1
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Drummond D, Roy C, Cornet M, Bucher J, Boussaud V, Pimpec-Barthes FL, Pontailler M, Raisky O, Lopez V, Barbanti C, Guillemain R, Renolleau S, Grimaud M, Oualha M, de Saint Blanquat L, Sermet-Gaudelus I. Acute respiratory failure due to pulmonary exacerbation in children with cystic fibrosis admitted in a pediatric intensive care unit: outcomes and factors associated with mortality. Respir Res 2024; 25:190. [PMID: 38685088 PMCID: PMC11059703 DOI: 10.1186/s12931-024-02778-2] [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: 01/18/2024] [Accepted: 03/15/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Children with advanced pulmonary disease due to cystic fibrosis (CF) are at risk of acute respiratory failure due to pulmonary exacerbations leading to their admission to pediatric intensive care units (PICU). The objectives of this study were to determine short and medium-term outcomes of children with CF admitted to PICU for acute respiratory failure due to pulmonary exacerbation and to identify prognosis factors. METHODS This retrospective monocentric study included patients less than 18 years old admitted to the PICU of a French university hospital between 2000 and 2020. Cox proportional hazard regression methods were used to determine prognosis factors of mortality or lung transplant. RESULTS Prior to PICU admission, the 29 patients included (median age 13.5 years) had a severe lung disease (median Forced Expiratory Volume in 1 s percentage predicted at 29%). Mortality rates were respectively 17%, 31%, 34%, 41% at discharge and at 3, 12 and 36 months post-discharge. Survival rates free of lung transplant were 34%, 32%, 24% and 17% respectively. Risk factors associated with mortality or lung transplant using the univariate analysis were female sex and higher pCO2 and chloride levels at PICU admission, and following pre admission characteristics: home respiratory and nutritional support, registration on lung transplant list and Stenotrophomonas Maltophilia bronchial colonization. CONCLUSION Children with CF admitted to PICU for acute respiratory failure secondary to pulmonary exacerbations are at high risk of death, both in the short and medium terms. Lung transplant is their main chance of survival and should be considered early.
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Affiliation(s)
- David Drummond
- Unité de Transplantation Pulmonaire Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Centre Maladies rares Mucoviscidose et maladies apparentées, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Charlotte Roy
- Unité de Transplantation Pulmonaire Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Centre Maladies rares Mucoviscidose et maladies apparentées, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Matthieu Cornet
- Institut Necker Enfants Malades, INSERM U1151, CNRS, Université de Paris, Paris, France
- CBIO-Centre de BioInformatique. Ecole des Mines, Paris, France
| | - Julie Bucher
- Centre Maladies rares Mucoviscidose et maladies apparentées, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Service de réanimation médico-chirurgicale pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Véronique Boussaud
- Hôpital Européen George Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
| | | | - Margaux Pontailler
- Unité de Transplantation Pulmonaire Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Service de chirurgie thoracique et cardio-vasculaire pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Olivier Raisky
- Unité de Transplantation Pulmonaire Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Service de chirurgie thoracique et cardio-vasculaire pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Vanessa Lopez
- Unité de Transplantation Pulmonaire Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Service d'anesthésie et réanimation pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Claudio Barbanti
- Unité de Transplantation Pulmonaire Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Service d'anesthésie et réanimation pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Romain Guillemain
- Hôpital Européen George Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Sylvain Renolleau
- Service de réanimation médico-chirurgicale pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Marion Grimaud
- Unité de Transplantation Pulmonaire Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Service de réanimation médico-chirurgicale pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Mehdi Oualha
- Unité de Transplantation Pulmonaire Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Service de réanimation médico-chirurgicale pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Laure de Saint Blanquat
- Unité de Transplantation Pulmonaire Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Service de réanimation médico-chirurgicale pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Isabelle Sermet-Gaudelus
- Unité de Transplantation Pulmonaire Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France.
- Centre Maladies rares Mucoviscidose et maladies apparentées, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France.
- Institut Necker Enfants Malades, INSERM U1151, CNRS, Université de Paris, Paris, France.
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Gao P, Li C, Wu J, Zhang P, Liu X, Li Y, Ding J, Su Y, Zhu Y, He W, Ning Y, Chen C. Establishment of a risk prediction model for prolonged mechanical ventilation after lung transplantation: a retrospective cohort study. BMC Pulm Med 2023; 23:11. [PMID: 36627599 PMCID: PMC9832679 DOI: 10.1186/s12890-023-02307-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/03/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Prolonged mechanical ventilation (PMV), mostly defined as mechanical ventilation > 72 h after lung transplantation with or without tracheostomy, is associated with increased mortality. Nevertheless, the predictive factors of PMV after lung transplant remain unclear. The present study aimed to develop a novel scoring system to identify PMV after lung transplantation. METHODS A total of 141 patients who underwent lung transplantation were investigated in this study. The patients were divided into PMV and non-prolonged ventilation (NPMV) groups. Univariate and multivariate logistic regression analyses were performed to assess factors associated with PMV. A risk nomogram was then established based on the multivariate analysis, and model performance was further examined regarding its calibration, discrimination, and clinical usefulness. RESULTS Eight factors were finally identified to be significantly associated with PMV by the multivariate analysis and therefore were included as risk factors in the nomogram as follows: the body mass index (BMI, P = 0.036); primary diagnosis as idiopathic pulmonary fibrosis (IPF, P = 0.038); pulmonary hypertension (PAH, P = 0.034); primary graft dysfunction grading (PGD, P = 0.011) at T0; cold ischemia time (CIT P = 0.012); and three ventilation parameters (peak inspiratory pressure [PIP, P < 0.001], dynamic compliance [Cdyn, P = 0.001], and P/F ratio [P = 0.015]) at T0. The nomogram exhibited superior discrimination ability with an area under the curve of 0.895. Furthermore, both calibration curve and decision-curve analysis indicated satisfactory performance. CONCLUSION A novel nomogram to predict individual risk of receiving PMV for patients after lung transplantation was established, which may guide preventative measures for tackling this adverse event.
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Affiliation(s)
- Peigen Gao
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200443 China ,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Chongwu Li
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200443 China ,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Junqi Wu
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200443 China ,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Pei Zhang
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200443 China ,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Xiucheng Liu
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200443 China ,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Yuping Li
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200443 China ,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Junrong Ding
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200443 China ,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Yiliang Su
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200443 China ,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Yuming Zhu
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200443 China ,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Wenxin He
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200443 China ,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Ye Ning
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200443 China ,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
| | - Chang Chen
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Shanghai, 200443 China ,Shanghai Engineering Research Center of Lung Transplantation, Shanghai, China
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Gibilaro JM, Keating C, Benvenuto L, Kramer A, Privorotskiy A, Zheng Y, Leu CS, DiMango E. Survival in cystic fibrosis after acute respiratory failure supported by extracorporeal membrane oxygenation and/or invasive mechanical ventilation. J Cyst Fibros 2021; 21:669-674. [PMID: 34479809 DOI: 10.1016/j.jcf.2021.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/17/2021] [Accepted: 08/22/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Despite therapeutic advances, people with cystic fibrosis (CF) develop progressive worsening and exacerbations of their lung disease, which can lead to acute respiratory failure. Historically, survival after mechanical ventilation (MV) has been poor. Outcomes related to use of extracorporeal membrane oxygenation (ECMO) have not been well described in CF. METHODS We conducted a retrospective analysis of adult patients with CF admitted to the ICU for acute respiratory failure and requiring invasive MV with or without ECMO between July 1, 2006 and June 30, 2016. Separate analysis for the subgroup of MV patients who were eligible for transplant was conducted. RESULTS Mortality for all patients with respiratory failure requiring advanced support was 37%. Ten of 28 (36%) MV patients, 10 of 26 (38%) ECMO+MV patients and 7 of the 21 (33%) transplant eligible MV patients died. Intensive care unit (ICU) length of stay (LOS) was 24.5±16.6 days for ECMO+MV; 12.9±9.0 days for MV (p=0.001), and 12.3 ±10 days for transplant eligible MV patients (p=0.005 for ECMO+MV comparison). Seven transplant eligible MV patients (33%) and 16 ECMO+MV patients (62%) underwent lung transplantation (p<0.001) during the hospital admission. One and 2-year survival for individuals who survived ICU admission was similar regardless of mode of support. Cox-proportional hazards model did not yield any variables that significantly influenced ICU mortality, 1-year or 2-year mortality. CONCLUSION Survival for CF patients with acute respiratory failure requiring MV with or without ECMO has improved over time. ECMO may be an appropriate modality for respiratory support in patients with CF and acute respiratory failure who have greater risk of death from MV alone.
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Affiliation(s)
| | - Claire Keating
- Columbia University Irving Medical Center, New York, NY, USA.
| | - Luke Benvenuto
- Columbia University Irving Medical Center, New York, NY, USA.
| | - Amanda Kramer
- Columbia University Irving Medical Center, New York, NY, USA.
| | | | - Yuan Zheng
- Columbia University Mailman School of Public Health, New York, NY, USA.
| | - Cheng-Shiun Leu
- Columbia University Mailman School of Public Health, New York, NY, USA.
| | - Emily DiMango
- Columbia University Irving Medical Center, New York, NY, USA.
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4
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Abstract
OBJECTIVES Data on outcomes of children with cystic fibrosis admitted to PICUs are limited and outdated. Prior studies cite PICU mortality rates ranging from 37.5% to 100%. Given the advances made in cystic fibrosis care, we expect outcomes for these patients to have changed significantly since last studied. We provide an updated report on PICU mortality and the factors associated with death among critically ill children with cystic fibrosis. DESIGN Retrospective multicenter cohort analysis utilizing data from the Virtual Pediatric Systems database. SETTING Data were collected from 135 PICUs from January 1, 2009, to June 20, 2018. PATIENTS One-thousand six-hundred thirty-three children with cystic fibrosis accounting for 2,893 PICU admissions were studied. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was mortality during PICU admission. Predictors included demographics, anthropometrics, diagnoses, clinical characteristics, and critical care interventions. Odds ratios of mortality were calculated in univariate and multivariable analyses to assess differences in mortality associated with predictor variables. Generalized estimating equation models were used to account for multiple admissions per patient. The overall PICU mortality rate was 6.6%. Factors associated with increased odds of mortality included hemoptysis/pulmonary hemorrhage, pneumothorax, gastrointestinal bleeding, bacterial/fungal infections, lower body mass index/malnutrition, and need for noninvasive or invasive respiratory support. Intubation/mechanical ventilation occurred in 26.4% of the 2,893 admissions and was associated with a 19.1% mortality rate. Of the nonsurvivors, 20.7% died without receiving mechanical ventilation. CONCLUSIONS The mortality rate during PICU admissions for patients with cystic fibrosis is lower than has been reported in prior studies, both in the overall cohort and in the subset requiring invasive mechanical ventilation. These data provide updated insight into the prognosis for cystic fibrosis patients requiring critical care.
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5
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Mortality in Adults with Cystic Fibrosis Requiring Mechanical Ventilation. Cross-Sectional Analysis of Nationwide Events. Ann Am Thorac Soc 2020; 16:1017-1023. [PMID: 31026405 DOI: 10.1513/annalsats.201804-268oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Rationale: Survival in patients with cystic fibrosis (CF) is improving over time. Traditionally, there has been concern about high mortality in individuals with CF requiring invasive mechanical ventilation (IMV) for respiratory failure.Objectives: We hypothesized that mortality has decreased over time in this population because of improvements in disease-specific therapies.Methods: The U.S. Nationwide Healthcare Cost and Utilization Project database was used to identify adult patients with CF undergoing IMV between 2002 and 2014. Patients with nonurgent/nonemergent admissions, pregnancy, and encounters related to lung transplantation were excluded. Demographic, geographic, and comorbidities were analyzed. The Cochran-Armitage trend test was used to examine trends in mortality over time. Multivariate mixed effects logistic regression was used to account for possible differences in hospital mortality patterns.Results: We identified 58,799 CF admissions from 2002 to 2014, with 3,727 (6.3%) undergoing IMV. After exclusions, 1,711 admissions remained. In 762 (44.5%) of adult hospitalizations, the patient died. Annual mortality per hospitalization ranged from 29.9 to 55.3%. The Cochran-Armitage trend test suggested an increased probability of survival over time. Factors significantly associated with mortality in multivariate analysis included female sex (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.14-2.09), acute renal failure (OR, 1.99; 95% CI, 1.32-3.01), and malnutrition (OR, 1.44; 95% CI, 1.01-2.06). IMV greater than 96 hours was associated with increased mortality in univariate analysis (OR, 1.51; 95% CI, 1.14-1.98); however, after adjustment for potential confounders, the association was no longer statistically significant (OR, 1.05; 95% CI, 0.77-1.43).Conclusions: Mortality per hospitalization in adults with CF who are not bridging to lung transplant and require emergent IMV is 44.5%, suggesting IMV is not futile. Furthermore, mortality decreased over the study period. These finding may help providers, families, and patients with CF weigh the risks and benefits of IMV for respiratory failure.
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6
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Kapnadak SG, Dimango E, Hadjiliadis D, Hempstead SE, Tallarico E, Pilewski JM, Faro A, Albright J, Benden C, Blair S, Dellon EP, Gochenour D, Michelson P, Moshiree B, Neuringer I, Riedy C, Schindler T, Singer LG, Young D, Vignola L, Zukosky J, Simon RH. Cystic Fibrosis Foundation consensus guidelines for the care of individuals with advanced cystic fibrosis lung disease. J Cyst Fibros 2020; 19:344-354. [DOI: 10.1016/j.jcf.2020.02.015] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 02/14/2020] [Accepted: 02/19/2020] [Indexed: 12/25/2022]
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7
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Chaparro C, Keshavjee S. Lung transplantation for cystic fibrosis: an update. Expert Rev Respir Med 2016; 10:1269-1280. [DOI: 10.1080/17476348.2016.1261016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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8
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9
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Davidson AC, Banham S, Elliott M, Kennedy D, Gelder C, Glossop A, Church AC, Creagh-Brown B, Dodd JW, Felton T, Foëx B, Mansfield L, McDonnell L, Parker R, Patterson CM, Sovani M, Thomas L. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax 2016; 71 Suppl 2:ii1-35. [DOI: 10.1136/thoraxjnl-2015-208209] [Citation(s) in RCA: 195] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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10
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Lynch JP, Sayah DM, Belperio JA, Weigt SS. Lung transplantation for cystic fibrosis: results, indications, complications, and controversies. Semin Respir Crit Care Med 2015; 36:299-320. [PMID: 25826595 DOI: 10.1055/s-0035-1547347] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Survival in patients with cystic fibrosis (CF) has improved dramatically over the past 30 to 40 years, with mean survival now approximately 40 years. Nonetheless, progressive respiratory insufficiency remains the major cause of mortality in CF patients, and lung transplantation (LT) is eventually required. Timing of listing for LT is critical, because up to 25 to 41% of CF patients have died while awaiting LT. Globally, approximately 16.4% of lung transplants are performed in adults with CF. Survival rates for LT recipients with CF are superior to other indications, yet LT is associated with substantial morbidity and mortality (∼50% at 5-year survival rates). Myriad complications of LT include allograft failure (acute or chronic), opportunistic infections, and complications of chronic immunosuppressive medications (including malignancy). Determining which patients are candidates for LT is difficult, and survival benefit remains uncertain. In this review, we discuss when LT should be considered, criteria for identifying candidates, contraindications to LT, results post-LT, and specific complications that may be associated with LT. Infectious complications that may complicate CF (particularly Burkholderia cepacia spp., opportunistic fungi, and nontuberculous mycobacteria) are discussed.
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David M Sayah
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S Sam Weigt
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
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Palma JA, Norcliffe-Kaufmann L, Fuente-Mora C, Percival L, Mendoza-Santiesteban C, Kaufmann H. Current treatments in familial dysautonomia. Expert Opin Pharmacother 2014; 15:2653-71. [PMID: 25323828 PMCID: PMC4236240 DOI: 10.1517/14656566.2014.970530] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Familial dysautonomia (FD) is a rare hereditary sensory and autonomic neuropathy (type III). The disease is caused by a point mutation in the IKBKAP gene that affects the splicing of the elongator-1 protein (ELP-1) (also known as IKAP). Patients have dramatic blood pressure instability due to baroreflex failure, chronic kidney disease, and impaired swallowing leading to recurrent aspiration pneumonia, which results in chronic lung disease. Diminished pain and temperature perception result in neuropathic joints and thermal injuries. Impaired proprioception leads to gait ataxia. Optic neuropathy and corneal opacities lead to progressive visual loss. AREAS COVERED This article reviews current therapeutic strategies for the symptomatic treatment of FD, as well as the potential of new gene-modifying agents. EXPERT OPINION Therapeutic focus on FD is centered on reducing the catecholamine surges caused by baroreflex failure. Managing neurogenic dysphagia with effective protection of the airway passages and prompt treatment of aspiration pneumonias is necessary to prevent respiratory failure. Sedative medications should be used cautiously due to the risk of respiratory depression. Non-invasive ventilation during sleep effectively manages apneas and prevents hypercapnia. Clinical trials of compounds that increase levels of IKAP (ELP-1) are underway and will determine whether they can reverse or slow disease progression.
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Affiliation(s)
- Jose-Alberto Palma
- New York University School of Medicine, Dysautonomia Center, Department of Neurology , 530 First Avenue, Suite 9Q New York, NY 10016 , USA +1 212 263 7225 ;
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12
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Abstract
Over the course of a career most physicians will manage only a handful of children through End Stage Lung Disease. Nonetheless, the approach of the physician to this challenge will have a profound impact on the children and families they encounter. Managing the end of life well can bring personal growth and professional satisfaction. In this review we highlight aspects of the Palliative Care approach and its integration with restorative and life-prolonging care. We review the role of active treatment, respiratory support, symptom management and psychosocial aspects of the management of End Stage Lung Disease.
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13
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Moreno Galdó A, Solé Montserrat J, Roman Broto A. Trasplante pulmonar en niños. Aspectos específicos. Arch Bronconeumol 2013; 49:523-8. [DOI: 10.1016/j.arbres.2013.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 09/24/2013] [Accepted: 09/26/2013] [Indexed: 11/28/2022]
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14
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Cheifetz IM. Extracorporeal membrane oxygenation of the future: smaller, simpler, and mobile. Pediatr Transplant 2013; 17:202-4. [PMID: 23601043 DOI: 10.1111/petr.12071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Pelluau S, Oualha M, Souilamas R, Hubert PH. [Respiratory failure in cystic fibrosis: management in pediatric intensive care unit, lung transplantation recommendation]. Arch Pediatr 2012; 19 Suppl 1:S40-3. [PMID: 22682491 DOI: 10.1016/s0929-693x(12)71109-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Admission to the ICU for respiratory failure of a child with cystic fibrosis is a telltale sign of the severity of the disease. Bronchopulmonary exacerbation, pneumothorax and hemoptysis are the primary causes, for which respiratory assistance is indispensable in these life-threatening situations. Non-invasive ventilation (NIV) has enabled significant progress in improving patient survival. The modalities of NIV must be tailored to both the patient and the cause of respiratory failure. Invasive ventilation, on the other hand, should be a treatment of last resort, because often associated with high mortality. It must be adapted to the therapeutic strategy involving an impending transplantation, including in critical situations where placement on a high emergency list is a possibility. Since admission to ICU is at times the reflection of the terminal evolution of the disease, ongoing treatment must hence be adapted to the comfort of the child.
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Affiliation(s)
- S Pelluau
- Service de réanimation pédiatrique et néonatale, Hôpital des Enfants, 330 avenue de Grande-Bretagne, 31026 Toulouse cedex 3, France.
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16
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Reeb J, Falcoz PE, Santelmo N, Massard G. Double lumen bi-cava cannula for veno-venous extracorporeal membrane oxygenation as bridge to lung transplantation in non-intubated patient. Interact Cardiovasc Thorac Surg 2011; 14:125-7. [PMID: 22108944 DOI: 10.1093/icvts/ivr046] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is used for refractory respiratory failure. Normally, ECMO is implanted in intubated patients as a last resort. We report the case of a non-intubated patient who benefited from veno-venous (VV) ECMO. A 35-year old cystic fibrosis man presented a severe respiratory decompensation with refractory hypercapnia. We opted for an ECMO instead of mechanical ventilation (MV). We implanted a double lumen bi-cava cannula (DLC) (Avalon Elite(TM)) in the right jugular vein. Before ECMO implantation, the patient presented refractory respiratory failure (pH = 7.1, PaO(2) = 83 mmHg, PaCO(2 )= 103 mmHg). We proposed that the patient be placed on the high emergency lung transplantation waiting list after failure to wean him from ECMO. This registration was effective 10 days after ECMO implantation. The patient was grafted the next day. Under ECMO, mean PaO(2), PaCO(2) and TCA were 80.6 ± 14.2, 53.8 ± 6.4 mmHg and 56.2 ± 9.7 s, respectively. The patient could eat, drink, talk and practice chest physiotherapy. The evolution was uneventful under ECMO. Weaning from ECMO was done in the operating theatre after transplantation. VV ECMO with DLC is safe and feasible in non-intubated patients. It avoids potential complications of MV, and allows respiratory assistance as bridge to transplantation.
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Affiliation(s)
- Jérémie Reeb
- Department of Thoracic Surgery, Lung Transplantation Team, Nouvel Hôpital Civil, University Hospital, Strasbourg, France
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Sheikh HS, Tiangco ND, Harrell C, Vender RL. Severe hypercapnia in critically ill adult cystic fibrosis patients. J Clin Med Res 2011; 3:209-12. [PMID: 22383907 PMCID: PMC3279481 DOI: 10.4021/jocmr612w] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2011] [Indexed: 01/27/2023] Open
Abstract
Background Cystic fibrosis (CF) is a monogenetic autosomal recessive multi-organ disease affecting approximately 50,000 patients worldwide. Overall median survival is continually increasing but pulmonary disease remains the most common cause of death. Guidelines have been published in relation to the outpatient maintenance of lung health for CF patients and treatment of acute lung exacerbations but little information exists about the management of the critically ill CF patient. Invasive mechanical ventilation in CF patients with acute respiratory failure is associated with poor outcome and high mortality. Methods Retrospective analysis of adult patients with CF who required endotracheal intubation and invasive mechanical ventilation in the Medical Intensive Care Unit (MICU). Results Between the years 2003 - 2009, 14 adult patients with CF required endotracheal intubation and invasive mechanical ventilation in the Medical Intensive Care Unit (MICU) of the Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA. Eleven patients died in the MICU because of progressive respiratory failure and inability to liberate from mechanical ventilation. Seven individuals consistently manifested arterial partial pressures of carbon dioxide (PaCO2) greater than 20.00 kPa despite high levels of conventional modes of mechanical ventilation. Conclusion Intubated CF patients with respiratory failure have a high mortality rate. Based on our experience, multiple factors contribute to severe hypercapnia and the effectiveness of conventional modes of mechanical ventilation in many of these patients is limited. Keywords Cystic fibrosis; Mechanical ventilation; Critical care; Hypercapnia; Respiratory failure
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Affiliation(s)
- Hassan S Sheikh
- Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA
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