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Yoshida T, Shimizu S, Fushimi K, Mihara T. Changing clinical practice and prognosis for severe respiratory failure over time: A nationwide inpatient database study. Respir Investig 2024; 62:778-784. [PMID: 38986214 DOI: 10.1016/j.resinv.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/26/2024] [Accepted: 07/05/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Severe respiratory failure requires numerous interventions and its clinical implementation changes over time. We aimed to clarify the clinical practice and prognosis of severe respiratory failure and its changes over time. METHODS In a nationwide Japanese administrative database from 2016 to 2019, we identified nonoperative patients with severe respiratory failure without congestive heart failure as the main diagnosis who received mechanical ventilation (MV) for more than four days. We examined trends in patient characteristics, adjunctive interventions, and prognosis. RESULTS Among 66,905 patients included in this study, patients received antibiotics (90%), high-dose corticosteroids (14%), low-dose corticosteroids (18%), and 51% were admitted to the critical care unit. Hospital mortality was 35%. Median mechanical ventilation lasted 10 days. Tracheostomy occurred in 23% of cases. Median critical care and hospital stays were 10 and 25 days, respectively. Among survivors, 23% had mechanical ventilation dependency at hospital discharge. Large relative changes in adjunctive therapies included fentanyl (30%-38%), rocuronium (4.4%-6.7%), vasopressin (3.8%-6.0%), early rehabilitation (27%-38%), extracorporeal membrane oxygenation (0.7%-1.2%), dopamine (15%-10%), and sivelestat (8.6%-3.5%). No notable changes were seen in mechanical ventilation duration, tracheostomy, critical care unit stay, hospital stay, or ventilator dependency at discharge, except for a slight reduction in hospital mortality (36%-34%). CONCLUSIONS Several adjunctive therapies for severe respiratory failure changed from 2016 to 2019, with an increase in evidence-based practices and a slight decrease in hospital mortality.
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Affiliation(s)
- Takuo Yoshida
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2, Seto, Kanazawa, Yokohama, 236-0027, Japan; Department of Emergency Medicine, The Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo 105-8471, Japan.
| | - Sayuri Shimizu
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2, Seto, Kanazawa, Yokohama, 236-0027, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Takahiro Mihara
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2, Seto, Kanazawa, Yokohama, 236-0027, Japan; Department of Anesthesiology, Yokohama City University School of Medicine, 3-9, Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
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Santa Cruz R, Matesa A, Gómez A, Nadur J, Pagano F, Prieto D, Bolaños O, Solis B, Yusta S, González-Velásquez E, Estenssoro E, Cavalcanti A. Mortality Due to Acute Respiratory Distress Syndrome in Latin America. Crit Care Med 2024; 52:1275-1284. [PMID: 38635486 DOI: 10.1097/ccm.0000000000006312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
OBJECTIVES Mortality due to acute respiratory distress syndrome (ARDS) is a major global health problem. Knowledge of epidemiological data on ARDS is crucial to design management, treatment strategies, and optimize resources. There is ample data regarding mortality of ARDS from high-income countries; in this review, we evaluated mortality due to ARDS in Latin America. DATA SOURCES We searched in PubMed, Cochrane Central Register of Controlled Trials, Web of Science, and Latin American and Caribbean Health Science Literature databases from 1967 to March 2023. STUDY SELECTION We searched prospective or retrospective observational studies and randomized controlled trials conducted in Latin American countries reporting ARDS mortality. DATA EXTRACTION Three pairs of independent reviewers checked all studies for eligibility based on their titles and abstracts. We performed meta-analysis of proportions using a random-effects model. We performed sensitivity analyses including studies with low risk of bias and with diagnosis using the Berlin definition. Subgroup analysis comparing different study designs, time of publication (up to 2000 and from 2001 to present), and studies in which the diagnosis of ARDS was made using Pa o2 /F io2 less than or equal to 200 and regional variations. Subsequently, we performed meta-regression analyses. Finally, we graded the certainty of the evidence (Grading of Recommendations Assessment, Development, and Evaluation). DATA SYNTHESIS Of 3315 articles identified, 32 were included (3627 patients). Mortality was 52% in the pooled group (low certainty of evidence). In the sensitivity analysis (according to the Berlin definition), mortality was 46% (moderate certainty of evidence). In the subgroup analysis mortality was 53% (randomized controlled trials), 51% (observational studies), 66% (studies published up to 2000), 50% (studies after 2000), 44% (studies with Pa o2 /F io2 ≤ 200), 56% (studies from Argentina/Brazil), and 40% (others countries). No variables were associated with mortality in the meta-regression. CONCLUSIONS ARDS mortality in Latin America remains high, as in other regions. These results should constitute the basis for action planning to improve the prognosis of patients with ARDS (PROSPERO [CRD42022354035]).
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Affiliation(s)
- Roberto Santa Cruz
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
- Universidad de Magallanes, Escuela de Medicina, Punta Arenas, Chile
- Instituto Universitario Ciencias de la Salud, Fundación Barceló, Argentina
| | - Amelia Matesa
- Clínica Basilea, Ciudad Autónoma de Buenos Aires, Argentina
| | - Antonella Gómez
- Hospital de Clínicas, Montevideo, Uruguay
- UDELAR, Universidad de la República, Montevideo, Uruguay
| | - Juan Nadur
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
- Clínica CIAREC (Clínica de Internación Aguda en Rehabilitación y Cirugía), Buenos Aires, Argentina
| | - Fernando Pagano
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
| | - Daniel Prieto
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
| | | | - Beatriz Solis
- Universidad de Magallanes, Escuela de Medicina, Punta Arenas, Chile
| | - Sara Yusta
- Universidad de Magallanes, Escuela de Medicina, Punta Arenas, Chile
| | | | - Elisa Estenssoro
- Dirección de Investigación, Escuela de Gobierno, Ministerio de Salud de la Provincia de Buenos Aires, Argentina
- Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Buenos Aires, Argentina
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Qadir N, Bauer PR. Acute Respiratory Distress Syndrome and the Meaning of Hospital Mortality. Crit Care Med 2024; 52:1319-1321. [PMID: 39007577 DOI: 10.1097/ccm.0000000000006340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Affiliation(s)
- Nida Qadir
- Division of Pulmonary and Critical Care Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Philippe R Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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Hochberg CH, Case AS, Psoter KJ, Brodie D, Dezube RH, Sahetya SK, Outten C, Street L, Eakin MN, Hager DN. Lung Protective Ventilation Adherence and Outcomes for Patients With COVID-19 Acute Respiratory Distress Syndrome Treated in an Intermediate Care Unit Repurposed to ICU Level of Care. Crit Care Explor 2024; 6:e1127. [PMID: 39018303 PMCID: PMC11257666 DOI: 10.1097/cce.0000000000001127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024] Open
Abstract
OBJECTIVE During the COVID-19 pandemic, some centers converted intermediate care units (IMCUs) to COVID-19 ICUs (IMCU/ICUs). In this study, we compared adherence to lung protective ventilation (LPV) and outcomes for patients with COVID-19-related acute respiratory distress syndrome (ARDS) treated in an IMCU/ICU versus preexisting medical ICUs (MICUs). DESIGN Retrospective observational study using electronic medical record data. SETTING Two academic medical centers from March 2020 to September 2020 (period 1) and October 2020 to May 2021 (period 2), which capture the first two COVID-19 surges in this health system. PATIENTS Adults with COVID-19 receiving invasive mechanical ventilation who met ARDS oxygenation criteria (Pao2/Fio2 ≤ 300 mm Hg or Spo2/Fio2 ≤ 315). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We defined LPV adherence as the percent of the first 48 hours of mechanical ventilation that met a restrictive definition of LPV of, tidal volume/predicted body weight (Vt/PBW) less than or equal to 6.5 mL/kg and plateau pressure (Pplat) less than or equal to 30 cm H2o. In an expanded definition, we added that if Pplat is greater than 30 cm H2o, Vt/PBW had to be less than 6.0 mL/kg. Using the restricted definition, period 1 adherence was lower among 133 IMCU/ICU versus 199 MICU patients (92% [95% CI, 50-100] vs. 100% [86-100], p = 0.05). Period 2 adherence was similar between groups (100% [75-100] vs. 95% CI [65-100], p = 0.68). A similar pattern was observed using the expanded definition. For the full study period, the adjusted hazard of death at 90 days was lower in IMCU/ICU versus MICU patients (hazard ratio [HR] 0.73 [95% CI, 0.55-0.99]), whereas ventilator liberation by day 28 was similar between groups (adjusted subdistribution HR 1.09 [95% CI, 0.85-1.39]). CONCLUSIONS In patients with COVID-19 ARDS treated in an IMCU/ICU, LPV adherence was similar to, and observed survival better than those treated in preexisting MICUs. With adequate resources, protocols, and staffing, IMCUs provide an effective source of additional ICU capacity for patients with acute respiratory failure.
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Affiliation(s)
- Chad H. Hochberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Aaron S. Case
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Kevin J. Psoter
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Rebecca H. Dezube
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Sarina K. Sahetya
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Carrie Outten
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Lara Street
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Michelle N. Eakin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - David N. Hager
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
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Levy E, Reilly JP. Pharmacologic Treatments in Acute Respiratory Failure. Crit Care Clin 2024; 40:275-289. [PMID: 38432696 DOI: 10.1016/j.ccc.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Acute respiratory failure relies on supportive care using non-invasive and invasive oxygen and ventilatory support. Pharmacologic therapies for the most severe form of respiratory failure, acute respiratory distress syndrome (ARDS), are limited. This review focuses on the most promising therapies for ARDS, targeting different mechanisms that contribute to dysregulated inflammation and resultant hypoxemia. Significant heterogeneity exists within the ARDS population. Treatment requires prompt recognition of ARDS and an understanding of which patients may benefit most from specific pharmacologic interventions. The key to finding effective pharmacotherapies for ARDS may rely on deeper understanding of pathophysiology and bedside identification of ARDS subphenotypes.
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Affiliation(s)
- Elizabeth Levy
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19146, USA
| | - John P Reilly
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19146, USA.
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Trieu M, Qadir N. Adjunctive Therapies in Acute Respiratory Distress Syndrome. Crit Care Clin 2024; 40:329-351. [PMID: 38432699 DOI: 10.1016/j.ccc.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Despite significant advances in understanding acute respiratory distress syndrome (ARDS), mortality rates remain high. The appropriate use of adjunctive therapies can improve outcomes, particularly for patients with moderate to severe hypoxia. In this review, the authors discuss the evidence basis behind prone positioning, recruitment maneuvers, neuromuscular blocking agents, corticosteroids, pulmonary vasodilators, and extracorporeal membrane oxygenation and considerations for their use in individual patients and specific clinical scenarios. Because the heterogeneity of ARDS poses challenges in finding universally effective treatments, an individualized approach and continued research efforts are crucial for optimizing the utilization of adjunctive therapies and improving patient outcomes.
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Affiliation(s)
- Megan Trieu
- Division of Pulmonary Critical Care Sleep Medicine and Physiology, Department of Medicine, University of California San Diego, 9300 Campus Point Drive, #7381, La Jolla, CA 92037-1300, USA
| | - Nida Qadir
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Avenue, Room 43-229 CHS, Los Angeles, CA 90095, USA.
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Padte S, Samala Venkata V, Mehta P, Tawfeeq S, Kashyap R, Surani S. 21st century critical care medicine: An overview. World J Crit Care Med 2024; 13:90176. [PMID: 38633477 PMCID: PMC11019625 DOI: 10.5492/wjccm.v13.i1.90176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 12/28/2023] [Accepted: 01/24/2024] [Indexed: 03/05/2024] Open
Abstract
Critical care medicine in the 21st century has witnessed remarkable advancements that have significantly improved patient outcomes in intensive care units (ICUs). This abstract provides a concise summary of the latest developments in critical care, highlighting key areas of innovation. Recent advancements in critical care include Precision Medicine: Tailoring treatments based on individual patient characteristics, genomics, and biomarkers to enhance the effectiveness of therapies. The objective is to describe the recent advancements in Critical Care Medicine. Telemedicine: The integration of telehealth technologies for remote patient monitoring and consultation, facilitating timely interventions. Artificial intelligence (AI): AI-driven tools for early disease detection, predictive analytics, and treatment optimization, enhancing clinical decision-making. Organ Support: Advanced life support systems, such as Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy provide better organ support. Infection Control: Innovative infection control measures to combat emerging pathogens and reduce healthcare-associated infections. Ventilation Strategies: Precision ventilation modes and lung-protective strategies to minimize ventilator-induced lung injury. Sepsis Management: Early recognition and aggressive management of sepsis with tailored interventions. Patient-Centered Care: A shift towards patient-centered care focusing on psychological and emotional well-being in addition to medical needs. We conducted a thorough literature search on PubMed, EMBASE, and Scopus using our tailored strategy, incorporating keywords such as critical care, telemedicine, and sepsis management. A total of 125 articles meeting our criteria were included for qualitative synthesis. To ensure reliability, we focused only on articles published in the English language within the last two decades, excluding animal studies, in vitro/molecular studies, and non-original data like editorials, letters, protocols, and conference abstracts. These advancements reflect a dynamic landscape in critical care medicine, where technology, research, and patient-centered approaches converge to improve the quality of care and save lives in ICUs. The future of critical care promises even more innovative solutions to meet the evolving challenges of modern medicine.
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Affiliation(s)
- Smitesh Padte
- Department of Research, Global Remote Research Scholars Program, St. Paul, MN 55104, United States
| | | | - Priyal Mehta
- Department of Research, Global Remote Research Scholars Program, St. Paul, MN 55104, United States
| | - Sawsan Tawfeeq
- Department of Research, Global Remote Research Scholars Program, St. Paul, MN 55104, United States
| | - Rahul Kashyap
- Department of Research, Global Remote Research Scholars Program, St. Paul, MN 55104, United States
- Department of Research, WellSpan Health, York, PA 17403, United States
- Department of Pulmonary & Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Salim Surani
- Department of Pulmonary & Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
- Department of Medicine & Pharmacology, Texas A&M University, College Station, TX 77843, United States
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8
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Aribindi K, Lim M, Lakshminrusimha S, Albertson T. Investigational pharmacological agents for the treatment of ARDS. Expert Opin Investig Drugs 2024; 33:243-277. [PMID: 38316432 DOI: 10.1080/13543784.2024.2315128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/25/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Acute Respiratory Distress Syndrome (ARDS) is a heterogeneous form of lung injury with severe hypoxemia and bilateral infiltrates after an inciting event that results in diffuse lung inflammation with a high mortality rate. While research in COVID-related ARDS has resulted in several pharmacotherapeutic agents that have undergone successful investigation, non-COVID ARDS studies have not resulted in many widely accepted pharmacotherapeutic agents despite exhaustive research. AREAS COVERED The aim of this review is to discuss adjuvant pharmacotherapies targeting non-COVID Acute Lung Injury (ALI)/ARDS and novel therapeutics in COVID associated ALI/ARDS. In ARDS, variable data may support selective use of neuromuscular blocking agents, corticosteroids and neutrophil elastase inhibitors, but are not yet universally used. COVID-ALI/ARDS has data supporting the use of IL-6 monoclonal antibodies, corticosteroids, and JAK inhibitor therapy. EXPERT OPINION Although ALI/ARDS modifying pharmacological agents have been identified in COVID-related disease, the data in non-COVID ALI/ARDS has been less compelling. The increased use of more specific molecular phenotyping based on physiologic parameters and biomarkers, will ensure equipoise between groups, and will likely allow more precision in confirming pharmacological agent efficacy in future studies.
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Affiliation(s)
- Katyayini Aribindi
- Department of Internal Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, U.C. Davis School of Medicine, Sacramento, CA, USA
- Department of Medicine, Veterans Affairs North California Health Care System, Mather, CA, USA
| | - Michelle Lim
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, U.C. Davis School of Medicine, Sacramento, CA, USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, U.C. Davis School of Medicine, Sacramento, CA, USA
| | - Timothy Albertson
- Department of Internal Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, U.C. Davis School of Medicine, Sacramento, CA, USA
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Seitz KP, Lloyd BD, Wang L, Shotwell MS, Qian ET, Richardson RK, Rooks JC, Hennings-Williams V, Sandoval CE, Richardson WD, Morgan T, Thompson AN, Hastings PG, Ring TP, Stollings JL, Talbot EM, Krasinski DJ, Decoursey B, Gibbs KW, Self WH, Mixon AS, Rice TW, Semler MW, Casey JD. Protocol and Statistical Analysis Plan for the Mode of Ventilation During Critical Illness (MODE) Trial. CHEST CRITICAL CARE 2024; 2:100033. [PMID: 38742219 PMCID: PMC11090486 DOI: 10.1016/j.chstcc.2023.100033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
BACKGROUND For every critically ill adult receiving invasive mechanical ventilation, clinicians must select a mode of ventilation. The mode of ventilation determines whether the ventilator directly controls the tidal volume or the inspiratory pressure. Newer hybrid modes allow clinicians to set a target tidal volume; the ventilator controls and adjusts the inspiratory pressure. A strategy of low tidal volumes and low plateau pressure improves outcomes, but the optimal mode to achieve these targets is not known. RESEARCH QUESTION Can a cluster-randomized trial design be used to assess whether the mode of mandatory ventilation affects the number of days alive and free of invasive mechanical ventilation among critically ill adults? STUDY DESIGN AND METHODS The Mode of Ventilation During Critical Illness (MODE) trial is a cluster-randomized, multiple-crossover pilot trial being conducted in the medical ICU at an academic center. The MODE trial compares the use of volume control, pressure control, and adaptive pressure control. The study ICU is assigned to a single-ventilator mode (volume control vs pressure control vs adaptive pressure control) for continuous mandatory ventilation during each 1-month study block. The assigned mode switches every month in a randomly generated sequence. The primary outcome is ventilator-free days to study day 28, defined as the number of days alive and free of invasive mechanical ventilation from the final receipt of mechanical ventilation to 28 days after enrollment. Enrollment began November 1, 2022, and will end on July 31, 2023. RESULTS This manuscript describes the protocol and statistical analysis plan for the MODE trial of ventilator modes comparing volume control, pressure control, and adaptive pressure control. INTERPRETATION Prespecifying the full statistical analysis plan prior to completion of enrollment increases rigor, reproducibility, and transparency of the trial results. CLINICAL TRIAL REGISTRATION The trial was registered with clinicaltrials.gov on October 3, 2022, before initiation of patient enrollment on November 1, 2022 (ClinicalTrials.gov identifier: NCT05563779).
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Affiliation(s)
- Kevin P Seitz
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Bradley D Lloyd
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Li Wang
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Matthew S Shotwell
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Edward T Qian
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Roger K Richardson
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Jeffery C Rooks
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Vanessa Hennings-Williams
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Claire E Sandoval
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Whitney D Richardson
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Tracy Morgan
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Amber N Thompson
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Pamela G Hastings
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Terry P Ring
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Joanna L Stollings
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Erica M Talbot
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - David J Krasinski
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Bailey Decoursey
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Kevin W Gibbs
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Wesley H Self
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Amanda S Mixon
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Todd W Rice
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Matthew W Semler
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Jonathan D Casey
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
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Samanta RJ, Ercole A, Harris S, Summers C. Low Tidal Volume Ventilation Is Poorly Implemented for Patients in North American and United Kingdom ICUs Using Electronic Health Records. Chest 2024; 165:333-347. [PMID: 37775039 PMCID: PMC10851261 DOI: 10.1016/j.chest.2023.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/09/2023] [Accepted: 09/15/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Low tidal volume ventilation (LTVV; < 8 mL/kg predicted body weight [PBW]) is a well-established standard of care associated with improved outcomes. This study used data collated in multicenter electronic health record ICU databases from the United Kingdom and the United States to analyze the use of LTVV in routine clinical practice. RESEARCH QUESTION What factors are associated with adherence to LTVV in the United Kingdom and North America? STUDY DESIGN This was a retrospective, multicenter study across the United Kingdom and United States of patients who were mechanically ventilated. METHODS Factors associated with adherence to LTVV were assessed in all patients in both databases who were mechanically ventilated for > 48 h. We observed trends over time and investigated whether LTVV was associated with patient outcomes (30-day mortality and duration of ventilation) and identified strategies to improve adherence to LTVV. RESULTS A total of 5,466 (Critical Care Health Informatics Collaborative [CCHIC]) and 7,384 electronic ICU collaborative research database [eICU-CRD] patients were ventilated for > 48 h and had data of suitable quality for analysis. The median tidal volume (VT) values were 7.48 mL/kg PBW (CCHIC) and 7.91 mL/kg PBW (eICU-CRD). The patients at highest risk of not receiving LTVV were shorter than 160 cm (CCHIC) and 165 cm (eICU-CRD). Those with BMI > 30 kg/m2 (CCHIC OR, 1.9 [95% CI, 1.7-2.13]; eICU-CRD OR, 1.61 [95% CI, 1.49-1.75]) and female patients (CCHIC OR, 2.39 [95% CI, 2.16-2.65]; eICU-CRD OR, 2.29 [95% CI, 2.26-2.31]) were at increased risk of having median VT > 8 mL/kg PBW. Patients with median VT < 8 mL/kg PBW had decreased 30-day mortality in the CCHIC database (CCHIC cause-specific hazard ratio, 0.86 [95% CI, 0.76-0.97]; eICU-CRD cause-specific hazard ratio, 0.9 [95% CI, 0.86-1.00]). There was a significant reduction in VT over time in the CCHIC database. INTERPRETATION There has been limited implementation of LTVV in routine clinical practice in the United Kingdom and the United States. VT > 8 mL/kg PBW was associated with worse patient outcomes.
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Affiliation(s)
- Romit J Samanta
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, England
| | - Ari Ercole
- Centre for AI in Medicine, University of Cambridge, Cambridge, England
| | - Steven Harris
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, England
| | - Charlotte Summers
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, England.
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Ofoma UR. Mechanical Power and Safer Lung Ventilation: Not Ready for Prime Time. Crit Care Med 2024; 52:150-153. [PMID: 38095523 PMCID: PMC10751058 DOI: 10.1097/ccm.0000000000006064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Uchenna R Ofoma
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, MO
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Qadir N, Sahetya S, Munshi L, Summers C, Abrams D, Beitler J, Bellani G, Brower RG, Burry L, Chen JT, Hodgson C, Hough CL, Lamontagne F, Law A, Papazian L, Pham T, Rubin E, Siuba M, Telias I, Patolia S, Chaudhuri D, Walkey A, Rochwerg B, Fan E. An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2024; 209:24-36. [PMID: 38032683 PMCID: PMC10870893 DOI: 10.1164/rccm.202311-2011st] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Indexed: 12/01/2023] Open
Abstract
Background: This document updates previously published Clinical Practice Guidelines for the management of patients with acute respiratory distress syndrome (ARDS), incorporating new evidence addressing the use of corticosteroids, venovenous extracorporeal membrane oxygenation, neuromuscular blocking agents, and positive end-expiratory pressure (PEEP). Methods: We summarized evidence addressing four "PICO questions" (patient, intervention, comparison, and outcome). A multidisciplinary panel with expertise in ARDS used the Grading of Recommendations, Assessment, Development, and Evaluation framework to develop clinical recommendations. Results: We suggest the use of: 1) corticosteroids for patients with ARDS (conditional recommendation, moderate certainty of evidence), 2) venovenous extracorporeal membrane oxygenation in selected patients with severe ARDS (conditional recommendation, low certainty of evidence), 3) neuromuscular blockers in patients with early severe ARDS (conditional recommendation, low certainty of evidence), and 4) higher PEEP without lung recruitment maneuvers as opposed to lower PEEP in patients with moderate to severe ARDS (conditional recommendation, low to moderate certainty), and 5) we recommend against using prolonged lung recruitment maneuvers in patients with moderate to severe ARDS (strong recommendation, moderate certainty). Conclusions: We provide updated evidence-based recommendations for the management of ARDS. Individual patient and illness characteristics should be factored into clinical decision making and implementation of these recommendations while additional evidence is generated from much-needed clinical trials.
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Locke BW, Brown J. What Are We Aiming for in Chronic Hypercapnic Respiratory Failure? Respir Care 2023; 68:1775-1778. [PMID: 38007234 PMCID: PMC10676247 DOI: 10.4187/respcare.11573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Affiliation(s)
- Brian W Locke
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine Department of Internal Medicine University of Utah Salt Lake City, Utah
| | - Jeanette Brown
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine Department of Internal Medicine University of Utah Salt Lake City, Utah
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Hochberg CH, Psoter KJ, Eakin MN, Hager DN. Declining Use of Prone Positioning After High Initial Uptake in COVID-19 Adult Respiratory Distress Syndrome. Crit Care Med 2023; 51:1547-1551. [PMID: 37294144 PMCID: PMC10987018 DOI: 10.1097/ccm.0000000000005969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Prone positioning for acute respiratory distress syndrome (ARDS) has historically been underused, but was widely adopted for COVID-19-associated ARDS early in the pandemic. Whether this successful implementation has been sustained over the first 3 years of the COVID-19 pandemic is unknown. In this study, we characterized proning use in patients with COVID-19 ARDS from March 2020 to December 2022. DESIGN Multicenter retrospective observational study. SETTING Five-hospital health system in Maryland, USA. PATIENTS Adults with COVID-19 supported with invasive mechanical ventilation and with a P ao2 /F io2 ratio of less than or equal to 150 mm Hg while receiving F io2 of greater than or equal to 0.6 within 72 hours of intubation. INTERVENTIONS None. MEASUREMENTS We extracted demographic, clinical, and positioning data from the electronic medical record. The primary outcome was the initiation of proning within 48 hours of meeting criteria. We compared proning use by year with univariate and multivariate relative risk (RR) regression. Additionally, we evaluated the association of treatment during a COVID-19 surge period and receipt of prone positioning. MAIN RESULTS We identified 656 qualifying patients; 341 from 2020, 224 from 2021, and 91 from 2022. More than half (53%) met severe ARDS criteria. Early proning occurred in 56.2% of patients in 2020, 56.7% in 2021, and 27.5% in 2022. This translated to a 51% reduction in use of prone positioning among patients treated in 2022 versus 2020 (RR = 0.49; 95% CI, 0.33-0.72; p < 0.001). This reduction remained significant in adjusted models (adjusted RR = 0.59; 95% CI, 0.42-0.82; p = 0.002). Treatment during COVID-19 surge periods was associated with a 7% increase in proning use (adjusted RR = 1.07; 95% CI, 1.02-1.13; p = 0.01). CONCLUSIONS The use of prone positioning for COVID-19 ARDS is declining. Interventions to increase and sustain appropriate use of this evidence-based therapy are warranted.
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Affiliation(s)
- Chad H Hochberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Kevin J Psoter
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Michelle N Eakin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - David N Hager
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
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Fawley JA, Tignanelli CJ, Werner NL, Kasotakis G, Mandell SP, Glass NE, Dries DJ, Costantini TW, Napolitano LM. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for management of acute respiratory distress syndrome and severe hypoxemia. J Trauma Acute Care Surg 2023; 95:592-602. [PMID: 37314843 PMCID: PMC10545067 DOI: 10.1097/ta.0000000000004046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 06/15/2023]
Abstract
LEVEL OF EVIDENCE Therapeutic/Care Management: Level V.
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16
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Wang JJ, Zhou Z, Zhang LY. Clinical evaluation of ventilation mode on acute exacerbation of chronic obstructive pulmonary disease with respiratory failure. World J Clin Cases 2023; 11:6040-6050. [PMID: 37731551 PMCID: PMC10507537 DOI: 10.12998/wjcc.v11.i26.6040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/19/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND At present, understanding of the most effective ventilation methods for treating chronic obstructive pulmonary disease (COPD) patients experiencing acute worsening symptoms and respiratory failure remains relatively limited. This report analyzed the efficiency and side effects of various ventilation techniques used for individuals experiencing an acute COPD exacerbation. AIM To determine whether pressure-controlled ventilation (PCV) can lower peak airway pressures (PAPs) and reduce the incidence of barotrauma compared to volume-controlled ventilation (VCV), without compromising clinical outcomes and oxygenation parameters. METHODS We have evaluated 600 patients who were hospitalized due to a severe COPD exacerbation, with 400 receiving mechanical ventilation for the respiratory failure. The participants were divided into two different groups, who were administered either VCV or PCV, along with appropriate management. We thereafter observed patients' attributes, clinical factors, and laboratory, radiographic, and arterial blood gas evaluations at the start and during their stay in the intensive care unit (ICU). We have also employed appropriate statistical methods for the data analysis. RESULTS Both the VCV and PCV groups experienced significant enhancements in the respiratory rate, tidal volume, and arterial blood gas values during their time in the ICU. However, no significant distinctions were detected between the groups in terms of oxygenation indices (partial pressures of oxygen/raction of inspired oxygen ratio) and partial pressures of carbon dioxide improvements. There was no considerable disparity observed between the VCV and PCV groups in the hospital mortality (32% vs 28%, P = 0.53), the number of days of ICU stay [median interquartile range (IQR): 9 (6-14) d vs 8 (5-13) d, P = 0.41], or the duration of the mechanical ventilation [median (IQR): 6 (4-10) d vs 5 (3-9) d, P = 0.47]. The PCV group displayed lower PAPs compared to the VCV group (P < 0.05) from the beginning of mechanical ventilation until extubation or ICU departure. The occurrence of barotrauma was considerably lower in the PCV group in comparison to the VCV group (6% vs 16%, P = 0.03). CONCLUSION Both VCV and PCV were found to be effective in treating patients with acute COPD exacerbation. However, PCV was associated with lower PAPs and a significant decrease in barotrauma, thus indicating that it might be a safer ventilation method for this group of patients. However, further large-scale study is necessary to confirm these findings and to identify the best ventilation approach for patients experiencing an acute COPD exacerbation.
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Affiliation(s)
- Jun-Jun Wang
- Department of Respiratory and Critical Care Medicine, The First People's Hospital of Yangquan City, Yangquan 045000, Shanxi Province, China
| | - Zhong Zhou
- Department of Respiratory and Critical Care Medicine, Guiyang Public Health Treatment Center, Guiyang 550001, Guizhou Province, China
| | - Li-Ying Zhang
- Department of Respiratory and Critical Care Medicine, The Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200023, China
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17
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Chen JT, Mehrizi R, Aasman B, Gong MN, Mirhaji P. Long short-term memory model identifies ARDS and in-hospital mortality in both non-COVID-19 and COVID-19 cohort. BMJ Health Care Inform 2023; 30:e100782. [PMID: 37709302 PMCID: PMC10503386 DOI: 10.1136/bmjhci-2023-100782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/21/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVE To identify the risk of acute respiratory distress syndrome (ARDS) and in-hospital mortality using long short-term memory (LSTM) framework in a mechanically ventilated (MV) non-COVID-19 cohort and a COVID-19 cohort. METHODS We included MV ICU patients between 2017 and 2018 and reviewed patient records for ARDS and death. Using active learning, we enriched this cohort with MV patients from 2016 to 2019 (MV non-COVID-19, n=3905). We collected a second validation cohort of hospitalised patients with COVID-19 in 2020 (COVID+, n=5672). We trained an LSTM model using 132 structured features on the MV non-COVID-19 training cohort and validated on the MV non-COVID-19 validation and COVID-19 cohorts. RESULTS Applying LSTM (model score 0.9) on the MV non-COVID-19 validation cohort had a sensitivity of 86% and specificity of 57%. The model identified the risk of ARDS 10 hours before ARDS and 9.4 days before death. The sensitivity (70%) and specificity (84%) of the model on the COVID-19 cohort are lower than MV non-COVID-19 cohort. For the COVID-19 + cohort and MV COVID-19 + patients, the model identified the risk of in-hospital mortality 2.4 days and 1.54 days before death, respectively. DISCUSSION Our LSTM algorithm accurately and timely identified the risk of ARDS or death in MV non-COVID-19 and COVID+ patients. By alerting the risk of ARDS or death, we can improve the implementation of evidence-based ARDS management and facilitate goals-of-care discussions in high-risk patients. CONCLUSION Using the LSTM algorithm in hospitalised patients identifies the risk of ARDS or death.
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Affiliation(s)
- Jen-Ting Chen
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, UCSF, San Francisco, California, USA
- Department of Medicine, Division of Critical Care Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Rahil Mehrizi
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Boudewijn Aasman
- Center for Health Data Innovations, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Michelle Ng Gong
- Department of Medicine, Division of Critical Care Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Parsa Mirhaji
- Department of Genetics, Albert Einstein College of Medicine, Bronx, New York, USA
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18
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Hochberg CH, Card ME, Seth B, Hager DN, Eakin MN. Adaptation and Uncertainty: A Qualitative Examination of Provider Experiences With Prone Positioning for Intubated Patients With COVID-19 ARDS. CHEST CRITICAL CARE 2023; 1:100008. [PMID: 37810258 PMCID: PMC10560392 DOI: 10.1016/j.chstcc.2023.100008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
BACKGROUND Prone positioning was widely adopted for use in patients with ARDS from COVID-19. However, proning was also delivered in ways that differed from historical evidence and practice. In implementation research, these changes are referred to as adaptations, and they occur constantly as evidence-based interventions are used in real-world practice. Adaptations can alter the delivered intervention, impacting patient and implementation outcomes. RESEARCH QUESTION How have clinicians adapted prone positioning to COVID-19 ARDS, and what uncertainties remain regarding optimal proning use? STUDY DESIGN AND METHODS We conducted a qualitative study using semi-structured interviews with ICU clinicians from two hospitals in Baltimore, MD, from February to July 2021. We interviewed physicians (MDs), registered nurses (RNs), respiratory therapists (RTs), advanced practice providers (APPs), and physical therapists (PTs) involved with proning mechanically ventilated patients with COVID-19 ARDS. We used thematic analysis of interviews to classify proning adaptations and clinician uncertainties about best practice for prone positioning. RESULTS Forty ICU clinicians (12 MDs, 4 APPs, 12 RNs, 7 RTs, and 5 PTs) were interviewed. Clinicians described several adaptations to the practice of prone positioning, including earlier proning initiation, extended duration of proning sessions, and less use of concomitant neuromuscular blockade. Clinicians expressed uncertainty regarding the optimal timing of initiation and duration of prone positioning. This uncertainty was viewed as a driver of practice variation. Although prescribers intended to use less deep sedation and paralysis in proned patients compared with historical evidence and practice, this raised concerns regarding patient comfort and safety amongst RNs and RTs. INTERPRETATION Prone positioning in patients with COVID-19 ARDS has been adapted from historically described practice. Understanding the impact of these adaptations on patient and implementation outcomes and addressing clinician uncertainties are priority areas for future research to optimize the use of prone positioning.
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Affiliation(s)
- Chad H Hochberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Mary E Card
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Bhavna Seth
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - David N Hager
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Michelle N Eakin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
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19
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Zhang J, Ge P, Liu J, Luo Y, Guo H, Zhang G, Xu C, Chen H. Glucocorticoid Treatment in Acute Respiratory Distress Syndrome: An Overview on Mechanistic Insights and Clinical Benefit. Int J Mol Sci 2023; 24:12138. [PMID: 37569514 PMCID: PMC10418884 DOI: 10.3390/ijms241512138] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Acute lung injury/acute respiratory distress syndrome (ALI/ARDS), triggered by various pathogenic factors inside and outside the lungs, leads to diffuse lung injury and can result in respiratory failure and death, which are typical clinical critical emergencies. Severe acute pancreatitis (SAP), which has a poor clinical prognosis, is one of the most common diseases that induces ARDS. When SAP causes the body to produce a storm of inflammatory factors and even causes sepsis, clinicians will face a two-way choice between anti-inflammatory and anti-infection objectives while considering the damaged intestinal barrier and respiratory failure, which undoubtedly increases the difficulty of the diagnosis and treatment of SAP-ALI/ARDS. For a long time, many studies have been devoted to applying glucocorticoids (GCs) to control the inflammatory response and prevent and treat sepsis and ALI/ARDS. However, the specific mechanism is not precise, the clinical efficacy is uneven, and the corresponding side effects are endless. This review discusses the mechanism of action, current clinical application status, effectiveness assessment, and side effects of GCs in the treatment of ALI/ARDS (especially the subtype caused by SAP).
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Affiliation(s)
- Jinquan Zhang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
| | - Peng Ge
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
| | - Jie Liu
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
| | - Yalan Luo
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
| | - Haoya Guo
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
| | - Guixin Zhang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
| | - Caiming Xu
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope, Biomedical Research Center, Comprehensive Cancer Center, Monrovia, CA 91016, USA
| | - Hailong Chen
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
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20
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Grissom CK, Lanspa MJ, Groat D, Jacobs JR, Carpenter L, Kuttler KG, Leither L, Peltan ID, Brown SM, Srivastava R. Implementation of Lung-Protective Ventilation in Patients With Acute Respiratory Failure. Crit Care Med 2023; 51:797-807. [PMID: 36988337 DOI: 10.1097/ccm.0000000000005840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
OBJECTIVES We implemented a computerized protocol for low tidal volume ventilation (LTVV) to improve management and outcomes of mechanically ventilated patients with, and without, the acute respiratory distress syndrome (ARDS). DESIGN Pragmatic, nonrandomized stepped wedge type II hybrid implementation/effectiveness trial. SETTING Twelve hospitals in an integrated healthcare system over a 2-year period. PATIENTS Patients greater than or equal to 18 years old who had initiation of mechanical ventilation in the emergency department or ICU. We excluded patients who died or transitioned to comfort care on the day of admission to the ICU. We defined a subgroup of patients with ARDS for analysis. INTERVENTIONS Implementation of ventilator protocols for LTVV in the ICU. MEASUREMENTS AND MAIN RESULTS Our primary clinical outcome was ventilator-free days (VFDs) to day 28. Our primary process outcome was median initial set tidal volume. We included 8,692 mechanically ventilated patients, 3,282 (38%) of whom had ARDS. After implementation, set tidal volume reported as mL/kg predicted body weight decreased from median 6.1 mL/kg (interquartile range [IQR], 6.0-6.8 mL/kg) to 6.0 mL/kg (IQR, 6.0-6.6 mL/kg) ( p = 0.009). The percent of patients receiving LTVV (tidal volume ≤ 6.5 mL/kg) increased from 69.8% ( n = 1,721) to 72.5% ( n = 1,846) ( p = 0.036) after implementation. The percent of patients receiving greater than 8 mL/kg initial set tidal volume was reduced from 9.0% ( n = 222) to 6.7% ( n = 174) ( p = 0.005) after implementation. Among patients with ARDS, day 1 positive end-expiratory pressure increased from 6.7 to 8.0 cm H 2 O ( p < 0.001). We observed no difference in VFD (adjusted odds ratio, 1.06; 95% CI, 0.91-1.24; p = 0.44), or in secondary outcomes of length of stay or mortality, either within the main cohort or the subgroup of patients with ARDS. CONCLUSIONS We observed improved adherence to optimal ventilator management with implementation of a computerized protocol and reduction in the number of patients receiving tidal volumes greater than 8 mL/kg. We did not observe improvement in clinical outcomes.
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Affiliation(s)
- Colin K Grissom
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Michael J Lanspa
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Danielle Groat
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Jason R Jacobs
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Lori Carpenter
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Kathryn G Kuttler
- Digital Technology Services, Intermountain Healthcare, Salt Lake City, UT
| | - Lindsay Leither
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Samuel M Brown
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Rajendu Srivastava
- Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, UT
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT
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21
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LeSieur MN, Bosch NA, Walkey AJ. Hospital Variation in Mortality and Ventilator Management among Mechanically Ventilated Patients with ARDS. J Intensive Care Med 2023; 38:179-187. [PMID: 35786134 DOI: 10.1177/08850666221111748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
RATIONALE Acute Respiratory Distress Syndrome (ARDS) is associated with significant mortality. Despite the mortality benefits of lung protective ventilation, adherence rates to evidence-based ventilator practice have remained low and ARDS mortality has remained high. OBJECTIVE Determine variation in ARDS mortality and adherence to low tidal volume ventilation (LTV) across US hospitals. MATERIALS AND METHODS We identified mechanically ventilated patients with ARDS using data from Philips eICU (2014-2015). We then used multi-variable hierarchical logistic regression models with hospital site as the random effect and patient and hospital level factors as fixed effects to assess the hospital risk adjusted mortality rate and median odds ratio for the association between mortality and hospital site. We then assessed associations between adherence to LTV (defined as 4-8 mL/kg PBW) and hospital risk adjusted mortality rates using Spearman correlation. RESULTS Among 4441 patients admitted at 110 hospitals with ARDS, the hospital risk-adjusted mortality rate ranged from 19% to 39%, and the MOR for hospital of admission was 1.33 (95% CI 1.25-1.41). Among 3070 patients at 72 hospitals with available ventilator data, 73% of patients had a median set Vt between 4 to 8 mL/kg PBW; hospital adherence rates to LTV ranged from 13% to 95%. There was no association between hospital adherence to LTV and risk-adjusted mortality rate (spearman correlation coefficient -0.01, p = .93). Similarly, among 956 patients who started with a Vt > 8 mL/kg PBW, there was no association between the percent of patients at each hospital whose Vt was decreased to ≤ 8 mL/kg PBW and risk adjusted mortality rate (spearman correlation coefficient .05, p = .73). CONCLUSION Risk adjusted mortality and use of LTV for patients with ARDS varied widely across hospitals. However, hospital adherence to LTV was not associated with ARDS mortality rates. Further evaluation of hospital practices associated with lower ARDS mortality are warranted.
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Affiliation(s)
- Mallory N LeSieur
- Department of Medicine, Pulmonary Center, 12259Boston University School of Medicine, Boston, MA, USA
| | - Nicholas A Bosch
- Department of Medicine, Pulmonary Center, 12259Boston University School of Medicine, Boston, MA, USA
| | - Allan J Walkey
- Department of Medicine, Pulmonary Center, 12259Boston University School of Medicine, Boston, MA, USA
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22
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Hochberg CH, Card ME, Seth B, Kerlin MP, Hager DN, Eakin MN. Factors Influencing the Implementation of Prone Positioning during the COVID-19 Pandemic: A Qualitative Study. Ann Am Thorac Soc 2023; 20:83-93. [PMID: 35947776 PMCID: PMC9819268 DOI: 10.1513/annalsats.202204-349oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/10/2022] [Indexed: 02/05/2023] Open
Abstract
Rationale: The adoption of prone positioning for patients with acute respiratory distress syndrome (ARDS) has historically been poor. However, in mechanically ventilated patients with coronavirus disease (COVID-19) ARDS, proning has increased. Understanding the factors influencing this change is important for further expanding and sustaining the use of prone positioning in appropriate clinical settings. Objectives: To characterize factors influencing the implementation of prone positioning in mechanically ventilated patients with COVID-19 ARDS. Methods: We conducted a qualitative study using semistructured interviews with 40 intensive care unit (ICU) team members (physicians, nurses, advanced practice providers, respiratory therapists, and physical therapists) working at two academic hospitals. We used the Consolidated Framework for Implementation Research, a widely used implementation science framework outlining important features of implementation, to structure the interview guide and thematic analysis of interviews. Results: ICU clinicians reported that during the COVID-19 pandemic, proning was viewed as standard early therapy for COVID-19 ARDS rather than salvage therapy for refractory hypoxemia. By caring for large volumes of proned patients, clinicians gained increased comfort with proning and now view proning as a low-risk, high-benefit intervention. Within ICUs, adequate numbers of trained staff members, increased team agreement around proning, and the availability of specific equipment (e.g., to limit pressure injuries) facilitated greater proning use. Hospital-level supports included proning teams, centralized educational resources specific to the management of COVID-19 (including a recommendation for prone positioning), and an electronic medical record proning order. Important implementation processes included informal dissemination of best practices through on-the-job learning and team interactions during routine bedside care. Conclusions: The implementation of prone positioning for COVID-19 ARDS took place in the context of evolving clinician viewpoints and ICU team cultures. Proning was facilitated by hospital support and buy-in and leadership from bedside clinicians. The successful implementation of prone positioning during the COVID-19 pandemic may serve as a model for the implementation of other evidence-based therapies in critical care.
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Affiliation(s)
- Chad H. Hochberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - Mary E. Card
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - Bhavna Seth
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - Meeta P. Kerlin
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David N. Hager
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - Michelle N. Eakin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; and
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23
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Sadana D, Kaur S, Sankaramangalam K, Saini I, Banerjee K, Siuba M, Amaral V, Gadre S, Torbic H, Krishnan S, Duggal A. Mortality associated with acute respiratory distress syndrome, 2009-2019: a systematic review and meta-analysis. CRIT CARE RESUSC 2022; 24:341-351. [PMID: 38047005 PMCID: PMC10692616 DOI: 10.51893/2022.4.oa4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Acute respiratory distress syndrome (ARDS) occurs commonly in intensive care units. The reported mortality rates in studies evaluating ARDS are highly variable. Objective: To investigate mortality rates due to ARDS from before the 2009 H1N1 influenza pandemic began until the start of coronavirus disease 2019 (COVID-19) pandemic. Design: We performed a systematic search and then ran a proportional meta-analysis for mortality. We ran our analysis in three ways: for randomised controlled trials only, for observational studies only, and for randomised controlled trials and observational studies combined. Data sources: MEDLINE and Embase, using a highly sensitive criterion and limiting the search to studies published from January 2009 to December 2019. Review methods: Two of us independently screened titles and abstracts to first identify studies and then complete full text reviews of selected studies. We assessed risk of bias using the Cochrane RoB-2 (a risk-of-bias tool for randomised trials) and the Cochrane ROBINS-1 (a risk-of-bias tool for non-randomised studies of interventions). Results: We screened 5844 citations, of which 102 fully met our inclusion criteria. These included 34 randomised controlled trials and 68 observational studies, with a total of 24 158 patients. The weighted pooled mortality rate for all 102 studies published from 2009 to 2019 was 39.4% (95% CI, 37.0-41.8%). Mortality was higher in observational studies compared with randomised controlled trials (41.8% [95% CI, 38.9-44.8%] v 34.5% [95% CI, 30.6-38.5%]; P = 0.005). Conclusions: Over the past decade, mortality rates due to ARDS were high. There is a clear distinction between mortality in observational studies and in randomised controlled trials. Future studies need to report mortality for different ARDS phenotypes and closely adhere to evidence-based medicine. PROSPERO registration: CRD42020149712 (April 2020).
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Affiliation(s)
- Divyajot Sadana
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, (OH), USA
| | - Simrat Kaur
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, (OH), USA
| | - Kesavan Sankaramangalam
- Department of Internal Medicine, Saint Peter’s University Hospital/Rutgers Robert Wood Johnson Medical School, New Brunswick, (NJ), USA
| | - Ishan Saini
- Windsor University School of Medicine, Cayon, Saint Kitts and Nevis, West Indies
| | - Kinjal Banerjee
- Department of Internal Medicine, Geisinger Medical Center, Danville, (PA), USA
| | - Matthew Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, (OH), USA
| | - Valentina Amaral
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, (OH), USA
| | - Shruti Gadre
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, (OH), USA
| | - Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, (OH), USA
| | - Sudhir Krishnan
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, (OH), USA
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, (OH), USA
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Hollenberg SM, Janz DR, Hua M, Malesker M, Qadir N, Rochwerg B, Sessler CN, Tatem G, Rice TW. COVID-19: Lessons Learned, Lessons Unlearned, Lessons for the Future. Chest 2022; 162:1297-1305. [PMID: 35952767 PMCID: PMC9512535 DOI: 10.1016/j.chest.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 07/10/2022] [Accepted: 08/02/2022] [Indexed: 12/15/2022] Open
Abstract
The COVID-19 pandemic has affected clinicians in many different ways. Clinicians have their own experiences and lessons that they have learned from their work in the pandemic. This article outlines a few lessons learned from the eyes of CHEST Critical Care Editorial Board members, namely practices which will be abandoned, novel practices to be adopted moving forward, and proposed changes to the health care system in general. In an attempt to start the discussion of how health care can grow from the pandemic, the editorial board members outline their thoughts on these lessons learned.
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Affiliation(s)
- Steven M Hollenberg
- Emory Heart & Vascular Institute, Emory University School of Medicine, Atlanta, GA
| | - David R Janz
- Medical Critical Care Services, University Medical Center New Orleans, Louisiana State University School of Medicine New Orleans, New Orleans, LA
| | - May Hua
- Mailman School of Public Health, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Mark Malesker
- Department of Pharmacy Practice, School of Pharmacy and Health Professions, Creighton University, Omaha, NE
| | - Nida Qadir
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | | | - Curtis N Sessler
- Center for Adult Critical Care, Virginia Commonwealth University Health System, Richmond, VA
| | - Geneva Tatem
- Pulmonary and Critical Care Medicine Fellowship Program, Henry Ford Health, Detroit, MI
| | - Todd W Rice
- Vanderbilt University Medical Center, Nashville, TN.
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Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome. Med Intensiva 2022; 46:609-618. [PMID: 36313965 PMCID: PMC9597521 DOI: 10.1016/j.medin.2022.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/25/2022] [Indexed: 01/05/2023]
Abstract
Objective Evidence only proves low surpasses high tidal volume (V T) for acute respiratory distress syndrome (ARDS). Intermediate V T is a common setting for ARDS patients and has been demonstrated as effective as low V T in non-ARDS patients. The effectiveness of intermediate V T in ARDS has not been studied and is the objective of this study. Design A retrospective cohort study. Setting Five ICUs with their totally 130 beds in Taiwan. Patients or participants ARDS patients under invasive ventilation. Interventions No. Main variables of interest 28-D mortality. Result Totally 382 patients, with 6958 ventilator settings eligible for lung protection, were classified into low (mean V T = 6.7 ml/kg), intermediate (mean V T = 8.9 ml/kg) and high (mean V T = 11.2 ml/kg) V T groups. With similar baseline ARDS and ICU severities, intermediate and low V T groups did not differ in 28-D mortality (47% vs. 63%, P = 0.06) or other outcomes such as 90-D mortality, ventilator-free days, ventilator-dependence rate. Multivariate analysis revealed high V T was independently associated with 28-D and 90-D mortality, but intermediate V T was not significantly associated with 28-D mortality (HR 1.34, CI 0.92-1.97, P = 0.13) or 90-D mortality. When the intermediate and low V T groups were matched in propensity scores (n = 66 for each group), their outcomes were also not significantly different. Conclusion Intermediate V T, with its outcomes similar to small V T, is an acceptable option for ventilated ARDS patients. This conclusion needs verification through clinical trials.
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Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome. MEDICINA INTENSIVA (ENGLISH EDITION) 2022; 46:609-618. [PMCID: PMC9633924 DOI: 10.1016/j.medine.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/25/2022] [Indexed: 11/06/2022]
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Respiratory Subsets in Patients with Moderate to Severe Acute Respiratory Distress Syndrome for Early Prediction of Death. J Clin Med 2022; 11:jcm11195724. [PMID: 36233592 PMCID: PMC9570540 DOI: 10.3390/jcm11195724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/19/2022] [Accepted: 09/24/2022] [Indexed: 12/16/2022] Open
Abstract
Introduction: In patients with acute respiratory distress syndrome (ARDS), the PaO2/FiO2 ratio at the time of ARDS diagnosis is weakly associated with mortality. We hypothesized that setting a PaO2/FiO2 threshold in 150 mm Hg at 24 h from moderate/severe ARDS diagnosis would improve predictions of death in the intensive care unit (ICU). Methods: We conducted an ancillary study in 1303 patients with moderate to severe ARDS managed with lung-protective ventilation enrolled consecutively in four prospective multicenter cohorts in a network of ICUs. The first three cohorts were pooled (n = 1000) as a testing cohort; the fourth cohort (n = 303) served as a confirmatory cohort. Based on the thresholds for PaO2/FiO2 (150 mm Hg) and positive end-expiratory pressure (PEEP) (10 cm H2O), the patients were classified into four possible subsets at baseline and at 24 h using a standardized PEEP-FiO2 approach: (I) PaO2/FiO2 ≥ 150 at PEEP < 10, (II) PaO2/FiO2 ≥ 150 at PEEP ≥ 10, (III) PaO2/FiO2 < 150 at PEEP < 10, and (IV) PaO2/FiO2 < 150 at PEEP ≥ 10. Primary outcome was death in the ICU. Results: ICU mortalities were similar in the testing and confirmatory cohorts (375/1000, 37.5% vs. 112/303, 37.0%, respectively). At baseline, most patients from the testing cohort (n = 792/1000, 79.2%) had a PaO2/FiO2 < 150, with similar mortality among the four subsets (p = 0.23). When assessed at 24 h, ICU mortality increased with an advance in the subset: 17.9%, 22.8%, 40.0%, and 49.3% (p < 0.0001). The findings were replicated in the confirmatory cohort (p < 0.0001). However, independent of the PEEP levels, patients with PaO2/FiO2 < 150 at 24 h followed a distinct 30-day ICU survival compared with patients with PaO2/FiO2 ≥ 150 (hazard ratio 2.8, 95% CI 2.2−3.5, p < 0.0001). Conclusions: Subsets based on PaO2/FiO2 thresholds of 150 mm Hg assessed after 24 h of moderate/severe ARDS diagnosis are clinically relevant for establishing prognosis, and are helpful for selecting adjunctive therapies for hypoxemia and for enrolling patients into therapeutic trials.
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Abstract
Acute respiratory distress syndrome (ARDS) occurs in up to 10% of patients with respiratory failure admitted through the emergency department. Use of noninvasive respiratory support has proliferated in recent years; clinicians must understand the relative merits and risks of these technologies and know how to recognize signs of failure. The cornerstone of ARDS care of the mechanically ventilated patient is low-tidal volume ventilation based on ideal body weight. Adjunctive therapies, such as prone positioning and neuromuscular blockade, may have a role in the emergency department management of ARDS depending on patient and department characteristics.
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Affiliation(s)
- Alin Gragossian
- Department of Critical Care Medicine, The Mount Sinai Hospital, New York, NY, USA
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
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Millington SJ, Cardinal P, Brochard L. Setting and Titrating Positive End-Expiratory Pressure. Chest 2022; 161:1566-1575. [DOI: 10.1016/j.chest.2022.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/12/2022] [Accepted: 01/28/2022] [Indexed: 12/16/2022] Open
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Seventeen Years Is Too Long to Move From the ICU to the Emergency Department. Crit Care Med 2022; 50:1032-1034. [PMID: 35612444 DOI: 10.1097/ccm.0000000000005472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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31
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Blondonnet R, Simand LA, Vidal P, Borao L, Bourguignon N, Morand D, Bernard L, Roszyk L, Audard J, Godet T, Monsel A, Garnier M, Quesnel C, Bazin JE, Sapin V, Bastarache JA, Ware LB, Hughes CG, Pandharipande PP, Ely EW, Futier E, Pereira B, Constantin JM, Jabaudon M. Design and Rationale of the Sevoflurane for Sedation in Acute Respiratory Distress Syndrome (SESAR) Randomized Controlled Trial. J Clin Med 2022; 11:2796. [PMID: 35628922 PMCID: PMC9147018 DOI: 10.3390/jcm11102796] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 02/07/2023] Open
Abstract
Preclinical studies have shown that volatile anesthetics may have beneficial effects on injured lungs, and pilot clinical data support improved arterial oxygenation, attenuated inflammation, and decreased lung epithelial injury in patients with acute respiratory distress syndrome (ARDS) receiving inhaled sevoflurane compared to intravenous midazolam. Whether sevoflurane is effective in improving clinical outcomes among patients with ARDS is unknown, and the benefits and risks of inhaled sedation in ARDS require further evaluation. Here, we describe the SESAR (Sevoflurane for Sedation in ARDS) trial designed to address this question. SESAR is a two-arm, investigator-initiated, multicenter, prospective, randomized, stratified, parallel-group clinical trial with blinded outcome assessment designed to test the efficacy of sedation with sevoflurane compared to intravenous propofol in patients with moderate to severe ARDS. The primary outcome is the number of days alive and off the ventilator at 28 days, considering death as a competing event, and the key secondary outcome is 90 day survival. The planned enrollment is 700 adult participants at 37 French academic and non-academic centers. Safety and long-term outcomes will be evaluated, and biomarker measurements will help better understand mechanisms of action. The trial is funded by the French Ministry of Health, the European Society of Anaesthesiology, and Sedana Medical.
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Affiliation(s)
- Raiko Blondonnet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; (R.B.); (L.-A.S.); (P.V.); (L.B.); (N.B.); (D.M.); (J.A.); (T.G.); (J.-E.B.); (E.F.)
- iGReD, Université Clermont Auvergne, CNRS, INSERM, 63000 Clermont-Ferrand, France; (L.R.); (V.S.)
| | - Laure-Anne Simand
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; (R.B.); (L.-A.S.); (P.V.); (L.B.); (N.B.); (D.M.); (J.A.); (T.G.); (J.-E.B.); (E.F.)
| | - Perine Vidal
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; (R.B.); (L.-A.S.); (P.V.); (L.B.); (N.B.); (D.M.); (J.A.); (T.G.); (J.-E.B.); (E.F.)
| | - Lucile Borao
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; (R.B.); (L.-A.S.); (P.V.); (L.B.); (N.B.); (D.M.); (J.A.); (T.G.); (J.-E.B.); (E.F.)
| | - Nathalie Bourguignon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; (R.B.); (L.-A.S.); (P.V.); (L.B.); (N.B.); (D.M.); (J.A.); (T.G.); (J.-E.B.); (E.F.)
| | - Dominique Morand
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; (R.B.); (L.-A.S.); (P.V.); (L.B.); (N.B.); (D.M.); (J.A.); (T.G.); (J.-E.B.); (E.F.)
| | - Lise Bernard
- Department of Clinical Research and Temporary Authorization, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France;
| | - Laurence Roszyk
- iGReD, Université Clermont Auvergne, CNRS, INSERM, 63000 Clermont-Ferrand, France; (L.R.); (V.S.)
- Department of Medical Biochemistry and Molecular Genetics, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Jules Audard
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; (R.B.); (L.-A.S.); (P.V.); (L.B.); (N.B.); (D.M.); (J.A.); (T.G.); (J.-E.B.); (E.F.)
| | - Thomas Godet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; (R.B.); (L.-A.S.); (P.V.); (L.B.); (N.B.); (D.M.); (J.A.); (T.G.); (J.-E.B.); (E.F.)
| | - Antoine Monsel
- Department of Anesthesiology and Critical Care, GRC 29, DMU DREAM, Pitié-Salpêtrière Hospital, Sorbonne University, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France; (A.M.); (J.-M.C.)
| | - Marc Garnier
- Department of Anesthesiology and Critical Care Medicine, DMU DREAM, Saint-Antoine University Hospital, Sorbonne University, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France;
| | - Christophe Quesnel
- Department of Anesthesiology and Critical Care Medicine, DMU DREAM, Tenon University Hospital, Sorbonne University, Assistance Publique-Hôpitaux de Paris, 75020 Paris, France;
| | - Jean-Etienne Bazin
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; (R.B.); (L.-A.S.); (P.V.); (L.B.); (N.B.); (D.M.); (J.A.); (T.G.); (J.-E.B.); (E.F.)
| | - Vincent Sapin
- iGReD, Université Clermont Auvergne, CNRS, INSERM, 63000 Clermont-Ferrand, France; (L.R.); (V.S.)
- Department of Medical Biochemistry and Molecular Genetics, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Julie A. Bastarache
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA; (J.A.B.); (L.B.W.); (E.W.E.)
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN 37232, USA
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA; (J.A.B.); (L.B.W.); (E.W.E.)
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Christopher G. Hughes
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA; (C.G.H.); (P.P.P.)
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN 37203, USA
- Anesthesia Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN 37212, USA
| | - Pratik P. Pandharipande
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA; (C.G.H.); (P.P.P.)
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN 37203, USA
- Anesthesia Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN 37212, USA
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA; (J.A.B.); (L.B.W.); (E.W.E.)
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN 37203, USA
- Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN 37212, USA
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; (R.B.); (L.-A.S.); (P.V.); (L.B.); (N.B.); (D.M.); (J.A.); (T.G.); (J.-E.B.); (E.F.)
- iGReD, Université Clermont Auvergne, CNRS, INSERM, 63000 Clermont-Ferrand, France; (L.R.); (V.S.)
| | - Bruno Pereira
- Biostatistics and Data Management Unit, Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France;
| | - Jean-Michel Constantin
- Department of Anesthesiology and Critical Care, GRC 29, DMU DREAM, Pitié-Salpêtrière Hospital, Sorbonne University, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France; (A.M.); (J.-M.C.)
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; (R.B.); (L.-A.S.); (P.V.); (L.B.); (N.B.); (D.M.); (J.A.); (T.G.); (J.-E.B.); (E.F.)
- iGReD, Université Clermont Auvergne, CNRS, INSERM, 63000 Clermont-Ferrand, France; (L.R.); (V.S.)
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Stocking JC, Drake C, Aldrich JM, Ong MK, Amin A, Marmor RA, Godat L, Cannesson M, Gropper MA, Romano PS, Sandrock C, Bime C, Abraham I, Utter GH. Outcomes and risk factors for delayed-onset postoperative respiratory failure: a multi-center case-control study by the University of California Critical Care Research Collaborative (UC 3RC). BMC Anesthesiol 2022; 22:146. [PMID: 35568812 PMCID: PMC9107656 DOI: 10.1186/s12871-022-01681-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 04/27/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Few interventions are known to reduce the incidence of respiratory failure that occurs following elective surgery (postoperative respiratory failure; PRF). We previously reported risk factors associated with PRF that occurs within the first 5 days after elective surgery (early PRF; E-PRF); however, PRF that occurs six or more days after elective surgery (late PRF; L-PRF) likely represents a different entity. We hypothesized that L-PRF would be associated with worse outcomes and different risk factors than E-PRF. METHODS This was a retrospective matched case-control study of 59,073 consecutive adult patients admitted for elective non-cardiac and non-pulmonary surgical procedures at one of five University of California academic medical centers between October 2012 and September 2015. We identified patients with L-PRF, confirmed by surgeon and intensivist subject matter expert review, and matched them 1:1 to patients who did not develop PRF (No-PRF) based on hospital, age, and surgical procedure. We then analyzed risk factors and outcomes associated with L-PRF compared to E-PRF and No-PRF. RESULTS Among 95 patients with L-PRF, 50.5% were female, 71.6% white, 27.4% Hispanic, and 53.7% Medicare recipients; the median age was 63 years (IQR 56, 70). Compared to 95 matched patients with No-PRF and 319 patients who developed E-PRF, L-PRF was associated with higher morbidity and mortality, longer hospital and intensive care unit length of stay, and increased costs. Compared to No-PRF, factors associated with L-PRF included: preexisiting neurologic disease (OR 4.36, 95% CI 1.81-10.46), anesthesia duration per hour (OR 1.22, 95% CI 1.04-1.44), and maximum intraoperative peak inspiratory pressure per cm H20 (OR 1.14, 95% CI 1.06-1.22). CONCLUSIONS We identified that pre-existing neurologic disease, longer duration of anesthesia, and greater maximum intraoperative peak inspiratory pressures were associated with respiratory failure that developed six or more days after elective surgery in adult patients (L-PRF). Interventions targeting these factors may be worthy of future evaluation.
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Affiliation(s)
- Jacqueline C Stocking
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Davis, 4150 V Street, Suite 3400, Sacramento, CA, 95817, USA.
| | - Christiana Drake
- Department of Statistics, University of California Davis, Davis, CA, USA
| | - J Matthew Aldrich
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Michael K Ong
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Alpesh Amin
- Department of Medicine, University of California Irvine, Irvine, CA, USA
| | - Rebecca A Marmor
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Laura Godat
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael A Gropper
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Patrick S Romano
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Davis, 4150 V Street, Suite 3400, Sacramento, CA, 95817, USA
- Center for Healthcare Policy and Research, University of California Davis, Sacramento, CA, USA
| | - Christian Sandrock
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Davis, 4150 V Street, Suite 3400, Sacramento, CA, 95817, USA
| | - Christian Bime
- College of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Ivo Abraham
- Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ, USA
| | - Garth H Utter
- Center for Healthcare Policy and Research, University of California Davis, Sacramento, CA, USA
- Department of Surgery, Outcomes Research Group, University of California Davis, Sacramento, CA, USA
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Hochberg CH, Psoter KJ, Sahetya SK, Nolley EP, Hossen S, Checkley W, Kerlin MP, Eakin MN, Hager DN. Comparing Prone Positioning Use in COVID-19 Versus Historic Acute Respiratory Distress Syndrome. Crit Care Explor 2022; 4:e0695. [PMID: 35783548 PMCID: PMC9243245 DOI: 10.1097/cce.0000000000000695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Use of prone positioning in patients with acute respiratory distress syndrome (ARDS) from COVID-19 may be greater than in patients treated for ARDS before the pandemic. However, the magnitude of this increase, sources of practice variation, and the extent to which use adheres to guidelines is unknown.
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Nijbroek SGLH, Hol L, Ivanov D, Schultz MJ, Paulus F, Neto AS. Low tidal volume ventilation is associated with mortality in COVID-19 patients-Insights from the PRoVENT-COVID study. J Crit Care 2022; 70:154047. [PMID: 35490503 PMCID: PMC9047696 DOI: 10.1016/j.jcrc.2022.154047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 03/28/2022] [Accepted: 04/17/2022] [Indexed: 12/02/2022]
Abstract
Purpose Low tidal volume ventilation (LTVV) is associated with mortality in patients with acute respiratory distress syndrome. We investigated the association of LTVV with mortality in COVID-19 patients. Methods Secondary analysis of a national observational study in COVID-19 patients in the first wave of the pandemic. We compared COVID-19 patients that received LTVV, defined as controlled ventilation with a median tidal volume ≤ 6 mL/kg predicted body weight over the first 4 calendar days of ventilation, with patients that did not receive LTVV. The primary endpoint was 28-day mortality. In addition, we identified factors associated with use of LTVV. Results Of 903 patients, 294 (32.5%) received LTVV. Disease severity scores and ARDS classification was not different between the two patient groups. The primary endpoint, 28-day mortality, was met in 68 out of 294 patients (23.1%) that received LTVV versus in 193 out of 609 patients (31.7%) that did not receive LTVV (P < 0.001). LTVV was independently associated with 28-day mortality (HR, 0.68 (0.45 to 0.95); P = 0.025). Age, height, the initial tidal volume and continuous muscle paralysis was independently associated with use of LTVV. Conclusions In this cohort of invasively ventilated COVID-19 patients, approximately a third of patients received LTVV. Use of LTVV was independently associated with reduced 28-day mortality. The initial tidal volume and continuous muscle paralysis were potentially modifiable factors associated with use of LTVV. These findings are important as they could help clinicians to recognize patients who are at risk of not receiving LTVV.
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Affiliation(s)
- Sunny G L H Nijbroek
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, the Netherlands.
| | - Liselotte Hol
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Dimitri Ivanov
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, the Netherlands; Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, the Netherlands; ACHIEVE, Centre of Applied Research, Amsterdam University of Applied Sciences, Faculty of Health, Amsterdam, the Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, the Netherlands; Department of Critical Care Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
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Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference? Crit Care Explor 2022; 4:e0632. [PMID: 35156050 PMCID: PMC8826963 DOI: 10.1097/cce.0000000000000632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND: Lung protective ventilation (LPV) is a key component in the management of acute respiratory distress syndrome and other acute respiratory pathology. Initiation of LPV in the emergency department (ED) is associated with improved patient-centered and system outcomes, but adherence to LPV among ED patients is low. The impact of an ED-based ICU (ED-ICU) on LPV adherence is not known. METHODS: This single-center, retrospective, cohort study analyzed rates of adherence to a multifaceted LPV strategy pre- and post-implementation of an ED-ICU. LPV strategy components included low tidal volume ventilation, avoidance of severe hyperoxia and high plateau pressures, and positive end-expiratory pressure settings in alignment with best-evidence recommendations. The primary outcome was adherence to the LPV strategy at time of ED departure. RESULTS AND CONCLUSIONS: A total of 561 ED visits were included in the analysis, of which 60.0% received some portion of their emergency care in the ED-ICU. Adherence to the LPV strategy was statistically significantly higher in the ED-ICU cohort compared with the pre-ED-ICU cohort (65.8% vs 41.4%; p < 0.001) and non-ED-ICU cohort (65.8% vs 43.1%; p < 0.001). Among the ED-ICU cohort, 92.8% of patients received low tidal volume ventilation. Care in the ED-ICU was also associated with shorter ICU and hospital length of stay. These findings suggest improved patient and resource utilization outcomes for mechanically ventilated ED patients receiving care in an ED-ICU.
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Some Patients Are More Equal Than Others: Variation in Ventilator Settings for Coronavirus Disease 2019 Acute Respiratory Distress Syndrome. Crit Care Explor 2021; 3:e0555. [PMID: 34671747 PMCID: PMC8522869 DOI: 10.1097/cce.0000000000000555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Supplemental Digital Content is available in the text. As coronavirus disease 2019 is a novel disease, treatment strategies continue to be debated. This provides the intensive care community with a unique opportunity as the population of coronavirus disease 2019 patients requiring invasive mechanical ventilation is relatively homogeneous compared with other ICU populations. We hypothesize that the novelty of coronavirus disease 2019 and the uncertainty over its similarity with noncoronavirus disease 2019 acute respiratory distress syndrome resulted in substantial practice variation between hospitals during the first and second waves of coronavirus disease 2019 patients.
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The Severe ARDS Generating Evidence (SAGE) Study: A Call for Action in the Daily Clinical Practice. Chest 2021; 160:1167-1168. [PMID: 34625163 PMCID: PMC8490917 DOI: 10.1016/j.chest.2021.07.2158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 11/21/2022] Open
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Gershengorn HB. Editorial: Critical care outcomes in the context of a pandemic. Curr Opin Crit Care 2021; 27:497-499. [PMID: 34334625 DOI: 10.1097/mcc.0000000000000864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
- Division of Critical Care Medicine, Albert Einstein College of Medicine, New York, New York, USA
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Affiliation(s)
- Nida Qadir
- David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Room 43-229 CHS, Los Angeles, CA 90095, USA.
| | - Steven Y Chang
- David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Room 43-229 CHS, Los Angeles, CA 90095, USA
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Mireles-Cabodevila E, Duggal A, Krishnan S. The First Day in ARDS Care: Your First Steps Should Be Your Best. Respir Care 2021; 66:1498-1500. [PMID: 34408084 PMCID: PMC9993872 DOI: 10.4187/respcare.09495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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