in the structural and functional properties of the airway epithelium.
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