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Mariappan N, Zafar I, Robichaud A, Wei CC, Shakil S, Ahmad A, Goymer HM, Abdelsalam A, Kashyap MP, Foote JB, Bae S, Agarwal A, Ahmad S, Athar M, Antony VB, Ahmad A. Pulmonary pathogenesis in a murine model of inhaled arsenical exposure. Arch Toxicol 2023; 97:1847-1858. [PMID: 37166470 DOI: 10.1007/s00204-023-03503-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 04/20/2023] [Indexed: 05/12/2023]
Abstract
Arsenic trioxide (ATO), an inorganic arsenical, is a toxic environmental contaminant. It is also a widely used chemical with industrial and medicinal uses. Significant public health risk exists from its intentional or accidental exposure. The pulmonary pathology of acute high dose exposure is not well defined. We developed and characterized a murine model of a single inhaled exposure to ATO, which was evaluated 24 h post-exposure. ATO caused hypoxemia as demonstrated by arterial blood-gas measurements. ATO administration caused disruption of alveolar-capillary membrane as shown by increase in total protein and IgM in the bronchoalveolar lavage fluid (BALF) supernatant and an onset of pulmonary edema. BALF of ATO-exposed mice had increased HMGB1, a damage-associated molecular pattern (DAMP) molecule, and differential cell counts revealed increased neutrophils. BALF supernatant also showed an increase in protein levels of eotaxin/CCL-11 and MCP-3/CCL-7 and a reduction in IL-10, IL-19, IFN-γ, and IL-2. In the lung of ATO-exposed mice, increased protein levels of G-CSF, CXCL-5, and CCL-11 were noted. Increased mRNA levels of TNF-a, and CCL2 in ATO-challenged lungs further supported an inflammatory pathogenesis. Neutrophils were increased in the blood of ATO-exposed animals. Pulmonary function was also evaluated using flexiVent. Consistent with an acute lung injury phenotype, respiratory and lung elastance showed significant increase in ATO-exposed mice. PV loops showed a downward shift and a decrease in inspiratory capacity in the ATO mice. Flow-volume curves showed a decrease in FEV0.1 and FEF50. These results demonstrate that inhaled ATO leads to pulmonary damage and characteristic dysfunctions resembling ARDS in humans.
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Affiliation(s)
- Nithya Mariappan
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th St S, PBMR2, Rm 312, Birmingham, AL, 35205, USA
| | - Iram Zafar
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th St S, PBMR2, Rm 312, Birmingham, AL, 35205, USA
| | | | - Chih-Chang Wei
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th St S, PBMR2, Rm 312, Birmingham, AL, 35205, USA
| | - Shazia Shakil
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th St S, PBMR2, Rm 312, Birmingham, AL, 35205, USA
| | - Aamir Ahmad
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th St S, PBMR2, Rm 312, Birmingham, AL, 35205, USA
| | - Hannah M Goymer
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th St S, PBMR2, Rm 312, Birmingham, AL, 35205, USA
| | - Ayat Abdelsalam
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th St S, PBMR2, Rm 312, Birmingham, AL, 35205, USA
| | - Mahendra P Kashyap
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeremy B Foote
- Comparative Pathology Laboratory, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sejong Bae
- Biostatistics and Bioinformatics Shared Facility, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Anupam Agarwal
- UAB Research Center of Excellence in Arsenicals, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shama Ahmad
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th St S, PBMR2, Rm 312, Birmingham, AL, 35205, USA
| | - Mohammad Athar
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
- UAB Research Center of Excellence in Arsenicals, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Veena B Antony
- UAB Research Center of Excellence in Arsenicals, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Aftab Ahmad
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th St S, PBMR2, Rm 312, Birmingham, AL, 35205, USA.
- UAB Research Center of Excellence in Arsenicals, University of Alabama at Birmingham, Birmingham, AL, USA.
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Bajon F, Gauthier V. Management of refractory hypoxemia using recruitment maneuvers and rescue therapies: A comprehensive review. Front Vet Sci 2023; 10:1157026. [PMID: 37065238 PMCID: PMC10098094 DOI: 10.3389/fvets.2023.1157026] [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: 02/02/2023] [Accepted: 03/14/2023] [Indexed: 04/18/2023] Open
Abstract
Refractory hypoxemia in patients with acute respiratory distress syndrome treated with mechanical ventilation is one of the most challenging conditions in human and veterinary intensive care units. When a conventional lung protective approach fails to restore adequate oxygenation to the patient, the use of recruitment maneuvers and positive end-expiratory pressure to maximize alveolar recruitment, improve gas exchange and respiratory mechanics, while reducing the risk of ventilator-induced lung injury has been suggested in people as the open lung approach. Although the proposed physiological rationale of opening and keeping open previously collapsed or obstructed airways is sound, the technique for doing so, as well as the potential benefits regarding patient outcome are highly controversial in light of recent randomized controlled trials. Moreover, a variety of alternative therapies that provide even less robust evidence have been investigated, including prone positioning, neuromuscular blockade, inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, and unconventional ventilatory modes such as airway pressure release ventilation. With the exception of prone positioning, these modalities are limited by their own balance of risks and benefits, which can be significantly influenced by the practitioner's experience. This review explores the rationale, evidence, advantages and disadvantages of each of these therapies as well as available methods to identify suitable candidates for recruitment maneuvers, with a summary on their application in veterinary medicine. Undoubtedly, the heterogeneous and evolving nature of acute respiratory distress syndrome and individual lung phenotypes call for a personalized approach using new non-invasive bedside assessment tools, such as electrical impedance tomography, lung ultrasound, and the recruitment-to-inflation ratio to assess lung recruitability. Data available in human medicine provide valuable insights that could, and should, be used to improve the management of veterinary patients with severe respiratory failure with respect to their intrinsic anatomy and physiology.
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Choi YJ, Cho JH. Current status of treatment of acute respiratory failure in Korea. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2022. [DOI: 10.5124/jkma.2022.65.3.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Acute respiratory failure (ARF) is one of the most common causes of intensive care unit (ICU) admission and in-hospital mortality. In South Korea, about 25% of patients admitted to the ICU require mechanical ventilation. The in-hospital mortality rate of these patients is 48%. Respiratory failure can be categorized based on pathophysiologic derangements, and the treatment options vary depending on their classification. This study discusses the status and treatment strategies of patients with ARF in Korea.Current Concepts: The most common treatment for ARF was conventional oxygen therapy, being used at least once in 7.0% of all admitted adult patients and 85.1% of patients admitted with respiratory failure. High-flow oxygen therapy was required in 1.4% of all admissions and 17.2% of respiratory failure-related admissions. High-flow oxygen therapy was attempted in 19.1% of patients who needed invasive mechanical ventilation. Non-invasive positive pressure ventilation (NIV) was used in 0.4% of all admissions and 5.1% of respiratory failure-related admissions. Hypercapnic respiratory failure (57.1%) was the most common reason for NIV use. Invasive mechanical ventilation was required in 2.8% of all admissions and 33.8% of respiratory failure-related admissions.Discussion and Conclusion: Despite its clinical significance, no large-scale studies have been performed on the etiology, treatment, and prognosis of patients with ARF in South Korea. A multicenter or a Korean National Health Insurance Service database study is necessary to accurately identify the characteristics, diagnose problems, and develop treatment guidelines for patients with ARF in South Korea.
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Vaquero-Roncero LM, Sánchez-Barrado E, Escobar-Macias D, Arribas-Pérez P, González de Castro R, González-Porras JR, Sánchez-Hernandez MV. C-Reactive protein and SOFA scale: A simple score as early predictor of critical care requirement in patients with COVID-19 pneumonia in Spain. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:513-522. [PMID: 34743905 PMCID: PMC8568297 DOI: 10.1016/j.redare.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 11/20/2020] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To identify potential markers at admission predicting the need for critical care in patients with COVID-19 pneumonia. MATERIAL AND METHODS An approved, observational, retrospective study was conducted between March 15 to April 15, 2020. 150 adult patients aged less than 75 with Charlson comorbidity index ≤6 diagnosed with COVID-19 pneumonia were included. Seventy-five patients were randomly selected from those admitted to the critical care units (critical care group [CG]) and seventy-five hospitalized patients who did not require critical care (non-critical care group [nCG]) represent the control group. One additional cohort of hospitalized patients with COVID-19 were used to validate the score. MEASUREMENTS AND MAIN RESULTS Multivariable regression showed increasing odds of in-hospital critical care associated with increased C-reactive protein (CRP) (odds ratio 1.052 [1.009-1.101]; P = 0.0043) and higher Sequential Organ Failure Assessment (SOFA) score (1.968 [1.389-2.590]; P < 0.0001), both at the time of hospital admission. The AUC-ROC for the combined model was 0.83 (0.76-0.90) (vs AUC-ROC SOFA P < 0.05). The AUC-ROC for the validation cohort was 0.89 (0.82-0.95) (P > 0.05 vs AUC-ROC development). CONCLUSION Patients COVID-19 presenting at admission SOFA score ≥ 2 combined with CRP ≥ 9.1 mg/mL could be at high risk to require critical care.
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Affiliation(s)
- L M Vaquero-Roncero
- Departamento de Anestesiología y Reanimación, Hospital Universitario de Salamanca-IBSAL, Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain
| | - E Sánchez-Barrado
- Departamento de Anestesiología y Reanimación, Hospital Universitario de Salamanca-IBSAL, Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain.
| | - D Escobar-Macias
- Departamento de Anestesiología y Reanimación, Hospital Universitario de Salamanca-IBSAL, Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain
| | - P Arribas-Pérez
- Departamento de Anestesiología y Reanimación, Hospital Universitario de Salamanca-IBSAL, Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain
| | - R González de Castro
- Departamento de Anestesiología y Reanimación, Hospital Universitario de León, Universidad de León, León, Spain
| | - J R González-Porras
- Departamento de Hematología, Hospital Universitario de Salamanca-IBSAL, Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain
| | - M V Sánchez-Hernandez
- Departamento de Anestesiología y Reanimación, Hospital Universitario de Salamanca-IBSAL, Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain
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Impact of ketamine as an adjunct sedative in acute respiratory distress syndrome due to COVID-19 Pneumonia. Respir Med 2021; 189:106667. [PMID: 34757277 PMCID: PMC8552750 DOI: 10.1016/j.rmed.2021.106667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/10/2021] [Accepted: 10/21/2021] [Indexed: 11/24/2022]
Abstract
Purpose Deep sedation is sometimes needed in acute respiratory distress syndrome. Ketamine is a sedative that has been shown to have analgesic and sedating properties without having a detrimental impact on hemodynamics. This pharmacological profile makes ketamine an attractive sedative, potentially reducing the necessity for other sedatives and vasopressors, but there are no studies evaluating its effect on these medications in patients requiring deep sedation for acute respiratory distress syndrome. Materials and methods This is a retrospective, observational study in a single center, quaternary care hospital in southeast Texas. We looked at adults with COVID-19 requiring mechanical ventilation from March 2020 to September 2020. Results We found that patients had less propofol requirements at 72 h after ketamine initiation when compared to 24 h (median 34.2 vs 54.7 mg/kg, p = 0.003). Norepinephrine equivalents were also significantly lower at 48 h than 24 h after ketamine initiation (median 38 vs 62.8 mcg/kg, p = 0.028). There was an increase in hydromorphone infusion rates at all three time points after ketamine was introduced. Conclusions In this cohort of patients with COVID-19 ARDS who required mechanical ventilation receiving ketamine we found propofol sparing effects and vasopressor requirements were reduced, while opioid infusions were not.
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Chiu LC, Kao KC. Mechanical Ventilation during Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome: A Narrative Review. J Clin Med 2021; 10:jcm10214953. [PMID: 34768478 PMCID: PMC8584351 DOI: 10.3390/jcm10214953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/15/2021] [Accepted: 10/25/2021] [Indexed: 12/12/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening condition involving acute hypoxemic respiratory failure. Mechanical ventilation remains the cornerstone of management for ARDS; however, potentially injurious mechanical forces introduce the risk of ventilator-induced lung injury, multiple organ failure, and death. Extracorporeal membrane oxygenation (ECMO) is a salvage therapy aimed at ensuring adequate gas exchange for patients suffering from severe ARDS with profound hypoxemia where conventional mechanical ventilation has failed. ECMO allows for lower tidal volumes and airway pressures, which can reduce the risk of further lung injury, and allow the lungs to rest. However, the collateral effect of ECMO should be considered. Recent studies have reported correlations between mechanical ventilator settings during ECMO and mortality. In many cases, mechanical ventilation settings should be tailored to the individual; however, researchers have yet to establish optimal ventilator settings or determine the degree to which ventilation load can be decreased. This paper presents an overview of previous studies and clinical trials pertaining to the management of mechanical ventilation during ECMO for patients with severe ARDS, with a focus on clinical findings, suggestions, protocols, guidelines, and expert opinions. We also identified a number of issues that have yet to be adequately addressed.
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Affiliation(s)
- Li-Chung Chiu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan;
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan;
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan 33302, Taiwan
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
- Correspondence: ; Tel.: +886-3-3281200 (ext. 8467)
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Wu HL, Lei YQ, Lin WH, Huang ST, Chen Q, Zheng YR. Comparison of Two Noninvasive Ventilation Strategies (NHFOV Versus NIPPV) as Initial Postextubation Respiratory Support in High-Risk Infants After Congenital Heart Surgery. J Cardiothorac Vasc Anesth 2021; 36:1962-1966. [PMID: 34593311 DOI: 10.1053/j.jvca.2021.09.003] [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: 04/19/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study aimed to compare the effects of nasal high-frequency oscillatory ventilation (NHFOV) and noninvasive positive-pressure ventilation (NIPPV) as the initial postextubation therapies on preventing extubation failure (EF) in high-risk infants younger than three months after congenital heart surgery (CHS). DESIGN This was a single-center, randomized, unblinded clinical trial. SETTING The study was performed in a teaching hospital. PARTICIPANTS Between January 2020 and January 2021, a total of 150 infants underwent CHS in the authors' hospital. INTERVENTIONS Infants younger than three months with a high risk for extubation failure who were ready for extubation were randomized to either an NHFOV therapy group or an NIPPV therapy group, and received the corresponding noninvasive mechanical ventilation to prevent EF. MEASUREMENTS Primary outcomes were reintubation, long-term noninvasive ventilation (NIV) support (more than 72 hours), and the time in NIV therapy. The secondary outcomes were adverse events, including mild-moderate hypercapnia, severe hypercapnia, severe hypoxemia, treatment intolerance, signs of discomfort, unbearable dyspnea, inability to clear secretions, emesis, and aspiration. MAIN RESULTS Of 92 infants, 45 received NHFOV therapy, and 47 received NIPPV therapy after extubation. There were no significant differences between the NHFOV and the NIPPV therapy groups in the incidences of reintubation, long-term NIV support, and total time under NIV therapy. No significant difference was found of the severe hypercapnia between the two groups, but NHFOV treatment significantly decreased the rate of mild-moderate hypercapnia (p < 0.05). Other outcomes were similar in the two groups. CONCLUSIONS Among infants younger than three months after CHS who had undergone extubation, NIPPV therapy and NHFOV therapy were the equivalent NIV strategies for preventing extubation failure, and NHFOV therapy was more effective in avoiding mild-moderate hypercapnia.
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Affiliation(s)
- Hong-Lin Wu
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China; Fujian Children's Hospital, Fuzhou, China; Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Yu-Qing Lei
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China; Fujian Children's Hospital, Fuzhou, China; Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Wen-Hao Lin
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China; Fujian Children's Hospital, Fuzhou, China; Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Shu-Ting Huang
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China; Fujian Children's Hospital, Fuzhou, China; Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China; Fujian Children's Hospital, Fuzhou, China; Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Yi-Rong Zheng
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China; Fujian Children's Hospital, Fuzhou, China; Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.
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Zhang L, Wang Z, Xu F, Ren Y, Wang H, Han D, Lyu J, Yin H. The Role of Glucocorticoids in the Treatment of ARDS: A Multicenter Retrospective Study Based on the eICU Collaborative Research Database. Front Med (Lausanne) 2021; 8:678260. [PMID: 34381796 PMCID: PMC8350484 DOI: 10.3389/fmed.2021.678260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/05/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Acute respiratory distress syndrome (ARDS) is a common cause of respiratory failure in patients in intensive care unit (ICU). The therapeutic value of glucocorticoids (GCs) in the prognosis of ARDS remains controversial. The aim of this research is studying the impacts of GCs treatment on ARDS patients in ICU. Methods: We retrospectively studied 2,167 ARDS patients whose data were collected from the public eICU Collaborative Research Database, among which 254 patients who received glucocorticoid (GCs) treatment were 1:1 matched by propensity matching analysis (PSM). The primary outcome was ICU mortality. Every oxygenation index (PaO2/FiO2) measurement before death or ICU discharge was recorded. A joint model (JM) which combined longitudinal sub-model (mixed-effect model) and time-to-event sub-model (Cox regression model) by trajectory functions of PaO2/FiO2 was conducted to determine the effects of GCs treatment on both ICU mortality and PaO2/FiO2 level and further PaO2/FiO2's effect on event status. The marginal structural cox model (MSCM) adjusted the overall PaO2/FiO2 of patients to further validate the results. Results: The result of the survival sub-model showed that GCs treatment was significantly associated with reduced ICU mortality in ARDS patients [HR (95% CI) = 0.642 (0.453, 0.912)], demonstrating that GCs treatment was a protective factor of ICU mortality. In the longitudinal sub-model, GCs treatment was not correlated to the PaO2/FiO2. After adjusted by the JM, the HR of GCs treatment was 0.602 while GCs was still not significantly related to PaO2/FiO2 level. The JM-induced association showed that higher PaO2/FiO2 was a significant protective factor of mortality in ARDS patients and the HR was 0.991 which demonstrated that one level increase of PaO2/FiO2 level decreased 0.9% risk of ICU mortality. MSCM results also show that GCs can improve the prognosis of patients. Conclusion: Rational use of GCs can reduce the ICU mortality of ARDS patients in ICU. In addition to the use of GCs treatment, clinicians should also focus on the shifting trend of PaO2/FiO2 level to provide better conditions for patients' survival.
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Affiliation(s)
- Luming Zhang
- Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zichen Wang
- Department of Public Health, University of California, Irvine, Irvine, CA, United States
| | - Fengshuo Xu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Yinlong Ren
- Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Hao Wang
- Department of Statistics, Iowa State University, Ames, IA, United States
| | - Didi Han
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Haiyan Yin
- Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
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Su D, Li J, Ren J, Gao Y, Li R, Jin X, Zhang J, Wang G. The relationship between serum lactate dehydrogenase level and mortality in critically ill patients. Biomark Med 2021; 15:551-559. [PMID: 33988459 DOI: 10.2217/bmm-2020-0671] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background: To assess the association between serum lactate dehydrogenase (LDH) levels and mortality in intensive care unit patients. Materials & methods: A total of 1981 patients in the eICU Collaborative Research Database were divided into four groups according to quartiles of LDH levels. Logistic regressions were performed. Results: Elevated LDH levels were significantly associated with higher mortality (intensive care unit mortality: Q2 vs Q1: 1.046 [0.622-1.758]; Q3 vs Q1: 1.667 [1.029-2.699]; and Q4 vs Q1: 1.760 [1.092-2.839]). Similar results persisted in patients with different acute physiology and chronic health evaluation IV scores, and with or without sepsis. Conclusion: The serum LDH level may aid in the early identification of mortality risk in critically ill patients.
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Affiliation(s)
- Dan Su
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jiamei Li
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jiajia Ren
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ya Gao
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ruohan Li
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xuting Jin
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jingjing Zhang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Gang Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Hao GW, Tu GW, Yu SJ, Luo JC, Liu K, Wang H, Ma GG, Su Y, Hou JY, Lai H, Fang Y, Luo Z. Inhaled nitric oxide reduces the intrapulmonary shunt to ameliorate severe hypoxemia after acute type A aortic dissection surgery. Nitric Oxide 2021; 109-110:26-32. [PMID: 33667622 DOI: 10.1016/j.niox.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND To assess the relationship between the intrapulmonary shunt and PaO2/FiO2 in severe hypoxemic patients after acute type A aortic dissection (ATAAD) surgery and to evaluate the effect of inhaled nitric oxide (iNO) on intrapulmonary shunt. METHODS Postoperative ATAAD patients with PaO2/FiO2 ≤ 150 mmHg were enrolled. Intrapulmonary shunt was calculated from oxygen content of different sites (artery [CaO2], mixed venous [CvO2], and alveolar capillary [CcO2]) using the Fick equation, where intrapulmonary shunt = (CcO2-CaO2)/(CcO2-CvO2). Related variables were measured at baseline (positive end expiratory pressure [PEEP] 5 cm H2O), 30 min after increasing PEEP (PEEP 10 cm H2O), 30 min after 5 ppm iNO therapy (PEEP 10 cm H2O + iNO), and 30 min after decreasing PEEP (PEEP 5 cm H2O + iNO). RESULTS A total of 20 patients were enrolled between April 2019 and December 2019. Intrapulmonary shunt and PaO2/FiO2 were correlated in severe hypoxemic, postoperative ATAAD patients (adjusted R2 = 0.467, p < 0.001). A mixed model for repeated measures revealed that iNO, rather than increasing PEEP, significantly decreased the intrapulmonary shunt (by 15% at a PEEP of 5 cm H2O and 16% at a PEEP of 10 cm H2O, p < 0.001 each) and increased PaO2/FiO2 (by 63% at a PEEP of 5 cm H2O and 65% at a PEEP of 10 cm H2O, p < 0.001 each). After iNO therapy, the decrement of intrapulmonary shunt and the increment of PaO2/FiO2 were also correlated (adjusted R2 = 0.375, p < 0.001). CONCLUSIONS This study showed that intrapulmonary shunt and PaO2/FiO2 were correlated in severe hypoxemic, postoperative ATAAD patients. Furthermore, iNO, rather than increasing PEEP, significantly decreased the intrapulmonary shunt to improve severe hypoxemic conditions.
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Affiliation(s)
- Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Shen-Ji Yu
- Department of Nursing, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Guo-Guang Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Jun-Yi Hou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Hao Lai
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yan Fang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China; Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital Fudan University, No. 668 Jinghu Road, Huli District, Xiamen, 361015, China.
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11
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Hsu JF, Yang MC, Chu SM, Yang LY, Chiang MC, Lai MY, Huang HR, Pan YB, Fu RH, Tsai MH. Therapeutic effects and outcomes of rescue high-frequency oscillatory ventilation for premature infants with severe refractory respiratory failure. Sci Rep 2021; 11:8471. [PMID: 33875758 PMCID: PMC8055989 DOI: 10.1038/s41598-021-88231-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/09/2021] [Indexed: 11/23/2022] Open
Abstract
Despite wide application of high frequency oscillatory ventilation (HFOV) in neonates with respiratory distress, little has been reported about its rescue use in preterm infants. We aimed to evaluate the therapeutic effects of HFOV in preterm neonates with refractory respiratory failure and investigate the independent risk factors of in-hospital mortality. We retrospectively analyzed data collected prospectively (January 2011–December 2018) in four neonatal intensive care units of two tertiary-level medical centers in Taiwan. All premature infants (gestational age 24–34 weeks) receiving HFOV as rescue therapy for refractory respiratory failure were included. A total of 668 preterm neonates with refractory respiratory failure were enrolled. The median (IQR) gestational age and birth weight were 27.3 (25.3–31.0) weeks and 915.0 (710.0–1380.0) g, respectively. Pre-HFOV use of cardiac inotropic agents and inhaled nitric oxide were 70.5% and 23.4%, respectively. The oxygenation index (OI), FiO2, and AaDO2 were markedly increased after HFOV initiation (all p < 0.001), and can be decreased within 24–48 h (all p < 0.001) after use of HFOV. 375 (56.1%) patients had a good response to HFOV within 3 days. The final in-hospital mortality rate was 34.7%. No association was found between specific primary pulmonary disease and survival in multivariate analysis. We found preterm neonates with gestational age < 28 weeks, occurrences of sepsis, severe hypotension, multiple organ dysfunctions, initial higher severity of respiratory failure and response to HFOV within the first 72 h were independently associated with final in-hospital mortality. The mortality rate of preterm neonates with severe respiratory failure remains high after rescue HFOV treatment. Aggressive therapeutic interventions to treat sepsis and prevent organ dysfunctions are the suggested strategies to optimize outcomes.
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Affiliation(s)
- Jen-Fu Hsu
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Mei-Chin Yang
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Taipei, Taiwan.,School of Business, Executive MBA Program in Health Care Management, Chang Gung University, Taoyüan, Taiwan
| | - Shih-Ming Chu
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Lan-Yan Yang
- Biostatistics Unit of Clinical Trial Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ming-Chou Chiang
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Mei-Yin Lai
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Hsuan-Rong Huang
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Yu-Bin Pan
- Biostatistics Unit of Clinical Trial Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ren-Huei Fu
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Ming-Horng Tsai
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, No.707, Gongye Rd., Sansheng, Mailiao Township, Yunlin, Taiwan, ROC. .,College of Medicine, Chang Gung University, Taoyüan, Taiwan.
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12
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Vaquero-Roncero LM, Sánchez-Barrado E, Escobar-Macias D, Arribas-Pérez P, González de Castro R, González-Porras JR, Sánchez-Hernandez MV. C-Reactive protein and SOFA scale: A simple score as early predictor of critical care requirement in patients with COVID-19 pneumonia in Spain. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:S0034-9356(20)30327-3. [PMID: 34247837 PMCID: PMC7833846 DOI: 10.1016/j.redar.2020.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/09/2020] [Accepted: 11/20/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To identify potential markers at admission predicting the need for critical care in patients with COVID-19 pneumonia. MATERIAL AND METHODS An approved, observational, retrospective study was conducted between March 15 to April 15, 2020. 150 adult patients aged less than 75 with Charlson comorbidity index ≤6 diagnosed with COVID-19 pneumonia were included. Seventy-five patients were randomly selected from those admitted to the critical care units (critical care group [CG]) and seventy-five hospitalized patients who did not require critical care (non-critical care group [nCG]) represent the control group. One additional cohort of hospitalized patients with COVID-19 were used to validate the score. MEASUREMENTS AND MAIN RESULTS Multivariable regression showed increasing odds of in-hospital critical care associated with increased C-reactive protein (CRP) (odds ratio 1.052 [1.009-1.101]; P=.0043) and higher Sequential Organ Failure Assessment (SOFA) score (1.968 [1.389-2.590]; P<.0001), both at the time of hospital admission. The AUC-ROC for the combined model was 0.83 (0.76-0.90) (vs AUC-ROC SOFA P<.05). The AUC-ROC for the validation cohort was 0.89 (0.82-0.95) (P>0.05 vs AUC-ROC development). CONCLUSION Patients COVID-19 presenting at admission SOFA score ≥2 combined with CRP ≥9,1mg/mL could be at high risk to require critical care.
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Affiliation(s)
- L M Vaquero-Roncero
- Departamento de Anestesiología y Reanimación, Hospital Universitario de Salamanca-IBSAL, Departamento de Medicina, Universidad de Salamanca, Salamanca, España
| | - E Sánchez-Barrado
- Departamento de Anestesiología y Reanimación, Hospital Universitario de Salamanca-IBSAL, Departamento de Medicina, Universidad de Salamanca, Salamanca, España.
| | - D Escobar-Macias
- Departamento de Anestesiología y Reanimación, Hospital Universitario de Salamanca-IBSAL, Departamento de Medicina, Universidad de Salamanca, Salamanca, España
| | - P Arribas-Pérez
- Departamento de Anestesiología y Reanimación, Hospital Universitario de Salamanca-IBSAL, Departamento de Medicina, Universidad de Salamanca, Salamanca, España
| | - R González de Castro
- Departamento de Anestesiología y Reanimación, Hospital Universitario de León, Universidad de León, León, España
| | - J R González-Porras
- Departamento de Hematología, Hospital Universitario de Salamanca-IBSAL, Departamento de Medicina, Universidad de Salamanca, Salamanca, España
| | - M V Sánchez-Hernandez
- Departamento de Anestesiología y Reanimación, Hospital Universitario de Salamanca-IBSAL, Departamento de Medicina, Universidad de Salamanca, Salamanca, España
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13
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Montgomery LD, Montgomery RW, Bodo M, Mahon RT, Pearce FJ. Thoracic, Peripheral, and Cerebral Volume, Circulatory and Pressure Responses To PEEP During Simulated Hemorrhage in a Pig Model: a Case Study. JOURNAL OF ELECTRICAL BIOIMPEDANCE 2021; 12:103-116. [PMID: 35069946 PMCID: PMC8713386 DOI: 10.2478/joeb-2021-0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Indexed: 06/14/2023]
Abstract
Positive end-expiratory pressure (PEEP) is a respiratory/ventilation procedure that is used to maintain or improve breathing in clinical and experimental cases that exhibit impaired lung function. Body fluid shift movement is not monitored during PEEP application in intensive care units (ICU), which would be interesting specifically in hypotensive patients. Brain injured and hypotensive patients are known to have compromised cerebral blood flow (CBF) autoregulation (AR) but currently, there is no non-invasive way to assess the risk of implementing a hypotensive resuscitation strategy and PEEP use in these patients. The advantage of electrical bioimpedance measurement is that it is noninvasive, continuous, and convenient. Since it has good time resolution, it is ideal for monitoring in intensive care units (ICU). The basis of its future use is to establish physiological correlates. In this study, we demonstrate the use of electrical bioimpedance measurement during bleeding and the use of PEEP in pig measurement. In an anesthetized pig, we performed multimodal recording on the torso and head involving electrical bioimpedance spectroscopy (EIS), fixed frequency impedance plethysmography (IPG), and bipolar (rheoencephalography - REG) measurements and processed data offline. Challenges (n=16) were PEEP, bleeding, change of SAP, and CO2 inhalation. The total measurement time was 4.12 hours. Systemic circulatory results: Bleeding caused a continuous decrease of SAP, cardiac output (CO), and increase of heart rate, temperature, shock index (SI), vegetative - Kerdo index (KI). Pulse pressure (PP) decreased only after second bleeding which coincided with loss of CBF AR. Pulmonary arterial pressure (PAP) increased during PEEP challenges as a function of time and bleeding. EIS/IPG results: Body fluid shift change was characterized by EIS-related variables. Electrical Impedance Spectroscopy was used to quantify the intravascular, interstitial, and intracellular volume changes during the application of PEEP and simulated hemorrhage. The intravascular fluid compartment was the primary source of blood during hemorrhage. PEEP produced a large fluid shift out of the intravascular compartment during the first bleeding period and continued to lose more blood following the second and third bleeding. Fixed frequency IPG was used to quantify the circulatory responses of the calf during PEEP and simulated hemorrhage. PEEP reduced the arterial blood flow into the calf and venous outflow from the calf. Head results: CBF AR was evaluated as a function of SAP change. Before bleeding, and after moderate bleeding, intracranial pressure (ICP), REG, and carotid flow pulse amplitudes (CFa) increased. This change reflected vasodilatation and active CBF AR. After additional hemorrhaging during PEEP, SAP, ICP, REG, CFa signal amplitudes decreased, indicating passive CBF AR. 1) The indicators of active AR status by modalities was the following: REG (n=9, 56 %), CFa (n=7, 44 %), and ICP (n=6, 38 %); 2) CBF reactivity was better for REG than ICP; 3) REG and ICP correlation coefficient were high (R2 = 0.81) during CBF AR active status; 4) PRx and REGx reflected active CBF AR status. CBF AR monitoring with REG offers safety for patients by preventing decreased CBF and secondary brain injury. We used different types of bioimpedance instrumentation to identify physiologic responses in the different parts of the body (that have not been discussed before) and how the peripheral responses ultimately lead to decreased cardiac output and changes in the head. These bioimpedance methods can improve ICU monitoring, increase the adequacy of therapy, and decrease mortality and morbidity.
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Affiliation(s)
| | | | - Michael Bodo
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Current position: Ochsner Medical Center, New Orleans, LA, USA
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14
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Banavasi H, Nguyen P, Osman H, Soubani AO. Management of ARDS - What Works and What Does Not. Am J Med Sci 2020; 362:13-23. [PMID: 34090669 PMCID: PMC7997862 DOI: 10.1016/j.amjms.2020.12.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/21/2020] [Indexed: 12/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a clinically and biologically heterogeneous disorder associated with a variety of disease processes that lead to acute lung injury with increased non-hydrostatic extravascular lung water, reduced compliance, and severe hypoxemia. Despite significant advances, mortality associated with this syndrome remains high. Mechanical ventilation remains the most important aspect of managing patients with ARDS. An in-depth knowledge of lung protective ventilation, optimal PEEP strategies, modes of ventilation and recruitment maneuvers are essential for ventilatory management of ARDS. Although, the management of ARDS is constantly evolving as new studies are published and guidelines being updated; we present a detailed review of the literature including the most up-to-date studies and guidelines in the management of ARDS. We believe this review is particularly helpful in the current times where more than half of the acute care hospitals lack in-house intensivists and the burden of ARDS is at large.
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Affiliation(s)
- Harsha Banavasi
- Division of Pulmonary Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Paul Nguyen
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Heba Osman
- Department of Medicine-Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA
| | - Ayman O Soubani
- Division of Pulmonary Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA.
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15
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Ahmed AR, Ebad CA, Stoneman S, Satti MM, Conlon PJ. Kidney injury in COVID-19. World J Nephrol 2020; 9:18-32. [PMID: 33312899 PMCID: PMC7701935 DOI: 10.5527/wjn.v9.i2.18] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/03/2020] [Accepted: 10/20/2020] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) continues to affect millions of people around the globe. As data emerge, it is becoming more evident that extrapulmonary organ involvement, particularly the kidneys, highly influence mortality. The incidence of acute kidney injury has been estimated to be 30% in COVID-19 non-survivors. Current evidence suggests four broad mechanisms of renal injury: Hypovolaemia, acute respiratory distress syndrome related, cytokine storm and direct viral invasion as seen on renal autopsy findings. We look to critically assess the epidemiology, pathophysiology and management of kidney injury in COVID-19.
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Affiliation(s)
- Adeel Rafi Ahmed
- Department of Nephrology, Beaumont Hospital, Dublin D09 V2N0, Ireland
| | | | - Sinead Stoneman
- Department of Nephrology, Beaumont Hospital, Dublin D09 V2N0, Ireland
| | | | - Peter J Conlon
- Department of Nephrology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin D09 V2N0, Ireland
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16
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Tavazzi G, Pozzi M, Mongodi S, Dammassa V, Romito G, Mojoli F. Inhaled nitric oxide in patients admitted to intensive care unit with COVID-19 pneumonia. Crit Care 2020; 24:508. [PMID: 32807220 PMCID: PMC7429937 DOI: 10.1186/s13054-020-03222-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/03/2020] [Indexed: 12/17/2022] Open
Affiliation(s)
- Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, Pavia, Italy.
- Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Anestesia e Rianimazione I, DEA Piano -1, Fondazione IRCCS Policlinico S. Matteo, Viale Golgi 19, 27100, Pavia, Italy.
| | - Marco Pozzi
- Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Anestesia e Rianimazione I, DEA Piano -1, Fondazione IRCCS Policlinico S. Matteo, Viale Golgi 19, 27100, Pavia, Italy
| | - Silvia Mongodi
- Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Anestesia e Rianimazione I, DEA Piano -1, Fondazione IRCCS Policlinico S. Matteo, Viale Golgi 19, 27100, Pavia, Italy
| | - Valentino Dammassa
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Giovanni Romito
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Francesco Mojoli
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, Pavia, Italy
- Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Anestesia e Rianimazione I, DEA Piano -1, Fondazione IRCCS Policlinico S. Matteo, Viale Golgi 19, 27100, Pavia, Italy
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17
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Connolly B, Barclay M, Blackwood B, Bradley J, Anand R, Borthwick M, Chikhani M, Dark P, Shyamsundar M, Warburton J, McAuley DF, O'Neill B. Airway clearance techniques and use of mucoactive agents for adult critically ill patients with acute respiratory failure: a qualitative study exploring UK physiotherapy practice. Physiotherapy 2020; 108:78-87. [PMID: 32721607 DOI: 10.1016/j.physio.2020.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To explore and describe current UK physiotherapy practice relating to airway clearance techniques and mucoactive agents in critically ill adult patients with acute respiratory failure in the intensive care unit. DESIGN A descriptive, qualitative study using focus group interviews. Focus groups were audio-recorded, independently transcribed, and data analysed thematically. Participants Senior, experienced physiotherapists, clinically active in critical care. RESULTS Fifteen physiotherapists participated in four interview sessions. Five themes emerged describing airway clearance techniques: 'Repertoire of airway clearance techniques', 'Staffing and skillset', 'Commencing respiratory physiotherapy', 'Technique selection', and 'Determining effectiveness' were themes related to airway clearance techniques. Five themes were also identified in relation to mucoactive agents: 'Use in clinical practice', 'Decision to commence', 'Selection of agent', 'Stopping mucoactive agents', and 'Determining effectiveness'. A summary of key features of standard practice was developed. CONCLUSIONS Standard UK physiotherapy practice of airway clearance techniques is variable, but patient-centred and targeted to individual need, with adjunctive use of mucoactive agents to enhance and optimise patient management if required. Based on this study, key features of airway clearance techniques have been summarised to help capture standard care, which could be used in future trials involving ACT as part of usual care.
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Affiliation(s)
- Bronwen Connolly
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK; Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK; Centre for Human and Applied Physiological Sciences, King's College London, London, UK; Department of Physiotherapy, The University of Melbourne, Australia.
| | - Matthew Barclay
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Judy Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Rohan Anand
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Mark Borthwick
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Marc Chikhani
- Nottingham University Hospitals NHS Trust, Nottingham, UK; Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, NIHR Biomedical Research Centre, Manchester University NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Murali Shyamsundar
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - John Warburton
- Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Brenda O'Neill
- Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK. https://twitter.com/@OneillBon
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18
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Anand R, McAuley DF, Blackwood B, Yap C, ONeill B, Connolly B, Borthwick M, Shyamsundar M, Warburton J, Meenen DV, Paulus F, Schultz MJ, Dark P, Bradley JM. Mucoactive agents for acute respiratory failure in the critically ill: a systematic review and meta-analysis. Thorax 2020; 75:623-631. [PMID: 32513777 PMCID: PMC7402561 DOI: 10.1136/thoraxjnl-2019-214355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/08/2020] [Accepted: 04/21/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE Acute respiratory failure (ARF) is a common cause of admission to intensive care units (ICUs). Mucoactive agents are medications that promote mucus clearance and are frequently administered in patients with ARF, despite a lack of evidence to underpin clinical decision making. The aim of this systematic review was to determine if the use of mucoactive agents in patients with ARF improves clinical outcomes. METHODS We searched electronic and grey literature (January 2020). Two reviewers independently screened, selected, extracted data and quality assessed studies. We included trials of adults receiving ventilatory support for ARF and involving at least one mucoactive agent compared with placebo or standard care. Outcomes included duration of mechanical ventilation. Meta-analysis was undertaken using random-effects modelling and certainty of the evidence was assessed using Grades of Recommendation, Assessment, Development and Evaluation. RESULTS Thirteen randomised controlled trials were included (1712 patients), investigating four different mucoactive agents. Mucoactive agents showed no effect on duration of mechanical ventilation (seven trials, mean difference (MD) -1.34, 95% CI -2.97 to 0.29, I2=82%, very low certainty) or mortality, hospital stay and ventilator-free days. There was an effect on reducing ICU length of stay in the mucoactive agent groups (10 trials, MD -3.22, 95% CI -5.49 to -0.96, I2=89%, very low certainty). CONCLUSION Our findings do not support the use of mucoactive agents in critically ill patients with ARF. The existing evidence is of low quality. High-quality randomised controlled trials are needed to determine the role of specific mucoactive agents in critically ill patients with ARF. PROSPERO REGISTRATION NUMBER CRD42018095408.
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Affiliation(s)
- Rohan Anand
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Chee Yap
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Brenda ONeill
- Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Bronwen Connolly
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK.,Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia.,Lane Fox Respiratory Unit, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Mark Borthwick
- Oxford Critical Care, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Murali Shyamsundar
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - John Warburton
- Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - David van Meenen
- University of Amsterdam, Academic Medical Center Department of Intensive Care Medicine, Amsterdam, Noord-Holland, Netherlands
| | - Frederique Paulus
- University of Amsterdam, Academic Medical Center Department of Intensive Care Medicine, Amsterdam, Noord-Holland, Netherlands
| | - Marcus J Schultz
- University of Amsterdam, Academic Medical Center Department of Intensive Care Medicine, Amsterdam, Noord-Holland, Netherlands.,Mahidol University, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Nuffield Department of Medicine, Oxford University, Oxford, Oxfordshire, UK
| | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, NIHR Manchester Biomedical Research Centre, The University of Manchester, Manchester, UK
| | - Judy M Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
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19
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Rahman OF, Murray DP, Zbeda RM, Volpi AD, Mo AZ, Wessling NA, Mina BA, Mendez-Zfass MS, Carpati CM. Repurposing Orthopaedic Residents Amid COVID-19: Critical Care Prone Positioning Team. JB JS Open Access 2020; 5:e0058. [PMID: 33117956 PMCID: PMC7408271 DOI: 10.2106/jbjs.oa.20.00058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Omar F Rahman
- Department of Orthopaedic Surgery, Lenox Hill Hospital-Northwell Health, New York, New York
| | - Daniel P Murray
- Department of Orthopaedic Surgery, Lenox Hill Hospital-Northwell Health, New York, New York
| | - Robert M Zbeda
- Department of Orthopaedic Surgery, Lenox Hill Hospital-Northwell Health, New York, New York
| | - Alexander D Volpi
- Department of Orthopaedic Surgery, Lenox Hill Hospital-Northwell Health, New York, New York
| | - Andrew Z Mo
- Department of Orthopaedic Surgery, Lenox Hill Hospital-Northwell Health, New York, New York
| | - Nicholas A Wessling
- Department of Orthopaedic Surgery, Lenox Hill Hospital-Northwell Health, New York, New York
| | - Bushra A Mina
- Department of Internal Medicine, Lenox Hill Hospital-Northwell Health, New York, New York
| | - Matthew S Mendez-Zfass
- Department of Orthopaedic Surgery, Lenox Hill Hospital-Northwell Health, New York, New York
| | - Charles M Carpati
- Department of Internal Medicine, Lenox Hill Hospital-Northwell Health, New York, New York
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20
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Borthwick M, McAuley D, Warburton J, Anand R, Bradley J, Connolly B, Blackwood B, O'Neill B, Chikhani M, Dark P, Shyamsundar M. Mucoactive agent use in adult UK Critical Care Units: a survey of health care professionals' perception, pharmacists' description of practice, and point prevalence of mucoactive use in invasively mechanically ventilated patients. PeerJ 2020; 8:e8828. [PMID: 32411506 PMCID: PMC7204825 DOI: 10.7717/peerj.8828] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 02/29/2020] [Indexed: 12/22/2022] Open
Abstract
Background Mechanical ventilation for acute respiratory failure is one of the most common indications for admission to intensive care units (ICUs). Airway mucus clearance is impaired in these patients medication, impaired mucociliary motility, increased mucus production etc. and mucoactive agents have the potential to improve outcomes. However, studies to date have provided inconclusive results. Despite this uncertainty, mucoactives are used in adult ICUs, although the extent of use and perceptions about place in therapy are not known. Aims and Objectives We aim to describe the use of mucoactive agents in mechanically ventilated patients in UK adult critical care units. Specifically, our objectives are to describe clinicians perceptions about the use of mucoactive agents, understand the indications and anticipated benefits, and describe the prevalence and type of mucoactive agents in use. Methods We conducted three surveys. Firstly, a practitioner-level survey aimed at nurses, physiotherapists and doctors to elucidate individual practitioners perceptions about the use of mucoactive agents. Secondly, a critical care unit-level survey aimed at pharmacists to understand how these perceptions translate into practice. Thirdly, a point prevalence survey to describe the extent of prescribing and range of products in use. The practitioner-level survey was disseminated through the UK Intensive Care Society for completion by a multi-professional membership. The unit-level and point prevalence surveys were disseminated cthrough the UK Clinical Pharmacy Association for completion by pharmacists. Results The individual practitioners survey ranked ‘thick secretions’ as the main reason for commencing mucoactive agents determined using clinical assessment. The highest ranked perceived benefit for patient centred outcomes was the duration of ventilation. Of these respondents, 79% stated that further research was important and 87% expressed support for a clinical trial. The unit-level survey found that mucoactive agents were used in 83% of units. The most highly ranked indication was again ‘thick secretions’ and the most highly ranked expected patient centred clinical benefit being improved gas exchange and reduced ventilation time. Only five critical care units provided guidelines to direct the use of mucoactive agents (4%). In the point prevalence survey, 411/993 (41%) of mechanically ventilated patients received at least one mucoactive agent. The most commonly administered mucoactives were inhaled sodium chloride 0.9% (235/993, 24%), systemic carbocisteine (161/993, 16%) and inhaled hypertonic sodium cloride (127/993, 13%). Conclusions Mucoactive agents are used extensively in mechanically ventilated adult patients in UK ICUs to manage ‘thick secretions’, with a key aim to reduce the duration of ventilation. There is widespread support for clinical trials to determine the optimal use of mucoactive agent therapy in this patient population.
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Affiliation(s)
- Mark Borthwick
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Danny McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - John Warburton
- University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Rohan Anand
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Judy Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Bronwen Connolly
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom.,Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Brenda O'Neill
- Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health Research, Ulster University, Newtownabbey, United Kingdom
| | - Marc Chikhani
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Paul Dark
- School of Biological Sciences, Salford Royal NHS Foundation Trust, University of Manchester, Manchester, United States of America
| | - Murali Shyamsundar
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
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21
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Barman B, Parihar A, Kohli N, Agarwal A, Dwivedi DK, Kumari G. Impact of Bedside Combined Cardiopulmonary Ultrasound on Etiological Diagnosis and Treatment of Acute Respiratory Failure in Critically Ill Patients. Indian J Crit Care Med 2020; 24:1062-1070. [PMID: 33384512 PMCID: PMC7751041 DOI: 10.5005/jp-journals-10071-23661] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Aims and objectives To prospectively evaluate the impact of cardiopulmonary ultrasound (CPUS) on etiological diagnosis and treatment of critically ill acute respiratory failure (ARF) patients. Design This is a prospective observational study conducted in a general intensive care unit (ICU) of a tertiary care center in India. Patients over 18 years old with presence of one of the objective criteria of ARF. Patients either consecutively admitted for ARF to ICU or already admitted to ICU for a different reason but later developed ARF during their hospital stay. Written informed consent in local language was obtained from next of kin. Interventions All included patients underwent bedside CPUS including lung ultrasound (US) and transthoracic echocardiography plus targeted venous US by single investigator, blinded to clinical data. The US diagnosis of ARF etiology was shared with treating intensivist. Initial clinical diagnosis (ICD) and treatment plan (made before US) of each patient were compared with post-US clinical diagnosis and treatment plan. The changes in diagnosis and treatment up to 24 hours post-US were considered as impact of US. Results Mean age of 108 included patients was 45.7 ± 20.4 years (standard deviation). The ICD was correct in 67.5% (73/108) cases, whereas the combined CPUS yielded correct etiological diagnosis in 88% (95/108) cases. Among the 108 included patients, etiological diagnosis of ARF was altered after CPUS in 40 (37%) patients, which included "diagnosis changed" in 18 (17%) and "diagnosis added" in 22 (20%). Treatment plan was changed in 39 (36%) patients after CPUS, which included surgical interventions in 17 (16%), changes in medical therapy in 12 (11%), and changes in ventilation strategy in 4 (3.5%) patients. Conclusion This study demonstrates that use of combined US approach as an initial test in ARF, improves diagnostic accuracy for identification of underlying etiology, and frequently changes clinical diagnosis and/or treatment. How to cite this article Barman B, Parihar A, Kohli N, Agarwal A, Dwivedi DK, Kumari G. Impact of Bedside Combined Cardiopulmonary Ultrasound on Etiological Diagnosis and Treatment of Acute Respiratory Failure in Critically Ill Patients. Indian J Crit Care Med 2020;24(11):1062-1070.
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Affiliation(s)
- Bapi Barman
- Department of Radiodiagnosis, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Anit Parihar
- Department of Radiodiagnosis, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Neera Kohli
- Department of Radiodiagnosis, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Avinash Agarwal
- Department of Critical Care Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Durgesh K Dwivedi
- Department of Radiodiagnosis, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Gangotri Kumari
- Department of Radiodiagnosis, King George's Medical University, Lucknow, Uttar Pradesh, India
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22
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The Association of Low Admission Serum Creatinine with the Risk of Respiratory Failure Requiring Mechanical Ventilation: A Retrospective Cohort Study. Sci Rep 2019; 9:18743. [PMID: 31822769 PMCID: PMC6904463 DOI: 10.1038/s41598-019-55362-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 11/21/2019] [Indexed: 11/16/2022] Open
Abstract
To assess the association between low serum creatinine (SCr) value at admission and the risk of respiratory failure requiring mechanical ventilation in hospitalized patients. A retrospective cohort study was conducted at a tertiary referral hospital. All hospitalized adult patients from 2011 through 2013 who had an admission SCr value were included in this study. Patients who were mechanically ventilated at the time of admission were excluded. Admission creatinine was stratified into 7 groups: ≤0.4, 0.5–0.6, 0.7–0.8, 0.9–1.0, 1.1–1.2, 1.3–1.4, and ≥1.5 mg/dL. The primary outcome was the occurrence of respiratory failure requiring mechanical ventilation during hospitalization. Logistic regression analysis was used to assess the independent risk of respiratory failure based on various admission SCr, using SCr of 0.7–0.8 mg/dL as the reference group in the analysis of all patients and female subgroup and of 0.9–1.0 mg/dL in analysis of male subgroup. A total of 67,045 eligible patients, with the mean admission SCr of 1.0 ± 0.4 mg/dL, were studied. Of these patients, 799 (1.1%) had admission SCr of ≤0.4 mg/dL, and 2886 (4.3%) developed respiratory failure requiring mechanical ventilation during hospitalization. The U-curve relationship between admission SCr and respiratory failure during hospitalization was observed, with the nadir incidence of in-hospital respiratory failure in SCr of 0.7–0.8 mg/dL and increased in-hospital respiratory failure associated with both reduced and elevated admission SCr. After adjustment for confounders, very low admission SCr of ≤0.4 mg/dL was significantly associated with increased in-hospital respiratory failure (OR 3.11; 95% CI 2.33–4.17), exceeding the risk related to markedly elevated admission SCr of ≥1.5 mg/dL (OR 1.61; 95% CI 1.39–1.85). The association remained significant in the subgroup analysis of male and female patients. Low SCr value at admission is independently associated with increased in-hospital respiratory failure requiring mechanical ventilation in hospitalized patients.
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23
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Joannidis M, Forni LG, Klein SJ, Honore PM, Kashani K, Ostermann M, Prowle J, Bagshaw SM, Cantaluppi V, Darmon M, Ding X, Fuhrmann V, Hoste E, Husain-Syed F, Lubnow M, Maggiorini M, Meersch M, Murray PT, Ricci Z, Singbartl K, Staudinger T, Welte T, Ronco C, Kellum JA. Lung-kidney interactions in critically ill patients: consensus report of the Acute Disease Quality Initiative (ADQI) 21 Workgroup. Intensive Care Med 2019; 46:654-672. [PMID: 31820034 PMCID: PMC7103017 DOI: 10.1007/s00134-019-05869-7] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/13/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Multi-organ dysfunction in critical illness is common and frequently involves the lungs and kidneys, often requiring organ support such as invasive mechanical ventilation (IMV), renal replacement therapy (RRT) and/or extracorporeal membrane oxygenation (ECMO). METHODS A consensus conference on the spectrum of lung-kidney interactions in critical illness was held under the auspices of the Acute Disease Quality Initiative (ADQI) in Innsbruck, Austria, in June 2018. Through review and critical appraisal of the available evidence, the current state of research, and both clinical and research recommendations were described on the following topics: epidemiology, pathophysiology and strategies to mitigate pulmonary dysfunction among patients with acute kidney injury and/or kidney dysfunction among patients with acute respiratory failure/acute respiratory distress syndrome. Furthermore, emphasis was put on patients receiving organ support (RRT, IMV and/or ECMO) and its impact on lung and kidney function. CONCLUSION The ADQI 21 conference found significant knowledge gaps about organ crosstalk between lung and kidney and its relevance for critically ill patients. Lung protective ventilation, conservative fluid management and early recognition and treatment of pulmonary infections were the only clinical recommendations with higher quality of evidence. Recommendations for research were formulated, targeting lung-kidney interactions to improve care processes and outcomes in critical illness.
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Affiliation(s)
- Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Lui G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, UK.,Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Sebastian J Klein
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.,Doctoral College Medical Law and Healthcare, Faculty of Law, University Innsbruck, Innsbruck, Austria
| | - Patrick M Honore
- Department of Intensive Care Medicine, CHU Brugmann University Hospital, Brussels, Belgium
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - John Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK.,William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Vincenzo Cantaluppi
- Nephrology, Dialysis and Kidney Transplantation Unit, Department of Translational Medicine, University of Eastern Piedmont "A. Avogadro", Maggiore della Carità University Hospital, Novara, Italy
| | - Michael Darmon
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris, France
| | - Xiaoqiang Ding
- Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai Key Laboratory of Kidney and Blood Purification, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Medicine B, University Muenster, Muenster, Germany
| | - Eric Hoste
- ICU, Ghent University Hospital, Ghent, Belgium.,Research Fund-Flanders (FWO), Brussels, Belgium
| | - Faeq Husain-Syed
- Division of Nephrology, Pulmonology and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Giessen, Germany
| | - Matthias Lubnow
- Department of Cardiology, Pulmonary and Critical Care Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Marco Maggiorini
- Medical Intensive Care Unit, Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Patrick T Murray
- School of Medicine, University College Dublin, Dublin, Ireland.,UCD Catherine McAuley Education and Research Centre, Dublin, Ireland
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Paediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Tobias Welte
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padua, Italy.,International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
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24
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Albecker D, Glen Bouder T, Franklin Lewis B. High frequency percussive ventilation as a rescue mode for refractory status asthmaticus - a case study. J Asthma 2019; 58:340-343. [PMID: 31668108 DOI: 10.1080/02770903.2019.1687714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION A severe asthma exacerbation is called status asthmaticus when symptoms worsen despite conventional medical treatment in the hospital. If arterial blood gas (ABG) values deteriorate and this is accompanied by respiratory muscle fatigue, the patient will require mechanical ventilation. However, mechanical ventilation of the severe asthmatic presents difficult challenges. CASE STUDY We report on High Frequency Percussive Ventilation (HFPV) used along with continuous inhaled albuterol and neuromuscular blockade, as rescue therapy for a case of acute, severe asthma that was refractory to conventional treatment and conventional mechanical ventilation. RESULTS This patient's arterial pH was 6.97 when we initiated HFPV, but ten hours post-intubation her ABG values normalized. She was successfully extubated six days later and discharged from ICU the following day. CONCLUSION This case describes the successful use of HFPV for a status asthmaticus patient failing conventional mechanical ventilation. We have anecdotal evidence of other medical centers using HFPV for these patients but larger studies are needed to verify its efficacy.
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25
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Dadras M, Wagner JM, Wallner C, Huber J, Buchwald D, Strauch J, Harati K, Kapalschinski N, Behr B, Lehnhardt M. Extracorporeal membrane oxygenation for acute respiratory distress syndrome in burn patients: a case series and literature update. BURNS & TRAUMA 2019; 7:28. [PMID: 31696126 PMCID: PMC6824128 DOI: 10.1186/s41038-019-0166-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/26/2019] [Indexed: 01/19/2023]
Abstract
Background Acute respiratory distress syndrome (ARDS) has a reported incidence of 34–43% in ventilated burn patients and is associated with a mortality of 59% in the severe form. The use and experience with extracorporeal membrane oxygenation (ECMO) in burn patients developing ARDS are still limited. We present our results and discuss the significance of ECMO in treating burn patients. Methods A retrospective analysis of burn patients treated with ECMO for ARDS between January 2017 and January 2019 was performed. Demographic, clinical, and outcome data were collected and analyzed. Results Eight burn patients were treated at our institution with ECMO in the designated time period. Of these, all but one patient had inhalation injury, burn percentage of TBSA was 37 ± 23%, ABSI score was 8.4 ± 2, and R-Baux-score was 98 ± 21. Seven patients developed severe ARDS and one patient moderate ARDS according to the Berlin classification with a PaO2/FiO2 ratio upon initiation of ECMO therapy of 62 ± 22 mmHg. ECMO duration was 388 ± 283 h. Three patients died from severe sepsis while five patients survived to hospital discharge. Conclusions ECMO is a viable therapy option in burn patients developing severe ARDS and can contribute to survival rates similar to ECMO therapy in non-burn-associated severe ARDS. Consequently, patients with severe respiratory insufficiency with unsuccessful conventional treatment and suspected worsening should be transferred to burn units with the possibility of ECMO treatment to improve outcome.
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Affiliation(s)
- Mehran Dadras
- 1Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Johannes M Wagner
- 1Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Christoph Wallner
- 1Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Julika Huber
- 1Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Dirk Buchwald
- 2Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Justus Strauch
- 2Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Kamran Harati
- 1Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Nicolai Kapalschinski
- 1Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Björn Behr
- 1Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Marcus Lehnhardt
- 1Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
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26
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Godoy DA, Di Napoli M, Rabinstein AA. Cerebral Fat Embolism: Recognition, Complications, and Prognosis. Neurocrit Care 2019; 29:358-365. [PMID: 28932982 DOI: 10.1007/s12028-017-0463-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Fat embolism syndrome (FES) is a rare syndrome caused by embolization of fat particles into multiple organs including the brain. It typically manifests with petechial rash, deteriorating mental status, and progressive respiratory insufficiency, usually occurring within 24-48 h of trauma with long-bone fractures or an orthopedic surgery. The diagnosis of FES is based on clinical and imaging findings, but requires exclusion of alternative diagnoses. Although there is no specific treatment for FES, prompt recognition is important because it can avoid unnecessary interventions and clarify prognosis. Patients with severe FES can become critically ill, but even comatose patients with respiratory failure may recover favorably. Prophylactic measures, such as early stabilization of fractures and certain intraoperative techniques, may help decrease the incidence and severity of FES.
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Affiliation(s)
- Daniel Agustín Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Chacabuco 675, 4700, Catamarca, Argentina.
- Intensive Care Unit, Hospital San Juan Bautista, Catamarca, Argentina.
| | - Mario Di Napoli
- Neurological Service, San Camillo de' Lellis General Hospital, Rieti, Italy
- Neurological Section, SMDN-Center for Cardiovascular Medicine and Cerebrovascular Disease Prevention, Sulmona, L'Aquila, Italy
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27
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Oribabor C, Gulkarov I, Khusid F, Ms EF, Esan A, Rizzuto N, Tortolani A, Dattilo PA, Suen K, Ugwu J, Kenney B. The use of high-frequency percussive ventilation after cardiac surgery significantly improves gas exchange without impairment of hemodynamics. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2018; 54:58-61. [PMID: 30996643 PMCID: PMC6422108 DOI: 10.29390/cjrt-2018-013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Respiratory failure represents a significant source of morbidity and mortality for surgical patients. High-frequency percussive ventilation (HFPV) is emerging as a potentially effective rescue therapy in patients failing conventional mechanical ventilation (CMV). Use of HFPV is often limited by concerns for potential effects on hemodynamics, which is particularly tenuous in patients immediately after cardiac surgery. In this manuscript we evaluated the effects of HFPV on gas exchange and cardiac hemodynamics in the immediate postoperative period after cardiac surgery, in comparison with CMV. Methods Twenty-four consecutive cardiac surgery patients were ventilated in immediate postoperative period with HFPV for two to four hours, then they switched to a CMV using the adaptive support ventilation mode for weaning. Arterial blood gases were performed during the first and second hour on HFPV, and at 45 minutes after initiation of CMV. Respiratory settings and invasive hemodynamic data (mixed venous oxygen saturation, central venous pressure, systemic and pulmonary blood pressure, cardiac output and index) were collected utilizing right heart pulmonary catheter and arterial lines during HFPV and CMV. Primary outcome was improvement in the ratio between partial pressure of oxygen to fraction of inspired oxygen (P/F ratio) and changes in hemodynamics. Results Analysis of data for 24 patients revealed a significantly better P/F ratio during the first and second hour on HFPV, compared with a P/F ratio on CMV (420.0 ± 158.8, 459.2 ± 138.5, and 260.2 ± 98.5 respectively, p < 0.05), suggesting much better gas exchange on HFPV than on CMV. Hemodynamics were not affected by the mode of the ventilation. Conclusions Improvement in gas exchange, reflected in a significantly improved P/F ratio, wasn't accompanied by worsening in hemodynamic parameters. The significant gains in the P/F ratio were lost when patients were switched to conventional ventilation. This data suggest that HFPV provides significantly better gas exchange compared with CMV and can be safely utilized in postoperative cardiac patients without any significant effect on hemodynamics.
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Affiliation(s)
- Charles Oribabor
- Department of Medicine, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Iosif Gulkarov
- Department of Cardiothoracic Surgery, Staten Island University Hospital Staten Island, NY, USA
| | - Felix Khusid
- Department of Respiratory Therapy, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Emma Fischer Ms
- Department of Respiratory Therapy, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Adebayo Esan
- Department of Medicine, Hanover Hospital, Hanover, PA, USA
| | - Nancy Rizzuto
- Department of Nursing, Brooklyn University Hospital and Medical Center, Brooklyn, NY, USA
| | - Anthony Tortolani
- Department of Surgery, Brooklyn University Hospital and Medical Center, Brooklyn, NY, USA
| | - Paris Ayanna Dattilo
- Department of Emergency Medicine, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Kaki Suen
- Department of Cardiothoracic Surgery, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Justin Ugwu
- Department of Medicine, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Brent Kenney
- Department of Respiratory Therapy, Mercy Hospital Springfield, Springfield, MO, USA
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28
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Surasarang SH, Sahakijpijarn S, Florova G, Komissarov AA, Nelson CL, Perenlei E, Fukuda S, Wolfson MR, Shaffer TH, Idell S, Williams RO. Nebulization of Single-Chain Tissue-Type and Single-Chain Urokinase Plasminogen Activator for Treatment of Inhalational Smoke-Induced Acute Lung Injury. J Drug Deliv Sci Technol 2018; 48:19-27. [PMID: 30123328 DOI: 10.1016/j.jddst.2018.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Single-chain tissue-type plasminogen activator (sctPA) and single-chain urokinase plasminogen activator (scuPA) have attracted interest as enzymes for the treatment of inhalational smoke-induced acute lung injury (ISALI). In this study, the pulmonary delivery of commercial human sctPA and lyophilized scuPA and their reconstituted solution forms were demonstrated using vibrating mesh nebulizers (Aeroneb® Pro (active) and EZ Breathe® (passive)). Both the Aeroneb® Pro and EZ Breathe® vibrating mesh nebulizers produced atomized droplets of protein solution of similar size of less than about 5 μm, which is appropriate for pulmonary delivery. Enzymatic activities of scuPA and of sctPA were determined after nebulization and both remained stable (88.0% and 93.9%). Additionally, the enzymatic activities of sctPA and tcuPA were not significantly affected by excipients, lyophilization or reconstitution conditions. The results of these studies support further development of inhaled formulations of fibrinolysins for delivery to the lungs following smoke-induced acute pulmonary injury.
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Affiliation(s)
- Soraya Hengsawas Surasarang
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA
| | - Sawittree Sahakijpijarn
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA
| | - Galina Florova
- The University of Texas Health Science Center at Tyler, School of Medical Biological Sciences, Tyler, TX, USA
| | - Andrey A Komissarov
- The University of Texas Health Science Center at Tyler, School of Medical Biological Sciences, Tyler, TX, USA
| | - Christina L Nelson
- The University of Texas Medical Branch, Translational Intensive Care Unit, Galveston, TX, USA
| | - Enkhbaatar Perenlei
- The University of Texas Medical Branch, Translational Intensive Care Unit, Galveston, TX, USA
| | - Satoshi Fukuda
- The University of Texas Medical Branch, Translational Intensive Care Unit, Galveston, TX, USA
| | - Marla R Wolfson
- Lewis Katz School of Medicine at Temple University, Departments of Physiology, Thoracic Medicine and Surgery, Pediatrics, Philadelphia, PA, USA
| | - Thomas H Shaffer
- Lewis Katz School of Medicine at Temple University, Departments of Physiology, Thoracic Medicine and Surgery, Pediatrics, Philadelphia, PA, USA.,Jefferson Medical College/Thomas Jefferson University, Department of Pediatrics, Philadelphia, PA, USA
| | - Steven Idell
- The University of Texas Health Science Center at Tyler, School of Medical Biological Sciences, Tyler, TX, USA
| | - Robert O Williams
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA
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Salvage therapies for refractory hypoxemia in ARDS. Respir Med 2018; 141:150-158. [PMID: 30053961 DOI: 10.1016/j.rmed.2018.06.030] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/15/2018] [Accepted: 06/29/2018] [Indexed: 02/06/2023]
Abstract
Acute Respiratory Distress Syndrome (ARDS) is a condition of varied etiology characterized by the acute onset (within 1 week of the inciting event) of hypoxemia, reduced lung compliance, diffuse lung inflammation and bilateral opacities on chest imaging attributable to noncardiogenic (increased permeability) pulmonary edema. Although multi-organ failure is the most common cause of death in ARDS, an estimated 10-15% of the deaths in ARDS are caused due to refractory hypoxemia, i.e.- hypoxemia despite lung protective conventional ventilator modes. In these cases, clinicians may resort to other measures with less robust evidence -referred to as "salvage therapies". These include proning, 48 h of paralysis early in the course of ARDS, various recruitment maneuvers, unconventional ventilator modes, inhaled pulmonary vasodilators, and Extracorporeal membrane oxygenation (ECMO). All the salvage therapies described have been associated with improved oxygenation, but with the exception of proning and 48 h of paralysis early in the course of ARDS, none of them have a proven mortality benefit. Based on the current evidence, no salvage therapy has been shown to be superior to the others and each of them is associated with its own risks and benefits. Hence, the order of application of these therapies varies in different institutions and should be applied following a risk-benefit analysis specific to the patient and local experience. This review explores the rationale, evidence, advantages and risks behind each of these strategies.
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Korzhuk A, Afzal A, Wong I, Khusid F, Worku B, Gulkarov I. High-Frequency Percussive Ventilation Rescue Therapy in Morbidly Obese Patients Failing Conventional Mechanical Ventilation. J Intensive Care Med 2018; 35:583-587. [PMID: 29683055 DOI: 10.1177/0885066618769596] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Morbidly obese patients with respiratory failure who do not improve on conventional mechanical ventilation (CMV) often undergo rescue therapy with extracorporeal membrane oxygenation (ECMO). We describe our experience with high-frequency percussive ventilation (HFPV) as a rescue modality. METHODS In a retrospective analysis from 2009 to 2016, 12 morbidly obese patients underwent HFPV after failing to wean from CMV. Data were collected regarding demographics, cause of respiratory failure, ventilation settings, and hospital course outcomes. Our end point data were pre- and post-HFPV partial pressure of arterial oxygen and PaO2 to fraction of inspired oxygen (PF) ratios measured at initiation, 2, and 24 hours. RESULTS Twelve morbidly obese patients required HFPV for respiratory failure. Causes of respiratory failure overlapped and included cardiogenic pulmonary edema (n = 8), pneumonia (n = 5), septic shock (n = 5), and asthma (n = 1). After HFPV initiation, mean fraction of inspired oxygen FiO2 was tapered from 98% to 82% and 66% at 2 and 24 hours, respectively. Mean PaO2 increased from 60.9 mm Hg before HFPV to 175.1 mm Hg (P < .05) at initiation of HFPV, then sustained at 129.5 mm Hg (P < .05) and 88.1 mm Hg (P < .005) at 2 and 24 hours, respectively. Mean PF ratio improved from 66.1 before HFPV to 180.3 (P < .05), 181.0 (P < .05) and 148.9 (P < .0005) at initiation, 2, and 24 hours, respectively. The improvement in mean PaO2 and PF ratios was durable at 24 hours whether or not the patient was returned to CMV (n = 10) or remained on HFPV (n = 2). Survival to discharge was 66.7%. CONCLUSION In our cohort of morbidly obese patients, HFPV was successfully utilized as a rescue therapy precluding the need for ECMO. Despite our small sample size, HFPV should be considered as a rescue therapy in morbidly obese patients failing CMV prior to the initiation of ECMO. Our retrospective analysis supports consideration for HFPV as another form of rescue therapy for obese patients with refractory hypoxemia and respiratory failure who are not improving with CMV.
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Affiliation(s)
- Anatoliy Korzhuk
- Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Ashwad Afzal
- Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Ivan Wong
- Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Felix Khusid
- Department of Respiratory Therapy, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Berhane Worku
- Department of Cardiothoracic Surgery, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Iosif Gulkarov
- Department of Cardiothoracic Surgery, Staten Island University Hospital, Staten Island, NY, USA
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31
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Scala R, Heunks L. Highlights in acute respiratory failure. Eur Respir Rev 2018; 27:27/147/180008. [PMID: 29592866 PMCID: PMC9489047 DOI: 10.1183/16000617.0008-2018] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 03/05/2018] [Indexed: 11/22/2022] Open
Abstract
Acute respiratory failure (ARF) is a devastating condition for patients that results from either impaired function of the respiratory muscle pump or from dysfunction of the lung. ARF is a challenging field for clinicians working both within and outside the intensive care unit (ICU) and respiratory high dependency care unit environment because this heterogeneous syndrome is associated with a high hospital morbidity and mortality rate, ethical issues in managing end of life decisions and increased consumption of healthcare resources. ARF management requires an escalation therapeutic strategy based on application of a wide range of ventilatory and non-ventilatory interventions; there are many unanswered questions that need to be addressed in the near futurehttp://ow.ly/xbPi30iUP2y
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Affiliation(s)
- Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy
| | - Leo Heunks
- Dept of Intensive Care, VU University Medical Centre, Amsterdam, The Netherlands
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Tran-Dinh A, Augustin P, Dufour G, Lasocki S, Allou N, Thabut G, Castier Y, Montravers P, Desmard M. Evaluation of Cardiac Index and Extravascular Lung Water After Single-Lung Transplantation Using the Transpulmonary Thermodilution Technique by the PiCCO2 Device. J Cardiothorac Vasc Anesth 2017; 32:1731-1735. [PMID: 29203299 DOI: 10.1053/j.jvca.2017.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES First evaluation of the transpulmonary thermodilution technique by the PiCCO2 device to assess cardiac index and pulmonary edema during the postoperative course after single-lung transplantation. DESIGN Prospective observational study. SETTINGS Intensive care unit, university hospital (single center). PARTICIPANTS Single-lung transplant patients. INTERVENTIONS The authors compared cardiac index measured by PiCCO2 and pulmonary artery catheter and assessed pulmonary edema using extravascular lung water index and pulmonary vascular permeability index measured by PiCCO2. MEASUREMENTS AND MAIN RESULTS A Bland-Altman method was used to compare cardiac index measured by PiCCO2 and pulmonary artery catheter. Extravascular lung water index and pulmonary vascular permeability index were compared according to the PaO2/FiO2 ratio with a threshold value of 150 mmHg. Ten single-lung transplant patients were included. Cardiac index measured by PiCCO2 and pulmonary artery catheter were 3.3 L/min/m2 (2.9-3.6) and 2.5 L/min/m2 (2.2-3.0). Bias for cardiac index was 0.71 L/min/m2 (-0.03; 1.44) and limit of agreements were -0.03 and 1.44 L/min/m2. Extravascular lung water index was 12 mL/kg (11-16) and pulmonary vascular permeability index was 2.3 (2.0-3.1), consistent with pulmonary edema. Extravascular lung water index was higher in the group of PaO2/FiO2 ratio ≤150 mmHg compared with the group of PaO2/FiO2 ratio >150 mmHg (17 v 12 mL/kg, p = 0.04), whereas pulmonary vascular permeability index only tended to be higher (3.1 v 2.1, p = 0.06). CONCLUSION PiCCO2 device systematically overestimated cardiac index compared with pulmonary artery catheter. However, it might be useful to assess pulmonary edema in acute respiratory failure after single-lung transplantation.
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Affiliation(s)
- Alexy Tran-Dinh
- Département d'AnesthésieRéanimation, Université Paris Diderot Sorbonne Cite, APHP, CHU Bichat-Claude Bernard, Paris, France; LVTS Inserm U1148, Hôpital Bichat-Claude Bernard, Paris, France.
| | - Pascal Augustin
- Département d'AnesthésieRéanimation, Université Paris Diderot Sorbonne Cite, APHP, CHU Bichat-Claude Bernard, Paris, France
| | - Guillaume Dufour
- Département d'AnesthésieRéanimation, Université Paris Diderot Sorbonne Cite, APHP, CHU Bichat-Claude Bernard, Paris, France
| | - Sigismond Lasocki
- Département d'AnesthésieRéanimation, Université Paris Diderot Sorbonne Cite, APHP, CHU Bichat-Claude Bernard, Paris, France
| | - Nicolas Allou
- Département d'AnesthésieRéanimation, Université Paris Diderot Sorbonne Cite, APHP, CHU Bichat-Claude Bernard, Paris, France
| | - Gabriel Thabut
- Service de Pneumologie B et Transplantation Pulmonaire, Université Paris Diderot Sorbonne Cite, APHP, CHU Bichat-Claude Bernard, Paris, France
| | - Yves Castier
- Inserm UMR 1152, Hôpital Bichat-Claude Bernard, Paris, France; Service de Chirurgie Thoracique et Vasculaire, Université Paris Diderot Sorbonne Cite, APHP(,) CHU Bichat-Claude Bernard, Paris, France
| | - Philippe Montravers
- Département d'AnesthésieRéanimation, Université Paris Diderot Sorbonne Cite, APHP, CHU Bichat-Claude Bernard, Paris, France; Inserm UMR 1152, Hôpital Bichat-Claude Bernard, Paris, France
| | - Mathieu Desmard
- Département d'AnesthésieRéanimation, Université Paris Diderot Sorbonne Cite, APHP, CHU Bichat-Claude Bernard, Paris, France
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