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Noeding Fischer CHRM, Bocanegra Román NFA, Nieto-Gutierrez W. An appraisal of the methodology and quality of evidence of systematic reviews on the efficacy of prone positional ventilation in adult patients with acute respiratory distress syndrome: an umbrella review. Intern Emerg Med 2022; 18:691-709. [PMID: 36585553 DOI: 10.1007/s11739-022-03174-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 12/06/2022] [Indexed: 12/31/2022]
Abstract
The objective of the study was to evaluate all available systematic reviews on the use of prone positional ventilation in adult patients with acute respiratory distress syndrome (ARDS). An umbrella review on the efficacy of prone positional ventilation in adult patients ventilation in adult patients with acute respiratory distress syndrome was conducted. We performed a systematic search in the database of Medline (Pubmed), Scopus, Cochrane Library, Web of Science, and Epistemonikos. The ROBIS tools and GRADE methodology were used to assess the risk of bias and certainty of evidence. We estimated the necessary number of patients to be treated to have benefit. For the synthesis of the result, we selected the review with the lowest risk of bias. Sixteen systematic reviews including 64 randomized clinical trials and evaluating the effect of prone positional ventilation, with or without other ventilation strategies were included. Aoyama 2019 observed prone positioning, without complementary ventilation strategies, leading to a reduction in the 28-day mortality only when compared to high-frequency oscillatory ventilation (RR 0.61; 95% CI 0.39-0.95) and lung-protective ventilation in the supine position (RR 0.69; 95% CI 0.48-0.98), with an ARR of 9.32% and 14.94%, an NNTB of 5.89 and 8.04, and a low and moderate certainty of evidence, respectively. Most reviews had severe methodological flaws that led to results with very low certainty of evidence. The review with the lowest risk of bias presented results in favor of prone positional ventilation compared with high-frequency oscillatory ventilation and lung-protective ventilation. There is a need to update the available reviews to obtain more accurate results.
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Ozawa Y, Miyake F, Isayama T. Efficacy and safety of permissive hypercapnia in preterm infants: A systematic review. Pediatr Pulmonol 2022; 57:2603-2613. [PMID: 35945674 DOI: 10.1002/ppul.26108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/07/2022] [Accepted: 08/05/2022] [Indexed: 11/11/2022]
Abstract
CONTEXT In adults, permissive hypercapnia reduces mortality and ventilation duration. However, in preterm infants, the findings from past research regarding the efficacy and safety of permissive hypercapnia are controversial. OBJECTIVE To evaluate the efficacy and safety of permissive hypercapnia versus normocapnia in preterm infants on mechanical ventilation. DATA SOURCES MEDLINE, EMBASE, CENTRAL, and CINAHL STUDY SELECTION: Published randomized controlled trials (RCTs), non-RCTs, interrupted time series, cohort studies, case-control studies, and controlled before-and-after studies were included. DATA EXTRACTION Two reviewers independently screened the title, abstract, and full text, extracted data, assessed the risk of bias, and evaluated certainty of evidence (CoE) according to the Grading of Recommendations Assessment and Development and Evaluation approach. A meta-analysis of RCTs was performed using the random-effects model. RESULTS Four RCTs (693 infants) and one cohort study (371 infants) were included. No significant differences existed between the permissive hypercapnia and normocapnia groups for bronchopulmonary dysplasia (BPD) (risk ratio [RR], 0.94; 95% confidence interval [CI], 0.74-1.18; very low CoE) and a composite outcome of death or BPD (RR, 1.05; 95% CI, 0.90-1.23; very low CoE). Permissive hypercapnia may increase necrotizing enterocolitis (RR, 1.69; 95% CI, 0.98-2.91; very low CoE), but the null or trivial effect cannot be excluded. No significant differences existed between the two groups for any other outcome assessed (very low-to-low CoE). LIMITATIONS The sample sizes were less than the optimal sizes for all outcomes assessed, indicating the need for further trials. CONCLUSIONS Permissive hypercapnia did not have any significant benefit or harm in preterm infants.
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Affiliation(s)
- Yuri Ozawa
- Division of Pediatrics, Kyorin University, Tokyo, Japan.,Division of Neonatology, Center for Maternal-Fetal Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Fuyu Miyake
- Division of Neonatology, Center for Maternal-Fetal Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan.,Department of Environmental Epidemiology, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Tetsuya Isayama
- Division of Neonatology, Center for Maternal-Fetal Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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Rollas K, Hanci P, Topeli A. Effects of end-expiratory lung volume versus PaO 2 guided PEEP determination on respiratory mechanics and oxygenation in moderate to severe ARDS. Exp Lung Res 2021; 48:12-22. [PMID: 34957895 DOI: 10.1080/01902148.2021.2021326] [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: 10/19/2022]
Abstract
There is no ideal method for determination of positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) patients. We compared the effects of end-expiratory lung volume (EELV)-guided versus PaO2-guided PEEP determination on respiratory mechanics and oxygenation during the first 48 hours in moderate to severe ARDS. Twenty-two patients with moderate to severe ARDS admitted to an academic medical ICU were assigned to PaO2-guided (n = 11) or to EELV-guided PEEP determination (n = 11) group. First, an incremental PEEP trial was performed by increasing PEEP by 3 cmH2O steps from 8 to 20 cmH2O and in each step EELV and lung mechanics were measured in both groups. Then, oxygenation and respiratory mechanics were measured under the determined PEEP at 4, 12, 24, and 48th hours. After the incremental PEEP trial, over the 48 hours of the study period, in the EELV-guided group PaO2 and PaO2/FiO2 increased (p = 0.04 and p = 0.02; respectively), whereas they did not change in PaO2-guided group (p = 0.09 and p = 0.27; respectively). In all patients, the median value of EELV change (ΔEELV) during incremental PEEP trial was 25%. In patients with ΔEELV > 25% (n = 11) PaO2, PaO2/FiO2 and Cs increased over time in 48 hours (p = 0.03, p < 0.01, and p = 0.04; respectively), whereas they did not change in those with ΔEELV ≤ 25% (n = 11) (p = 0.73, p = 0.51, and p = 0.73; respectively). Compared to PaO2-guided PEEP determination, EELV-guided PEEP determination resulted in greater improvement in oxygenation over time. Patients who had > 25% improvement in EELV during a PEEP trial had greater improvement in oxygenation and compliance over 48 hours. Supplemental data for this article is available online at.
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Affiliation(s)
- Kazim Rollas
- Division of Intensive Care Medicine, Department of Anaesthesiology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Pervin Hanci
- Division of Intensive Care Medicine, Department of Pulmonology, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Arzu Topeli
- Division of Intensive Care Medicine, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Rupp T, Maufrais C, Walther G, Esteve F, Macdonald JH, Bouzat P, Verges S. MEDEX 2015: Prophylactic Effects of Positive Expiratory Pressure in Trekkers at Very High Altitude. Front Physiol 2021; 12:710622. [PMID: 34621182 PMCID: PMC8490760 DOI: 10.3389/fphys.2021.710622] [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: 05/16/2021] [Accepted: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: Positive expiratory pressure (PEP) breathing has been shown to increase arterial oxygenation during acute hypoxic exposure but the underlying mechanisms and consequences on symptoms during prolonged high-altitude exposure remain to be elucidated. Methods: Twenty-four males (41 ± 16 years) were investigated, at sea level and at 5,085 m after 18 days of trekking from 570 m. Participants breathed through a face-mask with PEP = 0 cmH2O (PEP0, 0-45th min) and with PEP = 10 cmH2O (PEP10, 46-90th min). Arterial (SpO2), quadriceps and prefrontal (near infrared spectroscopy) oxygenation was measured continuously. Middle cerebral artery blood velocity (MCAv, transcranial Doppler), cardiac function (2D-echocardiography), extravascular lung water accumulation (UsLC, thoracic ultrasound lung comets) and acute mountain sickness (Lake Louise score, LLS) were assessed during PEP0 and PEP10. Results: At 5,085 m with PEP0, SpO2 was 78 ± 4%, UsLC was 8 ± 5 (a.u.) and the LLS was 2.3 ± 1.7 (all P < 0.05 versus sea level). At 5,085 m, PEP10 increased significantly SpO2 (+9 ± 5%), quadriceps (+2 ± 2%) and prefrontal cortex (+2 ± 2%) oxygenation (P < 0.05), and decreased significantly MCAv (-16 ± 14 cm.s-1) and cardiac output (-0.7 ± 1.2 L.min-1) together with a reduced stroke volume (-9 ± 15 mL, all P < 0.05) and no systemic hypotension. PEP10 decreased slightly the number of UsLC (-1.4 ± 2.7, P = 0.04) while the incidence of acute mountain sickness (LLS ≥ 3) fell from 42% with PEP0 to 25% after PEP10 (P = 0.043). Conclusion: PEP10 breathing improved arterial and tissue oxygenation and symptoms of acute mountain sickness after trekking to very high altitude, despite reduced cerebral perfusion and cardiac output. Further studies are required to establish whether PEP-breathing prophylactic mechanisms also occur in participants with more severe acute mountain sickness.
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Affiliation(s)
- Thomas Rupp
- Inter-University Laboratory of Human Movement Science (LIBM), University Savoie Mont Blanc, Chambéry, France
| | - Claire Maufrais
- Laboratoire de Pharm-Ecologie Cardiorespiratoire (LAPEC EA4278), Avignon University, Avignon, France.,HP2 Laboratory, INSERM, Grenoble Alpes University, Grenoble, France
| | - Guillaume Walther
- Laboratoire de Pharm-Ecologie Cardiorespiratoire (LAPEC EA4278), Avignon University, Avignon, France
| | - François Esteve
- RSRM EA7442, ID17-ESRF, Grenoble Alpes University, Grenoble, France
| | - Jamie Hugo Macdonald
- Extremes Research Group, School of Sport, Health and Exercise Sciences, Bangor University, Bangor, United Kingdom
| | - Pierre Bouzat
- Pôle Anesthésie Réanimation, Grenoble Alpes University Hospital, Grenoble, France
| | - Samuel Verges
- HP2 Laboratory, INSERM, Grenoble Alpes University, Grenoble, France
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Jung S, Kim J, Na S, Nam WS, Kim DH. Ability of Carotid Corrected Flow Time to Predict Fluid Responsiveness in Patients Mechanically Ventilated Using Low Tidal Volume after Surgery. J Clin Med 2021; 10:jcm10122676. [PMID: 34204523 PMCID: PMC8234831 DOI: 10.3390/jcm10122676] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 11/16/2022] Open
Abstract
Predicting fluid responsiveness in patients under mechanical ventilation with low tidal volume (VT) is challenging. This study evaluated the ability of carotid corrected flow time (FTc) assessed by ultrasound for predicting the fluid responsiveness during low VT ventilation. Patients under postoperative mechanical ventilation and clinically diagnosed with hypovolemia were enrolled. Carotid FTc and pulse pressure variation (PPV) were measured at VT of 6 and 10 mL/kg predicted body weight (PBW). FTc was calculated using both Bazett’s (FTcB) and Wodey’s (FTcW) formulas. Fluid responsiveness was defined as a ≥15% increase in the stroke volume index assessed by FloTrac/Vigileo monitor after administration of 8 mL/kg of balanced crystalloid. Among 36 patients, 16 (44.4%) were fluid responders. The areas under the receiver operating characteristic curves (AUROCs) for the FTcB at VT of 6 and 10 mL/kg PBW were 0.897 (95% confidence interval [95% CI]: 0.750–0.973) and 0.895 (95% CI: 0.748–0.972), respectively. The AUROCs for the FTcW at VT of 6 and 10 mL/kg PBW were 0.875 (95% CI: 0.722–0.961) and 0.891 (95% CI: 0.744–0.970), respectively. However, PPV at VT of 6 mL/kg PBW (AUROC: 0.714, 95% CI: 0.539–0.852) showed significantly lower accuracy than that of PPV at VT of 10 mL/kg PBW (AUROC: 0.867, 95% CI: 0.712–0.957; p = 0.034). Carotid FTc can predict fluid responsiveness better than PPV during low VT ventilation. However, further studies using automated continuous monitoring system are needed before its clinical use.
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Bo L, Jin F, Ma Z, Li C. Redox signaling and antioxidant therapies in acute respiratory distress syndrome: a systematic review and meta-analysis. Expert Rev Respir Med 2021; 15:1355-1365. [PMID: 33928830 DOI: 10.1080/17476348.2021.1924681] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objectives: No pharmacologic treatment that targets the pathophysiologic alterations of acute respiratory distress syndrome (ARDS) has proven effective. Previous studies have revealed overactive oxidative stress as a potential therapeutic target. Thus we conducted this systematic review to assess the efficacyof antioxidant therapy on the clinical outcomes of ARDS patients.Methods: We retrieved clinical trials from electronic databases. Articles and conference abstracts about antioxidant therapies for patients with ARDS were identified in which the overall effect of each antioxidant therapy on the mortality of ARDS patients was summarized.Results: We identified 18 relevant studies that met the inclusion criteria, including 899 patients in the experimental group and 870 patients in the control group. The pooled results indicated that most antioxidant therapies could not improve all-cause mortality and might even be harmful in ARDS patients at low risk of death.Conclusion: Unclassified patients could not benefit from the antioxidant therapies, and thus discretion must be exercised when using these therapies.Abbreviations ARDS: Acute respiratory distress syndrome; ICU: Intensive care unit; NAC: N-acetylcysteine; ROS: Reactive oxygen species; RNS: Reactive nitrogen species; RR: Relative risk; CI: Confidence interval; OTC: L-2-oxothiazolidine-4-carboxylic acid; EPA: Eicosapentaenoic acid; DHA: Docosahexaenoic acid; GLA: Gamma-linolenic acid; NA: Not applicable; PaO2/FiO2 ratio: The ratio of partial pressure arterial oxygen and fraction of inspired oxygen; ALI: Acute lung injury.
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Affiliation(s)
- Liyan Bo
- Department of Respiratory and Critical Care Medicine, General Hospital of Northern Theater Command, Shenyang, China.,Department of Respiratory and Critical Care Medicine, Chest Hospital of Xi'an, Xi'an, China
| | - Faguang Jin
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital, Air Force Medical University, Xi'an, China
| | - Zhuang Ma
- Department of Respiratory and Critical Care Medicine, General Hospital of Northern Theater Command, Shenyang, China
| | - Congcong Li
- Department of Respiratory and Critical Care Medicine, General Hospital of Northern Theater Command, Shenyang, China
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Zhang Z, Navarese EP, Zheng B, Meng Q, Liu N, Ge H, Pan Q, Yu Y, Ma X. Analytics with artificial intelligence to advance the treatment of acute respiratory distress syndrome. J Evid Based Med 2020; 13:301-312. [PMID: 33185950 DOI: 10.1111/jebm.12418] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 10/21/2020] [Indexed: 02/05/2023]
Abstract
Artificial intelligence (AI) has found its way into clinical studies in the era of big data. Acute respiratory distress syndrome (ARDS) or acute lung injury (ALI) is a clinical syndrome that encompasses a heterogeneous population. Management of such heterogeneous patient population is a big challenge for clinicians. With accumulating ALI datasets being publicly available, more knowledge could be discovered with sophisticated analytics. We reviewed literatures with big data analytics to understand the role of AI for improving the caring of patients with ALI/ARDS. Many studies have utilized the electronic medical records (EMR) data for the identification and prognostication of ARDS patients. As increasing number of ARDS clinical trials data is open to public, secondary analysis on these combined datasets provide a powerful way of finding solution to clinical questions with a new perspective. AI techniques such as Classification and Regression Tree (CART) and artificial neural networks (ANN) have also been successfully used in the investigation of ARDS problems. Individualized treatment of ARDS could be implemented with a support from AI as we are now able to classify ARDS into many subphenotypes by unsupervised machine learning algorithms. Interestingly, these subphenotypes show different responses to a certain intervention. However, current analytics involving ARDS have not fully incorporated information from omics such as transcriptome, proteomics, daily activities and environmental conditions. AI technology is assisting us to interpret complex data of ARDS patients and enable us to further improve the management of ARDS patients in future with individual treatment plans.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Eliano Pio Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
- Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Bin Zheng
- Department of Surgery, 2D, Walter C Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Qinghe Meng
- Department of Surgery, State University of New York Upstate Medical University, Syracuse, New York
| | - Nan Liu
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Huiqing Ge
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qing Pan
- College of Information Engineering, Zhejiang University of Technology, Hangzhou, China
| | - Yuetian Yu
- Department of Critical Care Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xuelei Ma
- Department of biotherapy, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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Zhou XL, Wei XJ, Li SP, Ma HL, Zhao Y. Lung-protective ventilation worsens ventilator-induced diaphragm atrophy and weakness. Respir Res 2020; 21:16. [PMID: 31924204 PMCID: PMC6954632 DOI: 10.1186/s12931-020-1276-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/02/2020] [Indexed: 02/07/2023] Open
Abstract
Background Lung–protective ventilation (LPV) has been found to minimize the risk of ventilator–induced lung injury (VILI). However, whether LPV is able to diminish ventilator–induced diaphragm dysfunction (VIDD) remains unknown. This study was designed to test the hypothesis that LPV protects the diaphragm against VIDD. Methods Adult male Wistar rats received either conventional mechanical (tidal volume [VT]: 10 ml/kg, positive end–expiratory pressure [PEEP]: 2 cm H2O; CV group) or lung-protective (VT: 5 ml/kg, PEEP: 10 cm H2O; LPV group) ventilation for 12 h. Then, diaphragms and lungs were collected for biochemical and histological analyses. Transcriptome sequencing (RNA–seq) was performed to determine the differentially expressed genes in the diaphragms between groups. Results Our results suggested that LPV was associated with diminished pulmonary injuries and reduced oxidative stress compared with the effects of the CV strategy in rats. However, animals that received LPV showed increased protein degradation, decreased cross–sectional areas (CSAs) of myofibers, and reduced forces of the diaphragm compared with the same parameters in animals receiving CV (p < 0.05). In addition, the LPV group showed a higher level of oxidative stress in the diaphragm than the CV group (p < 0.05). Moreover, RNA–seq and western blots revealed that the peroxisome proliferator–activated receptor γ coactivator–1alpha (PGC–1α), a powerful reactive oxygen species (ROS) inhibitor, was significantly downregulated in the LPV group compared with its expression in the CV group (p < 0.05). Conclusions Compared with the CV strategy, the LPV strategy did not protect the diaphragm against VIDD in rats. In contrast, the LPV strategy worsened VIDD by inducing oxidative stress together with the downregulation of PGC–1α in the diaphragm. However, further studies are required to determine the roles of PGC–1α in ventilator-induced diaphragmatic oxidative stress.
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Affiliation(s)
- Xian-Long Zhou
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Xiao-Jun Wei
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Shao-Ping Li
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Hao-Li Ma
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Yan Zhao
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China.
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Rupp T, Saugy JJ, Bourdillon N, Verges S, Millet GP. Positive expiratory pressure improves arterial and cerebral oxygenation in acute normobaric and hypobaric hypoxia. Am J Physiol Regul Integr Comp Physiol 2019; 317:R754-R762. [PMID: 31530174 DOI: 10.1152/ajpregu.00025.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Positive expiratory pressure (PEP) has been shown to limit hypoxia-induced reduction in arterial oxygen saturation, but its effectiveness on systemic and cerebral adaptations, depending on the type of hypoxic exposure [normobaric (NH) versus hypobaric (HH)], remains unknown. Thirteen healthy volunteers completed three randomized sessions consisting of 24-h exposure to either normobaric normoxia (NN), NH (inspiratory oxygen fraction, FiO2 = 13.6%; barometric pressure, BP = 716 mmHg; inspired oxygen partial pressure, PiO2 = 90.9 ± 1.0 mmHg), or HH (3,450 m, FiO2 = 20.9%, BP = 482 mmHg, PiO2 = 91.0 ± 0.6 mmHg). After the 6th and the 22nd hours, participants breathed quietly through a facemask with a 10-cmH2O PEP for 2 × 5 min interspaced with 5 min of free breathing. Arterial (SpO2, pulse oximetry), quadriceps, and cerebral (near-infrared spectroscopy) oxygenation, middle cerebral artery blood velocity (MCAv; transcranial Doppler), ventilation, and cardiovascular responses were recorded continuously. SpO2without PEP was significantly lower in HH (87 ± 4% on average for both time points, P < 0.001) compared with NH (91 ± 3%) and NN (97 ± 1%). PEP breathing did not change SpO2 in NN but increased it similarly in NH and HH (+4.3 ± 2.5 and +4.7 ± 4.1% after 6h; +3.5 ± 2.2 and +4.1 ± 2.9% after 22h, both P < 0.001). Although MCAv was reduced by PEP (in all sessions and at all time points, -6.0 ± 4.2 cm/s on average, P < 0.001), the cerebral oxygenation was significantly improved (P < 0.05) with PEP in both NH and HH, with no difference between conditions. These data indicate that PEP could be an attractive nonpharmacological means to improve arterial and cerebral oxygenation under both normobaric and hypobaric mild hypoxic conditions in healthy participants.
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Affiliation(s)
- Thomas Rupp
- Laboratoire Interuniversitaire de Biologie de la Motricité, Inter-University Laboratory of Human Movement Science, University Savoie Mont Blanc, Chambery, France
| | - Jonas J Saugy
- Institute of Sport Sciences of the University of Lausanne, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Nicolas Bourdillon
- Institute of Sport Sciences of the University of Lausanne, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Samuel Verges
- Hypoxia-pathophysiology 2 Laboratory, Grenoble Alpes University, France.,Unité 1042, INSERM, Grenoble, Grenoble, France
| | - Grégoire P Millet
- Institute of Sport Sciences of the University of Lausanne, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Aoyama H, Uchida K, Aoyama K, Pechlivanoglou P, Englesakis M, Yamada Y, Fan E. Assessment of Therapeutic Interventions and Lung Protective Ventilation in Patients With Moderate to Severe Acute Respiratory Distress Syndrome: A Systematic Review and Network Meta-analysis. JAMA Netw Open 2019; 2:e198116. [PMID: 31365111 PMCID: PMC6669780 DOI: 10.1001/jamanetworkopen.2019.8116] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE A number of interventions are available to manage patients with moderate to severe acute respiratory distress syndrome (ARDS). However, the associations of currently available ventilatory strategies and adjunctive therapies with mortality are uncertain. OBJECTIVES To compare and rank different therapeutic strategies to identify the best intervention associated with a reduction in mortality in adult patients with moderate to severe ARDS. DATA SOURCES An electronic search of MEDLINE, MEDLINE In-Process/ePubs Ahead of Print, Embase, Cochrane Controlled Clinical Trial Register (Central), PubMed, and CINAHL was conducted, from database inception to May 29, 2019. STUDY SELECTION Randomized clinical trials of interventions for adults with moderate to severe ARDS that used lung protective ventilation. No language restrictions were applied. DATA EXTRACTION AND SYNTHESIS Data were independently extracted by 2 reviewers and synthesized with Bayesian random-effects network meta-analyses. MAIN OUTCOMES AND MEASURES The primary outcome was 28-day mortality. Barotrauma was a secondary outcome. RESULTS Among 25 randomized clinical trials evaluating 9 interventions, 2686 of 7743 patients (34.6%) died within 28 days. Compared with lung protective ventilation alone, prone positioning and venovenous extracorporeal membrane oxygenation were associated with significantly lower 28-day mortality (prone positioning: risk ratio, 0.69; 95% credible interval, 0.48-0.99; low quality of evidence; venovenous extracorporeal membrane oxygenation: risk ratio, 0.60; 95% credible interval, 0.38-0.93; moderate quality of evidence). These 2 interventions had the highest ranking probabilities, although they were not significantly different from each other. Among 18 trials reporting on barotrauma, 448 of 6258 patients (7.2%) experienced this secondary outcome. No intervention was superior to any other in reducing barotrauma, and each represented low to very low quality of evidence. CONCLUSIONS AND RELEVANCE This network meta-analysis supports the use of prone positioning and venovenous extracorporeal membrane oxygenation in addition to lung protective ventilation in patients with ARDS. Moreover, venovenous extracorporeal membrane oxygenation may be considered as an early strategy for adults with severe ARDS receiving lung protective ventilation.
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Affiliation(s)
- Hiroko Aoyama
- Department of Anesthesiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kanji Uchida
- Department of Anesthesiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kazuyoshi Aoyama
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Petros Pechlivanoglou
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Yoshitsugu Yamada
- Department of Anesthesiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Xie Y, Wang Y, Liu K, Li X. Correlation analysis between mechanical power, transforming growth factor-β1, and connective tissue growth factor levels in acute respiratory distress syndrome patients and their clinical significance in pulmonary structural remodeling. Medicine (Baltimore) 2019; 98:e16531. [PMID: 31335733 PMCID: PMC6708710 DOI: 10.1097/md.0000000000016531] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND To identify the clinical correlations between mechanical power and transforming growth factor-β1 (TGF-β1) and connective tissue growth factor (CTGF) in acute respiratory distress syndrome (ARDS) patients, their clinical significance in pulmonary structural remodeling in ARDS patients was investigated. METHODS Ninety-five patients with moderate or severe ARDS, who required mechanical ventilation therapy, were randomly selected among hospitalized patients from January 2017 to February 2019. Their mechanical power was monitored and recorded, the TGF-β1 and CTGF levels were detected by enzyme-linked immunosorbent assay (ELISA), their relevance was analyzed, and the relationship between mechanical power and 28-day survival rate was investigated. According to the high-resolution computed tomography (HRCT) examination, the patients were divided into an ARDS group and an ARDS pulmonary fibrosis (ARDS-PF) group. The differences in mechanical power, TGF-β1, and CTGF between the 2 groups were compared, and the significance of TGF-β1 and CTGF in the diagnosis of ARDS pulmonary interstitial fibrosis were evaluated. RESULTS A significant positive correlation between mechanical power and serum TGF-β1 and CTGF in patients with ARDS was found and the correlation coefficients were 0.424 and 0.581, respectively. The difference between mechanical power and 28-day survival rate was statistically significant (P < .05), while the area under the receiver operating characteristic curves of TGF-β1 and CTGF for the diagnosis of ARDS pulmonary fibrosis was 0.838 and 0.884, respectively (P < .05). CONCLUSION A significant correlation between mechanical power and serum fibrosis biomarkers TGF-β1 and CTGF in ARDS patients was found, and its level was related to the survival prognosis of patients. Mechanical power, TGF-β1, and CTGF were clinically evaluated for the assessment of lung structural remodeling, such as ARDS pulmonary fibrosis. This study has particular significance to the early prevention of ventilator-induced lung injury and pulmonary fibrosis in patients with ARDS receiving mechanical ventilation.
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Affiliation(s)
| | - Yangli Wang
- Department of Emergency Medicine, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang City, Lianyungang, China
| | - Kexi Liu
- Department of Critical Care Medicine
| | - Xiaomin Li
- Department of Emergency Medicine, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang City, Lianyungang, China
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12
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Lovisari F, Fodor GH, Peták F, Habre W, Bayat S. Effect of PEEP and I:E ratio on cerebral oxygenation in ARDS: an experimental study in anesthetized rabbit. BMC Anesthesiol 2019; 19:110. [PMID: 31216981 PMCID: PMC6582519 DOI: 10.1186/s12871-019-0782-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 06/09/2019] [Indexed: 12/03/2022] Open
Abstract
Background Although PEEP and inversed I:E ratio have been shown to improve gas exchange in ARDS, both can adversely affect systemic hemodynamics and cerebral perfusion. The goal of this study was to assess how changes in PEEP and I:E ratio affect systemic and cerebral oxygenation and perfusion in normal and injured lung. Methods Eight anesthetized Chinchilla-Bastard rabbits were ventilated at baseline with pressure-regulated volume control mode, VT = 6 ml/kg, PEEP = 6 cmH2O, FIO2 = 0.4; respiratory rate set for ETCO2 = 5.5%, and I:E = 1:2, 1:1 or 2:1 in random order. Ultrasonic carotid artery flow (CF), arterial (PaO2), jugular venous blood gases and near infrared spectroscopic cerebral oxygenation (∆HBO2) were recorded for each experimental condition. After induced lung injury, the animals were ventilated with PEEP = 9 followed by 6 cmH2O. Results At baseline, inverse-ratio ventilation (IRV) significantly reduced cerebral oxygenation (∆O2HB; − 27 at 1:2; − 15 at 1:1 vs. 0.27 μmol/L at 2:1; p < 0.05), due to a significant reduction in mean arterial pressure and CF without modifying gas exchange. In injured lung, IRV improved gas exchange but decreased cerebral perfusion without affecting brain oxygenation. The higher PEEP level, however, improved PaO2 (67.5 ± 19.3 vs. 42.2 ± 8.4, p < 0.05), resulting in an improved ∆HBO2 (− 13.8 ± 14.7 vs. –43.5 ± 21.3, p < 0.05), despite a drop in CF. Conclusions Our data suggest that unlike moderate PEEP, IRV is not effective in improving brain oxygenation in ARDS. In normal lung, IRV had a deleterious effect on brain oxygenation, which is relevant in anesthetized patients. Electronic supplementary material The online version of this article (10.1186/s12871-019-0782-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Federica Lovisari
- Unit for Anesthesiological Investigations Department of Anesthesiology Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland.,University of Milano-Bicocca, Milan, Italy
| | - Gergely H Fodor
- Unit for Anesthesiological Investigations Department of Anesthesiology Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland
| | - Ferenc Peták
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Walid Habre
- Unit for Anesthesiological Investigations Department of Anesthesiology Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland.,Pediatric Anesthesia Unit, Geneva Children's Hospital, Geneva, Switzerland
| | - Sam Bayat
- Unit for Anesthesiological Investigations Department of Anesthesiology Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland. .,Inserm UA7 STROBE Laboratory, University of Grenoble, Grenoble, France. .,Department of Clinical Physiology, Sleep and Exercise, Grenoble University Hospital, Grenoble, France.
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13
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Zhang Z, Zheng B, Liu N, Ge H, Hong Y. Mechanical power normalized to predicted body weight as a predictor of mortality in patients with acute respiratory distress syndrome. Intensive Care Med 2019; 45:856-864. [PMID: 31062050 DOI: 10.1007/s00134-019-05627-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/22/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Protective mechanical ventilation based on multiple ventilator parameters such as tidal volume, plateau pressure, and driving pressure has been widely used in acute respiratory distress syndrome (ARDS). More recently, mechanical power (MP) was found to be associated with mortality. The study aimed to investigate whether MP normalized to predicted body weight (norMP) was superior to other ventilator variables and to prove that the discrimination power cannot be further improved with a sophisticated machine learning method. METHODS The study included individual patient data from eight randomized controlled trials conducted by the ARDSNet. The data was split 3:1 into training and testing subsamples. The discrimination of each ventilator variable was calculated in the testing subsample using the area under receiver operating characteristic curve. The gradient boosting machine was used to examine whether the discrimination could be further improved. RESULTS A total of 5159 patients with acute onset ARDS were included for analysis. The discrimination of norMP in predicting mortality was significantly better than the absolute MP (p = 0.011 for DeLong's test). The gradient boosting machine was not able to improve the discrimination as compared to norMP (p = 0.913 for DeLong's test). The multivariable regression model showed a significant interaction between norMP and ARDS severity (p < 0.05). While the norMP was not significantly associated with mortality outcome (OR 0.99; 95% CI 0.91-1.07; p = 0.862) in patients with mild ARDS, it was associated with increased risk of mortality in moderate (OR 1.11; 95% CI 1.02-1.23; p = 0.021) and severe (OR 1.13; 95% CI 1.03-1.24; p < 0.008) ARDS. CONCLUSIONS The study showed that norMP was a good ventilator variable associated with mortality, and its predictive discrimination cannot be further improved with a sophisticated machine learning method. Further experimental trials are needed to investigate whether adjusting ventilator variables according to norMP will significantly improve clinical outcomes.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No 3, East Qingchun Road, Hangzhou, 310016, Zhejiang, China.
| | - Bin Zheng
- Department of Surgery, 2D, Walter C Mackenzie Health Sciences Centre, University of Alberta, Edmonton, AB, Canada
| | - Nan Liu
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
| | - Huiqing Ge
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No 3, East Qingchun Road, Hangzhou, 310016, Zhejiang, China
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14
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Baez-Pravia OV, Montes-Andujar L, Menéndez J, Cardinal-Fernández P. What have we learned from network meta-analyses applied to critical care? Minerva Anestesiol 2019; 85:433-442. [PMID: 30735019 DOI: 10.23736/s0375-9393.19.13267-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
It is widely accepted in modern medicine that medical decisions must be supported by scientific evidence. Identifying the best intervention when several options are available constitute a great challenge for every clinician. Traditional meta-analysis (TMA) allows summarizing evidence from studies that compare the same two interventions for one event (head to head studies or direct comparisons). Network meta-analysis (NMA) is a relatively new procedure that allows to compare multiple interventions for one event, even when non-head to head studies have been conducted (indirect evidence). Other advantages of NMA include increasing the accuracy of the results and ranking all the interventions according to their effectiveness. These features are of paramount importance as: 1) they summarize information from events (e.g. diseases or outcomes) that has more than two possible interventions (e.g. treatments or procedures); 2) they strengthen the level of guideline recommendations; and 3) they identify new hypotheses based on indirect comparison. As this is a narrative review, all manuscripts have been selected from PubMed according to our best knowledge with the aim to illustrate different features, options or applications of NMA in critical care. First, we provide a description of the usefulness, interpretation, assumptions and main plots related to NMAs. Second, we analyzed some examples of NMAs related to critical care medicine. Third, we include a pragmatic approach about how results from NMAs can improve the clinical practice as well an R script with a database to conduct an NMAs and reproduce figures and tables that have been shown here. As a conclusion, NMA is an established, robust, objective and reproducible statistic technique that has been applied to several critical care areas. Clinical practice guidelines have started to include NMA evidence to support their recommendations. In future years, it seems highly probable that this technique will increase it applicability in almost all areas of critical care medicine.
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Affiliation(s)
| | - Lara Montes-Andujar
- Department of Emergency Medicine, HM Sanchinarro University Hospital, Madrid, Spain.,CEU San Pablo University, Madrid, Spain
| | - Justo Menéndez
- Department of Emergency Medicine, HM Sanchinarro University Hospital, Madrid, Spain.,CEU San Pablo University, Madrid, Spain
| | - Pablo Cardinal-Fernández
- Department of Emergency Medicine, HM Sanchinarro University Hospital, Madrid, Spain - .,HM Research Foundation, HM Hospitals, Madrid, Spain
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15
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Zhang Z. Identification of three classes of acute respiratory distress syndrome using latent class analysis. PeerJ 2018; 6:e4592. [PMID: 29610712 PMCID: PMC5880177 DOI: 10.7717/peerj.4592] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 03/19/2018] [Indexed: 02/05/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a highly heterogeneous syndrome that can exhibit significant differences in the underlying causes, leading to different responses to treatment. It is required to identify subtypes of ARDS to guideline clinical treatment and trial design. The study aimed to identify subtypes of ARDS using latent class analysis (LCA). The study was a secondary analysis of the EDEN study, which was a randomized, controlled, multicenter trial conducted from January 2, 2008 to April 12, 2011. The primary study endpoint was death through 90-day follow up. LCA was performed incorporating variables on day 0 before randomization. The number of classes was chosen by a bootstrapped likelihood ratio test, Bayesian information criterion and the number of patients in each class. A total of 943 patients were enrolled in the study, including 219 (23.2%) non-survivors and 724 (76.8%) survivors. The LCA identified three classes of ARDS. Class 1 (hemodynamically unstable type) had significantly higher mortality rate (p = 0.003) than class 2 (intermediate type) and 3 (stable type) through 90 days follow up. There was significant interaction between cumulative fluid balance and the class (p = 0.02). While more fluid balance was beneficial for class 1, it was harmful for class 2 and 3. In conclusion, the study identified three classes of ARDS, which showed different clinical presentations, responses to fluid therapy and prognosis. The classification system used simple clinical variables and could help to design ARDS trials in the future.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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16
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An Open Lung Strategy in the Management of Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. Shock 2018; 48:43-53. [PMID: 28125527 DOI: 10.1097/shk.0000000000000822] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE An open lung strategy (OLS) that includes positive end expiratory pressure and recruitment maneuvers during mechanical ventilation is probably an important treatment method in patients with acute respiratory distress syndrome (ARDS). However, the effect of OLS is unknown. We therefore hypothesized that patients with ARDS may benefit from OLS treatment. METHODS We identified relevant randomized controlled trials by searching through PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials updated to May 22, 2016. We performed a systematic review and meta-analysis to evaluate the effect of OLS in patients with ARDS. The primary outcome was mortality. RESULTS A total of 15 randomized controlled trials involving 1,563 patients in OLS group and 1,571 patients in control group were included. Pooled analysis showed that there was significant difference in hospital mortality (relative risk [RR], 0.88; 95% CI, 0.80-0.97; P = 0.009), 28-day mortality (RR, 0.83; 95% CI, 0.71-0.96; P = 0.010), and intensive care unit (ICU) mortality (RR, 0.77; 95% CI, 0.65-0.92; P = 0.003) between the OLS group and control group, with no substantial heterogeneity. There was no significant difference in ventilator-free days at 28-day (mean difference [MD]; 3.32 d; 95% CI, -0.49 to 7.12; P = 0.09) and ICU length of stay (MD; 1.60 d; 95% CI, -2.99 to 6.20; P = 0.49) between OLS group and control group. CONCLUSIONS Results from this systematic review and meta-analysis suggest that OLS during mechanical ventilation significantly reduces mortality among patients with ARDS.
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17
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The role of high airway pressure and dynamic strain on ventilator-induced lung injury in a heterogeneous acute lung injury model. Intensive Care Med Exp 2017; 5:25. [PMID: 28497420 PMCID: PMC5427060 DOI: 10.1186/s40635-017-0138-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 04/26/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute respiratory distress syndrome causes a heterogeneous lung injury with normal and acutely injured lung tissue in the same lung. Improperly adjusted mechanical ventilation can exacerbate ARDS causing a secondary ventilator-induced lung injury (VILI). We hypothesized that a peak airway pressure of 40 cmH2O (static strain) alone would not cause additional injury in either the normal or acutely injured lung tissue unless combined with high tidal volume (dynamic strain). METHODS Pigs were anesthetized, and heterogeneous acute lung injury (ALI) was created by Tween instillation via a bronchoscope to both diaphragmatic lung lobes. Tissue in all other lobes was normal. Airway pressure release ventilation was used to precisely regulate time and pressure at both inspiration and expiration. Animals were separated into two groups: (1) over-distension + high dynamic strain (OD + HDS, n = 6) and (2) over-distension + low dynamic strain (OD + LDS, n = 6). OD was caused by setting the inspiratory pressure at 40 cmH2O and dynamic strain was modified by changing the expiratory duration, which varied the tidal volume. Animals were ventilated for 6 h recording hemodynamics, lung function, and inflammatory mediators followed by an extensive necropsy. RESULTS In normal tissue (NT), OD + LDS caused minimal histologic damage and a significant reduction in BALF total protein (p < 0.05) and MMP-9 activity (p < 0.05), as compared with OD + HDS. In acutely injured tissue (ALIT), OD + LDS resulted in reduced histologic injury and pulmonary edema (p < 0.05), as compared with OD + HDS. CONCLUSIONS Both NT and ALIT are resistant to VILI caused by OD alone, but when combined with a HDS, significant tissue injury develops.
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18
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Aksan A, Işık H, Radeke HH, Dignass A, Stein J. Systematic review with network meta-analysis: comparative efficacy and tolerability of different intravenous iron formulations for the treatment of iron deficiency anaemia in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2017; 45:1303-1318. [PMID: 28326596 DOI: 10.1111/apt.14043] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 11/01/2016] [Accepted: 02/22/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Iron deficiency anaemia (IDA) is a common complication of inflammatory bowel disease (IBD) associated with reduced quality of life and increased hospitalisation rates. While the best way of treating IDA in IBD patients is not clearly established, current European guidelines recommend intravenous iron therapy in IBD patients with severe anaemia or intolerance to oral iron compounds. AIM To compare the efficacy and tolerability of different intravenous iron formulations used to treat IDA in IBD patients in a systematic review and Bayesian network meta-analysis (NMA), PROSPERO registration number: 42016046565. METHODS In June 2016, we systematically searched for studies analysing efficacy and safety of intravenous iron for IDA therapy in IBD. Primary outcome was therapy response, defined as Hb normalisation or increase ≥2 g/dL. RESULTS Five randomised, controlled trials (n = 1143 patients) were included in a network meta-analysis. Only ferric carboxymaltose was significantly more effective than oral iron [OR=1.9, 95% CrI: (1.1;3.2)]. Rank probabilities showed ferric carboxymaltose to be most effective, followed by iron sucrose, iron isomaltose and oral iron. Pooled data from the systematic review (n = 1746 patients) revealed adverse event rates of 12.0%, 15.3%, 12.0%, 17.0% for ferric carboxymaltose, iron sucrose, iron dextran and iron isomaltose respectively. One drug-related serious adverse event (SAE) each was reported for ferric carboxymaltose and iron isomaltoside, and one possibly drug-related SAE for iron sucrose. CONCLUSIONS Ferric carboxymaltose was the most effective intravenous iron formulation, followed by iron sucrose. In addition, ferric carboxymaltose tended to be better tolerated. Thus, nanocolloidal IV iron products exhibit differing therapeutic and safety characteristics and are not interchangeable.
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Affiliation(s)
- A Aksan
- Hacettepe University, Faculty of Health Sciences, Ankara, Turkey.,Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt/Main, Germany
| | - H Işık
- Hacettepe University, Faculty of Sciences, Ankara, Turkey
| | - H H Radeke
- Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt/Main, Germany.,Pharmazentrum frankfurt, Institute of Pharmacology and Toxicology, Hospital of the Goethe University, Frankfurt/Main, Germany
| | - A Dignass
- Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt/Main, Germany.,Agaplesion Markus Krankenhaus, Department of Gastroenterology, Frankfurt/Main, Germany
| | - J Stein
- Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt/Main, Germany.,DGD Clinics Sachsenhausen, Department of Gastroenterology and Clinical Nutrition, Frankfurt/Main, Germany
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19
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Lewandowski K, Bartlett RH. [The old man and the I sea U : Essay on faith, fate and evidence - after the manner of Hemingway]. Anaesthesist 2017; 66:34-44. [PMID: 27924353 PMCID: PMC7095939 DOI: 10.1007/s00101-016-0239-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Robert Bartlett, emeritus Professor of surgery at the University of Michigan in Ann Arbor, USA, transformed classical works of world literature (Charles Dickens: A Christmas Carol, Lewis Carroll: Alice in Wonderland) into teaching aids for advanced training in intensive care medicine. He recently turned his hand to the well-known work of Ernest Hemingway: the Nobel Prize winning novel The Old Man and the Sea. Subsequent to Robert Bartlett's essay this article provides background information and comments on the current problems in modern intensive care medicine addressed in his essay.
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Affiliation(s)
- K Lewandowski
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Elisabeth-Krankenhaus, Klara-Kopp-Weg 1, 45138, Essen, Deutschland.
| | - R H Bartlett
- Department of Surgery, University of Michigan Medical Center, Ann Arbor, USA
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20
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Zhang Z, Gu WJ, Chen K, Ni H. Mechanical Ventilation during Extracorporeal Membrane Oxygenation in Patients with Acute Severe Respiratory Failure. Can Respir J 2017; 2017:1783857. [PMID: 28127231 PMCID: PMC5239989 DOI: 10.1155/2017/1783857] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/28/2016] [Accepted: 12/18/2016] [Indexed: 02/07/2023] Open
Abstract
Conventionally, a substantial number of patients with acute respiratory failure require mechanical ventilation (MV) to avert catastrophe of hypoxemia and hypercapnia. However, mechanical ventilation per se can cause lung injury, accelerating the disease progression. Extracorporeal membrane oxygenation (ECMO) provides an alternative to rescue patients with severe respiratory failure that conventional mechanical ventilation fails to maintain adequate gas exchange. The physiology behind ECMO and its interaction with MV were reviewed. Next, we discussed the timing of ECMO initiation based on the risks and benefits of ECMO. During the running of ECMO, the protective ventilation strategy can be employed without worrying about catastrophic hypoxemia and carbon dioxide retention. There is a large body of evidence showing that protective ventilation with low tidal volume, high positive end-expiratory pressure, and prone positioning can provide benefits on mortality outcome. More recently, there is an increasing popularity on the use of awake and spontaneous breathing for patients undergoing ECMO, which is thought to be beneficial in terms of rehabilitation.
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Affiliation(s)
- Zhongheng Zhang
- 1Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
- *Zhongheng Zhang:
| | - Wan-Jie Gu
- 2Department of Anesthesiology, Nanjing Drum Tower Hospital, Medical College of Nanjing University, Nanjing 210008, China
| | - Kun Chen
- 3Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Zhejiang, China
| | - Hongying Ni
- 3Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Zhejiang, China
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Baid H. Patient Safety: Identifying and Managing Complications of Mechanical Ventilation. Crit Care Nurs Clin North Am 2016; 28:451-462. [PMID: 28236392 DOI: 10.1016/j.cnc.2016.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Mechanical ventilation is a fundamental aspect of critical care practice to help meet the respiratory needs of critically ill patients. Complications can occur though, as a direct result of being mechanically ventilated, or indirectly because of a secondary process. Preventing, identifying, and managing these complications significantly contribute to the role and responsibilities of critical care nurses in promoting patient safety. This article reviews common ventilator-associated events, including both infectious (eg, ventilator-associated pneumonia) and noninfectious causes (eg, acute respiratory distress syndrome, pulmonary edema, pleural effusion, and atelectasis).
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Affiliation(s)
- Heather Baid
- School of Health Sciences, University of Brighton, Westlain House, Village Way, Falmer Campus, Brighton BN1 9PH, UK.
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