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Borthwick M, McAuley D, Warburton J, Anand R, Bradley J, Connolly B, Blackwood B, O'Neill B, Chikhani M, Dark P, Shyamsundar M. Mucoactive agent use in adult UK Critical Care Units: a survey of health care professionals' perception, pharmacists' description of practice, and point prevalence of mucoactive use in invasively mechanically ventilated patients. PeerJ 2020; 8:e8828. [PMID: 32411506 PMCID: PMC7204825 DOI: 10.7717/peerj.8828] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 02/29/2020] [Indexed: 12/22/2022] Open
Abstract
Background Mechanical ventilation for acute respiratory failure is one of the most common indications for admission to intensive care units (ICUs). Airway mucus clearance is impaired in these patients medication, impaired mucociliary motility, increased mucus production etc. and mucoactive agents have the potential to improve outcomes. However, studies to date have provided inconclusive results. Despite this uncertainty, mucoactives are used in adult ICUs, although the extent of use and perceptions about place in therapy are not known. Aims and Objectives We aim to describe the use of mucoactive agents in mechanically ventilated patients in UK adult critical care units. Specifically, our objectives are to describe clinicians perceptions about the use of mucoactive agents, understand the indications and anticipated benefits, and describe the prevalence and type of mucoactive agents in use. Methods We conducted three surveys. Firstly, a practitioner-level survey aimed at nurses, physiotherapists and doctors to elucidate individual practitioners perceptions about the use of mucoactive agents. Secondly, a critical care unit-level survey aimed at pharmacists to understand how these perceptions translate into practice. Thirdly, a point prevalence survey to describe the extent of prescribing and range of products in use. The practitioner-level survey was disseminated through the UK Intensive Care Society for completion by a multi-professional membership. The unit-level and point prevalence surveys were disseminated cthrough the UK Clinical Pharmacy Association for completion by pharmacists. Results The individual practitioners survey ranked ‘thick secretions’ as the main reason for commencing mucoactive agents determined using clinical assessment. The highest ranked perceived benefit for patient centred outcomes was the duration of ventilation. Of these respondents, 79% stated that further research was important and 87% expressed support for a clinical trial. The unit-level survey found that mucoactive agents were used in 83% of units. The most highly ranked indication was again ‘thick secretions’ and the most highly ranked expected patient centred clinical benefit being improved gas exchange and reduced ventilation time. Only five critical care units provided guidelines to direct the use of mucoactive agents (4%). In the point prevalence survey, 411/993 (41%) of mechanically ventilated patients received at least one mucoactive agent. The most commonly administered mucoactives were inhaled sodium chloride 0.9% (235/993, 24%), systemic carbocisteine (161/993, 16%) and inhaled hypertonic sodium cloride (127/993, 13%). Conclusions Mucoactive agents are used extensively in mechanically ventilated adult patients in UK ICUs to manage ‘thick secretions’, with a key aim to reduce the duration of ventilation. There is widespread support for clinical trials to determine the optimal use of mucoactive agent therapy in this patient population.
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Affiliation(s)
- Mark Borthwick
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Danny McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - John Warburton
- University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Rohan Anand
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Judy Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Bronwen Connolly
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom.,Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Brenda O'Neill
- Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health Research, Ulster University, Newtownabbey, United Kingdom
| | - Marc Chikhani
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Paul Dark
- School of Biological Sciences, Salford Royal NHS Foundation Trust, University of Manchester, Manchester, United States of America
| | - Murali Shyamsundar
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
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Pietersen PI, Konge L, Graumann O, Nielsen BU, Laursen CB. Developing and Gathering Validity Evidence for a Simulation-Based Test of Competencies in Lung Ultrasound. Respiration 2018; 97:329-336. [PMID: 30404101 DOI: 10.1159/000493758] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 09/11/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Clinical lung ultrasound (LUS) is a fast bedside diagnostic tool which can assist clinicians in decisions regarding the treatment and monitoring of patients with respiratory symptoms. LUS training and education differ widely, and is often done in a clinical setting, with potential risks for patients if decisions are made based on the wrong interpretations. No clear guidelines or recommendations for objective and standardized assessment of LUS skills exist, and those that do are often based on a fixed time-frame or an arbitrary number of examinations performed; this does not ensure adequate competencies. OBJECTIVES The study aimed to develop and gather validity evidence for a practical, simulation-based test in LUS. METHODS Nine cases were developed in collaboration with 3D Systems Healthcare, Littleton, CO, USA, representing the most common diagnosis and sonographic findings in patients with respiratory symptoms. Thirty-six participants with different levels of competence in LUS, completed the test. The participants were divided into groups, i.e., novices, intermediates, and experienced, according to their experience with LUS, the number of examinations they had performed, and any research they had conducted. Their answers were used for item analyses. RESULTS The intraclass correlation coefficient, Cronbachs' α, was 0.69 summarized, and there was a statistically significant difference (p < 0.001) between the novices and the trained participants (intermediates and experienced). A pass/fail score of 16 points was calculated according to the contrasting-groups method. CONCLUSION We developed a test for the assessment of clinical competencies in LUS. The test proved solid validity evidence, and a pass/fail standard without any false-negatives, and only 2 explained false-positives.
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Affiliation(s)
- Pia Iben Pietersen
- Regional Center for Technical Simulation, Region of Southern Denmark, Odense, Denmark, .,Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark, .,Institute for Clinical Research, University of Southern Denmark, Odense, Denmark,
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation, Central Region of Denmark, Copenhagen, Denmark
| | - Ole Graumann
- Institute for Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Bjørn Ulrik Nielsen
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Christian B Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark.,Institute for Clinical Research, University of Southern Denmark, Odense, Denmark
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HIF and HOIL-1L-mediated PKCζ degradation stabilizes plasma membrane Na,K-ATPase to protect against hypoxia-induced lung injury. Proc Natl Acad Sci U S A 2017; 114:E10178-E10186. [PMID: 29109255 DOI: 10.1073/pnas.1713563114] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Organisms have evolved adaptive mechanisms in response to stress for cellular survival. During acute hypoxic stress, cells down-regulate energy-consuming enzymes such as Na,K-ATPase. Within minutes of alveolar epithelial cell (AEC) exposure to hypoxia, protein kinase C zeta (PKCζ) phosphorylates the α1-Na,K-ATPase subunit and triggers it for endocytosis, independently of the hypoxia-inducible factor (HIF). However, the Na,K-ATPase activity is essential for cell homeostasis. HIF induces the heme-oxidized IRP2 ubiquitin ligase 1L (HOIL-1L), which leads to PKCζ degradation. Here we report a mechanism of prosurvival adaptation of AECs to prolonged hypoxia where PKCζ degradation allows plasma membrane Na,K-ATPase stabilization at ∼50% of normoxic levels, preventing its excessive down-regulation and cell death. Mice lacking HOIL-1L in lung epithelial cells (CreSPC/HOIL-1Lfl/fl ) were sensitized to hypoxia because they express higher levels of PKCζ and, consequently, lower plasma membrane Na,K-ATPase levels, which increased cell death and worsened lung injury. In AECs, expression of an α1-Na,K-ATPase construct bearing an S18A (α1-S18A) mutation, which precludes PKCζ phosphorylation, stabilized the Na,K-ATPase at the plasma membrane and prevented hypoxia-induced cell death even in the absence of HOIL-1L. Adenoviral overexpression of the α1-S18A mutant Na,K-ATPase in vivo rescued the enhanced sensitivity of CreSPC/HOIL-1Lfl/fl mice to hypoxic lung injury. These data suggest that stabilization of Na,K-ATPase during severe hypoxia is a HIF-dependent process involving PKCζ degradation. Accordingly, we provide evidence of an important adaptive mechanism to severe hypoxia, whereby halting the exaggerated down-regulation of plasma membrane Na,K-ATPase prevents cell death and lung injury.
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Spoletini G, Hill NS. High-flow nasal oxygen versus noninvasive ventilation for hypoxemic respiratory failure: Do we know enough? Ann Thorac Med 2016; 11:163-6. [PMID: 27512504 PMCID: PMC4966217 DOI: 10.4103/1817-1737.185760] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Giulia Spoletini
- Respiratory Support and Sleep Centre, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Nicholas S Hill
- Pulmonary, Critical Care and Sleep Division, Tufts Medical Center, Boston, MA, USA
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Sekiguchi H, Schenck LA, Horie R, Suzuki J, Lee EH, McMenomy BP, Chen TE, Lekah A, Mankad SV, Gajic O. Critical Care Ultrasonography Differentiates ARDS, Pulmonary Edema, and Other Causes in the Early Course of Acute Hypoxemic Respiratory Failure. Chest 2015; 148:912-918. [DOI: 10.1378/chest.15-0341] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Abstract
Pulmonary edema clearance is necessary for patients with lung injury to recover and survive. The mechanisms regulating edema clearance from the lungs are distinct from the factors contributing edema formation during injury. Edema clearance is effected via vectorial transport of Na(+) out of the airspaces which generates an osmotic gradient causing water to follow the gradient out of the cells. This Na(+) transport across the alveolar epithelium is mostly effected via apical Na(+) and chloride channels and basolateral Na,K-ATPase. The Na,K-ATPase pumps Na(+) out of the cell and K(+) into the cell against their respective gradients in an ATP-consuming reaction. Two mechanisms contribute to the regulation of the Na,K-ATPase activity:recruitment of its subunits from intracellular compartments into the basolateral membrane, and transcriptional/translational regulation. Na,K-ATPase activity and edema clearance are increased by catecholamines, aldosterone, vasopressin, overexpression of the pump genes, and others. During lung injury, mechanisms regulating edema clearance are inhibited by yet unclear pathways. Better understanding of the mechanisms that regulate pulmonary edema clearance may lead to therapeutic interventions that counterbalance the inhibition of edema clearance during lung injury and improve the lungs' ability to clear fluid, which is crucial for patient survival.
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Affiliation(s)
- Zaher S. Azzam
- Internal Medicine “B”, Rambam Health Care Campus, Department of Physiology and Biophysics, The Rappaport Family Faculty of Medicine and Research Institute, Technion, Israel Institute of Technology, Haifa, Israel
| | - Jacob I. Sznajder
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, IL, USA
- To whom correspondence should be addressed. E-mail:
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Early exercise rehabilitation of muscle weakness in acute respiratory failure patients. Exerc Sport Sci Rev 2014; 41:208-15. [PMID: 23873130 DOI: 10.1097/jes.0b013e3182a4e67c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Acute respiratory failure patients experience significant muscle weakness, which contributes to prolonged hospitalization and functional impairments after hospital discharge. Based on our previous work, we hypothesize that an exercise intervention initiated early in the intensive care unit aimed at improving skeletal muscle strength could decrease hospital stay and attenuate the deconditioning and skeletal muscle weakness experienced by these patients.
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Arnold KM, Goeckeler ZM, Wysolmerski RB. Loss of Focal Adhesion Kinase Enhances Endothelial Barrier Function and Increases Focal Adhesions. Microcirculation 2013; 20:637-49. [DOI: 10.1111/micc.12063] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 04/16/2013] [Indexed: 12/30/2022]
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Ultrasound imaging and use of B-lines for functional lung evaluation in neurocritical care. Eur J Anaesthesiol 2013; 30:464-8. [DOI: 10.1097/eja.0b013e32835fe4a4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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