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Price AD, Baucom MR, Blakeman TC, Smith M, Gomaa D, Caskey C, Pritts T, Strilka R, Branson RD, Goodman MD. Just Say NO: Inhaled Nitric Oxide Effect on Respiratory Parameters Following Traumatic Brain Injury in Humans and a Porcine Model. J Surg Res 2024; 296:497-506. [PMID: 38325012 DOI: 10.1016/j.jss.2023.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 12/27/2023] [Accepted: 12/29/2023] [Indexed: 02/09/2024]
Abstract
INTRODUCTION The mechanism of post-traumatic brain injury (TBI) hypoxemia involves ventilation/perfusion mismatch and loss of pulmonary hypoxic vasoconstriction. Inhaled nitric oxide (iNO) has been studied as an adjunct treatment to avoid the use of high positive end-expiratory pressure and inspired oxygen in treatment-refractory hypoxia. We hypothesized that iNO treatment following TBI would improve systemic and cerebral oxygenation via improved matching of pulmonary perfusion and ventilation. METHODS Thirteen human patients with isolated TBI were enrolled and randomized to receive either placebo or iNO with measured outcomes including pulmonary parameters, blood gas data, and intracranial pressure (ICP) /perfusion. To complement this study, a porcine model of TBI (including 10 swine) was utilized with measured outcomes of brain tissue blood flow and oxygenation, ventilator parameters, and blood gas data both after administration and following drug removal and clearance. RESULTS There were no clinically significant changes in pulmonary parameters in either the human or porcine arm following administration of iNO when compared to either the placebo group (human arm) or the internal control (porcine arm). Analysis of pooled human data demonstrated the preservation of alveolar recruitment in TBI patients. There were no clinically significant changes in human ICP or cerebral perfusion pressure following iNO administration compared to controls. CONCLUSIONS iNO had no significant effect on clinically relevant pulmonary parameters or ICPs following TBI in both human patients and a porcine model. The pressure-based recruitment of the human lungs following TBI was preserved. Further investigation will be needed to determine the degree of utility of iNO in the setting of hypoxia after polytrauma.
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Affiliation(s)
- Adam D Price
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Matthew R Baucom
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Maia Smith
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Dina Gomaa
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Chelsea Caskey
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Timothy Pritts
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Richard Strilka
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Ziaka M, Exadaktylos A. Pathophysiology of acute lung injury in patients with acute brain injury: the triple-hit hypothesis. Crit Care 2024; 28:71. [PMID: 38454447 PMCID: PMC10918982 DOI: 10.1186/s13054-024-04855-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 03/01/2024] [Indexed: 03/09/2024] Open
Abstract
It has been convincingly demonstrated in recent years that isolated acute brain injury (ABI) may cause severe dysfunction of peripheral extracranial organs and systems. Of all potential target organs and systems, the lung appears to be the most vulnerable to damage after ABI. The pathophysiology of the bidirectional brain-lung interactions is multifactorial and involves inflammatory cascades, immune suppression, and dysfunction of the autonomic system. Indeed, the systemic effects of inflammatory mediators in patients with ABI create a systemic inflammatory environment ("first hit") that makes extracranial organs vulnerable to secondary procedures that enhance inflammation, such as mechanical ventilation (MV), surgery, and infections ("second hit"). Moreover, accumulating evidence supports the knowledge that gut microbiota constitutes a critical superorganism and an organ on its own, potentially modifying various physiological functions of the host. Furthermore, experimental and clinical data suggest the existence of a communication network among the brain, gastrointestinal tract, and its microbiome, which appears to regulate immune responses, gastrointestinal function, brain function, behavior, and stress responses, also named the "gut-microbiome-brain axis." Additionally, recent research evidence has highlighted a crucial interplay between the intestinal microbiota and the lungs, referred to as the "gut-lung axis," in which alterations during critical illness could result in bacterial translocation, sustained inflammation, lung injury, and pulmonary fibrosis. In the present work, we aimed to further elucidate the pathophysiology of acute lung injury (ALI) in patients with ABI by attempting to develop the "double-hit" theory, proposing the "triple-hit" hypothesis, focused on the influence of the gut-lung axis on the lung. Particularly, we propose, in addition to sympathetic hyperactivity, blast theory, and double-hit theory, that dysbiosis and intestinal dysfunction in the context of ABI alter the gut-lung axis, resulting in the development or further aggravation of existing ALI, which constitutes the "third hit."
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Affiliation(s)
- Mairi Ziaka
- Clinic for Geriatric Medicine, Center for Geriatric Medicine and Rehabilitation, Kantonsspital Baselland, Bruderholz, Switzerland.
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland.
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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Yoshizawa Y, Hirashima O, Uramoto S, Amagai T. Neurogenic pulmonary edema due to acute respiratory distress syndrome after status epilepticus. J Neurosci Rural Pract 2023; 14:196-197. [PMID: 36891118 PMCID: PMC9945022 DOI: 10.25259/jnrp-2022-5-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/20/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Yuki Yoshizawa
- Department of Medicine, Kikai Tokushukai General Hospital, Kikai, Japan
| | - Osamu Hirashima
- Department of Medicine, Naze Tokushukai General Hospital, Amami, Japan
| | - Satoshi Uramoto
- Department of Medicine, Kikai Tokushukai General Hospital, Kikai, Japan
| | - Teruyoshi Amagai
- Department of Clinical Engineering, University of Jikei Health Care Sciences, Osaka City, Japan
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Fan TH, Huang M, Price C, Premraj L, Kannapadi NV, Suarez JI, Cho SM. Prevalence and outcomes of acute respiratory distress syndrome in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. JOURNAL OF NEUROCRITICAL CARE 2022. [DOI: 10.18700/jnc.220043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: In this study, we aimed to investigate the prevalence, timing, risk factors, and outcomes of acute respiratory distress syndrome (ARDS) in patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods: PubMed and four other databases were searched for randomized controlled trials (RCTs) and observational studies of patients 18 years or older through October 20, 2021. Study quality was assessed, using the Cochrane Risk of Bias tool for RCTs and the Newcastle-Ottawa Scale for cohort and case-control studies. High-grade aSAH was defined as a Hunt-Hess grade≥3 and/or a modified Fisher score≥3. A good neurological outcome was defined as a Glasgow Outcome Scale score ≥4. Random-effects meta-analyses were conducted to estimate the pooled outcome prevalence and 95% confidence interval (CI). Results: Eleven observational studies (n=6,107) met the inclusion criteria. Overall, 15% of the patients (95% CI=10.5–20.0; I2=97.8%) developed ARDS after aSAH, with a mean time of 3 days (95% CI=1.9–3.7; I2=54%). Overall survival at discharge was 80% (95% CI=75–86; I2=96%), and 67% of aSAH patients (95% CI=54.9–78.9; I2=94%) had a good neurological outcome at any time. The aSAH cohort without ARDS had a higher rate of survival than those with ARDS (79% vs. 49%, P=0.028). Male sex, patients with a high-grade aSAH, patients who developed pneumonia, and systemic inflammatory response syndrome during hospital admission were at a higher risk of developing ARDS.Conclusion: In this meta-analysis, approximately one in six patients developed ARDS after aSAH, with a mean time of 3 days from the initial presentation, and ARDS was associated with increased mortality.
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Egan TM, Haithcock BE, Lobo J, Mody G, Love RB, Requard JJ, Espey J, Ali MH. Donation after circulatory death donors in lung transplantation. J Thorac Dis 2022; 13:6536-6549. [PMID: 34992833 PMCID: PMC8662509 DOI: 10.21037/jtd-2021-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 12/13/2022]
Abstract
Transplantation of any organ into a recipient requires a donor. Lung transplant has a long history of an inadequate number of suitable donors to meet demand, leading to deaths on the waiting list annually since national data was collected, and strict listing criteria. Before the Uniform Determination of Death Act (UDDA), passed in 1980, legally defined brain death in the U.S., all donors for lung transplant came from sudden death victims [uncontrolled Donation after Circulatory Death donors (uDCDs)] in the recipient’s hospital emergency department. After passage of the UDDA, uDCDs were abandoned to Donation after Brain Death donors (DBDs)—perhaps prematurely. Compared to livers and kidneys, many DBDs have lungs that are unsuitable for transplant, due to aspiration pneumonia, neurogenic pulmonary edema, trauma, and the effects of brain death on lung function. Another group of donors has become available—patients with a devastating irrecoverable brain injury that do not meet criteria for brain death. If a decision is made by next-of-kin (NOK) to withdraw life support and allow death to occur by asphyxiation, with NOK consent, these individuals can have organs recovered if death occurs relatively quickly after cessation of mechanical ventilation and maintenance of their airway. These are known as controlled Donation after Circulatory Death donors (cDCDs). For a variety of reasons, in the U.S., lungs are recovered from cDCDs at a much lower rate than kidneys and livers. Ex-vivo lung perfusion (EVLP) in the last decade has had a modest impact on increasing the number of lungs for transplant from DBDs, but may have had a larger impact on lungs from cDCDs, and may be indispensable for safe transplantation of lungs from uDCDs. In the next decade, DCDs may have a substantial impact on the number of lung transplants performed in the U.S. and around the world.
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Affiliation(s)
- Thomas M Egan
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
| | | | - Jason Lobo
- Department of Medicine, UNC at Chapel Hill, Chapel Hill, NC, USA
| | - Gita Mody
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
| | - Robert B Love
- Department of Surgery, Feinberg School of Medicine, Chicago, IL, USA
| | | | - John Espey
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
| | - Mir Hasnain Ali
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
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Prevalence and Outcome of Acute Respiratory Distress Syndrome in Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Lung 2021; 199:603-610. [PMID: 34779897 PMCID: PMC8590970 DOI: 10.1007/s00408-021-00491-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/26/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVES Acute respiratory distress syndrome (ARDS) in patients with traumatic brain injury (TBI) is associated with increased mortality. Information on the prevalence of ARDS and its neurological outcome after TBI is sparse. We aimed to systematically review the prevalence, risk factors, and outcome of ARDS in TBI population. DATA SOURCES PubMed and four other databases (Embase, Cochrane Library, Web of Science Core Collection, and Scopus) from inception to July 6, 2020. STUDY SELECTION Randomized controlled trials (RCTs) and observational studies in patients older than 18 years old. DATA EXTRACTION Two independent reviewers extracted the data. Study quality was assessed by the Cochrane Risk of Bias tool for RCTs, the Newcastle-Ottawa Scale for cohort and case-control studies. Good neurological outcome was defined as Glasgow Outcome Scale ≥ 4. Random-effects meta-analyses were conducted to estimate pooled outcome prevalence and their 95% confidence intervals (CI). DATA SYNTHESIS We included 20 studies (n = 2830) with median age of 44 years (interquartile range [IQR] = 35-47, 64% male) and 79% (n = 2237) suffered severe TBI. In meta-analysis, 19% patients (95% CI = 0.13-0.27, I2 = 93%) had ARDS after TBI. The median time from TBI to ARDS was 3 days (IQR = 2-5). Overall survival at discharge for the TBI cohort was 70% (95% CI = 0.64-0.75; I2 = 85%) and good neurological outcome at any time was achieved in 31% of TBI patients (95% CI = 0.23-0.40; I2 = 88%). TBI cohort without ARDS had higher survival (67% vs. 57%, p = 0.01) and good neurological outcomes (34% vs. 23%, p = 0.02) compared to those with ARDS. We did not find any specific risk factors for developing ARDS. CONCLUSION In this meta-analysis, approximately one in five patients had ARDS shortly after TBI with the median time of 3 days. The presence of ARDS was associated with worse neurological outcome and mortality in TBI. Further research on prevention and intervention strategy of TBI-associated ARDS is warranted.
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Ziaka M, Exadaktylos A. Brain-lung interactions and mechanical ventilation in patients with isolated brain injury. Crit Care 2021; 25:358. [PMID: 34645485 PMCID: PMC8512596 DOI: 10.1186/s13054-021-03778-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/30/2021] [Indexed: 11/29/2022] Open
Abstract
During the last decade, experimental and clinical studies have demonstrated that isolated acute brain injury (ABI) may cause severe dysfunction of peripheral extracranial organs and systems. Of all potential target organs and systems, the lung appears to be the most vulnerable to damage after brain injury (BI). The pathophysiology of these brain–lung interactions are complex and involve neurogenic pulmonary oedema, inflammation, neurodegeneration, neurotransmitters, immune suppression and dysfunction of the autonomic system. The systemic effects of inflammatory mediators in patients with BI create a systemic inflammatory environment that makes extracranial organs vulnerable to secondary procedures that enhance inflammation, such as mechanical ventilation (MV), surgery and infections. Indeed, previous studies have shown that in the presence of a systemic inflammatory environment, specific neurointensive care interventions—such as MV—may significantly contribute to the development of lung injury, regardless of the underlying mechanisms. Although current knowledge supports protective ventilation in patients with BI, it must be born in mind that ABI-related lung injury has distinct mechanisms that involve complex interactions between the brain and lungs. In this context, the role of extracerebral pathophysiology, especially in the lungs, has often been overlooked, as most physicians focus on intracranial injury and cerebral dysfunction. The present review aims to fill this gap by describing the pathophysiology of complications due to lung injuries in patients with a single ABI, and discusses the possible impact of MV in neurocritical care patients with normal lungs.
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Affiliation(s)
- Mairi Ziaka
- Department of Internal Medicine, Thun General Hospital, Thun, Switzerland.
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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8
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van Zanden JE, Rebolledo RA, Hoeksma D, Bubberman JM, Burgerhof JG, Breedijk A, Yard BA, Erasmus ME, Leuvenink HGD, Hottenrott MC. Rat donor lung quality deteriorates more after fast than slow brain death induction. PLoS One 2020; 15:e0242827. [PMID: 33253309 PMCID: PMC7704005 DOI: 10.1371/journal.pone.0242827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 11/10/2020] [Indexed: 01/22/2023] Open
Abstract
Donor brain death (BD) is initiated by an increase in intracranial pressure (ICP), which subsequently damages the donor lung. In this study, we investigated whether the speed of ICP increase affects quality of donor lungs, in a rat model for fast versus slow BD induction. Rats were assigned to 3 groups: 1) control, 2) fast BD induction (ICP increase over 1 min) or 3) slow BD induction (ICP increase over 30 min). BD was induced by epidural inflation of a balloon catheter. Brain-dead rats were sacrificed after 0.5 hours, 1 hour, 2 hours and 4 hours to study time-dependent changes. Hemodynamic stability, histological lung injury and inflammatory status were investigated. We found that fast BD induction compromised hemodynamic stability of rats more than slow BD induction, reflected by higher mean arterial pressures during the BD induction period and an increased need for hemodynamic support during the BD stabilization phase. Furthermore, fast BD induction increased histological lung injury scores and gene expression levels of TNF-α and MCP-1 at 0.5 hours after induction. Yet after donor stabilization, inflammatory status was comparable between the two BD models. This study demonstrates fast BD induction deteriorates quality of donor lungs more on a histological level than slow BD induction.
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Affiliation(s)
- Judith E. van Zanden
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- * E-mail:
| | - Rolando A. Rebolledo
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Institute for Medical and Biological Engineering, Schools of Engineering, Biological Sciences and Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Dane Hoeksma
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jeske M. Bubberman
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Johannes G. Burgerhof
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Annette Breedijk
- Department of Internal Medicine, V. Clinic, University Medical Center Mannheim, Mannheim, Germany
| | - Benito A. Yard
- Department of Internal Medicine, V. Clinic, University Medical Center Mannheim, Mannheim, Germany
| | - Michiel E. Erasmus
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henri G. D. Leuvenink
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maximilia C. Hottenrott
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Surgery, University of Regensburg, Regensburg, Germany
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Barile M. Pulmonary Edema: A Pictorial Review of Imaging Manifestations and Current Understanding of Mechanisms of Disease. Eur J Radiol Open 2020; 7:100274. [PMID: 33163585 PMCID: PMC7607415 DOI: 10.1016/j.ejro.2020.100274] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/22/2020] [Indexed: 12/20/2022] Open
Abstract
Pulmonary edema is a common clinical entity caused by the extravascular movement of fluid into the pulmonary interstitium and alveoli. The four physiologic categories of edema include hydrostatic pressure edema, permeability edema with and without diffuse alveolar damage (DAD), and mixed edema where there is both an increase in hydrostatic pressure and membrane permeability. As radiographic manifestations and etiologies are varied, an appreciation for both the common and uncommon manifestations and causes of pulmonary edema is essential for accurate diagnosis.
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Affiliation(s)
- Maria Barile
- Department of Radiology at University of Massachusetts Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, United States
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10
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Mrozek S, Gobin J, Constantin JM, Fourcade O, Geeraerts T. Crosstalk between brain, lung and heart in critical care. Anaesth Crit Care Pain Med 2020; 39:519-530. [PMID: 32659457 DOI: 10.1016/j.accpm.2020.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 05/05/2020] [Accepted: 06/07/2020] [Indexed: 12/17/2022]
Abstract
Extracerebral complications, especially pulmonary and cardiovascular, are frequent in brain-injured patients and are major outcome determinants. Two major pathways have been described: brain-lung and brain-heart interactions. Lung injuries after acute brain damages include ventilator-associated pneumonia (VAP), acute respiratory distress syndrome (ARDS) and neurogenic pulmonary œdema (NPE), whereas heart injuries can range from cardiac enzymes release, ECG abnormalities to left ventricle dysfunction or cardiogenic shock. The pathophysiologies of these brain-lung and brain-heart crosstalk are complex and sometimes interconnected. This review aims to describe the epidemiology and pathophysiology of lung and heart injuries in brain-injured patients with the different pathways implicated and the clinical implications for critical care physicians.
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Affiliation(s)
- Ségolène Mrozek
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France.
| | - Julie Gobin
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France
| | - Jean-Michel Constantin
- Department of anaesthesia and critical care, Sorbonne university, La Pitié-Salpêtrière hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Olivier Fourcade
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France
| | - Thomas Geeraerts
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France
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Qian Y, Gao C, Zhao X, Song Y, Luo H, An S, Huang J, Zhang J, Jiang R. Fingolimod Attenuates Lung Injury and Cardiac Dysfunction after Traumatic Brain Injury. J Neurotrauma 2020; 37:2131-2140. [PMID: 32434456 DOI: 10.1089/neu.2019.6951] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Acute lung injury (ALI) and cardiac dysfunction are common in traumatic brain injury (TBI) patients and always indicate poor outcomes. Inflammatory responses play important roles in TBI-induced cardiac and pulmonary damage. Fingolimod, an immunomodulatory agent, alleviates brain edema, restores the integrity of the blood-brain barrier (BBB), and improves functional deficits by inhibiting multiple inflammatory responses. Fingolimod (1 mg/kg) was injected intraperitoneally at 2 h after the controlled cortical impact (CCI) model was established in adult male mice. The concentration of inflammatory cytokines in the lung and heart after TBI was measured with a cytokine array. The lung wet/dry weight ratio and Evans blue dye leakage were used to quantify pulmonary edema and capillary leakage. Immunofluorescence, electron microscopy, and echocardiographic examination were used to assess the pathology and functional deficits in hearts. We found that TBI caused significant heart and lung damage. The administration of fingolimod significantly reduced the elevated inflammatory cytokine production, neutrophil infiltration, the leakage of protein in bronchoalveolar lavage fluid (BALF), and the wet/dry weight ratio in lung tissue at 3 days after TBI. In addition, fingolimod treatment also alleviated the inflammatory response in the heart; decreased cardiac apoptosis, fibrosis, and histological microstructural changes; and improved cardiac function from 3 days after TBI and maintained it for 30 days after TBI as measured by echocardiography. These results suggest that TBI resulted in significant cardiac and pulmonary damage accompanied by significant inflammatory responses in heart and lung tissue. Fingolimod treatment reduced the inflammatory response and alleviated TBI-induced lung and heart injury.
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Affiliation(s)
- Yu Qian
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China
| | - Chuang Gao
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China.,Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | | | - Yiming Song
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China.,Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongliang Luo
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China.,Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Shuo An
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China.,Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jinhao Huang
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China.,Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jianning Zhang
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China.,Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Rongcai Jiang
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin, China.,Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
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A Randomized Controlled Trial of Naloxone for Optimization of Hypoxemia in Lung Donors After Brain Death. Transplantation 2020; 103:1433-1438. [PMID: 30399122 DOI: 10.1097/tp.0000000000002511] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Persistent hypoxemia is the principal reason lungs from otherwise eligible brain dead (BD) organ donors are not transplanted. Experimental models and retrospective studies have suggested that naloxone attenuates neurogenic pulmonary edema and reverses hypoxemia after brain death. We undertook a multisite, randomized, placebo-controlled trial to evaluate whether naloxone is able to improve oxygenation in BD donors with hypoxemia. METHODS BD organ donors at 4 organ procurement organizations were randomized in a blinded manner to naloxone 8 mg or saline placebo if lung were being considered for allocation but exhibited hypoxemia (partial pressure of oxygen in arterial blood to fraction of inspired oxygen ratio [PFR] below 300 mm Hg). The primary outcome was change in PFR from baseline to final arterial blood gas. Secondary outcomes included early improvement in PFR and proportion of lungs transplanted. RESULTS A total of 199 lung-eligible BD donors were randomized to naloxone (n = 98) or placebo (n = 101). Groups were comparable at baseline. Both groups exhibited similar improvements in oxygenation (median improvement in PFR of 81 with naloxone versus 80 with saline, P = 0.68), with 37 (39%) versus 38 (40%) exhibiting reversal of hypoxemia. There was no difference in the rate of lungs transplanted (19% in both groups, P = 0.97) although it was significantly higher in those with reversal of hypoxemia (32/69 versus 2/111, P < 0.001). CONCLUSIONS Naloxone does not improve oxygenation more than placebo in hypoxemic organ donors. However, reversal of hypoxemia was a powerful predictor of lung utilization regardless of drug therapy. Further organ procurement organization-led research is needed to assess optimal interventions to improve oxygenation in BD donors with hypoxemia.
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13
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Shao XF, Li B, Shen J, Wang QF, Chen SS, Jiang XC, Qiang D. Ghrelin alleviates traumatic brain injury-induced acute lung injury through pyroptosis/NF-κB pathway. Int Immunopharmacol 2020; 79:106175. [PMID: 31918060 DOI: 10.1016/j.intimp.2019.106175] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/22/2019] [Accepted: 12/30/2019] [Indexed: 12/18/2022]
Abstract
Acute lung injury (ALI) is one of the severe complications in patients with traumatic brain injury (TBI), contributing to the high mortality. Ghrelin has protective effects against various inflammatory diseases, but the effects of Ghrelin on TBI-induced ALI and its mechanisms remain unknown. In this study, Ghrelin administration was performed on the mice with TBI, then histological change in cortex and lung tissues, lung vascular permeability and macrophage number in bronchoalveolar lavage fluid (BALF) were examined, respectively. Simultaneously, the alterations of proinflammatory factors and pyroptosis-related proteins in lung tissues were detected. As a result, TBI-induced ALI was ameliorated after Ghrelin treatment, which was demonstrated by improved histology, reduced lung vascular permeability, and peripheral macrophage number. Furthermore, Ghrelin decreased the mRNA levels of proinflammatory factors (IL-1β, IL-6, TNF-α and IL-18), the protein levels of pyroptosis-related proteins (NLRP3, Caspase1-P20, HMGB1 and Gasdermin D), and the phosphorylation levels of NF-κB in lung tissues. These results showed that Ghrelin attenuating TBI-induced ALI might be via ameliorating inflammasome-induced pyroptosis by blocking NF-κB signal, which are important for the prevention and treatment of TBI-induced ALI.
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Affiliation(s)
- Xue-Fei Shao
- Department of Neurosurgery, Yi Ji Shan Hospital of Wannan Medical College, Wuhu, China.
| | - Bo Li
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jun Shen
- Department of Neurosurgery, Yi Ji Shan Hospital of Wannan Medical College, Wuhu, China
| | - Qi-Fu Wang
- Department of Neurosurgery, Yi Ji Shan Hospital of Wannan Medical College, Wuhu, China
| | - San-Song Chen
- Department of Neurosurgery, Yi Ji Shan Hospital of Wannan Medical College, Wuhu, China
| | - Xiao-Chun Jiang
- Department of Neurosurgery, Yi Ji Shan Hospital of Wannan Medical College, Wuhu, China
| | - Di Qiang
- Department of Dermatology and STD, Yi-Ji Shan Hospital of Wannan Medical College, Wuhu, China.
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14
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Liao WC, Cheng WC, Wu BR, Chen WC, Chen CY, Chen CH, Tu CY, Hsia TC. Outcome and prognostic factors of patients treated in the intensive care unit for carbon monoxide poisoning. J Formos Med Assoc 2018; 118:821-827. [PMID: 30293927 DOI: 10.1016/j.jfma.2018.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/04/2018] [Accepted: 09/05/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Carbon monoxide (CO), a colorless and odorless gas, is one of the common causes of poisoning-related deaths worldwide. CO poisoning can result in hypoxic brain damage and death, but intensive care can improve the likely outcome for critically ill patients. However, there is a paucity of clinical data regarding the prognostic factors and association between organ dysfunction and clinical outcome of patients treated for CO poisoning in the intensive care unit (ICU). METHODS We performed a retrospective study of patients admitted to a university affiliated hospital ICU between July 2001 and December 2010 following CO poisoning. Outcomes were survival to ICU discharge and to hospital discharge. RESULTS Seven hundred and eighty-seven patients were admitted to the university hospital following CO poisoning, of which 140 (17.8%) were admitted to the hospital ICU. The overall mortality rate of the patients admitted to the ICU was 14.3% (20/140). Univariate analysis indicated that non-surviving patients with CO poisoning were more likely to have initial blood carboxyhemoglobin (COHb) level > 30%, shock, acute respiratory failure, Acute Physiology and Chronic Health Evaluation II (APACHE II) score ≥ 25, Glasgow coma scale (GCS) score of 3, acute renal failure, dysfunction or failure of more than 3 organs, low blood pH, low HCO3- level, high potassium level, and high glucose level. They were also more likely to have not received hyperbaric oxygen (HBO) intervention. Multivariate logistical regression analysis indicated that the mortality rate of patients treated in the ICU for CO poisoning was higher if their initial APACHE II score was ≥25, GCS was 3, and more than 3 organs were dysfunctional. Moreover, HBO intervention in ICU significantly decreased patients' risk of mortality due to CO poisoning. CONCLUSION In conclusion, we observed that APACHE II score >25, GCS 3, and dysfunction of more than 3 organ systems on admission to emergency department was associated with a significant mortality risk in patients treated in the ICU for CO poisoning. Moreover, HBO therapy could reduce the risk of mortality in patients with CO poisoning in ICU.
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Affiliation(s)
- Wei-Chih Liao
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan; Hyperbaric Oxygen Therapy Center, China Medical University Hospital, Taichung, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Wen-Chien Cheng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan; Hyperbaric Oxygen Therapy Center, China Medical University Hospital, Taichung, Taiwan
| | - Biing-Ru Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan; Hyperbaric Oxygen Therapy Center, China Medical University Hospital, Taichung, Taiwan
| | - Wei-Chun Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan; Hyperbaric Oxygen Therapy Center, China Medical University Hospital, Taichung, Taiwan; Department of Respiratory Therapy, China Medical University, Taichung, Taiwan
| | - Chih-Yu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan; Hyperbaric Oxygen Therapy Center, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Hung Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan; Department of Respiratory Therapy, China Medical University, Taichung, Taiwan.
| | - Chih-Yen Tu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan; Hyperbaric Oxygen Therapy Center, China Medical University Hospital, Taichung, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.
| | - Te-Chun Hsia
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan; Hyperbaric Oxygen Therapy Center, China Medical University Hospital, Taichung, Taiwan; Department of Respiratory Therapy, China Medical University, Taichung, Taiwan
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15
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Jin Y, Zhang C, Wang H, Zhou G, Wang X, Zhang R, Chen S, Ren J, Chen L, Dang D, Zhang P, Xi Y, Wu W, Zhang W, Duan G. Mast cells contribute to Enterovirus 71 infection-induced pulmonary edema in neonatal mice. J Transl Med 2018; 98:1039-1051. [PMID: 29765110 DOI: 10.1038/s41374-018-0075-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 03/15/2018] [Accepted: 04/09/2018] [Indexed: 11/09/2022] Open
Abstract
Enterovirus (EV) 71 infection has been widely acknowledged as the leading cause of severe hand, foot and mouth disease (HFMD), which may rapidly lead to fatal pulmonary edema. In this study, we established a mouse model for EV71 infection exhibiting high incidence of severe symptoms with pulmonary edema. Mast cells (MCs) accumulation, activation and allergic inflammation were found in the brains, lungs and skeletal muscle of mice after EV71 infection, especially in the lungs of mice. Levels of histamine, platelet-activating factor (PAF), interleukin (IL)-4, IL-5, IL-13, tumor necrosis factor-α (TNF-α), nitric oxide (NO), endocrine gland-derived vascular endothelial growth factor (EG-VEGF) and noradrenaline (NA) were increased in EV71-infected lungs. In addition, EV71 infection reduced the number of pulmonary T cells, dendritic cells (DCs) and monocytes, and increased the number of lung eosinophils, Tregs and MCs. MCs number and tryptase expression in target organs or tissues posed a trend towards an increase from control to severe mice. There were positive correlations between MCs number in the brains (r = 0.701, P = 0.003), lungs (r = 0.802, P < 0.0001), skeletal muscles (r = 0.737, P = 0.001) and mean clinical score. Thus, our results suggested that MCs contributed to the pulmonary edema during EV71 infection.
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Affiliation(s)
- Yuefei Jin
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Chao Zhang
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Hui Wang
- Henan Collaborative Innovation Center of Molecular Diagnosis and Laboratory Medicine, Xinxiang, Henan, People's Republic of China.,Research Center for Immunology, School of Laboratory Medicine, Xinxiang Medical University, Xinxiang, Henan, People's Republic of China
| | - Guangyuan Zhou
- School of Public Health, Xinxiang Medical University, Xinxiang, Henan, People's Republic of China
| | - Xiangpeng Wang
- Henan Collaborative Innovation Center of Molecular Diagnosis and Laboratory Medicine, Xinxiang, Henan, People's Republic of China.,Research Center for Immunology, School of Laboratory Medicine, Xinxiang Medical University, Xinxiang, Henan, People's Republic of China
| | - Rongguang Zhang
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China.,Henan Collaborative Innovation Center of Molecular Diagnosis and Laboratory Medicine, Xinxiang, Henan, People's Republic of China
| | - Shuaiyin Chen
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Jingchao Ren
- Henan Collaborative Innovation Center of Molecular Diagnosis and Laboratory Medicine, Xinxiang, Henan, People's Republic of China.,School of Public Health, Xinxiang Medical University, Xinxiang, Henan, People's Republic of China
| | - Lu Chen
- Department of Oncology, The Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, Henan, People's Republic of China
| | - Dejian Dang
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Peng Zhang
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yuanlin Xi
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Weidong Wu
- Henan Collaborative Innovation Center of Molecular Diagnosis and Laboratory Medicine, Xinxiang, Henan, People's Republic of China.,School of Public Health, Xinxiang Medical University, Xinxiang, Henan, People's Republic of China
| | - Weiguo Zhang
- Department of Immunology, Duke University Medical Center, Durham, NC, United States of America
| | - Guangcai Duan
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China.
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16
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Burzyńska M, Uryga A, Kasprowicz M, Kędziora J, Szewczyk E, Woźniak J, Jarmundowicz W, Kübler A. Changes in the level of cardiac troponine and disorders in pulmonary gas exchange as predictors of short- and long-term outcomes of patients with aneurysm subarachnoid haemorrhage. Br J Neurosurg 2017. [PMID: 28633535 DOI: 10.1080/02688697.2017.1339301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
SUBJECT Cardiopulmonary abnormalities are common after aneurysmal subarachnoid haemorrhage (aSAH). However, the relationship between short- and long-term outcome is poorly understood. In this paper, we present how cardiac troponine elevations (cTnI) and pulmonary disorders are associated with short- and long-term outcomes assessed by the Glasgow Outcome Scale (GOS) and Extended Glasgow Outcome Scale (GOSE). METHODS A total of 104 patients diagnosed with aSAH were analysed in the study. The non-parametric U Mann-Whitney test was used to evaluate the difference between good (GOS IV-V, GOSE V-VIII) and poor (GOS I-III, GOSE I-IV) outcomes in relation to cTnI elevation and pulmonary disorders. Outcome was assessed at discharge from the hospital, and then followed up 6 and 12 months later. Pulmonary disorders were determined by the PaO2/FiO2 ratio and radiography. The areas under the ROC curves (AUCs) were used to determine the predictive power of these factors. RESULTS In the group with good short-term outcomes cTnI elevation on the second day after aSAH was significantly lower (p = .00007) than in patients with poor short-term outcomes. The same trend was observed after 6 months, although there were different results 12 months from the onset (p = .024 and n.s., respectively). A higher peak of cTnI was observed in the group with a pathological X-ray (p = .008) and pathological PaO2/FiO2 ratio (p ≪ .001). cTnI was an accurate predictor of short-term outcomes (AUC = 0.741, p ≪ .001) and the outcome after 6 months (AUC = 0.688, p = .015). CONCLUSION The results showed that cardiopulmonary abnormalities perform well as predictive factors for short- and long-term outcomes after aSAH.
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Affiliation(s)
- Małgorzata Burzyńska
- a Department of Anaesthesiology and Intensive Care , Wroclaw Medical University , Wroclaw , Poland
| | - Agnieszka Uryga
- b Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology , Wroclaw University of Science and Technology , Wroclaw , Poland
| | - Magdalena Kasprowicz
- b Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology , Wroclaw University of Science and Technology , Wroclaw , Poland
| | - Jarosław Kędziora
- a Department of Anaesthesiology and Intensive Care , Wroclaw Medical University , Wroclaw , Poland
| | - Ewa Szewczyk
- a Department of Anaesthesiology and Intensive Care , Wroclaw Medical University , Wroclaw , Poland
| | - Jowita Woźniak
- c Department of Neurosurgery , Wroclaw Medical University , Wroclaw , Poland
| | | | - Andrzej Kübler
- a Department of Anaesthesiology and Intensive Care , Wroclaw Medical University , Wroclaw , Poland
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17
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Jeong JH. Brain and Lung: Lung Injury in Patients with Brain Injury. JOURNAL OF NEUROCRITICAL CARE 2017. [DOI: 10.18700/jnc.170009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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18
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Hu PJ, Pittet JF, Kerby JD, Bosarge PL, Wagener BM. Acute brain trauma, lung injury, and pneumonia: more than just altered mental status and decreased airway protection. Am J Physiol Lung Cell Mol Physiol 2017; 313:L1-L15. [PMID: 28408366 DOI: 10.1152/ajplung.00485.2016] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 03/24/2017] [Accepted: 04/07/2017] [Indexed: 01/25/2023] Open
Abstract
Traumatic brain injury (TBI) is a major cause of mortality and morbidity worldwide. Even when patients survive the initial insult, there is significant morbidity and mortality secondary to subsequent pulmonary edema, acute lung injury (ALI), and nosocomial pneumonia. Whereas the relationship between TBI and secondary pulmonary complications is recognized, little is known about the mechanistic interplay of the two phenomena. Changes in mental status secondary to acute brain injury certainly impair airway- and lung-protective mechanisms. However, clinical and translational evidence suggests that more specific neuronal and cellular mechanisms contribute to impaired systemic and lung immunity that increases the risk of TBI-mediated lung injury and infection. To better understand the cellular mechanisms of that immune impairment, we review here the current clinical data that support TBI-induced impairment of systemic and lung immunity. Furthermore, we also review the animal models that attempt to reproduce human TBI. Additionally, we examine the possible role of damage-associated molecular patterns, the chlolinergic anti-inflammatory pathway, and sex dimorphism in post-TBI ALI. In the last part of the review, we discuss current treatments and future pharmacological therapies, including fever control, tracheostomy, and corticosteroids, aimed to prevent and treat pulmonary edema, ALI, and nosocomial pneumonia after TBI.
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Affiliation(s)
- Parker J Hu
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jean-Francois Pittet
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama; and.,Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey D Kerby
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Patrick L Bosarge
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brant M Wagener
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama; and
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19
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Loftsgard TO, Newcome MD, Hanneman MR, Patch RK, Seelhammer TG. Management of Neurogenic Pulmonary Edema and Differential Hypoxemia in an Adult Supported on Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2017; 31:2170-2174. [PMID: 28764986 DOI: 10.1053/j.jvca.2017.03.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Theodore O Loftsgard
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN; Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN
| | - Marci D Newcome
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN; Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN
| | - Maria R Hanneman
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Richard K Patch
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Troy G Seelhammer
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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20
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Fujita M, Oda Y, Yamashita S, Kaneda K, Kaneko T, Suehiro E, Dohi K, Kuroda Y, Kobata H, Tsuruta R, Maekawa T. Early-Stage Hyperoxia Is Associated with Favorable Neurological Outcomes and Survival after Severe Traumatic Brain Injury: A Post-Hoc Analysis of the Brain Hypothermia Study. J Neurotrauma 2017; 34:1565-1570. [PMID: 27958774 DOI: 10.1089/neu.2016.4753] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The effects of hyperoxia on the neurological outcomes of patients with severe traumatic brain injury (TBI) are still controversial. We examined whether the partial pressure of arterial oxygen (PaO2) and hyperoxia were associated with neurological outcomes and survival by conducting post-hoc analyses of the Brain Hypothermia (B-HYPO) study, a multi-center randomized controlled trial of mild therapeutic hypothermia for severe TBI. The differences in PaO2 and PaO2/fraction of inspiratory oxygen (P/F) ratio on the 1st day of admission were compared between patients with favorable (n = 64) and unfavorable (n = 65) neurological outcomes and between survivors (n = 90) and deceased patients (n = 39). PaO2 and the P/F ratio were significantly greater in patients with favorable outcomes than in patients with unfavorable neurological outcomes (PaO2: 252 ± 122 vs. 202 ± 87 mm Hg, respectively, p = 0.008; P/F ratio: 455 ± 171 vs. 389 ± 155, respectively, p = 0.022) and in survivors than in deceased patients (PaO2: 242 ± 117 vs. 193 ± 75 mm Hg, respectively, p = 0.005; P/F ratio: 445 ± 171 vs. 370 ± 141, respectively, p = 0.018). Similar tendencies were observed in subgroup analyses in patients with fever control and therapeutic hypothermia, and in patients with an evacuated mass or other lesions (unevacuated lesions). PaO2 was independently associated with survival (odds ratio 1.008, p = 0.037). These results suggested that early-stage hyperoxia might be associated with favorable neurological outcomes and survival following severe TBI.
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Affiliation(s)
- Motoki Fujita
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Yasutaka Oda
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Susumu Yamashita
- Department of Emergency Medicine, Tokuyama Central Hospital, Yamaguchi, Japan
| | - Kotaro Kaneda
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Tadashi Kaneko
- Emergency and General Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Eiichi Suehiro
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Yamaguchi, Japan.,Department of Neurosurgery, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Kenji Dohi
- Department of Emergency and Critical Care Medicine, Showa University Hospital, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Hitoshi Kobata
- Osaka Mishima Emergency Critical Care Center, Osaka, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Yamaguchi, Japan
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21
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Abstract
A 29-year-old male admitted with severe traumatic brain injury following a road traffic accident was sedated and ventilated uneventfully for 72 h. On the fourth posttrauma day, after stopping sedation to assess readiness for extubation, he developed sudden onset desaturation; arterial blood gas showed severe diffusion defect with very low PaO2/FiO2 ratio following an episode of generalized tonic-clonic seizure. The differential diagnoses and further management are discussed.
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Affiliation(s)
- Ramanan Rajagopal
- Department of Neurological Sciences, CMC, Vellore, Tamil Nadu, India
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22
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Lin X, Xu Z, Wang P, Xu Y, Zhang G. Role of PiCCO monitoring for the integrated management of neurogenic pulmonary edema following traumatic brain injury: A case report and literature review. Exp Ther Med 2016; 12:2341-2347. [PMID: 27698733 DOI: 10.3892/etm.2016.3615] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 07/22/2016] [Indexed: 01/18/2023] Open
Abstract
Neurogenic pulmonary edema (NPE) is occasionally observed in patients with traumatic brain injury (TBI); however, this condition is often underappreciated. NPE is frequently misdiagnosed due to its atypical clinical performance, thus delaying appropriate treatment. A comprehensive management protocol of NPE in patients with TBI has yet to be established. The current study reported the case of a 67-year-old man with severe TBI who was transferred to our intensive care unit (ICU). On day 7 after hospitalization, the patient suddenly suffered tachypnea, tachycardia, systemic hypertension and hypoxemia during lumbar cistern drainage. Intravenous diuretics, tranquilizer and glucocorticoid were administered due to suspected left heart failure attack. Chest radiography examination supported the diagnosis of pulmonary edema; however, hypotension and hypovolemia were subsequently observed. Pulse index continuous cardiac output (PiCCO) hemodynamic monitoring and bedside echocardiography were performed, which excluded the diagnosis of cardiac pulmonary edema, and thus the diagnosis of NPE was confirmed. Goal-directed therapy by dynamic PiCCO monitoring was then implemented. In addition, levosimendan, an inotropic agent, was introduced to improve cardiac output. The patient had complete recovered from pulmonary edema and regained consciousness on day 11 of hospitalization. The current case demonstrated that PiCCO monitoring may serve a central role in the integrated management of NPE in patients with TBI. Levosimendan may be a potential medicine in treating cardiac dysfunction, along with its benefit from improving neurological function in NPE patients.
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Affiliation(s)
- Xiaoping Lin
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, P.R. China
| | - Zhijun Xu
- General Intensive Care Unit, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, P.R. China
| | - Pengfei Wang
- General Intensive Care Unit, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, P.R. China
| | - Yan Xu
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, P.R. China
| | - Gensheng Zhang
- General Intensive Care Unit, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, P.R. China
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23
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A clinically authentic mouse model of enterovirus 71 (EV-A71)-induced neurogenic pulmonary oedema. Sci Rep 2016; 6:28876. [PMID: 27357918 PMCID: PMC4928123 DOI: 10.1038/srep28876] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/09/2016] [Indexed: 12/18/2022] Open
Abstract
Enterovirus 71 (EV-A71) is a neurotropic virus that sporadically causes fatal neurologic illness among infected children. Animal models of EV-A71 infection exist, but they do not recapitulate in animals the spectrum of disease and pathology observed in fatal human cases. Specifically, neurogenic pulmonary oedema (NPE)—the main cause of EV-A71 infection-related mortality—is not observed in any of these models. This limits their utility in understanding viral pathogenesis of neurologic infections. We report the development of a mouse model of EV-A71 infection displaying NPE in severely affected animals. We inoculated one-week-old BALB/c mice with an adapted EV-A71 strain and identified clinical signs consistent with observations in human cases and other animal models. We also observed respiratory distress in some mice. At necropsy, we found their lungs to be heavier and incompletely collapsed compared to other mice. Serum levels of catecholamines and histopathology of lung and brain tissues of these mice strongly indicated onset of NPE. The localization of virally-induced brain lesions also suggested a potential pathogenic mechanism for EV-A71-induced NPE. This novel mouse model of virally-induced NPE represents a valuable resource for studying viral mechanisms of neuro-pathogenesis and pre-clinical testing of potential therapeutics and prophylactics against EV-A71-related neurologic complications.
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24
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Yasui H, Donahue DL, Walsh M, Castellino FJ, Ploplis VA. Early coagulation events induce acute lung injury in a rat model of blunt traumatic brain injury. Am J Physiol Lung Cell Mol Physiol 2016; 311:L74-86. [PMID: 27190065 PMCID: PMC4967191 DOI: 10.1152/ajplung.00429.2015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 05/17/2016] [Indexed: 12/20/2022] Open
Abstract
Acute lung injury (ALI) and systemic coagulopathy are serious complications of traumatic brain injury (TBI) that frequently lead to poor clinical outcomes. Although the release of tissue factor (TF), a potent initiator of the extrinsic pathway of coagulation, from the injured brain is thought to play a key role in coagulopathy after TBI, its function in ALI following TBI remains unclear. In this study, we investigated whether the systemic appearance of TF correlated with the ensuing coagulopathy that follows TBI in ALI using an anesthetized rat blunt trauma TBI model. Blood and lung samples were obtained after TBI. Compared with controls, pulmonary edema and increased pulmonary permeability were observed as early as 5 min after TBI without evidence of norepinephrine involvement. Systemic TF increased at 5 min and then diminished 60 min after TBI. Lung injury and alveolar hemorrhaging were also observed as early as 5 min after TBI. A biphasic elevation of TF was observed in the lungs after TBI, and TF-positive microparticles (MPs) were detected in the alveolar spaces. Fibrin(ogen) deposition was also observed in the lungs within 60 min after TBI. Additionally, preadministration of a direct thrombin inhibitor, Refludan, attenuated lung injuries, thus implicating thrombin as a direct participant in ALI after TBI. The results from this study demonstrated that enhanced systemic TF may be an initiator of coagulation activation that contributes to ALI after TBI.
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Affiliation(s)
- Hideki Yasui
- W. M. Keck Center for Transgene Research, University of Notre Dame, Notre Dame, Indiana
| | - Deborah L Donahue
- W. M. Keck Center for Transgene Research, University of Notre Dame, Notre Dame, Indiana
| | - Mark Walsh
- W. M. Keck Center for Transgene Research, University of Notre Dame, Notre Dame, Indiana; Memorial Hospital of South Bend, South Bend, Indiana
| | - Francis J Castellino
- W. M. Keck Center for Transgene Research, University of Notre Dame, Notre Dame, Indiana; Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, Indiana; and
| | - Victoria A Ploplis
- W. M. Keck Center for Transgene Research, University of Notre Dame, Notre Dame, Indiana; Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, Indiana; and
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25
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Sarı MY, Yıldızdaş RD, Yükselmiş U, Horoz ÖÖ. Our patients followed up with a diagnosis of neurogenic pulmonary edema. Turk Arch Pediatr 2015; 50:241-4. [PMID: 26884694 DOI: 10.5152/turkpediatriars.2015.1411] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 02/25/2014] [Indexed: 01/11/2023]
Abstract
Neurogenic pulmonary edema is a clinical situation which developes as a result of central nervous system injury. It is rare in the childhood. Neurogenic pulmonary edema is a clinical diagnosis. Although the pathogenesis is not elucidated well, there is increase in pulmonary interstitial and alveolar fluid. The main principle in treatment of neurogenic pulmonary edema is supportive treatment and decreasing intracranial pressure as in acute respiratory distress syndrome. In this article, clinical properties of our two patients diagnosed with neurogenic pulmonary edema developed as a result of central nervous system injury are presented.
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Affiliation(s)
- Mehmet Yusuf Sarı
- Division of Pediatric Intensive Care, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Rıza Dinçer Yıldızdaş
- Division of Pediatric Intensive Care, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Ufuk Yükselmiş
- Division of Pediatric Intensive Care, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Özden Ögür Horoz
- Division of Pediatric Intensive Care, Çukurova University Faculty of Medicine, Adana, Turkey
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26
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Mrozek S, Constantin JM, Geeraerts T. Brain-lung crosstalk: Implications for neurocritical care patients. World J Crit Care Med 2015; 4:163-178. [PMID: 26261769 PMCID: PMC4524814 DOI: 10.5492/wjccm.v4.i3.163] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 04/29/2015] [Accepted: 05/28/2015] [Indexed: 02/06/2023] Open
Abstract
Major pulmonary disorders may occur after brain injuries as ventilator-associated pneumonia, acute respiratory distress syndrome or neurogenic pulmonary edema. They are key points for the management of brain-injured patients because respiratory failure and mechanical ventilation seem to be a risk factor for increased mortality, poor neurological outcome and longer intensive care unit or hospital length of stay. Brain and lung strongly interact via complex pathways from the brain to the lung but also from the lung to the brain. Several hypotheses have been proposed with a particular interest for the recently described “double hit” model. Ventilator setting in brain-injured patients with lung injuries has been poorly studied and intensivists are often fearful to use some parts of protective ventilation in patients with brain injury. This review aims to describe the epidemiology and pathophysiology of lung injuries in brain-injured patients, but also the impact of different modalities of mechanical ventilation on the brain in the context of acute brain injury.
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Egan TM, Requard JJ. Uncontrolled Donation After Circulatory Determination of Death Donors (uDCDDs) as a Source of Lungs for Transplant. Am J Transplant 2015; 15:2031-6. [PMID: 25873272 PMCID: PMC5491386 DOI: 10.1111/ajt.13246] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 12/31/2014] [Accepted: 02/01/2015] [Indexed: 02/06/2023]
Abstract
In April 2014, the American Journal of Transplantation published a report on the first lung transplant in the United States recovered from an uncontrolled donation after circulatory determination of death donor (uDCDD), assessed by ex vivo lung perfusion (EVLP). The article identified logistical and ethical issues related to introduction of lung transplant from uDCDDs. In an open clinical trial, we have Food and Drug Administration and Institutional Review Board approval to transplant lungs recovered from uDCDDs judged suitable after EVLP. Through this project and other experiences with lung recovery from uDCDDs, we have identified solutions to many logistical challenges and have addressed ethical issues surrounding lung transplant from uDCDDs that were mentioned in this case report. Here, we discuss those challenges, including issues related to recovery of other solid organs from uDCDDs. Despite logistical challenges, uDCDDs could solve the critical shortage of lungs for transplant. Furthermore, by avoiding the deleterious impact of brain death and days of positive pressure ventilation, and by using opportunities to treat lungs in the decedent or during EVLP, lungs recovered from uDCDDs may ultimately prove to be better than lungs currently being transplanted from conventional brain-dead organ donors.
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Affiliation(s)
- T. M. Egan
- Division of Cardiothoracic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC,Corresponding author: Thomas M. Egan,
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28
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Kondo R, Sugita Y, Arakawa K, Nakashima S, Umeno Y, Todoroki K, Yoshida T, Takase Y, Kage M, Oshima K, Yano H. Neurogenic pulmonary edema following Cryptococcal meningoencephalitis associated with HIV infection. Neuropathology 2015; 35:343-7. [PMID: 25955768 DOI: 10.1111/neup.12193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 12/15/2014] [Accepted: 12/16/2014] [Indexed: 11/30/2022]
Abstract
Neurogenic pulmonary edema (NPE) is a clinical syndrome characterized by the acute onset of pulmonary edema following a significant central nervous system insult. Only a few cases of NPE after Cryptococcal meningitis have been reported. We report a case of NPE following Cryptococcal meningoencephalitis. A 40-year-old man with no medical history was hospitalized for disturbance of consciousness. Blood glucose level was 124 mg/dL. Non-contrast head computed tomography showed no abnormalities. Lumbar puncture revealed a pressure of over 300 mm H2 O and cerebrospinal fluid (CSF) confirmed a white blood cell count of 65/mm(3) . The CSF glucose level was 0 mg/dL. The patient was empirically started on treatment for presumptive bacterial and viral meningitis. Four days after, the patient died in a sudden severe pulmonary edema. Autopsy was performed. We found at autopsy a brain edema with small hemorrhage of the right basal ganglia, severe pulmonary edema and mild cardiomegaly. Histologically, dilated Virchow-Robin spaces, crowded with Cryptococci were observed. In the right basal ganglia, Virchow-Robin spaces were destroyed with hemorrhage and Cryptococci spread to parenchyma of the brain. No inflammatory reaction of the lung was seen. Finally, acute pulmonary edema in this case was diagnosed as NPE following Cryptococcal meningoencephalitis. After autopsy, we found that he was positive for serum antibodies to human immunodeficiency virus.
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Affiliation(s)
- Reiichiro Kondo
- Department of Pathology, Kurume University School of Medicine, Fukuoka, Japan.,Cancer Center, Fukuoka, Japan.,Department of Diagnostic Pathology, Kurume University Hospital, Fukuoka, Japan
| | - Yasuo Sugita
- Department of Pathology, Kurume University School of Medicine, Fukuoka, Japan
| | - Kenji Arakawa
- Department of Neurology, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
| | - Shinji Nakashima
- Department of Pathology, Kurume University School of Medicine, Fukuoka, Japan
| | - Yumi Umeno
- Department of Pathology, Kurume University School of Medicine, Fukuoka, Japan
| | - Keita Todoroki
- Department of Pathology, Kurume University School of Medicine, Fukuoka, Japan
| | - Tomoko Yoshida
- Department of Diagnostic Pathology, Kurume University Hospital, Fukuoka, Japan
| | - Yorihiko Takase
- Department of Diagnostic Pathology, Kurume University Hospital, Fukuoka, Japan
| | - Masayoshi Kage
- Cancer Center, Fukuoka, Japan.,Department of Diagnostic Pathology, Kurume University Hospital, Fukuoka, Japan
| | - Koichi Oshima
- Department of Pathology, Kurume University School of Medicine, Fukuoka, Japan
| | - Hirohisa Yano
- Department of Pathology, Kurume University School of Medicine, Fukuoka, Japan
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29
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Dai Q, Su L. Neurogenic pulmonary edema caused by spontaneous cerebellar hemorrhage: A fatal case report. Surg Neurol Int 2014; 5:103. [PMID: 25101198 PMCID: PMC4123267 DOI: 10.4103/2152-7806.135579] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 06/04/2014] [Indexed: 11/30/2022] Open
Abstract
Background: Neurogenic pulmonary edema (NPE) is a clinical syndrome characterized by an acute increase of pulmonary interstitial and alveolar fluid. It could result from a significant central nervous system (CNS) insult such as intracranial hemorrhage. However, NPE as a major presenting manifestation of cerebellar hemorrhage was seldom reported. Case Description: We introduce a rare case of a 34-year-old woman suffering from a fulminant NPE in parallel with a spontaneous cerebellar hemorrhage. Although appropriate supportive measures were taken in the neuroscience care unit, the patient failed to survive hypoxemia within 28 h after hospital admission. Conclusion: Pathological lesions of the cerebellum may initiate a cascade of reactions including massive sympathetic discharge and catecholamine storm, leading to a dysfunction of both cardiovascular and respiratory systems. By far, no effective therapeutic strategies have been utilized to treat such a situation. Our present report would shed light on the underlying mechanism of NPE.
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Affiliation(s)
- Qiaoding Dai
- Department of Rheumatism and Immunology, the First Affiliated Hospital of Zhejiang Chinese Medicine University, Hangzhou City, Zhejiang Province, PR, China
| | - Lida Su
- Neuroscience Care Unit, Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR, China
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30
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Ware LB, Landeck M, Koyama T, Zhao Z, Singer J, Kern R, Neidlinger N, Nguyen J, Johnson E, Janz DR, Bernard GR, Lee JW, Matthay MA. A randomized trial of the effects of nebulized albuterol on pulmonary edema in brain-dead organ donors. Am J Transplant 2014; 14:621-8. [PMID: 24730050 PMCID: PMC3986821 DOI: 10.1111/ajt.12564] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Donor lung utilization rates are persistently low primarily due to donor lung dysfunction. We hypothesized that a treatment that enhances the resolution of pulmonary edema by stimulating the rate of alveolar fluid clearance would improve donor oxygenation and increase donor lung utilization. We conducted a randomized, blinded, placebo-controlled trial of aerosolized albuterol (5mg q4h) versus saline placebo during active donor management in 506 organ donors.The primary outcome was change in oxygenation arterial partial pressure of oxygen/fraction of inspired oxygen [PaO2/FiO2] from enrollment to organ procurement.The albuterol (n¼260) and placebo (n¼246)groups were well matched for age, gender, ethnicity,smoking, and cause of brain death. The change in PaO2/FiO2 from enrollment to organ procurement did not differ between treatment groups (p¼0.54) nor did donor lung utilization (albuterol 29% vs. placebo 32%,p¼0.44). Donors in the albuterol versus placebo groups were more likely to have the study drug dose reduced (13% vs. 1%, p<0.001) or stopped (8% vs. 0%,p<0.001) for tachycardia. In summary, treatment with high dose inhaled albuterol during the donor management period did not improve donor oxygenation or increase donor lung utilization but did cause tachycardia.High dose aerosolized albuterol should not be used in donors to enhance the resolution of pulmonary edema.
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Affiliation(s)
- Lorraine B. Ware
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN,Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | | | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Jonathan Singer
- Pulmonary and Critical Care Medicine, University of California San Francisco, CA
| | - Ryan Kern
- Pulmonary and Critical Care Medicine, University of California San Francisco, CA
| | | | - John Nguyen
- California Transplant Donor Network, Oakland, CA
| | | | - David R. Janz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Gordon R. Bernard
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Jae W. Lee
- Department of Anesthesia and Cardiovascular Research Institute, University of California, San Francisco, CA
| | - Michael A. Matthay
- Pulmonary and Critical Care Medicine, University of California San Francisco, CA,Department of Anesthesia and Cardiovascular Research Institute, University of California, San Francisco, CA
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31
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Davison DL, Terek M, Chawla LS. Neurogenic pulmonary edema. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:212. [PMID: 22429697 PMCID: PMC3681357 DOI: 10.1186/cc11226] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Danielle L Davison
- Department of Critical Care Medicine and Anesthesiology, George Washington University Medical Center, 900 23rd Street NW, Room G-105, Washington, DC 20037, USA
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32
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Pulmonary complications in patients with severe brain injury. Crit Care Res Pract 2012; 2012:207247. [PMID: 23133746 PMCID: PMC3485871 DOI: 10.1155/2012/207247] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 09/15/2012] [Accepted: 09/23/2012] [Indexed: 01/06/2023] Open
Abstract
Pulmonary complications are prevalent in the critically ill neurological population. Respiratory failure, pneumonia, acute lung injury and the acute respiratory distress syndrome (ALI/ARDS), pulmonary edema, pulmonary contusions and pneumo/hemothorax, and pulmonary embolism are frequently encountered in the setting of severe brain injury. Direct brain injury, depressed level of consciousness and inability to protect the airway, disruption of natural defense barriers, decreased mobility, and secondary neurological insults inherent to severe brain injury are the main cause of pulmonary complications in critically ill neurological patients. Prevention strategies and current and future therapies need to be implemented to avoid and treat the development of these life-threatening medical complications.
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33
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Kim JE, Park JH, Lee SH, Lee Y. Neurogenic pulmonary edema following intracranial coil embolization for subarachnoid hemorrhage -A case report-. Korean J Anesthesiol 2012; 63:368-71. [PMID: 23115693 PMCID: PMC3483499 DOI: 10.4097/kjae.2012.63.4.368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 08/25/2011] [Accepted: 08/29/2011] [Indexed: 11/14/2022] Open
Abstract
Neurogenic pulmonary edema (NPE) is a well-known complication of acute central neurologic injury, particularly aneurysmal subarachnoid hemorrhage. Both increased intracranial pressure and severe over-activation of the sympathetic nervous system seem to be pathogenetic for the onset of NPE. Although intracranial endovascular therapy is minimally invasive, it may affect brain stem regions and result in sympathetic activation. We now report the case of a 70-year-old woman who suddenly developed pulmonary edema during coil embolization of a ruptured aneurysm. During the intervention, oxygen saturation declined suddenly and a chest radiograph revealed pulmonary edema. The delayed appearance of NPE in this patient implies a risk for sympathetically mediated NPE during endovascular therapy.
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Affiliation(s)
- Jeong Eun Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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34
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Lakkireddigari SKR, Durga P, Nayak M, Ramchandran G. Preoperative neurogenic pulmonary edema: A dilemma for decision making. J Anaesthesiol Clin Pharmacol 2012; 28:232-4. [PMID: 22557750 PMCID: PMC3339732 DOI: 10.4103/0970-9185.94905] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Neurogenic pulmonary edema may be a less-recognized consequence of obstructive hydrocephalus. The authors report a patient with acute obstructive hydrocephalus due to cerebellar metastatic lesion, who presented with neurogenic pulmonary edema. The edema resolved on placement of the ventriculoperitonial shunt. This report addresses the importance of recognition of neurogenic pulmonary edema as a possible perioperative complication resulting from an increase in intracranial pressure and the issues involved with anesthetic management of co-existing neurogenic pulmonary edema and intracranial hypertension.
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35
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Mascia L. Acute lung injury in patients with severe brain injury: a double hit model. Neurocrit Care 2011. [PMID: 19548120 DOI: 10.1007/s12028-009-9242-8].] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
The presence of pulmonary dysfunction after brain injury is well recognized. Acute lung injury (ALI) occurs in 20% of patients with isolated brain injury and is associated with a poor outcome. The "blast injury" theory, which proposes combined "hydrostatic" and "high permeability" mechanisms for the formation of neurogenic pulmonary edema, has been challenged recently by the observation that a systemic inflammatory response may play an integral role in the development of pulmonary dysfunction associated with brain injury. As a result of the primary cerebral injury, a systemic inflammatory reaction occurs, which induces an alteration in blood-brain barrier permeability and infiltration of activated neutrophils into the lung. This preclinical injury makes the lungs more susceptible to the mechanical stress of an injurious ventilatory strategy. Tight CO2 control is a therapeutic priority in patients with acute brain injury, but the use of high tidal volume ventilation may contribute to the development of ALI. Establishment of a therapeutic regimen that allows the combination of protective ventilation with the prevention of hypercapnia is, therefore, required. Moreover, in patients with brain injury, hypoxemia represents a secondary insult associated with a poor outcome. Optimal oxygenation may be achieved by using an adequate FiO2 and by application of positive end-expiratory pressure (PEEP). PEEP may, however, affect the cerebral circulation by hemodynamic and CO2-mediated mechanisms and the effects of PEEP on cerebral hemodynamics should be monitored in these patients and used to titrate its application.
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Affiliation(s)
- Luciana Mascia
- Dipartimento di Anestesiologia e Rianimazione, Università di Torino, Ospedale S. Giovanni Battista, Corso Dogliotti 14, 10126 Torino, Italy.
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Oddo M, Nduom E, Frangos S, MacKenzie L, Chen I, Maloney-Wilensky E, Kofke WA, Levine JM, LeRoux PD. Acute lung injury is an independent risk factor for brain hypoxia after severe traumatic brain injury. Neurosurgery 2011; 67:338-44. [PMID: 20644419 DOI: 10.1227/01.neu.0000371979.48809.d9] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pulmonary complications are frequently observed after severe traumatic brain injury (TBI), but little is known about the consequences of lung injury on brain tissue oxygenation and metabolism. OBJECTIVE We examined the association between lung function and brain tissue oxygen tension (PbtO2) in patients with severe TBI. METHODS We analyzed data from 78 patients with severe, nonpenetrating TBI who underwent continuous PbtO2 and intracranial pressure monitoring. Acute lung injury was defined by the presence of pulmonary infiltrates with a PaO2/FiO2 (PF) ratio less than 300 and the absence of left ventricular failure. A total of 587 simultaneous measurements of PbtO2 and PF ratio were examined using longitudinal data analysis. RESULTS PbtO2 correlated strongly with PaO2 and PF ratio (P < .05) independent of PaCO2, brain temperature, cerebral perfusion pressure, and hemoglobin. Acute lung injury was associated with lower PbtO2 (34.6 +/- 13.8 mm Hg at PF ratio >300 vs 30.2 +/- 10.8 mm Hg [PF ratio 200-300], 28.9 +/- 9.8 mm Hg [PF ratio 100-199], and 21.1 +/- 7.4 mm Hg [PF ratio <100], all P values <.01). After adjusting for intracranial pressure, Marshall computed tomography score, and APACHE II (Acute Physiology and Chronic Health Evaluation) score, acute lung injury was an independent risk factor for compromised PbtO2 (PbtO2 <20 mm Hg; adjusted odds ratio: 2.13, 95% confidence interval: 1.21-3.77; P < .01). CONCLUSION After severe TBI, PbtO2 correlates with PF ratio. Acute lung injury is associated with an increased risk of compromised PbtO2, independent from intracerebral and systemic injuries. Our findings support the use of lung-protective strategies to prevent brain hypoxia in TBI patients.
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Affiliation(s)
- Mauro Oddo
- Department of Neurosurgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19107, USA
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37
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Figueiredo EG, Oliveira AMP, Almeida CERD, Teixeira MJ. Subarachnoid hemorrhage and hydrocephalus causing neurogenic pulmonary edema. ARQUIVOS DE NEURO-PSIQUIATRIA 2010; 68:461-2. [PMID: 20602055 DOI: 10.1590/s0004-282x2010000300025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
Gift of Life Michigan determined that the largest gap between the number of organ donors and the number of organs transplanted has been in the number of lungs transplanted. The literature was reviewed for lung donor management strategies and other organ procurement organizations were surveyed for existing donor management guidelines to improve lung function. On the basis of pulmonary physiology and the knowledge gained from the literature search, Gift of Life Michigan developed a lung donor management protocol that has been very effective. In 4 years, the number of lungs transplanted has increased from 37 to 135, representing a 265% improvement.
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39
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Shen HY, Zhao Y, Chen XY, Xiong RP, Lu JL, Chen JF, Chen LY, Zhou YG. Differential alteration of heat shock protein 90 in mice modifies glucocorticoid receptor function and susceptibility to trauma. J Neurotrauma 2010; 27:373-81. [PMID: 19845467 DOI: 10.1089/neu.2009.0926] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Heat shock protein 90 (Hsp90), encoded by the murine hsp84 and hsp86 genes in mice, is a pivotal regulator of glucocorticoid receptor (GR) function in the hypothalamus-pituitary-adrenal axis and affords stress protection. To explore the underlying molecular mechanisms of strain susceptibility to traumatic stress, we investigated the alteration by Hsp90 of the function of the glucocorticoid-glucocorticoid receptor (GC-GR) pathway in attenuating stress responses in C57BL/6 and BALB/c mice using the whole-body blast injury (WBBI) model. We found that C57BL/6 mice had a lower WBBI-induced mortality, higher nuclear GR level, and higher glucocorticoid-response element (GRE) binding activity than BALB/c mice. This study is the first report identifying four genetic variations of the murine hsp84 gene: 226A>C, 996G>C, 1483G>C, and 2000G>T. These nucleotide changes occur in the functional domains associated with the nuclear/cytosolic translocation of GR, GR-Hsp90 interaction, ATP binding, and self-dimerization of Hsp90, respectively. Further, we used a specific Hsp90 inhibitor, geldanamycin (GA), to assess the role of Hsp90 in the discriminative traumatic response in C57BL/6 mice. Pretreatment with GA reduced nuclear GR levels and GRE binding activity, and enhanced WBBI-induced mortality. These findings suggest that Hsp90 may underlie the strain-selective (C57BL/6 versus BALB/c) susceptibility to WBBI by mediating the nuclear translocation of GRs and GRE binding. Thus, pharmacological manipulation of Hsp90 may represent a therapeutic strategy to modify the function of the GC-GR pathway and traumatic stress response.
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Affiliation(s)
- Hai-Ying Shen
- Molecular Biology Center, State Key Laboratory of Trauma, Burn and Combined Injury, Third Military Medical University, Chongqing, PR China
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40
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41
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Non-Neurological Complications of Brain Injury. Neurocrit Care 2010. [DOI: 10.1007/978-1-84882-070-8_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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42
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Eagan C, Keller CA, Baz MA, Thibault M. Effects of administration of intravenous naloxone on gas exchange in brain-dead lung donors. Prog Transplant 2009. [PMID: 19813490 DOI: 10.7182/prtr.19.3.q2v7403k25144525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To observe the effect of naloxone on the lung function of potential lung transplant donors with neurogenic pulmonary edema. DESIGN AND INTERVENTIONS Donors aged 16 to 55 years without any factors to contraindicate lung donation (pneumonia, pulmonary contusion, etc) were included. Ventilator settings were standardized to a tidal volume of 10 to 12 mL/kg, an FIO2 of 0.40, and a respiratory rate that kept PCO2 between 35 and 45 mm Hg. Chest physiotherapy, nebulizer treatments, and frequent suctioning were undertaken. Baseline arterial blood gas analysis and an oxygen challenge were performed. The patients were then given 8 to 10 mg of naloxone. Oxygen challenges and arterial blood gas analyses were repeated every 4 to 6 hours. The data were analyzed by using a paired t test, and each patient served as his or her own control. SETTING These interventions were performed on the 19 LifeQuest donors who met the set criteria from July 2002 to July 2004. RESULTS The PaO2 on the oxygen challenge immediately after administration of naloxone increased from 329 (SD 177) to 363 (SD 191) mm Hg, although the increase from baseline was not significant. The PaO2 from the second oxygen challenge (median time, 7 hours after administration of naloxone) increased to 413 (SD 177) mm Hg (P<.01).
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Affiliation(s)
- Christina Eagan
- LifeQuest Organ Recovery Services, Gainesville, FL 32601, USA.
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Lapinsky SE, Posadas-Calleja JG, McCullagh I. Clinical review: Ventilatory strategies for obstetric, brain-injured and obese patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:206. [PMID: 19291279 PMCID: PMC2689449 DOI: 10.1186/cc7146] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The ventilatory management of patients with acute respiratory failure is supported by good evidence, aiming to reduce lung injury by pressure limitation and reducing the duration of ventilatory support by regular assessment for discontinuation. Certain patient groups, however, due to their altered physiology or disease-specific complications, may require some variation in usual ventilatory management. The present manuscript reviews the ventilatory management in three special populations, namely the patient with brain injury, the pregnant patient and the morbidly obese patient.
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Affiliation(s)
- Stephen E Lapinsky
- Intensive Care Unit, Mount Sinai Hospital, 600 University Ave, Toronto, Ontario, M5G 1X5, Canada.
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44
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Eagan C, Keller CA, Baz MA, Thibault M. Effects of Administration of Intravenous Naloxone on Gas Exchange in Brain-Dead Lung Donors. Prog Transplant 2009; 19:267-71. [DOI: 10.1177/152692480901900313] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective To observe the effect of naloxone on the lung function of potential lung transplant donors with neurogenic pulmonary edema. Design and Interventions Donors aged 16 to 55 years without any factors to contraindicate lung donation (pneumonia, pulmonary contusion, etc) were included. Ventilator settings were standardized to a tidal volume of 10 to 12 mL/kg, an FiO2 of 0.40, and a respiratory rate that kept PCO2 between 35 and 45 mm Hg. Chest physiotherapy, nebulizer treatments, and frequent suctioning were undertaken. Baseline arterial blood gas analysis and an oxygen challenge were performed. The patients were then given 8 to 10 mg of naloxone. Oxygen challenges and arterial blood gas analyses were repeated every 4 to 6 hours. The data were analyzed by using a paired t test, and each patient served as his or her own control. Setting These interventions were performed on the 19 LifeQuest donors who met the set criteria from July 2002 to July 2004. Results The PaO2 on the oxygen challenge immediately after administration of naloxone increased from 329 (SD 177) to 363 (SD 191) mm Hg, although the increase from baseline was not significant. The PaO2 from the second oxygen challenge (median time, 7 hours after administration of naloxone) increased to 413 (SD 177) mm Hg ( P < .01).
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Affiliation(s)
- Christina Eagan
- LifeQuest Organ Recovery Services, Gainesville, Florida (CE, MT), Mayo Clinic, Jacksonville, Florida (CAK), University of Florida College of Medicine, Gainesville, Florida (MAB)
| | - Cesar A. Keller
- LifeQuest Organ Recovery Services, Gainesville, Florida (CE, MT), Mayo Clinic, Jacksonville, Florida (CAK), University of Florida College of Medicine, Gainesville, Florida (MAB)
| | - Maher A. Baz
- LifeQuest Organ Recovery Services, Gainesville, Florida (CE, MT), Mayo Clinic, Jacksonville, Florida (CAK), University of Florida College of Medicine, Gainesville, Florida (MAB)
| | - Michael Thibault
- LifeQuest Organ Recovery Services, Gainesville, Florida (CE, MT), Mayo Clinic, Jacksonville, Florida (CAK), University of Florida College of Medicine, Gainesville, Florida (MAB)
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Sherr GT, Beal A, Irwin E, Roach R, Dyste G. Acute and critical care management of a pediatric patient with medullo-cerebellar impaling. J Clin Neurosci 2009; 16:1239-41. [PMID: 19564111 DOI: 10.1016/j.jocn.2008.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 11/29/2008] [Indexed: 11/17/2022]
Abstract
The authors present a child with an accidental cervical medullo-cerebellar impaling by an aluminum rod. Careful planning for safe removal of the rod as well as vigilant attention to early cardiac instability and flash neurogenic pulmonary edema were paramount to her successful recovery. This patient illustrates that it is possible to survive impaling of the brainstem but it requires both innovation and collaboration by multiple specialists across different departments. The value of well coordinated and collaborative neuro surgical intensive care is demonstrated in this young girl's nearly complete recovery from the accident.
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Affiliation(s)
- Gregory T Sherr
- Department of Neurosurgery, University of Minnesota, Mayo Mail Code 96, 420 Delaware Street SE, Minneapolis, Minnesota 55455, USA.
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Acute lung injury in patients with severe brain injury: a double hit model. Neurocrit Care 2009. [PMID: 19548120 DOI: 10.1007/s12028-009-9242-8]] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The presence of pulmonary dysfunction after brain injury is well recognized. Acute lung injury (ALI) occurs in 20% of patients with isolated brain injury and is associated with a poor outcome. The "blast injury" theory, which proposes combined "hydrostatic" and "high permeability" mechanisms for the formation of neurogenic pulmonary edema, has been challenged recently by the observation that a systemic inflammatory response may play an integral role in the development of pulmonary dysfunction associated with brain injury. As a result of the primary cerebral injury, a systemic inflammatory reaction occurs, which induces an alteration in blood-brain barrier permeability and infiltration of activated neutrophils into the lung. This preclinical injury makes the lungs more susceptible to the mechanical stress of an injurious ventilatory strategy. Tight CO2 control is a therapeutic priority in patients with acute brain injury, but the use of high tidal volume ventilation may contribute to the development of ALI. Establishment of a therapeutic regimen that allows the combination of protective ventilation with the prevention of hypercapnia is, therefore, required. Moreover, in patients with brain injury, hypoxemia represents a secondary insult associated with a poor outcome. Optimal oxygenation may be achieved by using an adequate FiO2 and by application of positive end-expiratory pressure (PEEP). PEEP may, however, affect the cerebral circulation by hemodynamic and CO2-mediated mechanisms and the effects of PEEP on cerebral hemodynamics should be monitored in these patients and used to titrate its application.
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Sajadi MM, Roddy KM, Chan-Tack KM, Forrest GN. Risk factors for mortality from primary cryptococcosis in patients with HIV. Postgrad Med 2009; 121:107-13. [PMID: 19332968 DOI: 10.3810/pgm.2009.03.1983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Cryptococcosis continues to have a high mortality rate in human immunodeficiency virus (HIV)-positive patients despite advances made in antifungal treatment, intracranial pressure management, and antiretroviral therapy. This retrospective chart review was conducted at the University of Maryland Medical Center and Baltimore VA Medical Center from 1993 to 2004. We reviewed all inpatient cases of cryptococcal infections to assess predictors of inpatient mortality among HIV-positive patients. Data collected included patient demographics, presenting symptoms and CD4 counts, lumbar puncture (LP) results including opening pressure (OP), cryptococcal antigen (CAg) levels, sites of infection, and drug therapy. Multivariate and survival analyses were performed. We identified 202 patients with primary cryptococcosis. The main sites of infection included blood (72%), central nervous system (85%), and lower respiratory tract (34%). Overall 30-day mortality was 14%. Predictors of mortality included syncope (P = 0.039; OR, 4.5), concomitant pneumonia (P = 0.001; OR, 3.5), respiratory failure (P < 0.001; OR, 10.5), and admission into the intensive care unit (P < 0.001; OR, 8). Amphotericin dose, OP > or = 250 mm H2O, and number of LPs were not found to be predictive of mortality. Mortality attributable to cryptococcosis remains high. Our study findings suggest that syncope, respiratory failure, pneumonia, and admission to the intensive care unit are independently associated with an increased risk of death within 30 days after cryptococcosis diagnosis.
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Affiliation(s)
- Mohammad M Sajadi
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Evaluation of pulmonary GLUT1 and VEGF mRNA levels in relation to lung weight in medicolegal autopsy cases. Leg Med (Tokyo) 2009; 11 Suppl 1:S290-3. [DOI: 10.1016/j.legalmed.2009.01.094] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Accepted: 01/14/2009] [Indexed: 11/17/2022]
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