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Liu X, Liu X, Meng J, Liu D, Huang Y, Sang L, Xu Y, Xu Z, He W, Chen S, Zhang R, Liu X, Li Y. Electrical impedance tomography for titration of positive end-expiratory pressure in acute respiratory distress syndrome patients with chronic obstructive pulmonary disease. Crit Care 2022; 26:339. [PMCID: PMC9635124 DOI: 10.1186/s13054-022-04201-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is one of most common comorbidities in acute respiratory distress syndrome (ARDS). There are few specific studies on the appropriate ventilation strategy for patients with ARDS comorbid with COPD, especially regarding on positive end-expiratory pressure (PEEP) titration. Methods To compare the respiratory mechanics in mechanical ventilated ARDS patients with or without COPD and to determine whether titration of PEEP based on electrical impedance tomography (EIT) is superior to the ARDSnet protocol. This is a single center, perspective, repeated measure study. ARDS patients requiring mechanical ventilation who were admitted to the intensive care unit between August 2017 and December 2020 were included. ARDS patients were divided according to whether they had COPD into a COPD group and a non-COPD group. Respiratory mechanics, gas exchange, and hemodynamics during ventilation were compared between the groups according to whether the PEEP level was titrated by EIT or the ARDSnet protocol. Results A total of twenty-seven ARDS patients including 14 comorbid with and 13 without COPD who met the study eligibility criteria were recruited. The PEEP levels titrated by EIT and the ARDSnet protocol were lower in the COPD group than in the non-COPD group (6.93 ± 1.69 cm H2O vs. 12.15 ± 2.40 cm H2O, P < 0.001 and 10.43 ± 1.20 cm H2O vs. 14.0 ± 3.0 cm H2O, P < 0.001, respectively). In the COPD group, the PEEP level titrated by EIT was lower than that titrated by the ARDSnet protocol (6.93 ± 1.69 cm H2O vs. 10.43 ± 1.20 cm H2O, P < 0.001), as was the global inhomogeneity (GI) index (0.397 ± 0.040 vs. 0.446 ± 0.052, P = 0.001), plateau airway pressure (16.50 ± 4.35 cm H2O vs. 20.93 ± 5.37 cm H2O, P = 0.001), dead space ventilation ratio (48.29 ± 6.78% vs. 55.14 ± 8.85%, P < 0.001), ventilation ratio (1.63 ± 0.33 vs. 1.87 ± 0.33, P < 0.001), and mechanical power (13.92 ± 2.18 J/min vs. 15.87 ± 2.53 J/min, P < 0.001). The cardiac index was higher when PEEP was treated by EIT than when it was titrated by the ARDSnet protocol (3.41 ± 0.50 L/min/m2 vs. 3.02 ± 0.43 L/min/m2, P < 0.001), as was oxygen delivery (466.40 ± 71.08 mL/min/m2 vs. 411.10 ± 69.71 mL/min/m2, P = 0.001). Conclusion Titrated PEEP levels were lower in patients with ARDS with COPD than in ARDS patients without COPD. In ARDS patient comorbid with COPD, application of PEEP titrated by EIT was lower than those titrated by the ARDSnet protocol, which contributed to improvements in the ventilation ratio, mechanical energy, cardiac index, and oxygen delivery with less of an adverse impact on hemodynamics. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04201-y.
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Affiliation(s)
- Xuesong Liu
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Xiao Liu
- Department of Critical Care Medicine, Huadu District People’s Hospital, Guangzhou, 510800 China
| | - Jue Meng
- grid.79703.3a0000 0004 1764 3838Department of Respiratory Medicine, Nanhai District People’s Hospital and Sixth Affiliated Hospital of South China University of Technology, Foshan, 528200 Guangdong China
| | - Dongdong Liu
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Yongbo Huang
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Ling Sang
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Yonghao Xu
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Zhiheng Xu
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Weiqun He
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Sibei Chen
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Rong Zhang
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Xiaoqing Liu
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Yimin Li
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
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Parissopoulos S, Mpouzika MDA, Timmins F. Optimal support techniques when providing mechanical ventilation to patients with acute respiratory distress syndrome. Nurs Crit Care 2015; 22:40-51. [PMID: 26493043 DOI: 10.1111/nicc.12205] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 07/17/2015] [Accepted: 07/27/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Adult respiratory distress syndrome (ARDS) is a type of acute diffuse lung injury characterized by severe inflammation, increased pulmonary vascular permeability and a loss of aerated lung tissue. The effects of high fraction of inspired oxygen (FiO2 ) include oxygen toxicity manifested by damage to the lung parenchyma in the acute phase of lung injury. There is still a high mortality rate among this group of patients, so clinically sensitive evidence-based interventions are paramount to maximize survival chances during critical care. AIMS AND OBJECTIVES The aim of this article is to explore the current opinion concerning optimal mechanical ventilation support techniques for patients with acute respiratory distress syndrome. SEARCH STRATEGY, INCLUSION AND EXCLUSION CRITERIA A literature search of clinical trials and observation studies, reviews, discussion papers, meta-analyses and clinical guidelines written in English up to 2015, derived from the databases of Scopus, CINAHL, Cochrane Library databases and PubMed was conducted. CONCLUSIONS Low tidal volume, pressure limitation and prone positioning in severe ARDS patients appear to be of some benefit. More research is required and further development and use of standardized protocols is an important strategy for reducing practice variations across disciplines, as well as giving clear guidelines to nurses practising in critical care. There is also evidence that this syndrome is under-diagnosed and the utilization of lung protective ventilation is still variable. RELEVANCE TO CLINICAL PRACTICE It is important that nurses have underlying knowledge of both aetiology of ARDS and ventilation management, and that they monitor patients very closely. The adoption of a low tidal ventilation protocol, which is based on quality evidence guidelines, the value of rescue therapies and patient observation practices in the overall patient management, and the need to place emphasis on long-term patient outcomes, all these emerge as key factors for consideration and future research. However, there is also a need for more research that would explore the unique contribution of nurses in the management of this patient group, as it is difficult to discern this in the current literature.
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Affiliation(s)
- Stelios Parissopoulos
- Department of Nursing, Technological Educational Institute (T.E.I.) of Athens, Egaleo, Greece
| | | | - Fiona Timmins
- School of Nursing and Midwifery, Trinity College, Dublin, Ireland
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Mondrinos MJ, Knight LC, Kennedy PA, Wu J, Kauffman M, Baker ST, Wolfson MR, Kilpatrick LE. Biodistribution and Efficacy of Targeted Pulmonary Delivery of a Protein Kinase C-δ Inhibitory Peptide: Impact on Indirect Lung Injury. J Pharmacol Exp Ther 2015; 355:86-98. [PMID: 26243739 DOI: 10.1124/jpet.115.224832] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 08/03/2015] [Indexed: 11/22/2022] Open
Abstract
Sepsis and sepsis-induced lung injury remain a leading cause of death in intensive care units. We identified protein kinase C-δ (PKCδ) as a critical regulator of the acute inflammatory response and demonstrated that PKCδ inhibition was lung-protective in a rodent sepsis model, suggesting that targeting PKCδ is a potential strategy for preserving pulmonary function in the setting of indirect lung injury. In this study, whole-body organ biodistribution and pulmonary cellular distribution of a transactivator of transcription (TAT)-conjugated PKCδ inhibitory peptide (PKCδ-TAT) was determined following intratracheal (IT) delivery in control and septic [cecal ligation and puncture (CLP)] rats to ascertain the impact of disease pathology on biodistribution and efficacy. There was negligible lung uptake of radiolabeled peptide upon intravenous delivery [<1% initial dose (ID)], whereas IT administration resulted in lung retention of >65% ID with minimal uptake in liver or kidney (<2% ID). IT delivery of a fluorescent-tagged (tetramethylrhodamine-PKCδ-TAT) peptide demonstrated uniform spatial distribution and cellular uptake throughout the peripheral lung. IT delivery of PKCδ-TAT at the time of CLP surgery significantly reduced PKCδ activation (tyrosine phosphorylation, nuclear translocation and cleavage) and acute lung inflammation, resulting in improved lung function and gas exchange. Importantly, peptide efficacy was similar when delivered at 4 hours post-CLP, demonstrating therapeutic relevance. Conversely, spatial lung distribution and efficacy were significantly impaired at 8 hours post-CLP, which corresponded to marked histopathological progression of lung injury. These studies establish a functional connection between peptide spatial distribution, inflammatory histopathology in the lung, and efficacy of this anti-inflammatory peptide.
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Affiliation(s)
- Mark J Mondrinos
- Center for Inflammation, Clinical and Translational Lung Research (M.J.M., P.A.K., J.W., M.K., S.T.B., M.R.W., L.E.K.), Department of Physiology (M.J.M., P.A.K., J.W., S.T.B., M.R.W., L.E.K.), Sol Sherry Thrombosis Research Center (M.J.M., L.C.K., L.E.K.), Departments of Pediatrics and Medicine (M.R.W.), and Department of Radiology (L.C.K.), Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Linda C Knight
- Center for Inflammation, Clinical and Translational Lung Research (M.J.M., P.A.K., J.W., M.K., S.T.B., M.R.W., L.E.K.), Department of Physiology (M.J.M., P.A.K., J.W., S.T.B., M.R.W., L.E.K.), Sol Sherry Thrombosis Research Center (M.J.M., L.C.K., L.E.K.), Departments of Pediatrics and Medicine (M.R.W.), and Department of Radiology (L.C.K.), Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Paul A Kennedy
- Center for Inflammation, Clinical and Translational Lung Research (M.J.M., P.A.K., J.W., M.K., S.T.B., M.R.W., L.E.K.), Department of Physiology (M.J.M., P.A.K., J.W., S.T.B., M.R.W., L.E.K.), Sol Sherry Thrombosis Research Center (M.J.M., L.C.K., L.E.K.), Departments of Pediatrics and Medicine (M.R.W.), and Department of Radiology (L.C.K.), Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Jichuan Wu
- Center for Inflammation, Clinical and Translational Lung Research (M.J.M., P.A.K., J.W., M.K., S.T.B., M.R.W., L.E.K.), Department of Physiology (M.J.M., P.A.K., J.W., S.T.B., M.R.W., L.E.K.), Sol Sherry Thrombosis Research Center (M.J.M., L.C.K., L.E.K.), Departments of Pediatrics and Medicine (M.R.W.), and Department of Radiology (L.C.K.), Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Matthew Kauffman
- Center for Inflammation, Clinical and Translational Lung Research (M.J.M., P.A.K., J.W., M.K., S.T.B., M.R.W., L.E.K.), Department of Physiology (M.J.M., P.A.K., J.W., S.T.B., M.R.W., L.E.K.), Sol Sherry Thrombosis Research Center (M.J.M., L.C.K., L.E.K.), Departments of Pediatrics and Medicine (M.R.W.), and Department of Radiology (L.C.K.), Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Sandy T Baker
- Center for Inflammation, Clinical and Translational Lung Research (M.J.M., P.A.K., J.W., M.K., S.T.B., M.R.W., L.E.K.), Department of Physiology (M.J.M., P.A.K., J.W., S.T.B., M.R.W., L.E.K.), Sol Sherry Thrombosis Research Center (M.J.M., L.C.K., L.E.K.), Departments of Pediatrics and Medicine (M.R.W.), and Department of Radiology (L.C.K.), Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Marla R Wolfson
- Center for Inflammation, Clinical and Translational Lung Research (M.J.M., P.A.K., J.W., M.K., S.T.B., M.R.W., L.E.K.), Department of Physiology (M.J.M., P.A.K., J.W., S.T.B., M.R.W., L.E.K.), Sol Sherry Thrombosis Research Center (M.J.M., L.C.K., L.E.K.), Departments of Pediatrics and Medicine (M.R.W.), and Department of Radiology (L.C.K.), Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Laurie E Kilpatrick
- Center for Inflammation, Clinical and Translational Lung Research (M.J.M., P.A.K., J.W., M.K., S.T.B., M.R.W., L.E.K.), Department of Physiology (M.J.M., P.A.K., J.W., S.T.B., M.R.W., L.E.K.), Sol Sherry Thrombosis Research Center (M.J.M., L.C.K., L.E.K.), Departments of Pediatrics and Medicine (M.R.W.), and Department of Radiology (L.C.K.), Temple University School of Medicine, Philadelphia, Pennsylvania
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