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Shahn Z, Jung B, Talmor D, Kennedy EH, Lehman LWH, Baedorf-Kassis E. The impact of aggressive and conservative propensity for initiation of neuromuscular blockade in mechanically ventilated patients with hypoxemic respiratory failure. J Crit Care 2024; 82:154803. [PMID: 38552450 PMCID: PMC11139559 DOI: 10.1016/j.jcrc.2024.154803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION Neuromuscular blockade (NMB) in ventilated patients may cause benefit or harm. We applied "incremental interventions" to determine the impact of altering NMB initiation aggressiveness. METHODS Retrospective cohort study of ventilated patients with PaO2/FiO2 ratio < 150 mmHg and PEEP≥ 8cmH2O from the Medical Information Mart of Intensive Care IV database (MIMIC-IV version 1.0) estimating the effect of incremental interventions on in-hospital mortality and ventilator-free days, modifying hourly propensity for NMB initiation to be aggressive or conservative relative to usual care, adjusting for confounding with inverse probability weighting. RESULTS 5221 patients were included (13.3% initiated on NMB). Incremental interventions estimated a strong effect on NMB usage: 5-fold higher hourly odds of initiation increased usage to 36.5% (CI = [34.3%,38.7%]) and 5-fold lower odds decreased usage to 3.8% (CI = [3.3%,4.3%]). Aggressive and conservative strategies demonstrated a U-shaped mortality relationship. 5-fold higher or lower propensity increased in-hospital mortality by 2.6% (0.95 CI = [1.5%,3.7%]) or 1.3% (0.95 CI = [0.1%,2.5%]) respectively. In secondary analysis of a healthier patient cohort, results were similar, however conservative strategies also improved ventilator-free days. INTERPRETATION Aggressive or conservative initiation of NMB may worsen mortality. In healthier populations, marginally conservative NMB initiation strategies may lead to increased ventilator free days with minimal impact on mortality.
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Affiliation(s)
- Zach Shahn
- MIT-IBM Watson AI Lab, Cambridge, MA, United States of America; CUNY Graduate School of Public Health and Health Policy, New York City, NY, United States of America
| | - Boris Jung
- Medical Intensive Care Unit, Lapeyronie Teaching Hospital, Montpellier University, Montpellier, France; Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America; Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America
| | - Daniel Talmor
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America
| | - Edward H Kennedy
- Department of Statistics & Data Science, Carnegie Mellon University, Pittsburgh, PA 15213, United States of America
| | - Li-Wei H Lehman
- MIT-IBM Watson AI Lab, Cambridge, MA, United States of America; Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA, 02142, United States of America
| | - Elias Baedorf-Kassis
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America; Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America.
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Torbic H, Bulgarelli L, Deliberato RO, Duggal A. Potential Impact of Subphenotyping in Pharmacologic Management of Acute Respiratory Distress Syndrome. J Pharm Pract 2024; 37:955-966. [PMID: 37337327 DOI: 10.1177/08971900231185392] [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] [Indexed: 06/21/2023]
Abstract
Background: Acute respiratory distress syndrome (ARDS) is an acute inflammatory process in the lungs associated with high morbidity and mortality. Previous research has studied both nonpharmacologic and pharmacologic interventions aimed at targeting this inflammatory process and improving ventilation. Hypothesis: To date, only nonpharmacologic interventions including lung protective ventilation, prone positioning, and high positive end-expiratory pressure ventilation strategies have resulted in significant improvements in patient outcomes. Given the high mortality associated with ARDS despite these advancements, interest in subphenotyping has grown, aiming to improve diagnosis and develop personalized treatment approaches. Data Collection: Previous trials evaluating pharmacologic therapies in heterogeneous populations have primarily demonstrated no positive effect, but hope to show benefit when targeting specific subphenotypes, thus increasing their efficacy, while simultaneously decreasing adverse effects. Results: Although most studies evaluating pharmacologic therapies for ARDS have not demonstrated a mortality benefit, there is limited data evaluating pharmacologic therapies in ARDS subphenotypes, which have found promising results. Neuromuscular blocking agents, corticosteroids, and simvastatin have resulted in a mortality benefit when used in patients with the hyper-inflammatory ARDS subphenotype. Therapeutic Opinion: The use of subphenotyping could revolutionize the way ARDS therapies are applied and therefore improve outcomes while also limiting the adverse effects associated with their ineffective use. Future studies should evaluate ARDS subphenotypes and their response to pharmacologic intervention to advance this area of precision medicine.
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Affiliation(s)
- Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Lucas Bulgarelli
- Department of Clinical Data Science Research, Endpoint Health, Inc, Palo Alto, CA, USA
| | | | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Costa ELV, Alcala GC, Tucci MR, Goligher E, Morais CC, Dianti J, Nakamura MAP, Oliveira LB, Pereira SM, Toufen C, Barbas CSV, Carvalho CRR, Amato MBP. Impact of extended lung protection during mechanical ventilation on lung recovery in patients with COVID-19 ARDS: a phase II randomized controlled trial. Ann Intensive Care 2024; 14:85. [PMID: 38849605 PMCID: PMC11161454 DOI: 10.1186/s13613-024-01297-z] [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: 01/25/2024] [Accepted: 04/15/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Protective ventilation seems crucial during early Acute Respiratory Distress Syndrome (ARDS), but the optimal duration of lung protection remains undefined. High driving pressures (ΔP) and excessive patient ventilatory drive may hinder lung recovery, resulting in self-inflicted lung injury. The hidden nature of the ΔP generated by patient effort complicates the situation further. Our study aimed to assess the feasibility of an extended lung protection strategy that includes a stepwise protocol to control the patient ventilatory drive, assessing its impact on lung recovery. METHODS We conducted a single-center randomized study on patients with moderate/severe COVID-19-ARDS with low respiratory system compliance (CRS < 0.6 (mL/Kg)/cmH2O). The intervention group received a ventilation strategy guided by Electrical Impedance Tomography aimed at minimizing ΔP and patient ventilatory drive. The control group received the ARDSNet low-PEEP strategy. The primary outcome was the modified lung injury score (mLIS), a composite measure that integrated daily measurements of CRS, along with oxygen requirements, oxygenation, and X-rays up to day 28. The mLIS score was also hierarchically adjusted for survival and extubation rates. RESULTS The study ended prematurely after three consecutive months without patient enrollment, attributed to the pandemic subsiding. The intention-to-treat analysis included 76 patients, with 37 randomized to the intervention group. The average mLIS score up to 28 days was not different between groups (P = 0.95, primary outcome). However, the intervention group showed a faster improvement in the mLIS (1.4 vs. 7.2 days to reach 63% of maximum improvement; P < 0.001), driven by oxygenation and sustained improvement of X-ray (P = 0.001). The intervention group demonstrated a sustained increase in CRS up to day 28 (P = 0.009) and also experienced a shorter time from randomization to room-air breathing (P = 0.02). Survival at 28 days and time until liberation from the ventilator were not different between groups. CONCLUSIONS The implementation of an individualized PEEP strategy alongside extended lung protection appears viable. Promising secondary outcomes suggested a faster lung recovery, endorsing further examination of this strategy in a larger trial. Clinical trial registration This trial was registered with ClinicalTrials.gov (number NCT04497454) on August 04, 2020.
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Affiliation(s)
- Eduardo L V Costa
- Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil
- Research and Education Institute, Hospital Sírio-Libanes, Sao Paulo, Brazil
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil
| | - Glasiele C Alcala
- Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil
| | - Mauro R Tucci
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil
| | - Ewan Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Toronto General Hospital Research Institute, Toronto, Canada
| | - Caio C Morais
- Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil
- Departamento de Fisioterapia, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Toronto General Hospital Research Institute, Toronto, Canada
| | - Miyuki A P Nakamura
- Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil
| | - Larissa B Oliveira
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil
| | - Sérgio M Pereira
- Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Carlos Toufen
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil
| | - Carmen S V Barbas
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil
- Adult ICU Albert Einstein Hospital, São Paulo, Brazil
| | - Carlos R R Carvalho
- Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil.
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil.
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Battaglini D, Iavarone IG, Rocco PRM. An update on the pharmacological management of acute respiratory distress syndrome. Expert Opin Pharmacother 2024; 25:1229-1247. [PMID: 38940703 DOI: 10.1080/14656566.2024.2374461] [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: 05/10/2024] [Accepted: 06/26/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION Acute respiratory distress syndrome (ARDS) is characterized by acute inflammatory injury to the lungs, alterations in vascular permeability, loss of aerated tissue, bilateral infiltrates, and refractory hypoxemia. ARDS is considered a heterogeneous syndrome, which complicates the search for effective therapies. The goal of this review is to provide an update on the pharmacological management of ARDS. AREAS COVERED The difficulties in finding effective pharmacological therapies are mainly due to the challenges in designing clinical trials for this unique, varied population of critically ill patients. Recently, some trials have been retrospectively analyzed by dividing patients into hyper-inflammatory and hypo-inflammatory sub-phenotypes. This approach has led to significant outcome improvements with some pharmacological treatments that previously failed to demonstrate efficacy, which suggests that a more precise selection of ARDS patients for clinical trials could be the key to identifying effective pharmacotherapies. This review is provided after searching the main studies on this topics on the PubMed and clinicaltrials.gov databases. EXPERT OPINION The future of ARDS therapy lies in precision medicine, innovative approaches to drug delivery, immunomodulation, cell-based therapies, and robust clinical trial designs. These should lead to more effective and personalized treatments for patients with ARDS.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genova, Italy
| | - Ida Giorgia Iavarone
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genova, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Levy E, Reilly JP. Pharmacologic Treatments in Acute Respiratory Failure. Crit Care Clin 2024; 40:275-289. [PMID: 38432696 DOI: 10.1016/j.ccc.2023.12.002] [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] [Indexed: 03/05/2024]
Abstract
Acute respiratory failure relies on supportive care using non-invasive and invasive oxygen and ventilatory support. Pharmacologic therapies for the most severe form of respiratory failure, acute respiratory distress syndrome (ARDS), are limited. This review focuses on the most promising therapies for ARDS, targeting different mechanisms that contribute to dysregulated inflammation and resultant hypoxemia. Significant heterogeneity exists within the ARDS population. Treatment requires prompt recognition of ARDS and an understanding of which patients may benefit most from specific pharmacologic interventions. The key to finding effective pharmacotherapies for ARDS may rely on deeper understanding of pathophysiology and bedside identification of ARDS subphenotypes.
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Affiliation(s)
- Elizabeth Levy
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19146, USA
| | - John P Reilly
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19146, USA.
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Barbarot N, Tinelli A, Fillatre P, Debarre M, Magalhaes E, Massart N, Wallois J, Legay F, Mari A. The depth of neuromuscular blockade is not related to chest wall elastance and respiratory mechanics in moderate to severe acute respiratory distress syndrome patients. A prospective cohort study. J Crit Care 2024; 80:154505. [PMID: 38141458 DOI: 10.1016/j.jcrc.2023.154505] [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: 04/17/2023] [Revised: 09/04/2023] [Accepted: 12/01/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Data concerning the depth of neuromuscular blockade (NMB) required for effective relaxation of the respiratory muscles in ARDS are scarce. We hypothesised that complete versus partial NMB can modify respiratory mechanics. METHOD Prospective study to compare the respiratory mechanics of ARDS patients according to the NMB depth. Each patient was analysed at two times: deep NMB (facial train of four count (TOFC) = 0) and intermediate NMB (TOFC >0). The primary endpoint was the comparison of chest wall elastance (ELCW) according to the NMB level. RESULTS 33 ARDS patients were analysed. There was no statistical difference between the ELCW at TOFC = 0 compared to TOFC >0: 7 cmH2O/l [5.7-9.5] versus 7 cmH2O/l [5.3-10.8] (p = 0.36). The depth of NMB did not modify the expiratory nor inspiratory oesophageal pressure (Pesexp = 8 cmH2O [5-9.5] at TOFC = 0 versus 7 cmH2O [5-10] at TOFC >0; (p = 0.16) and Pesinsp = 10 cmH2O [8.2-13] at TOFC = 0 versus 10 cmH2O [8-13] at TOFC >0; (p = 0.12)). CONCLUSION In ARDS, the relaxation of the respiratory muscles seems to be independent of the NMB level.
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Grangier B, Vacheron CH, De Marignan D, Casalegno JS, Couray-Targe S, Bestion A, Ader F, Richard JC, Frobert E, Argaud L, Rimmele T, Lukaszewicz AC, Aubrun F, Dailler F, Fellahi JL, Bohe J, Piriou V, Allaouchiche B, Friggeri A, Wallet F. Comparison of mortality and outcomes of four respiratory viruses in the intensive care unit: a multicenter retrospective study. Sci Rep 2024; 14:6690. [PMID: 38509095 PMCID: PMC10954612 DOI: 10.1038/s41598-024-55378-x] [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: 07/13/2023] [Accepted: 02/22/2024] [Indexed: 03/22/2024] Open
Abstract
This retrospective study aimed to compare the mortality and burden of respiratory syncytial virus (RSV group), SARS-CoV-2 (COVID-19 group), non-H1N1 (Seasonal influenza group) and H1N1 influenza (H1N1 group) in adult patients admitted to intensive care unit (ICU) with respiratory failure. A total of 807 patients were included. Mortality was compared between the four following groups: RSV, COVID-19, seasonal influenza, and H1N1 groups. Patients in the RSV group had significantly more comorbidities than the other patients. At admission, patients in the COVID-19 group were significantly less severe than the others according to the simplified acute physiology score-2 (SAPS-II) and sepsis-related organ failure assessment (SOFA) scores. Using competing risk regression, COVID-19 (sHR = 1.61; 95% CI 1.10; 2.36) and H1N1 (sHR = 1.87; 95% CI 1.20; 2.93) were associated with a statistically significant higher mortality while seasonal influenza was not (sHR = 0.93; 95% CI 0.65; 1.31), when compared to RSV. Despite occurring in more severe patients, RSV and seasonal influenza group appear to be associated with a more favorable outcome than COVID-19 and H1N1 groups.
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Affiliation(s)
- Baptiste Grangier
- Service de Médecine Intensive Réanimation, Hôpital Lyon SUD, 415 chemin du grand Revoyet, 69495, Pierre-Bénite, France
| | - Charles-Hervé Vacheron
- Service de Médecine Intensive Réanimation, Hôpital Lyon SUD, 415 chemin du grand Revoyet, 69495, Pierre-Bénite, France
- Service de Biostatistique - Bio-informatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Donatien De Marignan
- Service de Médecine Intensive Réanimation, Hôpital Lyon SUD, 415 chemin du grand Revoyet, 69495, Pierre-Bénite, France
| | - Jean-Sebastien Casalegno
- Laboratoire de Virologie, Institut des Agents Infectieux (IAI), Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), INSERM U1111, Team VirPatH, ENS Lyon, Claude Bernard Lyon 1 University, Lyon, France
| | - Sandrine Couray-Targe
- Pôle de Santé Publique, Département d'Information Médicale, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Audrey Bestion
- Pôle de Santé Publique, Département d'Information Médicale, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Florence Ader
- Service de Maladies Infectieuses et Tropicales, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), INSERM U1111, CNRS UMR5308, ENS Lyon, Claude Bernard Lyon 1 University, Lyon, France
| | - Jean-Christophe Richard
- Service de Médecine Intensive Réanimation, Hôpital De La Croix Rousse, Hospices Civils de Lyon, Lyon, France
- CNRS, Inserm, CREATIS UMR 5220, U1206, Université de Lyon, Claude Bernard Lyon 1 university, INSA-Lyon, UJM-Saint Etienne, Lyon, France
| | - Emilie Frobert
- Laboratoire de Virologie, Institut des Agents Infectieux (IAI), Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), INSERM U1111, Team VirPatH, ENS Lyon, Claude Bernard Lyon 1 University, Lyon, France
| | - Laurent Argaud
- Service de Médecine Intensive Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Thomas Rimmele
- Service d'Anesthésie Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Anne-Claire Lukaszewicz
- Service d'Anesthésie Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Frédéric Aubrun
- Service d'Anesthésie Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - Frédéric Dailler
- Service d'Anesthésie Réanimation, Hôpital Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Julien Bohe
- Service de Médecine Intensive Réanimation, Hôpital Lyon SUD, 415 chemin du grand Revoyet, 69495, Pierre-Bénite, France
| | - Vincent Piriou
- Service de Médecine Intensive Réanimation, Hôpital Lyon SUD, 415 chemin du grand Revoyet, 69495, Pierre-Bénite, France
- RESHAPE Research on Healthcare Performance, U1290, Claude Bernard Lyon 1 university, Lyon, France
| | - Bernard Allaouchiche
- Service de Médecine Intensive Réanimation, Hôpital Lyon SUD, 415 chemin du grand Revoyet, 69495, Pierre-Bénite, France
- Pulmonary and Cardiovascular Aggression in Sepsis (APCSe), Université de Lyon, VetAgro Sup, Campus Vétérinaire de Lyon, UPSP 2016.A101, Marcy l'Étoile, France
| | - Arnaud Friggeri
- Service de Médecine Intensive Réanimation, Hôpital Lyon SUD, 415 chemin du grand Revoyet, 69495, Pierre-Bénite, France
- Centre International de Recherche en Infectiologie (CIRI), INSERM U1111, Team VirPatH, ENS Lyon, Claude Bernard Lyon 1 University, Lyon, France
| | - Florent Wallet
- Service de Médecine Intensive Réanimation, Hôpital Lyon SUD, 415 chemin du grand Revoyet, 69495, Pierre-Bénite, France.
- RESHAPE Research on Healthcare Performance, U1290, Claude Bernard Lyon 1 university, Lyon, France.
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Rathi V, Ish P, Malhotra N. Muscle relaxants in ARDS - The final verdict with the updated evidence. Lung India 2024; 41:81-83. [PMID: 38700399 PMCID: PMC10959317 DOI: 10.4103/lungindia.lungindia_605_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 05/05/2024] Open
Affiliation(s)
- Vidushi Rathi
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Pranav Ish
- Department of Pulmonary, Critical Care and Sleep Medicine, Safdarjung Hospital and VMMC, New Delhi, India
| | - Nipun Malhotra
- Department of Pulmonary, Critical Care and Sleep Medicine, PGIMSR-ESIC Model Hospital, New Delhi, India. E-mail:
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Plens GM, Droghi MT, Alcala GC, Pereira SM, Wawrzeniak IC, Victorino JA, Crivellari C, Grassi A, Rezoagli E, Foti G, Costa ELV, Amato MBP, Bellani G. Expiratory Muscle Activity Counteracts Positive End-Expiratory Pressure and Is Associated with Fentanyl Dose in Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:563-572. [PMID: 38190718 DOI: 10.1164/rccm.202308-1376oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/02/2024] [Indexed: 01/10/2024] Open
Abstract
Rationale: Hypoxemia during mechanical ventilation might be worsened by expiratory muscle activity, which reduces end-expiratory lung volume through lung collapse. A proposed mechanism of benefit of neuromuscular blockade in acute respiratory distress syndrome (ARDS) is the abolition of expiratory efforts. This may contribute to the restoration of lung volumes. The prevalence of this phenomenon, however, is unknown. Objectives: To investigate the incidence and amount of end-expiratory lung impedance (EELI) increase after the administration of neuromuscular blocking agents (NMBAs), clinical factors associated with this phenomenon, its impact on regional lung ventilation, and any association with changes in pleural pressure. Methods: We included mechanically ventilated patients with ARDS monitored with electrical impedance tomography (EIT) who received NMBAs in one of two centers. We measured changes in EELI, a surrogate for end-expiratory lung volume, before and after NMBA administration. In an additional 10 patients, we investigated the characteristic signatures of expiratory muscle activity depicted by EIT and esophageal catheters simultaneously. Clinical factors associated with EELI changes were assessed. Measurements and Main Results: We included 46 patients, half of whom showed an increase in EELI of >10% of the corresponding Vt (46.2%; IQR, 23.9-60.9%). The degree of EELI increase correlated positively with fentanyl dosage and negatively with changes in end-expiratory pleural pressures. This suggests that expiratory muscle activity might exert strong counter-effects against positive end-expiratory pressure that are possibly aggravated by fentanyl. Conclusions: Administration of NMBAs during EIT monitoring revealed activity of expiratory muscles in half of patients with ARDS. The resultant increase in EELI had a dose-response relationship with fentanyl dosage. This suggests a potential side effect of fentanyl during protective ventilation.
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Affiliation(s)
- Glauco M Plens
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Maddalena T Droghi
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Glasiele C Alcala
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Sérgio M Pereira
- Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Iuri C Wawrzeniak
- Programa de Pós-Graduação em Ciências Médicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Josué A Victorino
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Internal Medicine Department, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Chiara Crivellari
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Alice Grassi
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Emanuele Rezoagli
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Eduardo L V Costa
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
- Research and Education Institute, Hospital Sírio-Libanes, Sao Paulo, Brazil
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Giacomo Bellani
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy; and
- Department of Anesthesia and Intensive Care, Santa Chiara Regional Hospital, Azienda Provinciale per i Servizi Sanitari Trento, Trento, Italy
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10
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de Vries HJ, Drummond G. Neuromuscular Blockade Improves Results in Acute Respiratory Distress Syndrome: A Mechanism May Be Prevention of Expiratory Muscle Activity, Which Allows More Lung Expansion. Am J Respir Crit Care Med 2024; 209:478-481. [PMID: 38285592 PMCID: PMC10919110 DOI: 10.1164/rccm.202401-0012ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/26/2024] [Indexed: 01/31/2024] Open
Affiliation(s)
- Heder Jonathan de Vries
- Department of Critical Care Medicine Amsterdam University Medical Center Amsterdam, the Netherlands
- Amsterdam Cardiovascular Science Research Institute Amsterdam, the Netherlands
| | - Gordon Drummond
- Department of Anaesthesia, Critical Care and Pain Medicine Royal Infirmary Edinburgh, United Kingdom
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11
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Iavarone IG, Al-Husinat L, Vélez-Páez JL, Robba C, Silva PL, Rocco PRM, Battaglini D. Management of Neuromuscular Blocking Agents in Critically Ill Patients with Lung Diseases. J Clin Med 2024; 13:1182. [PMID: 38398494 PMCID: PMC10889521 DOI: 10.3390/jcm13041182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/09/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024] Open
Abstract
The use of neuromuscular blocking agents (NMBAs) is common in the intensive care unit (ICU). NMBAs have been used in critically ill patients with lung diseases to optimize mechanical ventilation, prevent spontaneous respiratory efforts, reduce the work of breathing and oxygen consumption, and avoid patient-ventilator asynchrony. In patients with acute respiratory distress syndrome (ARDS), NMBAs reduce the risk of barotrauma and improve oxygenation. Nevertheless, current guidelines and evidence are contrasting regarding the routine use of NMBAs. In status asthmaticus and acute exacerbation of chronic obstructive pulmonary disease, NMBAs are used in specific conditions to ameliorate patient-ventilator synchronism and oxygenation, although their routine use is controversial. Indeed, the use of NMBAs has decreased over the last decade due to potential adverse effects, such as immobilization, venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, ICU-acquired weakness, and residual paralysis after cessation of NMBAs use. The aim of this review is to highlight current knowledge and synthesize the evidence for the effects of NMBAs for critically ill patients with lung diseases, focusing on patient-ventilator asynchrony, ARDS, status asthmaticus, and chronic obstructive pulmonary disease.
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Affiliation(s)
- Ida Giorgia Iavarone
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, 16132 Genova, Italy
| | - Lou’i Al-Husinat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Jorge Luis Vélez-Páez
- Facultad de Ciencias Médicas, Universidad Central de Ecuador, Quito 170129, Ecuador;
- Unidad de Terapia Intensiva, Hospital Pablo Arturo Suárez, Centro de Investigación Clínica, Quito 170129, Ecuador
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, 16132 Genova, Italy
- Facultad de Ciencias Médicas, Universidad Central de Ecuador, Quito 170129, Ecuador;
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
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12
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Qadir N, Sahetya S, Munshi L, Summers C, Abrams D, Beitler J, Bellani G, Brower RG, Burry L, Chen JT, Hodgson C, Hough CL, Lamontagne F, Law A, Papazian L, Pham T, Rubin E, Siuba M, Telias I, Patolia S, Chaudhuri D, Walkey A, Rochwerg B, Fan E. An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2024; 209:24-36. [PMID: 38032683 PMCID: PMC10870893 DOI: 10.1164/rccm.202311-2011st] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Indexed: 12/01/2023] Open
Abstract
Background: This document updates previously published Clinical Practice Guidelines for the management of patients with acute respiratory distress syndrome (ARDS), incorporating new evidence addressing the use of corticosteroids, venovenous extracorporeal membrane oxygenation, neuromuscular blocking agents, and positive end-expiratory pressure (PEEP). Methods: We summarized evidence addressing four "PICO questions" (patient, intervention, comparison, and outcome). A multidisciplinary panel with expertise in ARDS used the Grading of Recommendations, Assessment, Development, and Evaluation framework to develop clinical recommendations. Results: We suggest the use of: 1) corticosteroids for patients with ARDS (conditional recommendation, moderate certainty of evidence), 2) venovenous extracorporeal membrane oxygenation in selected patients with severe ARDS (conditional recommendation, low certainty of evidence), 3) neuromuscular blockers in patients with early severe ARDS (conditional recommendation, low certainty of evidence), and 4) higher PEEP without lung recruitment maneuvers as opposed to lower PEEP in patients with moderate to severe ARDS (conditional recommendation, low to moderate certainty), and 5) we recommend against using prolonged lung recruitment maneuvers in patients with moderate to severe ARDS (strong recommendation, moderate certainty). Conclusions: We provide updated evidence-based recommendations for the management of ARDS. Individual patient and illness characteristics should be factored into clinical decision making and implementation of these recommendations while additional evidence is generated from much-needed clinical trials.
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13
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Chudow MB, Condeni MS, Dhar S, Heavner MS, Nei AM, Bissell BD. Current Practice Review in the Management of Acute Respiratory Distress Syndrome. J Pharm Pract 2023; 36:1454-1471. [PMID: 35728076 DOI: 10.1177/08971900221108713] [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] [Indexed: 12/15/2022]
Abstract
Acute respiratory distress syndrome (ARDS) presents as an acute inflammatory lung injury characterized by refractory hypoxemia and non-cardiac pulmonary edema. An estimated 10% of patients in the intensive care unit and 25% of those who are mechanically ventilated are diagnosed with ARDS. Increased awareness is warranted as mortality rates remain high and delays in diagnosing ARDS are common. The COVID-19 pandemic highlights the importance of understanding ARDS management. Treatment of ARDS can be challenging due to the complexity of the disease state and conflicting existing evidence. Therefore, it is imperative that pharmacists understand both pharmacologic and non-pharmacologic treatment strategies to optimize patient care. This narrative review provides a critical evaluation of current literature describing management practices for ARDS. A review of treatment modalities and supportive care strategies will be presented.
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Affiliation(s)
- Melissa B Chudow
- Department of Pharmacotherapeutics and Clinical Research, University of South Florida Taneja College of Pharmacy, Tampa, FL, USA
| | - Melanie S Condeni
- MUSC College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Sanjay Dhar
- Pulmonary Critical Care Ultrasound and Research, Pulmonary and Critical Care Fellowship Program, Division of Pulmonary, Critical Care & Sleep Medicine, University of Kentucky, Lexington, KY, USA
| | - Mojdeh S Heavner
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Andrea M Nei
- Mayo Clinic College of Medicine & Science, Critical Care Pharmacist, Department of Pharmacy, Mayo Clinic Hospital, Rochester, MN, USA
| | - Brittany D Bissell
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
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14
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Takahashi K, Toyama H, Ejima Y, Yang J, Kikuchi K, Ishikawa T, Yamauchi M. Endotracheal tube, by the venturi effect, reduces the efficacy of increasing inlet pressure in improving pendelluft. PLoS One 2023; 18:e0291319. [PMID: 37708106 PMCID: PMC10501657 DOI: 10.1371/journal.pone.0291319] [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: 03/16/2023] [Accepted: 08/27/2023] [Indexed: 09/16/2023] Open
Abstract
In mechanically ventilated severe acute respiratory distress syndrome patients, spontaneous inspiratory effort generates more negative pressure in the dorsal lung than in the ventral lung. The airflow caused by this pressure difference is called pendelluft, which is a possible mechanisms of patient self-inflicted lung injury. This study aimed to use computer simulation to understand how the endotracheal tube and insufficient ventilatory support contribute to pendelluft. We established two models. In the invasive model, an endotracheal tube was connected to the tracheobronchial tree with 34 outlets grouped into six locations: the right and left upper, lower, and middle lobes. In the non-invasive model, the upper airway, including the glottis, was connected to the tracheobronchial tree. To recreate the inspiratory effort of acute respiratory distress syndrome patients, the lower lobe pressure was set at -13 cmH2O, while the upper and middle lobe pressure was set at -6.4 cmH2O. The inlet pressure was set from 10 to 30 cmH2O to recreate ventilatory support. Using the finite volume method, the total flow rates through each model and toward each lobe were calculated. The invasive model had half the total flow rate of the non-invasive model (1.92 L/s versus 3.73 L/s under 10 cmH2O, respectively). More pendelluft (gas flow into the model from the outlets) was observed in the invasive model than in the non-invasive model. The inlet pressure increase from 10 to 30 cmH2O decreased pendelluft by 11% and 29% in the invasive and non-invasive models, respectively. In the invasive model, a faster jet flowed from the tip of the endotracheal tube toward the lower lobes, consequently entraining gas from the upper and middle lobes. Increasing ventilatory support intensifies the jet from the endotracheal tube, causing a venturi effect at the bifurcation in the tracheobronchial tree. Clinically acceptable ventilatory support cannot completely prevent pendelluft.
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Affiliation(s)
- Kazuhiro Takahashi
- Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Toyama
- Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yutaka Ejima
- Division of Surgical Center and Supply, Sterilization, Tohoku University Hospital, Sendai, Japan
| | - Jinyou Yang
- Department of Biophysics, School of Intelligent Medicine, China Medical University, Shenyang, China
| | - Kenji Kikuchi
- Department of Finemechanics, Graduate School of Engineering, Tohoku University, Sendai, Japan
| | - Takuji Ishikawa
- Graduate School of Biomedical Engineering, Tohoku University, Sendai, Japan
| | - Masanori Yamauchi
- Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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15
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Grasselli G, Calfee CS, Camporota L, Poole D, Amato MBP, Antonelli M, Arabi YM, Baroncelli F, Beitler JR, Bellani G, Bellingan G, Blackwood B, Bos LDJ, Brochard L, Brodie D, Burns KEA, Combes A, D'Arrigo S, De Backer D, Demoule A, Einav S, Fan E, Ferguson ND, Frat JP, Gattinoni L, Guérin C, Herridge MS, Hodgson C, Hough CL, Jaber S, Juffermans NP, Karagiannidis C, Kesecioglu J, Kwizera A, Laffey JG, Mancebo J, Matthay MA, McAuley DF, Mercat A, Meyer NJ, Moss M, Munshi L, Myatra SN, Ng Gong M, Papazian L, Patel BK, Pellegrini M, Perner A, Pesenti A, Piquilloud L, Qiu H, Ranieri MV, Riviello E, Slutsky AS, Stapleton RD, Summers C, Thompson TB, Valente Barbas CS, Villar J, Ware LB, Weiss B, Zampieri FG, Azoulay E, Cecconi M. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med 2023; 49:727-759. [PMID: 37326646 PMCID: PMC10354163 DOI: 10.1007/s00134-023-07050-7] [Citation(s) in RCA: 170] [Impact Index Per Article: 170.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.
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Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | | | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Francesca Baroncelli
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Geoff Bellingan
- Intensive Care Medicine, University College London, NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurent Brochard
- Keenan Research Center, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Critical Care, Unity Health Toronto - Saint Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013, Paris, France
| | - Sonia D'Arrigo
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Sharon Einav
- Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology and Critical Care, Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Departments of Medicine and Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jean-Pierre Frat
- CHU De Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM, CIC-1402, IS-ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Claude Guérin
- University of Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7200, Créteil, France
| | - Margaret S Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Catherine L Hough
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi Teaching Hospital, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier, France
| | - Nicole P Juffermans
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken Der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arthur Kwizera
- Makerere University College of Health Sciences, School of Medicine, Department of Anesthesia and Intensive Care, Kampala, Uganda
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, College of Medicine Nursing and Health Sciences, University of Galway, Galway, Ireland
- Anesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospitals Groups, Galway, Ireland
| | - Jordi Mancebo
- Intensive Care Department, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Alain Mercat
- Département de Médecine Intensive Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - Nuala J Meyer
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Canada
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Michelle Ng Gong
- Division of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Laurent Papazian
- Bastia General Hospital Intensive Care Unit, Bastia, France
- Aix-Marseille University, Faculté de Médecine, Marseille, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mariangela Pellegrini
- Anesthesia and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Marco V Ranieri
- Alma Mater Studiorum - Università di Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Elisabeth Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charlotte Summers
- Department of Medicine, University of Cambridge Medical School, Cambridge, UK
| | - Taylor B Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Carmen S Valente Barbas
- University of São Paulo Medical School, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jesús Villar
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM CVK), Charitè - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Fernando G Zampieri
- Academic Research Organization, Albert Einstein Hospital, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris Cité University, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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16
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Choi C, Lemmink G, Humanez J. Postoperative Respiratory Failure and Advanced Ventilator Settings. Anesthesiol Clin 2023; 41:141-159. [PMID: 36871996 DOI: 10.1016/j.anclin.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Postoperative respiratory failure has a multifactorial etiology, of which atelectasis is the most common mechanism. Its injurious effects are magnified by surgical inflammation, high driving pressures, and postoperative pain. Chest physiotherapy and noninvasive ventilation are good options to prevent progression of respiratory failure. Acute respiratory disease syndrome is a late and severe finding, which is associated with high morbidity and mortality. If present, proning is a safe, effective, and underutilized therapy. Extracorporeal membrane oxygenation is an option only when traditional supportive measures have failed.
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Affiliation(s)
- Christopher Choi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9068, USA.
| | - Gretchen Lemmink
- Department of Anesthesiology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0531, USA
| | - Jose Humanez
- Department of Anesthesiology, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, C72, Jacksonville, FL 32209, USA
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17
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Application of Neuromuscular Blockers in Patients with ARDS in ICU: A Retrospective Study Based on the MIMIC-III Database. J Clin Med 2023; 12:jcm12051878. [PMID: 36902664 PMCID: PMC10003530 DOI: 10.3390/jcm12051878] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/17/2023] [Accepted: 02/19/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Although neuromuscular blocker agents (NMBAs) are recommended by guidelines as a treatment for ARDS patients, the efficacy of NMBAs is still controversial. Our study aimed to investigate the association between cisatracurium infusion and the medium- and long-term outcomes of critically ill patients with moderate and severe ARDS. METHODS We performed a single-center, retrospective study of 485 critically ill adult patients with ARDS based on the Medical Information Mart for Intensive Care III (MIMIC-III) database. Propensity score matching (PSM) was used to match patients receiving NMBA administration with those not receiving NMBAs. The Cox proportional hazards model, Kaplan-Meier method, and subgroup analysis were used to evaluate the relationship between NMBA therapy and 28-day mortality. RESULTS A total of 485 moderate and severe patients with ARDS were reviewed and 86 pairs of patients were matched after PSM. NMBAs were not associated with reduced 28-day mortality (hazard ratio (HR) 1.44; 95% CI: 0.85~2.46; p = 0.20), 90-day mortality (HR = 1.49; 95% CI: 0.92~2.41; p = 0.10), 1-year mortality (HR = 1.34; 95% CI: 0.86~2.09; p = 0.20), or hospital mortality (HR = 1.34; 95% CI: 0.81~2.24; p = 0.30). However, NMBAs were associated with a prolonged duration of ventilation and the length of ICU stay. CONCLUSIONS NMBAs were not associated with improved medium- and long-term survival and may result in some adverse clinical outcomes.
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Bellaver P, Schaeffer AF, Leitao CB, Rech TH, Nedel WL. Association between neuromuscular blocking agents and the development of intensive care unit-acquired weakness (ICU-AW): A systematic review with meta-analysis and trial sequential analysis. Anaesth Crit Care Pain Med 2023; 42:101202. [PMID: 36804373 DOI: 10.1016/j.accpm.2023.101202] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 01/21/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND The present study aims to review the literature and synthesize evidence concerning the effects of the use of neuromuscular blocking agents (NMBA) regarding the development of intensive care unit-acquired weakness (ICU-AW). METHODS This study was registered in the PROSPERO database CRD42020142916. Systematic review in PubMed, Embase, and the Cochrane Central, Randomized clinical trials (RCTs), and cohort studies with adults that reported the use of NMBA and the development of ICU-AW were included. Pre-specified subgroup analyses were performed for presence of sepsis and type of NMBA used. The quality of evidence for intervention effects was summarized. The certainty of evidence was assessed using the GRADE approach. RESULTS We included 30 studies, four RCTs, 21 prospective and 5 retrospective cohorts, enrolling a total of 3839 patients. Most of the included studies were observational with high heterogeneity, whereas the RCTs had a high risk of bias. The use of NMBA increased the odds of developing ICU-AW (OR = 2.77 [95% CI 1.98-3.88], I2 = 62%), with low-quality of evidence. A trial sequential analysis showed the need to include 22,330 patients in order to provide evidence for either beneficial or harmful intervention effects. CONCLUSIONS This meta-analysis suggests that the use of NMBA might be implicated in the development of ICU-AW. However, there is not enough evidence to definitively conclude about the association between the use of NMBA and the development of ICU-AW, as these results are based mostly on observational studies with high heterogeneity.
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Affiliation(s)
- Priscila Bellaver
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Ariell F Schaeffer
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Cristiane B Leitao
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Tatiana H Rech
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Wagner L Nedel
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Brazilian Research in Intensive Care Network - BRICNet, Brazil.
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Nonpulmonary Treatments for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S45-S60. [PMID: 36661435 DOI: 10.1097/pcc.0000000000003158] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To provide an updated review of the literature on nonpulmonary treatments for pediatric acute respiratory distress syndrome (PARDS) from the Second Pediatric Acute Lung Injury Consensus Conference. DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION Searches were limited to children with PARDS or hypoxic respiratory failure focused on nonpulmonary adjunctive therapies (sedation, delirium management, neuromuscular blockade, nutrition, fluid management, transfusion, sleep management, and rehabilitation). DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-five studies were identified for full-text extraction. Five clinical practice recommendations were generated, related to neuromuscular blockade, nutrition, fluid management, and transfusion. Thirteen good practice statements were generated on the use of sedation, iatrogenic withdrawal syndrome, delirium, sleep management, rehabilitation, and additional information on neuromuscular blockade and nutrition. Three research statements were generated to promote further investigation in nonpulmonary therapies for PARDS. CONCLUSIONS These recommendations and statements about nonpulmonary treatments in PARDS are intended to promote optimization and consistency of care for patients with PARDS and identify areas of uncertainty requiring further investigation.
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Savoie-White FH, Tremblay L, Menier CA, Duval C, Bergeron F, Tadrous M, Tougas J, Guertin JR, Ugalde PA. The use of early neuromuscular blockage in acute respiratory distress syndrome: A systematic review and meta-analyses of randomized clinical trials. Heart Lung 2023; 57:186-197. [PMID: 36242824 DOI: 10.1016/j.hrtlng.2022.10.001] [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: 06/27/2022] [Revised: 08/12/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acute Respiratory Distress Syndrome (ARDS) as defined by the Berlin definition has an approximate mortality rate of 40% and no curative treatment. Mutliple therapies have been studied to reduce mortality but only neuromuscular blocking agents show potential benefits on mortality and other complications of ARDS. OBJECTIVE This review aimed to investigate the efficacy of neuromuscular blockers in ARDS METHODS: Medline, Embase, Cochrane Central and Web of Science were queried on October 1st, 2021. Randomized clinical trials comparing neuromuscular blockers to any comparator in treating ARDS were included. Primary outcome was mortality. Secondary outcomes were ventilator-free days, intensive care (ICU) length of stay (LOS) and complications. Results between sedation levels were examined with a Bayesian Network for Meta-analysis method. RESULTS We included 6 trials compiling a total of 1557 patients. Neuromuscular blockers compared to any comparator in treating ARDS showed a reduction in mortality (RR 0.79 [95% CI, 0.62 to 0.99]). No difference in ventilator-free days (MD 0.68 [95% CI, -0.50 to 1.85]) or ICU LOS (MD 0.77 [95% CI, -2.99 to 4.54]) were found. A Bayesian Network Meta-analysis yielded no difference in mortality when using light sedation compared to heavy sedation in ARDS. (OR 0.58 [95% CrI, 0.07 to 4.46].) CONCLUSION: Neuromuscular blockers safely reduce mortality. Light sedation potentially has a similar impact on mortality as heavy sedation that carries some burden. A non-inferiority trial comparing both sedation levels may be warranted considering the added value of light sedation.
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Affiliation(s)
- Félix H Savoie-White
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada; Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, Québec, Canada; Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada.
| | - Laurence Tremblay
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Charles Antoine Menier
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Cécile Duval
- Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, Québec, Canada
| | | | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Jade Tougas
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Jason R Guertin
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada; Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
| | - Paula A Ugalde
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Harvard University, Cambridge, Boston, United States
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21
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Baek MS, Kim JH, Lim Y, Kwon YS. Neuromuscular blockade in mechanically ventilated pneumonia patients with moderate to severe hypoxemia: A multicenter retrospective study. PLoS One 2022; 17:e0277503. [PMID: 36520923 PMCID: PMC9754162 DOI: 10.1371/journal.pone.0277503] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 10/28/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND/PURPOSE The benefit of neuromuscular blockades (NMBs) in critically ill patients receiving mechanical ventilation remains uncertain. Therefore, we aimed to investigate whether NMB use is associated with improved survival of mechanically ventilated pneumonia patients with moderate to severe hypoxemia. METHODS This retrospective multicenter study was conducted at five university-affiliated hospitals. Data of pneumonia patients aged 18 years and older who received mechanical ventilation between January 1, 2011, and December 31, 2020, were analyzed. RESULTS In a total of 1,130 patients, the mean patient age was 73.1 years (SD±12.6), and the overall mortality rate at 30 d was 29.5% (n = 333). NMB users had a higher 30 d mortality rate than NMB nonusers (33.9% vs. 26.8%, P = 0.014). After PS matching, the 30 d mortality rate was not significantly different between NMB users and nonusers (33.4% vs. 27.8%, p = 0.089). However, 90 d mortality rate was significantly increased in NMB users (39.7% vs. 31.9%, p = 0.021). Univariable Cox proportional hazard regression analyses showed that NMB use ≥ 3 d was significant risk factor for the 90 d mortality than those with < 3 d use (90 d mortality HR 1.39 [95% CI: 1.01-1.91], P = 0.045). CONCLUSIONS NMB use was not associated with lower 30 d mortality among mechanically ventilated pneumonia patients with moderate to severe hypoxemia. Rather, NMB users had higher 90 d mortality, furthermore, and NMB use ≥ 3 d was associated with a higher risk of long-term mortality compared to NMB use < 3 d. Therefore, care should be taken to avoid extended use of NMB in critically ill pneumonia patients during mechanical ventilation.
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Affiliation(s)
- Moon Seong Baek
- Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Jong Ho Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea
- Institute of New Frontier Research Team, Hallym University, Chuncheon, South Korea
| | - Yaeji Lim
- Department of Applied Statistics, Chung-Ang University, Seoul, Republic of Korea
| | - Young Suk Kwon
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea
- Institute of New Frontier Research Team, Hallym University, Chuncheon, South Korea
- * E-mail:
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Meng L, Liao X, Wang Y, Chen L, Gao W, Wang M, Dai H, Yan N, Gao Y, Wu X, Wang K, Liu Q. Pharmacologic therapies of ARDS: From natural herb to nanomedicine. Front Pharmacol 2022; 13:930593. [PMID: 36386221 PMCID: PMC9651133 DOI: 10.3389/fphar.2022.930593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/03/2022] [Indexed: 12/15/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a common critical illness in respiratory care units with a huge public health burden. Despite tremendous advances in the prevention and treatment of ARDS, it remains the main cause of intensive care unit (ICU) management, and the mortality rate of ARDS remains unacceptably high. The poor performance of ARDS is closely related to its heterogeneous clinical syndrome caused by complicated pathophysiology. Based on the different pathophysiology phases, drugs, protective mechanical ventilation, conservative fluid therapy, and other treatment have been developed to serve as the ARDS therapeutic methods. In recent years, there has been a rapid development in nanomedicine, in which nanoparticles as drug delivery vehicles have been extensively studied in the treatment of ARDS. This study provides an overview of pharmacologic therapies for ARDS, including conventional drugs, natural medicine therapy, and nanomedicine. Particularly, we discuss the unique mechanism and strength of nanomedicine which may provide great promises in treating ARDS in the future.
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Affiliation(s)
- Linlin Meng
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Ximing Liao
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Yuanyuan Wang
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Liangzhi Chen
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Wei Gao
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Muyun Wang
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Huiling Dai
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Na Yan
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Yixuan Gao
- Department of Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xu Wu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Kun Wang
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
- *Correspondence: Kun Wang, ; Qinghua Liu,
| | - Qinghua Liu
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
- *Correspondence: Kun Wang, ; Qinghua Liu,
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Ajibowo AO, Kolawole OA, Sadia H, Amedu OS, Chaudhry HA, Hussaini H, Hambolu E, Khan T, Kauser H, Khan A. A Comprehensive Review of the Management of Acute Respiratory Distress Syndrome. Cureus 2022; 14:e30669. [DOI: 10.7759/cureus.30669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 11/05/2022] Open
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Tsolaki V, Zakynthinos GE, Papadonta ME, Bardaka F, Fotakopoulos G, Pantazopoulos I, Makris D, Zakynthinos E. Neuromuscular Blockade in the Pre- and COVID-19 ARDS Patients. J Pers Med 2022; 12:jpm12091538. [PMID: 36143323 PMCID: PMC9504585 DOI: 10.3390/jpm12091538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/03/2022] [Accepted: 09/15/2022] [Indexed: 11/24/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) accounts for a quarter of mechanically ventilated patients, while during the pandemic, it overwhelmed the capacity of intensive care units (ICUs). Lung protective ventilation (low tidal volume, positive-end expiratory pressure titrated to lung mechanics and oxygenation, permissive hypercapnia) is a non-pharmacological approach that is the gold standard of management. Among the pharmacological treatments, the use of neuromuscular blocking agents (NMBAs), although extensively studied, has not yet been well clarified. The rationale is to minimize the risk for lung damage progression, in the already-injured pulmonary parenchyma. By abolishing rigorous spontaneous efforts, NMBAs may decrease the generation of high transpulmonary pressures that could aggravate patients’ self-inflicted lung injury. Moreover, NMBAs can harmonize the patient–ventilator interaction. Recent randomized controlled trials reported contradictory results and changed the clinical practice in a bidirectional way. NMBAs have not been documented to improve long-term survival; thus, the current guidance suggests their use only in patients in whom a lung protective ventilation protocol cannot be applied, due to asynchrony or increased respiratory efforts. In the present review, we discuss the published data and additionally the clinical practice in the “war” conditions of the COVID-19 pandemic, concerning NMBA use in the management of patients with ARDS.
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Affiliation(s)
- Vasiliki Tsolaki
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
- Correspondence: ; Tel.: +30-2413502964
| | - George E. Zakynthinos
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
- Third Department of Cardiology, Sotiria General Hospital, 11527 Athens, Greece
| | - Maria-Eirini Papadonta
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Fotini Bardaka
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - George Fotakopoulos
- Neurosurgical Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Ioannis Pantazopoulos
- Emergency Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Demosthenes Makris
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Epaminondas Zakynthinos
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
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Abraham S, Lussier BL. Bundled Bispectral Index Monitoring and Sedation During Paralysis in Acute Respiratory Distress Syndrome. AACN Adv Crit Care 2022; 33:253-261. [PMID: 36067265 DOI: 10.4037/aacnacc2022240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Clinical assessments of depth of sedation are insufficient for patients undergoing neuromuscular blockade during treatment of acute respiratory distress syndrome (ARDS). This quality initiative was aimed to augment objective assessment and improve sedation during therapeutic paralysis using the bispectral index (BIS). METHODS This quality improvement intervention provided education and subsequent implementation of a BIS monitoring and sedation/analgesia bundle in a large, urban, safety-net intensive care unit. After the intervention, a retrospective review of the first 70 admissions with ARDS assessed use and documented sedation changes in response to BIS. RESULTS Therapeutic neuromuscular blockade was initiated for 58 of 70 patients (82.8%) with ARDS, of whom 43 (74%) had BIS monitoring and 29.3% had bundled BIS sedation-titration orders. Explicit documentation of sedation titration in response to BIS values occurred in 27 (62.8%) of those with BIS recordings. CONCLUSIONS BIS sedation/analgesia bundled order sets are underused, but education and access to BIS monitoring led to high use of monitoring alone and subsequent sedation changes.
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Affiliation(s)
- Sunitha Abraham
- Sunitha Abraham is Nurse Practitioner, Neurointensive Care Unit, Parkland Memorial Hospital, Dallas, Texas
| | - Bethany L Lussier
- Bethany L. Lussier is Assistant Professor of Pulmonary and Critical Care, Neurocritical Care in the Department of Medicine and the Department of Neurology and Neurosurgery, Parkland Memorial Hospital, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, CS-08417, Dallas, TX 75370
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26
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Tasaka S, Ohshimo S, Takeuchi M, Yasuda H, Ichikado K, Tsushima K, Egi M, Hashimoto S, Shime N, Saito O, Matsumoto S, Nango E, Okada Y, Hayashi K, Sakuraya M, Nakajima M, Okamori S, Miura S, Fukuda T, Ishihara T, Kamo T, Yatabe T, Norisue Y, Aoki Y, Iizuka Y, Kondo Y, Narita C, Kawakami D, Okano H, Takeshita J, Anan K, Okazaki SR, Taito S, Hayashi T, Mayumi T, Terayama T, Kubota Y, Abe Y, Iwasaki Y, Kishihara Y, Kataoka J, Nishimura T, Yonekura H, Ando K, Yoshida T, Masuyama T, Sanui M. ARDS Clinical Practice Guideline 2021. J Intensive Care 2022; 10:32. [PMID: 35799288 PMCID: PMC9263056 DOI: 10.1186/s40560-022-00615-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/10/2022] [Indexed: 12/16/2022] Open
Abstract
Background The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. Methods The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. Results Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4–8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). Conclusions This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00615-6.
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Affiliation(s)
- Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan.
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kazuya Ichikado
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kenji Tsushima
- International University of Health and Welfare, Tokyo, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Hyogo, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Osamu Saito
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Eishu Nango
- Department of Family Medicine, Seibo International Catholic Hospital, Tokyo, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichiro Hayashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mikio Nakajima
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Satoshi Okamori
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinya Miura
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Urayasu Hospital, Juntendo University, Chiba, Japan
| | - Tetsuro Kamo
- Department of Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology, Nishichita General Hospital, Tokai, Japan
| | | | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Daisuke Kawakami
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Hiromu Okano
- Department of Critical Care and Emergency Medicine, National Hospital Organization Yokohama Medical Center, Kanagawa, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kyoto, Japan
| | | | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Takuya Hayashi
- Pediatric Emergency and Critical Care Center, Saitama Children's Medical Center, Saitama, Japan
| | - Takuya Mayumi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Saitama, Japan
| | - Yoshifumi Kubota
- Kameda Medical Center Department of Infectious Diseases, Chiba, Japan
| | - Yoshinobu Abe
- Division of Emergency and Disaster Medicine Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yuki Kishihara
- Department of Emergency Medicine, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Jun Kataoka
- Department of Critical Care Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Aichi, Japan
| | - Koichi Ando
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Tomoyuki Masuyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
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Hohmann F, Wedekind L, Grundeis F, Dickel S, Frank J, Golinski M, Griesel M, Grimm C, Herchenhahn C, Kramer A, Metzendorf MI, Moerer O, Olbrich N, Thieme V, Vieler A, Fichtner F, Burns J, Laudi S. Early spontaneous breathing for acute respiratory distress syndrome in individuals with COVID-19. Cochrane Database Syst Rev 2022; 6:CD015077. [PMID: 35767435 PMCID: PMC9242537 DOI: 10.1002/14651858.cd015077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) represents the most severe course of COVID-19 (caused by the SARS-CoV-2 virus), usually resulting in a prolonged stay in an intensive care unit (ICU) and high mortality rates. Despite the fact that most affected individuals need invasive mechanical ventilation (IMV), evidence on specific ventilation strategies for ARDS caused by COVID-19 is scarce. Spontaneous breathing during IMV is part of a therapeutic concept comprising light levels of sedation and the avoidance of neuromuscular blocking agents (NMBA). This approach is potentially associated with both advantages (e.g. a preserved diaphragmatic motility and an optimised ventilation-perfusion ratio of the ventilated lung), as well as risks (e.g. a higher rate of ventilator-induced lung injury or a worsening of pulmonary oedema due to increases in transpulmonary pressure). As a consequence, spontaneous breathing in people with COVID-19-ARDS who are receiving IMV is subject to an ongoing debate amongst intensivists. OBJECTIVES To assess the benefits and harms of early spontaneous breathing activity in invasively ventilated people with COVID-19 with ARDS compared to ventilation strategies that avoid spontaneous breathing. SEARCH METHODS We searched the Cochrane COVID-19 Study Register (which includes CENTRAL, PubMed, Embase, Clinical Trials.gov WHO ICTRP, and medRxiv) and the WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies from their inception to 2 March 2022. SELECTION CRITERIA Eligible study designs comprised randomised controlled trials (RCTs) that evaluated spontaneous breathing in participants with COVID-19-related ARDS compared to ventilation strategies that avoided spontaneous breathing (e.g. using NMBA or deep sedation levels). Additionally, we considered controlled before-after studies, interrupted time series with comparison group, prospective cohort studies and retrospective cohort studies. For these non-RCT studies, we considered a minimum total number of 50 participants to be compared as necessary for inclusion. Prioritised outcomes were all-cause mortality, clinical improvement or worsening, quality of life, rate of (serious) adverse events and rate of pneumothorax. Additional outcomes were need for tracheostomy, duration of ICU length of stay and duration of hospitalisation. DATA COLLECTION AND ANALYSIS We followed the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors independently screened all studies at the title/abstract and full-text screening stage. We also planned to conduct data extraction and risk of bias assessment in duplicate. We planned to conduct meta-analysis for each prioritised outcome, as well as subgroup analyses of mortality regarding severity of oxygenation impairment and duration of ARDS. In addition, we planned to perform sensitivity analyses for studies at high risk of bias, studies using NMBA in addition to deep sedation level to avoid spontaneous breathing and a comparison of preprints versus peer-reviewed articles. We planned to assess the certainty of evidence using the GRADE approach. MAIN RESULTS We identified no eligible studies for this review. AUTHORS' CONCLUSIONS We found no direct evidence on whether early spontaneous breathing in SARS-CoV-2-induced ARDS is beneficial or detrimental to this particular group of patients. RCTs comparing early spontaneous breathing with ventilatory strategies not allowing for spontaneous breathing in SARS-CoV-2-induced ARDS are necessary to determine its value within the treatment of severely ill people with COVID-19. Additionally, studies should aim to clarify whether treatment effects differ between people with SARS-CoV-2-induced ARDS and people with non-SARS-CoV-2-induced ARDS.
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Affiliation(s)
- Friedrich Hohmann
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Lisa Wedekind
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
- Institute of Medical Statistics, Computer and Data Sciences, University Hospital Jena, Jena, Germany
| | - Felicitas Grundeis
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Steffen Dickel
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - Johannes Frank
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Martin Golinski
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - Mirko Griesel
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Clemens Grimm
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - Cindy Herchenhahn
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Andre Kramer
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Maria-Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Onnen Moerer
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - Nancy Olbrich
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Volker Thieme
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Astrid Vieler
- Medicine and Sciences Library, Leipzig University, Leipzig, Germany
| | - Falk Fichtner
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Jacob Burns
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
| | - Sven Laudi
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
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Tasaka S, Ohshimo S, Takeuchi M, Yasuda H, Ichikado K, Tsushima K, Egi M, Hashimoto S, Shime N, Saito O, Matsumoto S, Nango E, Okada Y, Hayashi K, Sakuraya M, Nakajima M, Okamori S, Miura S, Fukuda T, Ishihara T, Kamo T, Yatabe T, Norisue Y, Aoki Y, Iizuka Y, Kondo Y, Narita C, Kawakami D, Okano H, Takeshita J, Anan K, Okazaki SR, Taito S, Hayashi T, Mayumi T, Terayama T, Kubota Y, Abe Y, Iwasaki Y, Kishihara Y, Kataoka J, Nishimura T, Yonekura H, Ando K, Yoshida T, Masuyama T, Sanui M. ARDS clinical practice guideline 2021. Respir Investig 2022; 60:446-495. [PMID: 35753956 DOI: 10.1016/j.resinv.2022.05.003] [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: 04/19/2022] [Revised: 05/07/2022] [Accepted: 05/13/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. METHODS The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. RESULTS Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D); we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D); we suggest against routinely implementing NO inhalation therapy (GRADE 2C); and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). CONCLUSIONS This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jrs.or.jp/publication/jrs_guidelines/). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.
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Affiliation(s)
- Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Aomori, Japan.
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Kazuya Ichikado
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kenji Tsushima
- International University of Health and Welfare, Tokyo, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Hyogo, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Osamu Saito
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Eishu Nango
- Department of Family Medicine, Seibo International Catholic Hospital, Tokyo, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichiro Hayashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mikio Nakajima
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Satoshi Okamori
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinya Miura
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, Chiba, Japan
| | - Tetsuro Kamo
- Department of Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology, Nishichita General Hospital, Aichi, Japan
| | | | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, Chiba, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Daisuke Kawakami
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Hiromu Okano
- Department of Critical Care and Emergency Medicine, National Hospital Organization Yokohama Medical Center, Kanagawa, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Takuya Hayashi
- Pediatric Emergency and Critical Care Center, Saitama Children's Medical Center, Saitama, Japan
| | - Takuya Mayumi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Saitama, Japan
| | - Yoshifumi Kubota
- Department of Infectious Diseases, Kameda Medical Center, Chiba, Japan
| | - Yoshinobu Abe
- Division of Emergency and Disaster Medicine, Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yuki Kishihara
- Department of Emergency Medicine, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Jun Kataoka
- Department of Critical Care Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Aichi, Japan
| | - Koichi Ando
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Tomoyuki Masuyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
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Guérin C, Cour M, Argaud L. Prone Positioning and Neuromuscular Blocking Agents as Adjunctive Therapies in Mechanically Ventilated Patients with Acute Respiratory Distress Syndrome. Semin Respir Crit Care Med 2022; 43:453-460. [DOI: 10.1055/s-0042-1744304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AbstractNeuromuscular blocking agents (NMBAs) and prone position (PP) are two major adjunctive therapies that can improve outcome in moderate-to-severe acute respiratory distress syndrome. NMBA should be used once lung-protective mechanical ventilation has been set, for 48 hours or less and as a continuous intravenous infusion. PP should be used as early as possible for long sessions; in COVID-19 its use has exploded. In nonintubated patients, PP might reduce the rate of intubation but not mortality. The goal of this article is to perform a narrative review on the pathophysiological rationale, the clinical effects, and the clinical use and recommendations of both NMBA and PP.
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Affiliation(s)
- Claude Guérin
- Médecine Intensive Réanimation, Hôpital Edouard Herriot, Lyon, France
- Faculté de Médecine Lyon-Est, Université de Lyon, Lyon, France
- INSERM 955 CNRS 7200, Institut Mondor de Recherches Biomédicales, Créteil, France
| | - Martin Cour
- Médecine Intensive Réanimation, Hôpital Edouard Herriot, Lyon, France
- Faculté de Médecine Lyon-Est, Université de Lyon, Lyon, France
| | - Laurent Argaud
- Médecine Intensive Réanimation, Hôpital Edouard Herriot, Lyon, France
- Faculté de Médecine Lyon-Est, Université de Lyon, Lyon, France
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30
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Saha R, Assouline B, Mason G, Douiri A, Summers C, Shankar-Har M. The Impact of Sample Size Misestimations on the Interpretation of ARDS Trials: Systematic Review and Meta-analysis. Chest 2022; 162:1048-1062. [PMID: 35643115 DOI: 10.1016/j.chest.2022.05.018] [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: 12/13/2021] [Revised: 04/06/2022] [Accepted: 05/04/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Indeterminate randomized controlled trials (RCTs) in ARDS may arise from sample size misspecification, leading to abandonment of efficacious therapies. RESEARCH QUESTIONS If evidence exists for sample size misspecification in ARDS RCTs, has this led to rejection of potentially beneficial therapies? Does evidence exist for prognostic enrichment in RCTs using mortality as a primary outcome? STUDY DESIGN AND METHODS We identified 150 ARDS RCTs commencing recruitment after the 1994 American European Consensus Conference ARDS definition and published before October 31, 2020. We examined predicted-observed sample size, predicted-observed control event rate (CER), predicted-observed average treatment effect (ATE), and the relationship between observed CER and observed ATE for RCTs with mortality and nonmortality primary outcome measures. To quantify the strength of evidence, we used Bayesian-averaged meta-analysis, trial sequential analysis, and Bayes factors. RESULTS Only 84 of 150 RCTs (56.0%) reported sample size estimations. In RCTs with mortality as the primary outcome, CER was overestimated in 16 of 28 RCTs (57.1%). To achieve predicted ATE, interventions needed to prevent 40.8% of all deaths, compared with the original prediction of 29.3%. Absolute reduction in mortality ≥ 10% was observed in 5 of 28 RCTs (17.9%), but predicted in 21 of 28 RCTs (75%). For RCTs with mortality as the primary outcome, no association was found between observed CER and observed ATE (pooled OR: β = -0.04; 95% credible interval, -0.18 to 0.09). We identified three interventions that are not currently standard of care with a Bayesian-averaged effect size of > 0.20 and moderate strength of existing evidence: corticosteroids, airway pressure release ventilation, and noninvasive ventilation. INTERPRETATION Reporting of sample size estimations was inconsistent in ARDS RCTs, and misspecification of CER and ATE was common. Prognostic enrichment strategies in ARDS RCTs based on all-cause mortality are unlikely to be successful. Bayesian methods can be used to prioritize interventions for future effectiveness RCTs.
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Affiliation(s)
- Rohit Saha
- Critical Care Centre, King's College London, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Benjamin Assouline
- Service de Médecine Intensive Réanimation, Faculté de Médecine Sorbonne Université, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Georgina Mason
- Critical Care Centre, King's College London, London, United Kingdom
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, King's College London, London, United Kingdom; National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Charlotte Summers
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Manu Shankar-Har
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom.
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Li Bassi G, Gibbons K, Suen JY, Dalton HJ, White N, Corley A, Shrapnel S, Hinton S, Forsyth S, Laffey JG, Fan E, Fanning JP, Panigada M, Bartlett R, Brodie D, Burrell A, Chiumello D, Elhazmi A, Esperatti M, Grasselli G, Hodgson C, Ichiba S, Luna C, Marwali E, Merson L, Murthy S, Nichol A, Ogino M, Pelosi P, Torres A, Ng PY, Fraser JF. Early short course of neuromuscular blocking agents in patients with COVID-19 ARDS: a propensity score analysis. Crit Care 2022; 26:141. [PMID: 35581612 PMCID: PMC9112652 DOI: 10.1186/s13054-022-03983-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/10/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The role of neuromuscular blocking agents (NMBAs) in coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) is not fully elucidated. Therefore, we aimed to investigate in COVID-19 patients with moderate-to-severe ARDS the impact of early use of NMBAs on 90-day mortality, through propensity score (PS) matching analysis. METHODS We analyzed a convenience sample of patients with COVID-19 and moderate-to-severe ARDS, admitted to 244 intensive care units within the COVID-19 Critical Care Consortium, from February 1, 2020, through October 31, 2021. Patients undergoing at least 2 days and up to 3 consecutive days of NMBAs (NMBA treatment), within 48 h from commencement of IMV were compared with subjects who did not receive NMBAs or only upon commencement of IMV (control). The primary objective in the PS-matched cohort was comparison between groups in 90-day in-hospital mortality, assessed through Cox proportional hazard modeling. Secondary objectives were comparisons in the numbers of ventilator-free days (VFD) between day 1 and day 28 and between day 1 and 90 through competing risk regression. RESULTS Data from 1953 patients were included. After propensity score matching, 210 cases from each group were well matched. In the PS-matched cohort, mean (± SD) age was 60.3 ± 13.2 years and 296 (70.5%) were male and the most common comorbidities were hypertension (56.9%), obesity (41.1%), and diabetes (30.0%). The unadjusted hazard ratio (HR) for death at 90 days in the NMBA treatment vs control group was 1.12 (95% CI 0.79, 1.59, p = 0.534). After adjustment for smoking habit and critical therapeutic covariates, the HR was 1.07 (95% CI 0.72, 1.61, p = 0.729). At 28 days, VFD were 16 (IQR 0-25) and 25 (IQR 7-26) in the NMBA treatment and control groups, respectively (sub-hazard ratio 0.82, 95% CI 0.67, 1.00, p = 0.055). At 90 days, VFD were 77 (IQR 0-87) and 87 (IQR 0-88) (sub-hazard ratio 0.86 (95% CI 0.69, 1.07; p = 0.177). CONCLUSIONS In patients with COVID-19 and moderate-to-severe ARDS, short course of NMBA treatment, applied early, did not significantly improve 90-day mortality and VFD. In the absence of definitive data from clinical trials, NMBAs should be indicated cautiously in this setting.
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Affiliation(s)
- Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside, Brisbane, QLD, 4032, Australia.
- University of Queensland, Brisbane, Australia.
- Institut dInvestigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain.
- Queensland University of Technology, Brisbane, Australia.
- UnitingCare Hospitals, Brisbane, Australia.
- Wesley Medical Research, Brisbane, Australia.
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside, Brisbane, QLD, 4032, Australia
- University of Queensland, Brisbane, Australia
| | - Heidi J Dalton
- INOVA Fairfax Medical Center, Heart and Vascular Institute, Falls Church, VA, USA
| | - Nicole White
- Queensland University of Technology, Brisbane, Australia
| | - Amanda Corley
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside, Brisbane, QLD, 4032, Australia
- University of Queensland, Brisbane, Australia
| | - Sally Shrapnel
- University of Queensland, Brisbane, Australia
- The Australian Research Council Centre of Excellence for Engineered Quantum Systems (EQUS, CE170100009), Brisbane, Australia
| | | | | | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland, and Galway University Hospitals, Galway, Ireland
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside, Brisbane, QLD, 4032, Australia
- University of Queensland, Brisbane, Australia
- UnitingCare Hospitals, Brisbane, Australia
- Wesley Medical Research, Brisbane, Australia
| | - Mauro Panigada
- Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | | | - Daniel Brodie
- Department of Medicine, Columbia College of Physicians and Surgeons, and Center for Acute Respiratory Failure, New-York-Presbyterian Hospital, New York, NY, USA
| | - Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre, School of Public Health, Monash University, Melbourne, Australia
| | - Davide Chiumello
- Ospedale San Paolo, Milan, Italy
- University of Milan, Milan, Italy
| | - Alyaa Elhazmi
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mariano Esperatti
- Hospital Privado de Comunidad, Escuela de Medicina, Universidad Nacional de Mar del Plata, Mar del Plata, Argentina
| | - Giacomo Grasselli
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- University of Milan, Milan, Italy
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health, Monash University, Melbourne, Australia
| | | | - Carlos Luna
- Neumonología, Hospital de Clínicas, UBA, Buenos Aires, Argentina
| | - Eva Marwali
- National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Laura Merson
- ISARIC, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Srinivas Murthy
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- BC Childrens Hospital Research Institute, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health, Monash University, Melbourne, Australia
- University College Dublin-Clinical Research Centre at St Vincents University Hospital, Dublin, Ireland
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - Mark Ogino
- Nemours Alfred I duPont Hospital for Children, Wilmington, DE, USA
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Antoni Torres
- Institut dInvestigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Hospital Clinic of Barcelona, Barcelona, Spain
| | - Pauline Yeung Ng
- Department of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside, Brisbane, QLD, 4032, Australia
- University of Queensland, Brisbane, Australia
- Institut dInvestigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Queensland University of Technology, Brisbane, Australia
- UnitingCare Hospitals, Brisbane, Australia
- Wesley Medical Research, Brisbane, Australia
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Acute respiratory distress syndrome. JAAPA 2022; 35:29-33. [DOI: 10.1097/01.jaa.0000823164.50706.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Rudolph MW, Slager S, Burgerhof JGM, van Woensel JB, Alffenaar JWC, Wösten - van Asperen RM, de Hoog M, IJland MM, Kneyber MCJ. Paediatric Acute Respiratory Distress Syndrome Neuromuscular Blockade study (PAN-study): a phase IV randomised controlled trial of early neuromuscular blockade in moderate-to-severe paediatric acute respiratory distress syndrome. Trials 2022; 23:96. [PMID: 35101098 PMCID: PMC8802263 DOI: 10.1186/s13063-021-05927-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/08/2021] [Indexed: 11/11/2022] Open
Abstract
Background Paediatric acute respiratory distress syndrome (PARDS) is a manifestation of severe, life-threatening lung injury necessitating mechanical ventilation with mortality rates ranging up to 40–50%. Neuromuscular blockade agents (NMBAs) may be considered to prevent patient self-inflicted lung injury in PARDS patients, but two trials in adults with severe ARDS yielded conflicting results. To date, randomised controlled trials (RCT) examining the effectiveness and efficacy of NMBAs for PARDS are lacking. We hypothesise that using NMBAs for 48 h in paediatric patients younger than 5 years of age with early moderate-to-severe PARDS will lead to at least a 20% reduction in cumulative respiratory morbidity score 12 months after discharge from the paediatric intensive care unit (PICU). Methods This is a phase IV, multicentre, randomised, double-blind, placebo-controlled trial performed in level-3 PICUs in the Netherlands. Eligible for inclusion are children younger than 5 years of age requiring invasive mechanical ventilation with positive end-expiratory pressure (PEEP) ≥ 5 cm H2O for moderate-to-severe PARDS occurring within the first 96 h of PICU admission. Patients are randomised to continuous infusion of rocuronium bromide or placebo for 48 h. The primary endpoint is the cumulative respiratory morbidity score 12 months after PICU discharge, adjusted for confounding by age, gestational age, family history of asthma and/or allergy, season in which questionnaire was filled out, day-care and parental smoking. Secondary outcomes include respiratory mechanics, oxygenation and ventilation metrics, pulmonary and systemic inflammation markers, prevalence of critical illness polyneuropathy and myopathy and metrics for patient outcome including ventilator free days at day 28, length of PICU and hospital stay, and mortality Discussion This is the first paediatric trial evaluating the effects of muscular paralysis in moderate-to-severe PARDS. The proposed study addresses a huge research gap identified by the Paediatric Acute Lung Injury Consensus Collaborative by evaluating practical needs regarding the treatment of PARDS. Paediatric critical care practitioners are inclined to use interventions such as NMBAs in the most critically ill. This liberal use must be weighed against potential side effects. The proposed study will provide much needed scientific support in the decision-making to start NMBAs in moderate-to-severe PARDS. Trial registration ClinicalTrials.govNCT02902055. Registered on September 15, 2016.
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Panusitthikorn P, Suthisisang C, Tangsujaritvijit V, Nosoongnoen W, Dilokpattanamongkol P. Pharmacokinetics and pharmacodynamics studies of a loading dose of cisatracurium in critically ill patients with respiratory failure. BMC Anesthesiol 2022; 22:32. [PMID: 35065599 PMCID: PMC8783433 DOI: 10.1186/s12871-022-01571-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Previous studies reported a slow neuromuscular response with the currently recommended dose of cisatracurium in critically ill patients. Pharmacokinetic and pharmacodynamic studies of cisatracurium in critically ill patients are still limited. To our knowledge, this is the first study performed to better understand the pharmacokinetics (PKs) and pharmacodynamics (PDs) of a loading dose of cisatracurium and to identify factors that affect PK and PD changes in critically ill patients.
Methods
A prospective PKs and PDs study was designed. Arterial blood samples of 10 critically ill patients with respiratory failure were collected after administering a loading dose of 0.2 mg/kg of cisatracurium. Plasma cisatracurium and laudanosine concentrations were determined using liquid chromatography-tandem mass spectrometry. The achievement of the desired pharmacodynamic response was evaluated by both 1) clinical assessment and 2) train-of-four monitoring. The PK/PD indices were analyzed for their correlation with patient’characteristics and other factors.
Results
The one-compartment model best described the plasma pharmacokinetic parameters of cisatracurium. The volume of distribution at steady state and total clearance were 0.11 ± 0.04 L/kg and 2.74 ± 0.87 ml/minute/kg, respectively. The mean time to train-of-four 0/4 was 6 ± 3.86 minutes. A time to the desired pharmacodynamic response of less than 5 minutes was found in 10% of the patients. A positive correlation was found between cisatracurium concentration and albumin levels and between pharmacokinetics data and patient factors [partial pressure of carbon dioxide and respiratory alkalosis].
Conclusion
The currently recommended loading dose of cisatracurium might not lead to the desired pharmacodynamic response in critically ill patients with respiratory failure.
Trial registration
ClinicalTrials.gov, NCT03337373. Registered on 9 November 2017
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Hussain M, Khurram Syed S, Fatima M, Shaukat S, Saadullah M, Alqahtani AM, Alqahtani T, Bin Emran T, Alamri AH, Barkat MQ, Wu X. Acute Respiratory Distress Syndrome and COVID-19: A Literature Review. J Inflamm Res 2022; 14:7225-7242. [PMID: 34992415 PMCID: PMC8710428 DOI: 10.2147/jir.s334043] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/17/2021] [Indexed: 12/12/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is an overwhelming inflammatory disorder of the lung due to direct and indirect insults to the lungs. ARDS is characterized by increased vascular permeability, protein-rich edema, diffuse alveolar infiltrate, and loss of aerated lung tissue, leading to decreased lung compliance, tachypnea, and severe hypoxemia. COVID-19 is generally associated with ARDS, and it has gained prime importance since it started. The mortality rate is alarmingly high in COVID-19-related ARDS patients regardless of advances in mechanical ventilation. Several pharmacological agents, including corticosteroids, nitric oxide, neuromuscular blocker, anti-TNF, statins, and exogenous surfactant, have been studied and some are under investigation, like ketoconazole, lisofylline, N-acetylcysteine, prostaglandins, prostacyclin, and fish oil. The purpose of this review is to appraise the understanding of the pathophysiology of ARDS, biomarkers, and clinical trials of pharmacological therapies of ARDS and COVID-19-related ARDS.
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Affiliation(s)
- Musaddique Hussain
- Department of Pharmacology, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, 63100, Pakistan
| | - Shahzada Khurram Syed
- Department of Basic Medical Sciences, School of Health Sciences, University of Management and Technology Lahore, Lahore, 54000, Pakistan
| | - Mobeen Fatima
- Department of Pharmacology, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, 63100, Pakistan
| | - Saira Shaukat
- Department of Pharmacology, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, 63100, Pakistan
| | - Malik Saadullah
- Department of Pharmaceutical Chemistry, Government College University, Faisalabad, 38000, Pakistan
| | - Ali M Alqahtani
- Department of Pharmacology, College of Pharmacy, King Khalid University, Abha, 62529, Saudi Arabia
| | - Taha Alqahtani
- Department of Pharmacology, College of Pharmacy, King Khalid University, Abha, 62529, Saudi Arabia
| | - Talha Bin Emran
- Department of Pharmacy, BGC Trust University Bangladesh, Chittagong, 4381, Bangladesh
| | - Ali H Alamri
- Department of Pharmaceutics, College of Pharmacy, King Khalid University, Abha, 62529, Saudi Arabia
| | - Muhammad Qasim Barkat
- Department of Pharmacology, School of Medicine, Zhejiang University, Hangzhou City, 310000, People's Republic of China
| | - Ximei Wu
- Department of Pharmacology, School of Medicine, Zhejiang University, Hangzhou City, 310000, People's Republic of China
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Early Neuromuscular Blockade in Moderate-to-Severe Pediatric Acute Respiratory Distress Syndrome. Crit Care Med 2022; 50:e445-e457. [PMID: 35029869 DOI: 10.1097/ccm.0000000000005426] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objectives The use of neuromuscular blocking agents (NMBAs) in pediatric acute respiratory distress syndrome (PARDS) is common but unsupported by efficacy data. We sought to compare the outcomes between patients with moderate-to-severe PARDS receiving continuous NMBA during the first 48 hours of endotracheal intubation (early NMBA) and those without. Design Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial, a pediatric multicenter cluster randomized trial of sedation. Setting Thirty-one PICUs in the United States. Patients Children 2 weeks to 17 years receiving invasive mechanical ventilation (MV) for moderate-to-severe PARDS (i.e., oxygenation index >= 8 and bilateral infiltrates on chest radiograph on days 0-1 of endotracheal intubation). Interventions NMBA for the entire duration of days 1 and 2 after intubation. Measurements and Main Results Among 1,182 RESTORE patients with moderate-to-severe PARDS, 196 (17%) received early NMBA for a median of 50.0% ventilator days (interquartile range, 33.3-60.7%). The propensity score model predicting the probability of receiving early NMBA included high-frequency oscillatory ventilation on days 0-2 (odds ratio [OR], 7.61; 95% CI, 4.75-12.21) and severe PARDS on days 0-1 (OR, 2.16; 95% CI, 1.50-3.12). After adjusting for risk category, early use of NMBA was associated with a longer duration of MV (hazard ratio, 0.57; 95% CI, 0.48-0.68; p < 0.0001), but not with mortality (OR, 1.62; 95% CI, 0.92-2.85; p = 0.096) compared with no early use of NMBA. Other outcomes including cognitive, functional, and physical impairment at 6 months post-PICU discharge were similar. Outcomes did not differ when comparing high versus low NMBA usage sites or when patients were stratified by baseline PaO2/FIO2 less than 150. Conclusions Early NMBA use was associated with a longer duration of MV. This propensity score analysis underscores the need for a randomized controlled trial in pediatrics.
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Adams CE, McAuley DF. Acute Respiratory Distress Syndrome. ENCYCLOPEDIA OF RESPIRATORY MEDICINE 2022. [PMCID: PMC8106506 DOI: 10.1016/b978-0-08-102723-3.00233-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a prevalent and important cause of respiratory failure. Underlying causes include pulmonary and non-pulmonary aetiologies. ARDS is acute hypoxaemic respiratory failure associated with non-cardiogenic pulmonary oedema, reduced pulmonary compliance, and can lead to lung fibrosis. In addition to treating the underlying cause, often the mainstay of the management of ARDS is invasive mechanical ventilation. This can perpetuate lung injury—ventilator-associated lung injury (VALI). Despite recent advances in our understanding of this, ARDS-associated morbidity and mortality remains high. This chapter discusses the pathophysiology of ARDS and its management, including mechanical ventilation, adjunctive therapies, and some recently trialed pharmacotherapies.
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Terzi N, Guérin C. Optimizing Mechanical Ventilation in Refractory ARDS. ENCYCLOPEDIA OF RESPIRATORY MEDICINE 2022. [PMCID: PMC8740657 DOI: 10.1016/b978-0-12-801238-3.11480-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Mechanical ventilation in patients with refractory acute respiratory distress syndrome (ARDS) must provide lung protection. This is achieved by limiting tidal volume (VT) and plateau pressure (Pplat). With the current evidence available VT should be initially set around 6 mL per kg predicted body weight and PPlat maintained below 30 cmH2O and monitored. Positive end-expiratory pressure (PEEP), which also contributes to lung protection, should be set > 12 cmH2O, provided oxygenation gets improved, with same Pplat target. Recruitment maneuvers should be used with caution avoiding higher PEEP. Neuromuscular blockade should be started and prone position performed for sessions longer than 16 h. High frequency oscillation ventilation should be used in expert centers only if previous management failed to improve oxygenation.
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 891] [Impact Index Per Article: 297.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1449] [Impact Index Per Article: 483.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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Chalmers SJ, Lal A, Gajic O, Kashyap R. Timing of ARDS Resolution (TARU): A Pragmatic Clinical Assessment of ARDS Resolution in the ICU. Lung 2021; 199:439-445. [PMID: 34585258 PMCID: PMC8478608 DOI: 10.1007/s00408-021-00479-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 09/13/2021] [Indexed: 12/14/2022]
Abstract
Purpose Lack of a pragmatic outcome measures for acute respiratory distress syndrome (ARDS) resolution is a barrier to meaningful interventional trials of novel treatments. We evaluated a pragmatic, electronic health record (EHR)-based approach toward the clinical assessment of a novel outcome measure: ICU ARDS resolution. Methods We conducted a retrospective observational cohort study evaluating adult patients with moderate–severe ARDS admitted to the medical intensive care unit (ICU) at Mayo Clinic in Rochester, MN, from January 2001 through December 2010. We compared the association of ICU ARDS resolution vs non-resolution with mortality. ICU ARDS resolution was defined as improvement in P/F > 200 for at least 48 h or (if arterial blood gas unavailable) SpO2:FiO2 (S/F) > 235, or discharge prior to 48 h from first P/F > 200 without subsequent decline in P/F, as documented in EHR. Results Of the 254 patients included, ICU ARDS resolution was achieved in 179 (70%). Hospital mortality was lower in patients who met ICU ARDS resolution criteria as compared to those who did not (23% vs. 41%, p < 0.01). After adjusting for age, gender, and illness severity, the patients who met ICU ARDS resolution criteria had lower odds of hospital mortality [odds ratio 0.47, 95% CI 0.25–0.86; p = 0.015]. Conclusion The electronic health record-based pragmatic measure of ICU ARDS resolution is associated with patient outcomes and may serve as an intermediate outcome assessing novel mechanistic treatments.
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Affiliation(s)
- Sarah J Chalmers
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC-EPM), Mayo Clinic, Rochester, MN, USA. .,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA. .,Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Amos Lal
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC-EPM), Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC-EPM), Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rahul Kashyap
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC-EPM), Mayo Clinic, Rochester, MN, USA.,Department of Anesthesia, Mayo Clinic, Rochester, MN, USA
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Comparison of three cisatracurium dosing strategies in acute respiratory distress syndrome: A focus on drug utilization and improvement in oxygenation. J Crit Care 2021; 66:166-172. [PMID: 34301439 PMCID: PMC8285260 DOI: 10.1016/j.jcrc.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/03/2021] [Accepted: 07/12/2021] [Indexed: 11/22/2022]
Abstract
Purpose Three continuous dosing strategies of cisatracurium (CIS) for acute respiratory distress syndrome (ARDS) have been described in the literature. After implementation of a ventilator synchrony protocol (VSP), we sought to determine which continuous CIS dosing strategy utilized the least amount of drug without compromising efficacy. Methods We retrospectively reviewed patients with ARDS receiving continuous CIS from January 1, 2013 to December 31, 2018. We categorized patients into one of three dosing strategies: fixed dose (FD), titration based solely on train-of-four (TOF), or the VSP. We documented drug consumption and determined efficacy by comparing the change in PaO2/FiO2 ratio (P/F) and oxygenation index (OI) from baseline up to 48 h. Results A total of 1047 patients were screened, and 189 met inclusion criteria (VSP = 69, TOF = 99, FD = 21). Drug consumption (mg) was significantly lower in the VSP arm: 415 [IQR 318–528] compared to both the TOF: 665 [IQR 472–927] and the FD arms: 1730 [IQR 1695–1800], p < 0.001 for each. The change in P/F and OI from baseline were statistically equivalent at all time points. Conclusion Without impacting efficacy of gas exchange, a protocol using ventilator synchrony for CIS titration required significantly less drug compared to TOF-based titration and a fixed dosing regimen.
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Saha R, Assouline B, Mason G, Douiri A, Summers C, Shankar-Hari M. Impact of differences in acute respiratory distress syndrome randomised controlled trial inclusion and exclusion criteria: systematic review and meta-analysis. Br J Anaesth 2021; 127:85-101. [PMID: 33812666 PMCID: PMC9768208 DOI: 10.1016/j.bja.2021.02.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/31/2021] [Accepted: 02/21/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Control-arm mortality varies between acute respiratory distress syndrome (ARDS) RCTs. METHODS We systematically reviewed ARDS RCTs that commenced recruitment after publication of the American-European Consensus (AECC) definition (MEDLINE, Embase, and Cochrane central register of controlled trials; January 1994 to October 2020). We assessed concordance of RCT inclusion criteria to ARDS consensus definitions and whether exclusion criteria are strongly or poorly justified. We estimated the proportion of between-trial difference in control-arm 28-day mortality explained by the inclusion criteria and RCT design characteristics using meta-regression. RESULTS A literature search identified 43 709 records. One hundred and fifty ARDS RCTs were included; 146/150 (97.3%) RCTs defined ARDS inclusion criteria using AECC/Berlin definitions. Deviations from consensus definitions, primarily aimed at improving ARDS diagnostic certainty, frequently related to duration of hypoxaemia (117/146; 80.1%). Exclusion criteria could be grouped by rationale for selection into strongly or poorly justified criteria. Common poorly justified exclusions included pregnancy related, age, and comorbidities (infectious/immunosuppression, hepatic, renal, and human immunodeficiency virus/acquired immunodeficiency syndrome). Control-arm 28-day mortality varied between ARDS RCTs (mean: 29.8% [95% confidence interval: 27.0-32.7%; I2=88.8%; τ2=0.02; P<0.01]), and differed significantly between RCTs with different Pao2:FiO2 ratio inclusion thresholds (26.6-39.9 kPa vs <26.6 kPa; P<0.01). In a meta-regression model, inclusion criteria and RCT design characteristics accounted for 30.6% of between-trial difference (P<0.01). CONCLUSIONS In most ARDS RCTs, consensus definitions are modified to use as inclusion criteria. Between-RCT mortality differences are mostly explained by the Pao2:FiO2 ratio threshold within the consensus definitions. An exclusion criteria framework can be applied when designing and reporting exclusion criteria in future ARDS RCTs.
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Affiliation(s)
- Rohit Saha
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Georgina Mason
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, King's College London, London, UK,National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Manu Shankar-Hari
- Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK,School of Immunology & Microbial Sciences, King's College London, London, UK,Corresponding author
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Thompson Bastin ML, Smith RR, Bissell BD, Wolf HN, Wiegand AM, Cavagnini ME, Ahmad Y, Flannery AH. Comparison of fixed dose versus train-of-four titration of cisatracurium in acute respiratory distress syndrome. J Crit Care 2021; 65:86-90. [PMID: 34118504 DOI: 10.1016/j.jcrc.2021.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 05/06/2021] [Accepted: 05/15/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE To compare the ventilatory and clinical outcomes associated with a fixed-dose cisatracurium infusion versus a titrated infusion strategy in patients with Acute Respiratory Distress Syndrome (ARDS). MATERIALS AND METHODS Single-center, retrospective, cohort study in a medical ICU of a tertiary care academic medical center. Adult patients ≥18 years old with a continuous infusion of cisatracurium for ≥12 h for treatment of ARDS were included. The primary outcome was the PaO2 /FiO2 ratio assessed at 24 and 48 h following cisatracurium initiation. Secondary outcomes included amount of average dose of drug administered, 28-day ventilator-free days, LOS, and hospital mortality. RESULTS 167 patients were included; median baseline PaO2/FiO2 was 97 (76-146), median SOFA score of 9 (7-11), and ICU mortality was 71/167 (43%). In a mixed-effects model, fixed dose and titrated cisatracurium associated with similar changes in PaO2/FiO2 assessed at 24 and 48 h (p = 0.316). Fixed-dose was associated with a >3-fold increase in drug exposure (average dose 6.4 (5.4-8.0) vs. 2.0 (1.5-2.8) mcg/kg/min; p < 0.001, respectively). No differences were observed in secondary clinical endpoints. CONCLUSION Fixed-dose cisatracurium was associated with similar ventilatory and clinical outcomes compared to titrated strategy, yet it was associated with a 3-fold increase in dose administered.
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Affiliation(s)
- Melissa L Thompson Bastin
- University of Kentucky HealthCare, Department of Pharmacy Services, United States of America; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, United States of America.
| | - Rebecca R Smith
- University of Arkansas for Medical Sciences, Department of Pharmacy Services, United States of America.
| | - Brittany D Bissell
- University of Kentucky HealthCare, Department of Pharmacy Services, United States of America; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, United States of America; University of Kentucky College of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, United States of America.
| | - Heather N Wolf
- St. Elizabeth Healthcare, Department of Pharmacy Services, United States of America.
| | - Alexandra M Wiegand
- University of Kentucky HealthCare, Department of Pharmacy Services, United States of America.
| | - Megan E Cavagnini
- University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, United States of America.
| | - Yahya Ahmad
- University of Kentucky College of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, United States of America.
| | - Alexander H Flannery
- University of Kentucky HealthCare, Department of Pharmacy Services, United States of America; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, United States of America.
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45
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Response to Proning in Moderate to Severe Acute Respiratory Distress Syndrome: A New Talking Point in an Ongoing Conversation. Crit Care Med 2021; 48:1889-1891. [PMID: 33255104 DOI: 10.1097/ccm.0000000000004649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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46
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Chaves-Cardona H, Hernandez-Torres V, Kiley S, Renew J. Neuromuscular blockade management in patients with COVID-19. Korean J Anesthesiol 2021; 74:285-292. [PMID: 33934595 PMCID: PMC8342831 DOI: 10.4097/kja.21106] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/02/2021] [Indexed: 01/08/2023] Open
Abstract
This narrative review evaluates the evidence for using neuromuscular blocking agents (NMBA) in patients being treated for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While large prospective randomized-controlled trials (RCTs) are lacking at this point in time, smaller observational studies and case series are reviewed to ascertain the indications and utility of NMBAs. Additionally, large RCTs that address similar clinical scenarios are reviewed and the authors translate these findings to patients with COVID-19. Specifically, NMBAs can be helpful during endotracheal intubation to minimize the risk of patient coughing and possibly infecting healthcare personnel. NMBAs can also be used in patients to promote patient-ventilator synchrony while reducing the driving pressure needed with mechanical ventilation (MV), particularly in patients with the severe clinical presentation (Type H phenotype). Prone positioning has also become a cornerstone in managing refractory hypoxemia in patients with SARS-CoV-2 acute respiratory distress syndrome, and NMBAs can be useful in facilitating this maneuver. In the perioperative setting, deep levels of neuromuscular blockade can improve patient outcomes during laparoscopic operations and may theoretically reduce the risk of aerosolization as lower insufflation pressures may be utilized. Regardless of the indication, quantitative neuromuscular monitoring remains the only reliable method to confirm adequate recovery following cessation of neuromuscular blockade. Such monitors may serve a unique purpose in patients with COVID-19 as automation of measurements can reduce healthcare personnel-patient contact that would occur during periodic subjective evaluation with a peripheral nerve stimulator.
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Affiliation(s)
- Harold Chaves-Cardona
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Vivian Hernandez-Torres
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Sean Kiley
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, Jacksonville, FL, USA.,Department of Critical Care Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Johnathan Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
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47
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Kadry RW, Adil MS, Newsome AS, Somanath PR. Cisatracurium attenuates LPS-induced modulation of MMP3 and junctional protein expression in human microvascular endothelial cells. Biosci Trends 2021; 15:50-54. [PMID: 33627570 DOI: 10.5582/bst.2020.03399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening form of acute lung injury (ALI) associated with hypoxemic lung damage and inflammation. Matrix metalloproteinase protein-3 (MMP3 or Stromelysin-1) is known to promote vascular injury in ALI/ARDS. Cisatracurium, a nicotinic neuromuscular blocker, is used in ARDS patients to decrease mechanical ventilator dyssynchrony, increase oxygenation, and improve mortality. However, the magnitude and the underlying mechanisms of these potential benefits of cisatracurium remains unclear. We investigated the effect of cisatracurium on lipopolysaccharide-induced MMP3 expression in human microvascular endothelial cells. In our results, cisatracurium treatment significantly decreased LPS-induced MMP3 expression and increased expression of cell junction proteins such as vascular endothelial cadherin (VE-cadherin) and claudin-5.
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Affiliation(s)
- Rana W Kadry
- Clinical and Experimental Therapeutics, University of Georgia, and Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - Mir S Adil
- Clinical and Experimental Therapeutics, University of Georgia, and Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - Andrea Sikora Newsome
- Clinical and Experimental Therapeutics, University of Georgia, and Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - Payaningal R Somanath
- Clinical and Experimental Therapeutics, University of Georgia, and Charlie Norwood VA Medical Center, Augusta, GA, USA
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48
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Juschten J, Tuinman PR, Guo T, Juffermans NP, Schultz MJ, Loer SA, Girbes ARJ, de Grooth HJ. Between-trial heterogeneity in ARDS research. Intensive Care Med 2021; 47:422-434. [PMID: 33713156 PMCID: PMC7955690 DOI: 10.1007/s00134-021-06370-w] [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: 12/23/2020] [Accepted: 02/15/2021] [Indexed: 02/07/2023]
Abstract
Purpose Most randomized controlled trials (RCTs) in patients with acute respiratory distress syndrome (ARDS) revealed indeterminate or conflicting study results. We aimed to systematically evaluate between-trial heterogeneity in reporting standards and trial outcome. Methods A systematic review of RCTs published between 2000 and 2019 was performed including adult ARDS patients receiving lung-protective ventilation. A random-effects meta-regression model was applied to quantify heterogeneity (non-random variability) and to evaluate trial and patient characteristics as sources of heterogeneity. Results In total, 67 RCTs were included. The 28-day control-group mortality rate ranged from 10 to 67% with large non-random heterogeneity (I2 = 88%, p < 0.0001). Reported baseline patient characteristics explained some of the outcome heterogeneity, but only six trials (9%) reported all four independently predictive variables (mean age, mean lung injury score, mean plateau pressure and mean arterial pH). The 28-day control group mortality adjusted for patient characteristics (i.e. the residual heterogeneity) ranged from 18 to 45%. Trials with significant benefit in the primary outcome reported a higher control group mortality than trials with an indeterminate outcome or harm (mean 28-day control group mortality: 44% vs. 28%; p = 0.001). Conclusion Among ARDS RCTs in the lung-protective ventilation era, there was large variability in the description of baseline characteristics and significant unexplainable heterogeneity in 28-day control group mortality. These findings signify problems with the generalizability of ARDS research and underline the urgent need for standardized reporting of trial and baseline characteristics. Supplementary Information The online version of this article (10.1007/s00134-021-06370-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J Juschten
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands. .,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands. .,Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - P R Tuinman
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - T Guo
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Division of System Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - N P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, Universiteit Van Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
| | - M J Schultz
- Department of Intensive Care, Amsterdam UMC, Universiteit Van Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - S A Loer
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - A R J Girbes
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - H J de Grooth
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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49
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Longobardo A, Snow TA, Tam K, Singer M, Bellingan G, Arulkumaran N. Non-specialist therapeutic strategies in acute respiratory distress syndrome. Minerva Anestesiol 2021; 87:803-816. [PMID: 33594874 DOI: 10.23736/s0375-9393.21.15254-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Acute respiratory distress syndrome (ARDS) is associated with significant morbidity and mortality. We undertook a meta-analysis of randomized controlled trials (RCTs) to determine the mortality benefit of non-specialist therapeutic interventions for ARDS available to general critical care units. EVIDENCE ACQUISITION A systematic search of MEDLINE, Embase, and the Cochrane Central Register for RCTs investigating therapeutic interventions in ARDS including corticosteroids, fluid management strategy, high PEEP, low tidal volume ventilation, neuromuscular blockade, prone position ventilation, or recruitment maneuvers. Data was collected on demographic information, treatment strategy, duration and dose of treatment, and primary (28 or 30-day mortality) and secondary (P<inf>a</inf>O<inf>2</inf>:FiO<inf>2</inf> ratio at 24-48 hours) outcomes. EVIDENCE SYNTHESIS No improvement in 28-day mortality could be demonstrated in three RCTs investigating high PEEP (28.0% vs. 30.2% control; risk ratio [confidence interval] 0.93 [0.82-1.06]; eight assessing prone position ventilation (39.3% vs. 44.5%; RR 0.83 [0.68-1.01]; seven investigating neuromuscular blockade (37.8% vs. 42.0%; RR 0.91 [0.81-1.03]); ten investigating recruitment maneuvers (42.4% vs. 42.1%; RR 1.01 [0.91-1.12]); eight investigating steroids (34.8% vs. 41.1%; RR 0.81 [0.59-1.12]); and one investigating conservative fluid strategies (25.4% vs. 28.4%; RR 0.90 [0.73-1.10]). Three studies assessing low tidal volume ventilation (33.1% vs. 41.9%; RR 0.79 (0.68-0.91); P=0.001), and subgroup analyses within studies investigating prone position ventilation greater than 12 hours (33.1% vs. 44.4%; RR 0.75 [0.59-0.95), P=0.02) did reveal outcome benefit. CONCLUSIONS Among non-specialist therapeutic strategies available to general critical care units, low tidal volumes and prone position ventilation for greater than 12 hours improve mortality in ARDS.
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Affiliation(s)
- Alessia Longobardo
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Timothy A Snow
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK - .,Royal Free Perioperative Research Group, Royal Free Hospital, London, UK
| | - Karen Tam
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Geoff Bellingan
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
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50
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Stevanović P. Treatment of critically ill COVID-19 patients: Practical guidelines. MEDICINSKI PODMLADAK 2021. [DOI: 10.5937/mp72-33371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
The coronavirus disease pandemic (2019) has burdened health systems around the world with a large number of severe patients in a short period of time. According to the law of large numbers, a significant number of critically ill COVID-19 patients appear in such conditions which require treatment in the intensive care unit. That percentage of those patients is around 3 - 5% in different countries. It is similar in Serbia; however, every rule has its exceptions. KBC "Dr Dragiša Mišović-Dedinje" in Belgrade has been determined to take care of the most difficult COVID-19 patients since the beginning of the epidemic due to its space, organizational and personnel possibilities. Out of the total number of patients treated in KBC "Dr Dragiša Mišović-Dedinje", about 25% of patients were treated in the intensive care unit for the above mentioned reasons. Guided by valid treatment protocols, Anesthesiology and Intensive Care clinic of the KBC "Dr Dragiša Mišović-Dedinje" has developed its own work protocols for rapid diagnosis, isolation and clinical management of such difficult patients. These protocols are important not only for the treatment of the most severe COVID-19 patients, but also for the best utilization of hospital resources, as well as for the prevention of the spread of the infection to the medical staff. Extensive experience in the treatment of critically ill patients was gained from the entire engagement during the epidemic, experienced doctors, anesthesiologists-intensivists with great knowledge in the field of work in the intensive care unit, but also managers of clinics and institutions, who can share their experience with health care policy makers. It is clear that in the future, the capacities and organization of work in the field of intensive care medicine should be redefined, as well as health workers should be trained to work in the most demanding field of medicine. Expert experience in the form of practical guidelines, derived from over fourteen months of continuous work in the red zone of COVID-19, where they fought for every breath of the patient, in this review are translated into simplified guidelines for orientation of those who find themselves in a similar situation.
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