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Yehya N, Booth TJ, Ardhanari GD, Thompson JM, Lam LM, Till JE, Mai MV, Keim G, McKeone DJ, Halstead ES, Lahni P, Varisco BM, Zhou W, Carpenter EL, Christie JD, Mangalmurti NS. Inflammatory and tissue injury marker dynamics in pediatric acute respiratory distress syndrome. J Clin Invest 2024; 134:e177896. [PMID: 38573766 PMCID: PMC11093602 DOI: 10.1172/jci177896] [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: 11/22/2023] [Accepted: 03/27/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUNDThe molecular signature of pediatric acute respiratory distress syndrome (ARDS) is poorly described, and the degree to which hyperinflammation or specific tissue injury contributes to outcomes is unknown. Therefore, we profiled inflammation and tissue injury dynamics over the first 7 days of ARDS, and associated specific biomarkers with mortality, persistent ARDS, and persistent multiple organ dysfunction syndrome (MODS).METHODSIn a single-center prospective cohort of intubated pediatric patients with ARDS, we collected plasma on days 0, 3, and 7. Nineteen biomarkers reflecting inflammation, tissue injury, and damage-associated molecular patterns (DAMPs) were measured. We assessed the relationship between biomarkers and trajectories with mortality, persistent ARDS, or persistent MODS using multivariable mixed effect models.RESULTSIn 279 patients (64 [23%] nonsurvivors), hyperinflammatory cytokines, tissue injury markers, and DAMPs were higher in nonsurvivors. Survivors and nonsurvivors showed different biomarker trajectories. IL-1α, soluble tumor necrosis factor receptor 1, angiopoietin 2 (ANG2), and surfactant protein D increased in nonsurvivors, while DAMPs remained persistently elevated. ANG2 and procollagen type III N-terminal peptide were associated with persistent ARDS, whereas multiple cytokines, tissue injury markers, and DAMPs were associated with persistent MODS. Corticosteroid use did not impact the association of biomarker levels or trajectory with mortality.CONCLUSIONSPediatric ARDS survivors and nonsurvivors had distinct biomarker trajectories, with cytokines, endothelial and alveolar epithelial injury, and DAMPs elevated in nonsurvivors. Mortality markers overlapped with markers associated with persistent MODS, rather than persistent ARDS.FUNDINGNIH (K23HL-136688, R01-HL148054).
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Affiliation(s)
- Nadir Yehya
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas J. Booth
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
| | - Gnana D. Ardhanari
- Division of Pediatric Cardiac Critical Care Medicine, Children’s Heart Institute, Memorial Hermann Hospital, University of Texas Health McGovern Medical School, Houston, Texas, USA
| | - Jill M. Thompson
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
| | - L.K. Metthew Lam
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
| | - Jacob E. Till
- Division of Hematology-Oncology, Department of Medicine, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark V. Mai
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta and Emory University, Atlanta, Georgia, USA
| | - Garrett Keim
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel J. McKeone
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and
| | - E. Scott Halstead
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Patrick Lahni
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Brian M. Varisco
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Research Institute, Little Rock, Arkansas, USA
| | - Wanding Zhou
- Center for Computational and Genomic Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Erica L. Carpenter
- Division of Hematology-Oncology, Department of Medicine, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
- Center for Translational Lung Biology and
- Center for Clinical Epidemiology and Biostatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nilam S. Mangalmurti
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
- Center for Translational Lung Biology and
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Wu SH, Kor CT, Chi SH, Li CY. Categorizing Acute Respiratory Distress Syndrome with Different Severities by Oxygen Saturation Index. Diagnostics (Basel) 2023; 14:37. [PMID: 38201346 PMCID: PMC10795683 DOI: 10.3390/diagnostics14010037] [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: 11/03/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
The oxygen saturation index (OSI), defined by FIO2/SpO2 multiplied by the mean airway pressure, has been reported to exceed the Berlin definition in predicting the mortality of acute respiratory distress syndrome (ARDS). The OSI has served as an alternative to the Berlin definition in categorizing pediatric ARDS. However, the use of the OSI for the stratification of adult ARDS has not been reported. A total of 379 invasively ventilated adult ARDS patients were retrospectively studied. The ARDS patients were classified into three groups by their incidence rate of mortality: mild (OSI < 14.69), moderate (14.69 < OSI < 23.08) and severe (OSI > 23.08). OSI-based categorization was highly correlated with the Berlin definition by a Kendall's tau of 0.578 (p < 0.001). The Kaplan-Meier curves of the three OSI-based groups were significantly different (p < 0.001). By the Berlin definition, the hazard ratio for 28-day mortality was 0.58 (0.33-1.05) and 0.95 (0.55-1.67) for the moderate and severe groups, respectively (compared to the mild group). In contrast, the corresponding hazard ratio was 1.01 (0.69-1.47) and 2.39 (1.71-3.35) for the moderate and severe groups defined by the OSI. By multivariate analysis, OSI-based severe ARDS was independently associated with 28-D or 90-D mortality. In conclusion, we report the first OSI-based stratification for adult ARDS and find that it serves well as an alternative to the Berlin definition.
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Affiliation(s)
- Shin-Hwar Wu
- Division of Critical Care Internal Medicine, Department of Emergency Medicine and Critical Care, Changhua Christian Hospital, Changhua 50006, Taiwan
| | - Chew-Teng Kor
- Big Data Center, Changhua Christian Hospital, Changhua 50006, Taiwan;
- Graduate Institute of Statistics and Information Science, National Changhua University of Education, Changhua 50006, Taiwan
| | - Shu-Hua Chi
- Section of Respiratory Therapy, Department of Emergency Medicine and Critical Care, Changhua Christian Hospital, Changhua 50006, Taiwan; (S.-H.C.); (C.-Y.L.)
| | - Chun-Yu Li
- Section of Respiratory Therapy, Department of Emergency Medicine and Critical Care, Changhua Christian Hospital, Changhua 50006, Taiwan; (S.-H.C.); (C.-Y.L.)
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Nishiyama K, Ichikado K, Anan K, Nakamura K, Kawamura K, Suga M, Sakagami T. The ROX index (Index combining the respiratory rate with oxygenation) is a prognostic factor for acute respiratory distress syndrome. PLoS One 2023; 18:e0282241. [PMID: 36848346 PMCID: PMC9970069 DOI: 10.1371/journal.pone.0282241] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/10/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND There is no existing reliable and practical method for predicting the prognosis of acute respiratory distress syndrome (ARDS). OBJECTIVE We aimed to clarify the association between the ROX index, which is calculated as the ratio of peripheral oxygen saturation divided by the fraction of inspired oxygen to the respiratory rate, and the prognosis of patients with ARDS under ventilator support. METHODS In this single-center retrospective cohort study from prospectively collected database, eligible patients were categorized into three groups based on ROX tertiles. The primary outcome was the 28-day survival, and the secondary outcome was 28-day liberation from ventilator support. We performed multivariable analysis using the Cox proportional hazards model. RESULTS Among 93 eligible patients, 24 (26%) patients died. The patients were divided into three groups according to the ROX index (< 7.4, 7.4-11, ≥ 11), with 13, 7, and 4 patients dying in the groups, respectively. A higher ROX index was associated with lower mortality; adjusted hazard ratios [95% CIs] for increasing tertiles of ROX index: 1[reference], 0.54[0.21-1.41], 0.23[0.074-0.72] (P = 0.011 for trend) and a higher rate of successful 28-day liberation from ventilator support; adjusted hazard ratios [95% CIs] for increasing tertiles of ROX index: 1[reference], 1.41[0.68-2.94], 2.80[1.42-5.52] (P = 0.001 for trend). CONCLUSIONS The ROX index at 24 h after initiating ventilator support is a predictor of outcomes in patients with ARDS and might inform initiation of more advanced treatments.
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Affiliation(s)
- Kenta Nishiyama
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
- * E-mail:
| | - Kazuya Ichikado
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kazunori Nakamura
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kodai Kawamura
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Moritaka Suga
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Takuro Sakagami
- Department of Respiratory Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Akbaş T, Güneş H. Characteristics and outcomes of patients with chronic obstructive pulmonary disease admitted to the intensive care unit due to acute hypercapnic respiratory failure. Acute Crit Care 2023; 38:49-56. [PMID: 36935534 PMCID: PMC10030250 DOI: 10.4266/acc.2022.01011] [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: 08/02/2022] [Accepted: 12/07/2022] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND The study aimed to describe the clinical course, outcomes, and prognostic factors of chronic obstructive pulmonary disease (COPD) patients with acute hypercapnic respiratory failure. METHODS This retrospective study involved patients with acute hypercapnic respiratory failure due to COPD of any cause admitted to the intensive care unit (ICU) for non-invasive or invasive mechanical ventilation (IMV) support between December 2015 and February 2020. RESULTS One hundred patients were evaluated. The main causes of acute hypercapnic respiratory failure were bronchitis, pneumonia, and heart failure. The patients' mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 23.0±7.2, and their IMV rate was 43%. ICU, in-hospital, and 90-day mortality rates were 21%, 29%, and 39%, respectively. Non-survivors had more pneumonia, shock within the first 24 hours of admission, IMV, vasopressor use, and renal replacement therapy, along with higher APACHE II scores, lower admission albumin levels and PaO2/ FiO2 ratios, and longer ICU and hospital stays than survivors. Logistic regression analysis identified APACHE II score (odds ratio [OR], 1.157; 95% confidence interval [CI], 1.017-1.317; P=0.026), admission PaO2/FiO2 ratio (OR, 0.989; 95% CI, 0.978-0.999; P=0.046), and vasopressor use (OR, 8.827; 95% CI, 1.650-47.215; P=0.011) as predictors of ICU mortality. APACHE II score (OR, 1.099; 95% CI, 1.021-1.182; P=0.011) and admission albumin level (OR, 0.169; 95% CI, 0.056-0.514; P=0.002) emerged as predictors of 90-day mortality. CONCLUSIONS APACHE II scores, the PaO2/FiO2 ratio, vasopressor use, and albumin levels are significant short-term mortality predictors in severely ill COPD patients with acute hypercapnic respiratory failure.
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Affiliation(s)
- Türkay Akbaş
- Division of Intensive Care, Department of Internal Medicine, School of Medicine, Düzce University, Düzce, Türkiye
| | - Harun Güneş
- Department of Emergency Medicine, School of Medicine, Balıkesir University, Balıkesir, Türkiye
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Immunocompromised Children With Acute Respiratory Distress Syndrome Possess a Distinct Circulating Inflammatory Profile. Crit Care Explor 2023; 5:e0844. [PMID: 36699254 PMCID: PMC9829269 DOI: 10.1097/cce.0000000000000844] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Immunocompromised status, with and without stem cell transplant, confers a worse prognosis in pediatric acute respiratory distress syndrome. An improved understanding of the biochemical profile of immunocompromised children with acute respiratory distress syndrome would inform whether specific pathways are targetable, or merely bystanders, in order to improve outcomes in this high-risk subgroup. OBJECTIVES We aimed to identify a biomarker profile of immunocompromised children, with and without stem cell transplant, independent of illness severity. DESIGN SETTINGS AND PARTICIPANTS This was a secondary analysis of a prospective cohort study of intubated children with Berlin-defined acute respiratory distress syndrome with existing biomarker measurements conducted in a large academic PICU between 2014 and 2019. MAIN OUTCOMES AND MEASURES Biomarker levels were compared between immunocompetent and immunocompromised children, with and without stem cell transplant, both prior to and after adjusting for severity of illness. RESULTS In 333 children with acute respiratory distress syndrome, 84 were immunocompromised, of whom 39 had a stem cell transplant. Circulating neutrophil levels were strongly correlated with biomarkers, with 14 of 18 measured proteins differentially expressed in patients with versus without neutropenia. In order to identify biomarker levels independent of severity of illness, acute respiratory distress syndrome etiology, and neutrophil levels, we computed predicted (log-transformed) biomarker levels after adjusting for confounders using linear regression and then compared these severity-adjusted levels between immunocompetent and immunocompromised (with and without stem cell transplant) subjects using analyses of variance and post hoc Bonferroni. After multivariable adjustment, 11 biomarkers were higher in immunocompromised subjects without stem cell transplant, relative to immunocompetent, implicating endotheliopathy (angiopoietin-2), tissue damage (procollagen type III N-terminal peptide), and innate immunity. A single biomarker, C-C motif chemokine ligand 22, was lower in immunocompromised subjects with and without stem cell transplant. CONCLUSIONS AND RELEVANCE Immunocompromised children with acute respiratory distress syndrome were characterized by elevations in pro-inflammatory and endothelial damage biomarkers. Our study provides insight into mechanisms underlying the molecular heterogeneity of this population and potentially identifies targetable pathways to mitigate their increased mortality risk.
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Audi SH, Taheri P, Zhao M, Hu K, Jacobs ER, Clough AV. In vivo molecular imaging stratifies rats with different susceptibilities to hyperoxic acute lung injury. Am J Physiol Lung Cell Mol Physiol 2022; 323:L410-L422. [PMID: 35943727 PMCID: PMC9484995 DOI: 10.1152/ajplung.00126.2022] [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: 04/18/2022] [Revised: 06/26/2022] [Accepted: 08/05/2022] [Indexed: 11/22/2022] Open
Abstract
99mTc-hexamethylpropyleneamine oxime (HMPAO) and 99mTc-duramycin in vivo imaging detects pulmonary oxidative stress and cell death, respectively, in rats exposed to >95% O2 (hyperoxia) as a model of acute respiratory distress syndrome (ARDS). Preexposure to hyperoxia for 48 h followed by 24 h in room air (H-T) is protective against hyperoxia-induced lung injury. This study's objective was to determine the ability of 99mTc-HMPAO and 99mTc-duramycin to track this protection and to elucidate underlying mechanisms. Rats were exposed to normoxia, hyperoxia for 60 h, H-T, or H-T followed by 60 h of hyperoxia (H-T + 60). Imaging was performed 20 min after intravenous injection of either 99mTc-HMPAO or 99mTc-duramycin. 99mTc-HMPAO and 99mTc-duramycin lung uptake was 200% and 167% greater (P < 0.01) in hyperoxia compared with normoxia rats, respectively. On the other hand, uptake of 99mTc-HMPAO in H-T + 60 was 24% greater (P < 0.01) than in H-T rats, but 99mTc-duramycin uptake was not significantly different (P = 0.09). Lung wet-to-dry weight ratio, pleural effusion, endothelial filtration coefficient, and histological indices all showed evidence of protection and paralleled imaging results. Additional results indicate higher mitochondrial complex IV activity in H-T versus normoxia rats, suggesting that mitochondria of H-T lungs may be more tolerant of oxidative stress. A pattern of increasing lung uptake of 99mTc-HMPAO and 99mTc-duramycin correlates with advancing oxidative stress and cell death and worsening injury, whereas stable or decreasing 99mTc-HMPAO and stable 99mTc-duramycin reflects hyperoxia tolerance, suggesting the potential utility of molecular imaging for identifying at-risk hosts that are more or less susceptible to progressing to ARDS.
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Affiliation(s)
- Said H Audi
- Department of Biomedical Engineering, Marquette University-Medical College of Wisconsin, Milwaukee, Wisconsin
- Clement J. Zablocki Veterans Administration Medical Center, Milwaukee, Wisconsin
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pardis Taheri
- Department of Biomedical Engineering, Marquette University-Medical College of Wisconsin, Milwaukee, Wisconsin
- Clement J. Zablocki Veterans Administration Medical Center, Milwaukee, Wisconsin
| | - Ming Zhao
- Department of Medicine, Northwestern University, Chicago, Illinois
| | - Kurt Hu
- Clement J. Zablocki Veterans Administration Medical Center, Milwaukee, Wisconsin
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Elizabeth R Jacobs
- Clement J. Zablocki Veterans Administration Medical Center, Milwaukee, Wisconsin
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anne V Clough
- Clement J. Zablocki Veterans Administration Medical Center, Milwaukee, Wisconsin
- Department of Mathematical and Statistical Sciences, Marquette University, Milwaukee, Wisconsin
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Surfactant protein D: a predictor for severity of community-acquired pneumonia in children. Pediatr Res 2022; 91:665-671. [PMID: 33790414 PMCID: PMC8010482 DOI: 10.1038/s41390-021-01492-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/29/2021] [Accepted: 03/04/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surfactant protein D (SP-D) is a promising biomarker proposed for the prediction of community-acquired pneumonia (CAP) severity. Therefore, we aimed to assess the role of SP-D in the prediction of CAP severity in pediatric patients. METHODS A prospective cohort study was carried out at the Pediatric Intensive Care Unit (PICU) and wards of Menoufia University Hospital. We recruited 112 children admitted into wards with pneumonia (simple pneumonia) and 68 children admitted into PICU with severe pneumonia (PICU admitted). World Health Organization (WHO) classification and mortality predictive scores were calculated to determine the severity of pneumonia for the two groups, including the Pediatric Respiratory Severity Score (PRESS) and the Predisposition, Insult, Response, and Organ dysfunction modified Score (PIROm). SP-D was measured at admission. RESULTS The SP-D level was significantly lower in patients with simple pneumonia than in patients with severe pneumonia (P < 0.001). SP-D was significantly higher among children with severe pneumonia, as determined by WHO, PRESS, and PIROm (P = 0.001). SP-D was significantly higher among children with mechanical ventilation, shock, hypoxia, sepsis, and mortality. Receiver operating characteristic curve analysis for SP-D showed that the area under the curve was 0.741 (P value < 0.001), with a sensitivity of 85.3% and a specificity of 44.6%. CONCLUSIONS Serum SP-D level has a predictive value for the detection of community-acquired pneumonia severity in children. IMPACT SP-D is a good predictor for the detection of CAP severity in hospitalized children. SP-D was correlated with severity scores and was associated with indicators of CAP severity, including mechanical ventilation, shock, hypoxia, sepsis, and mortality.
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Chiu LC, Lin SW, Liu PH, Chuang LP, Chang CH, Hung CY, Li SH, Lee CS, Wu HP, Huang CC, Li HH, Kao KC, Hu HC. Reclassifying severity after 48 hours could better predict mortality in acute respiratory distress syndrome. Ther Adv Respir Dis 2021; 14:1753466620936877. [PMID: 32631150 PMCID: PMC7343354 DOI: 10.1177/1753466620936877] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Disease severity may change in the first week after acute respiratory distress syndrome (ARDS) onset. The aim of this study was to evaluate whether the reclassification of disease severity after 48 h (i.e. day 3) of ARDS onset could help in predicting mortality and determine factors associated with ARDS persistence and mortality. METHODS We performed a secondary analysis of a 3-year prospective, observational cohort study of ARDS in a tertiary care referral center. Disease severity was reclassified after 48 h of enrollment, and cases that still fulfilled the Berlin criteria were regarded as nonresolving ARDS. RESULTS A total of 1034 ARDS patients were analyzed. Overall hospital mortality was 57.7% (56.7%, 57.5%, and 58.6% for patients with initial mild, moderate, and severe ARDS, respectively, p = 0.189). On day 3 reclassification, the hospital mortality rates were as follows: resolved (42.1%), mild (47.9%), moderate (62.4%), and severe ARDS (76.1%) (p < 0.001). Patients with improving severity on day 3 had lower mortality (48.8%), whereas patients with the same or worsening severity on day 3 had higher mortality (62.7% and 76.3%, respectively). Patients who were older, had lower PaO2/FiO2, or higher positive end-expiratory pressure on day 1 were significantly associated with nonresolving ARDS on day 3. A Cox regression model with ARDS severity as a time-dependent covariate and competing risk analysis demonstrated that ARDS severity was independently associated with hospital mortality, and nonresolving ARDS had significantly increased hazard of death than resolved ARDS (p < 0.0001). Cumulative mortality curve for ARDS severity comparisons demonstrated significantly different (overall comparison, p < 0.001). CONCLUSIONS Reclassification of disease severity after 48 h of ARDS onset could help to divide patients into subgroups with greater separation in terms of mortality. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Li-Chung Chiu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan.,Department of Thoracic Medicine, New Taipei Municipal TuCheng Hospital and Chang Gung University, Taoyuan
| | - Shih-Wei Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Pi-Hua Liu
- Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, Taoyuan.,Department of Internal Medicine, Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Taoyuan
| | - Li-Pang Chuang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Chih-Hao Chang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Department of Thoracic Medicine, New Taipei Municipal TuCheng Hospital and Chang Gung University, Taoyuan
| | - Chen-Yiu Hung
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Department of Thoracic Medicine, New Taipei Municipal TuCheng Hospital and Chang Gung University, Taoyuan
| | - Shih-Hong Li
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Chung-Shu Lee
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Huang-Pin Wu
- Division of Pulmonary, Critical Care and Sleep Medicine, Chang Gung Memorial Hospital, Keelung
| | - Chung-Chi Huang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan
| | - Hsin-Hsien Li
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan.,Department of Intensive Care, Xiamen Chang Gung Hospital, China
| | - Han-Chung Hu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., GuiShan, Taoyua 333.,Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan
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Postintubation Decline in Oxygen Saturation Index Predicts Mortality in COVID-19: A Retrospective Pilot Study. Crit Care Res Pract 2021; 2021:6682944. [PMID: 34136282 PMCID: PMC8162249 DOI: 10.1155/2021/6682944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 05/11/2021] [Indexed: 01/25/2023] Open
Abstract
Background Acute respiratory failure from COVID-19 pneumonia is a major cause of death after SARS-CoV-2 infection. We investigated whether PaO2/FiO2, oxygenation index (OI), SpO2/FiO2, and oxygen saturation index (OSI), commonly used to assess the severity of acute respiratory distress syndrome (ARDS), can predict mortality in mechanically ventilated COVID-19 patients. Methods In this single-centered retrospective pilot study, we enrolled 68 critically ill mechanically ventilated adult patients with confirmed COVID-19. Physiological variables were recorded on the day of intubation (day 0) and postintubation days 3 and 7. The association between physiological parameters, PaO2/FiO2, OI, SpO2/FiO2, and OSI with mortality was assessed using multiple variable logistic regression analysis. Receiver operating characteristic analysis was conducted to evaluate the performance of the predictive models. Results The ARDS severity indices were not statistically different on the day of intubation, suggesting similar baseline conditions in nonsurviving and surviving patients. However, these indices were significantly worse in the nonsurviving as compared to surviving patients on postintubation days 3 and 7. On intubation day 3, PaO2/FiO2 was 101.0 (61.4) in nonsurviving patients vs. 140.2 (109.6) in surviving patients, p=0.004, and on day 7 106.3 (94.2) vs. 178.0 (69.3), p < 0.001. OI was 135.0 (129.7) in nonsurviving vs. 84.8 (86.1) in surviving patients (p=0.003) on day 3 and 150.0 (118.4) vs. 61.5 (46.7) (p < 0.001) on day 7. OSI was 12.0 (11.7) vs. 8.0 (10.0) (p=0.006) on day 3 and 14.7 (13.2) vs. 6.5 (5.4) (p < 0.001) on day 7. Similarly, SpO2/FiO2 was 130 (90) vs. 210 (90) (p=0.003) on day 3 and 130 (90) vs. 230 (50) (p < 0.001) on day 7, while OSI was 12.0 (11.7) vs. 8.0 (10.0) (p=0.006) on day 3 and 14.7 (13.2) vs. 6.5 (5.4) (p < 0.001) on day 7 in the nonsurviving and surviving patients, respectively. All measures were independently associated with hospital mortality, with significantly greater odds ratios observed on day 7. The area under the receiver operating characteristic curve (AUC) for mortality prediction was greatest on intubation day 7 (AUC = 0.775, 0.808, and 0.828 for PaO2/FiO2, OI, SpO2/FiO2, and OSI, respectively). Conclusions Decline in oxygenation indices after intubation is predictive of mortality in COVID-19 patients. This time window is critical to the outcome of these patients and a possible target for future interventions. Future large-scale studies to confirm the prognostic value of the indices in COVID-19 patients are warranted.
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Serdaroglu E, Kesici S, Bayrakci B, Kale G. Diffuse Alveolar Damage Correlation with Clinical Diagnosis of Pediatric Acute Respiratory Distress Syndrome. J Pediatr Intensive Care 2021; 10:52-57. [PMID: 33585062 PMCID: PMC7870331 DOI: 10.1055/s-0040-1714127] [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: 03/25/2020] [Accepted: 05/26/2020] [Indexed: 10/23/2022] Open
Abstract
Diffuse alveolar damage (DAD) is one of the pathological hallmarks of acute respiratory distress syndrome (ARDS). We aimed to compare pathological findings of DAD with clinical ARDS criteria. We re-evaluated 20 patients whose clinical autopsy revealed DAD. Total 11/20 patients with DAD (55%) met the 1994 American-European Consensus Conference and 7/17 (41%) met the 2012 Berlin clinical criteria. DAD showed only moderate correlation with current clinical ARDS definition. Oxygenation index (OI), seems to be the most valuable tool in predicting pulmonary damage severity, though OI is not listed in either of the previous definitions. We support the recommended use of OI by 2015 consensus conference.
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Affiliation(s)
- Esra Serdaroglu
- Department of Pediatric Critical Care, Hacettepe University Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Selman Kesici
- Department of Pediatric Critical Care, Hacettepe University Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Benan Bayrakci
- Department of Pediatric Critical Care, Hacettepe University Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Gulsev Kale
- Department of Pediatric Pathology, Hacettepe University Ihsan Dogramaci Children's Hospital, Ankara, Turkey
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11
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Hu J, Liu L, Zeng X, Wang K, Wang H, Zeng Z, Cao Y, Gao L, Cheng M, Wang T, Wen F. Prognostic Value of Angiopoietin-like 4 in Patients with Acute Respiratory Distress Syndrome. Shock 2021; 56:403-411. [PMID: 33900712 DOI: 10.1097/shk.0000000000001734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Angiopoietin-like 4 (ANGPTL4) is a secreted glycoprotein that plays an important role in endothelial injury and the inflammatory response. Experimental models have implicated ANGPTL4 in acute respiratory distress syndrome (ARDS), but its impact on the progression of ARDS is unclear. METHODS Paired bronchoalveolar lavage fluid (BALF) and serum samples were obtained from patients with ARDS (n = 56) within 24 h of diagnosis and from control subjects (n = 32). ANGPTL4, angiopoietin-2, interleukin (IL)-6, and TNF-α levels were measured by magnetic Luminex assay. BALF albumin (BA) and serum albumin (SA) were evaluated by enzyme-linked immunosorbent assay. RESULTS BALF and serum ANGPTL4 concentrations were higher in patients with ARDS than in controls and were even higher in non-survivors than in survivors. The serum ANGPTL4 level was higher in indirect (extrapulmonary) ARDS than in direct (pulmonary) ARDS. Furthermore, BALF and serum ANGPTL4 levels correlated well with angiopoietin-2, IL-6, and TNF-α levels in BALF and serum. BALF ANGPTL4 was positively correlated with the BA/SA ratio (an indicator of pulmonary vascular permeability), and serum ANGPTL4 was associated with the severity of multiple organ dysfunction syndrome based on SOFA and APACHE II scores. Moreover, serum ANGPTL4 was better able to predict 28-day ARDS-related mortality (AUC 0.746, P < 0.01) than the APACHE II score or PaO2/FiO2 ratio. Serum ANGPTL4 was identified as an independent risk factor for mortality in a univariate Cox regression model (P < 0.001). CONCLUSION ANGPTL4 levels were elevated in patients with ARDS and significantly correlated with disease severity and mortality. ANGPTL4 may be a novel prognostic biomarker in ARDS.
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Affiliation(s)
- Jun Hu
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Lian Liu
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xianghu Zeng
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ke Wang
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Hao Wang
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Zijian Zeng
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yufang Cao
- Department of Critical Care Medicine, Haikou Hospital of Xiangya Medical College, Central South University, Haikou, Hainan, China
| | - Lijuan Gao
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Mengxin Cheng
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Tao Wang
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Fuqiang Wen
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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12
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Lin W, Jia D, Fu C, Zheng Y, Lin Z. Electro-Acupuncture on ST36 and SP6 Acupoints Ameliorates Lung Injury via Sciatic Nerve in a Rat Model of Limb Ischemia-Reperfusion. J Inflamm Res 2020; 13:465-470. [PMID: 32904499 PMCID: PMC7455772 DOI: 10.2147/jir.s264093] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/05/2020] [Indexed: 02/01/2023] Open
Abstract
Introduction Electro-acupuncture (EA) can significantly improve inflammatory response, but the specific mechanism is not clear. Limb ischemia-reperfusion (I/R) first produces inflammatory reactions in the lungs. In this study, EA on Zusanli (ST36) and Sanyinjiao (SP6) were used to explore the mechanism of improving tissue inflammation by sciatic nerve disconnection. Material and Methods A total of 56 male Sprague-Dawley rats were randomly divided into sham group, model group, EA group, SEA group, SNC+EA group, TNC+EA group and PNC+EA group. The sham groups were not given any treatment. Rats in the model group were treated with limb I/R without acupuncture intervention. In the EA group, ST36 and SP6 were given EA treatment for 30min before modeling. No electric current was given in the SEA group, and other operations were the same as those in the EA group. The SNC+EA group, TNC+EA group and PNC+EA group were respectively given sciatic nerve, tibial nerve or peroneal nerve amputation 72h before modeling, and the others were the same as the model group. Results Compared with the sham group, PaO2 and a/A ratios decreased significantly in the model group (P <0.05), while PA-aO2, RI, the ratio of wet to dry, lung injury value and inflammatory factor TNF-α, IL-1, IL-6, and MPO increased significantly (P <0.05). Compared with the model group, PaO2, a/A ratios increased significantly in the EA group (P <0.05), while PA-aO2, RI, the ratio of wet to dry lung, lung injury value, and TNF-α, IL-1, IL-6, and MPO decreased significantly (P <0.05). After transection of the sciatic nerve, the protective effect of EA disappeared. However, when the peroneal or tibial nerve was severed, EA continued to maintain the protective effect. Conclusion EA on ST36 and SP6 can alleviate lung injury caused by limb I/R through the sciatic nerve.
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Affiliation(s)
- Wei Lin
- Department of Pediatrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, People's Republic of China
| | - Danyun Jia
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province 325000, People's Republic of China
| | - Changchang Fu
- Department of Pediatrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, People's Republic of China
| | - Yihui Zheng
- Department of Pediatrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, People's Republic of China
| | - Zhenlang Lin
- Department of Pediatrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, People's Republic of China
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13
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Adams JY, Rogers AJ, Schuler A, Marelich GP, Fresco JM, Taylor SL, Riedl AW, Baker JM, Escobar GJ, Liu VX. Association Between Peripheral Blood Oxygen Saturation (SpO 2)/Fraction of Inspired Oxygen (FiO 2) Ratio Time at Risk and Hospital Mortality in Mechanically Ventilated Patients. Perm J 2020; 24:19.113. [PMID: 32069205 DOI: 10.7812/tpp/19.113] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Acute respiratory failure requiring mechanical ventilation is a leading cause of mortality in the intensive care unit. Although single peripheral blood oxygen saturation/fraction of inspired oxygen (SpO2/FiO2) ratios of hypoxemia have been evaluated to risk-stratify patients with acute respiratory distress syndrome, the utility of longitudinal SpO2/FiO2 ratios is unknown. OBJECTIVE To assess time-based SpO2/FiO2 ratios ≤ 150-SpO2/FiO2 time at risk (SF-TAR)-for predicting mortality in mechanically ventilated patients. METHODS Retrospective, observational cohort study of mechanically ventilated patients at 21 community and 2 academic hospitals. Association between the SF-TAR in the first 24 hours of ventilation and mortality was examined using multivariable logistic regression and compared with the worst recorded isolated partial pressure of arterial oxygen/fraction of inspired oxygen (P/F) ratio. RESULTS In 28,758 derivation cohort admissions, every 10% increase in SF-TAR was associated with a 24% increase in adjusted odds of hospital mortality (adjusted odds ratio = 1.24; 95% confidence interval [CI] = 1.23-1.26); a similar association was observed in validation cohorts. Discrimination for mortality modestly improved with SF-TAR (area under the receiver operating characteristic curve [AUROC] = 0.81; 95% CI = 0.81-0.82) vs the worst P/F ratio (AUROC = 0.78; 95% CI = 0.78-0.79) and worst SpO2/FiO2 ratio (AUROC = 0.79; 95% CI = 0.79-0.80). The SF-TAR in the first 6 hours offered comparable discrimination for hospital mortality (AUROC = 0.80; 95% CI = 0.79-0.80) to the 24-hour SF-TAR. CONCLUSION The SF-TAR can identify ventilated patients at increased risk of death, offering modest improvements compared with single SpO2/FiO2 and P/F ratios. This longitudinal, noninvasive, and broadly generalizable tool may have particular utility for early phenotyping and risk stratification using electronic health record data in ventilated patients.
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Affiliation(s)
- Jason Y Adams
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis, Sacramento
| | - Angela J Rogers
- Division of Pulmonary and Critical Care Medicine, Stanford University, CA
| | | | | | | | - Sandra L Taylor
- Department of Public Health Sciences, University of California, Davis, Sacramento
| | - Albert W Riedl
- Department of Public Health Sciences, University of California, Davis, Sacramento
| | | | | | - Vincent X Liu
- Division of Research, Kaiser Permanente, Oakland, CA
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14
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Bime C, Casanova N, Oita RC, Ndukum J, Lynn H, Camp SM, Lussier Y, Abraham I, Carter D, Miller EJ, Mekontso-Dessap A, Downs CA, Garcia JGN. Development of a biomarker mortality risk model in acute respiratory distress syndrome. Crit Care 2019; 23:410. [PMID: 31842964 PMCID: PMC6916252 DOI: 10.1186/s13054-019-2697-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/09/2019] [Indexed: 12/03/2022] Open
Abstract
Background There is a compelling unmet medical need for biomarker-based models to risk-stratify patients with acute respiratory distress syndrome. Effective stratification would optimize participant selection for clinical trial enrollment by focusing on those most likely to benefit from new interventions. Our objective was to develop a prognostic, biomarker-based model for predicting mortality in adult patients with acute respiratory distress syndrome. Methods This is a secondary analysis using a cohort of 252 mechanically ventilated subjects with the diagnosis of acute respiratory distress syndrome. Survival to day 7 with both day 0 (first day of presentation) and day 7 sample availability was required. Blood was collected for biomarker measurements at first presentation to the intensive care unit and on the seventh day. Biomarkers included cytokine-chemokines, dual-functioning cytozymes, and vascular injury markers. Logistic regression, latent class analysis, and classification and regression tree analysis were used to identify the plasma biomarkers most predictive of 28-day ARDS mortality. Results From eight biologically relevant biomarker candidates, six demonstrated an enhanced capacity to predict mortality at day 0. Latent-class analysis identified two biomarker-based phenotypes. Phenotype A exhibited significantly higher plasma levels of angiopoietin-2, macrophage migration inhibitory factor, interleukin-8, interleukin-1 receptor antagonist, interleukin-6, and extracellular nicotinamide phosphoribosyltransferase (eNAMPT) compared to phenotype B. Mortality at 28 days was significantly higher for phenotype A compared to phenotype B (32% vs 19%, p = 0.04). Conclusions An adult biomarker-based risk model reliably identifies ARDS subjects at risk of death within 28 days of hospitalization.
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Affiliation(s)
- Christian Bime
- College of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Nancy Casanova
- College of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Radu C Oita
- College of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Juliet Ndukum
- College of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Heather Lynn
- College of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Sara M Camp
- College of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Yves Lussier
- College of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Ivo Abraham
- College of Pharmacy, University of Arizona Health Sciences, Tucson, USA
| | | | | | | | - Charles A Downs
- College of Nursing and Health Sciences, University of Florida, Gainesville, USA
| | - Joe G N Garcia
- College of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA.
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15
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Lynn H, Sun X, Casanova N, Gonzales-Garay M, Bime C, Garcia JGN. Genomic and Genetic Approaches to Deciphering Acute Respiratory Distress Syndrome Risk and Mortality. Antioxid Redox Signal 2019; 31:1027-1052. [PMID: 31016989 PMCID: PMC6939590 DOI: 10.1089/ars.2018.7701] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Significance: Acute respiratory distress syndrome (ARDS) is a severe, highly heterogeneous critical illness with staggering mortality that is influenced by environmental factors, such as mechanical ventilation, and genetic factors. Significant unmet needs in ARDS are addressing the paucity of validated predictive biomarkers for ARDS risk and susceptibility that hamper the conduct of successful clinical trials in ARDS and the complete absence of novel disease-modifying therapeutic strategies. Recent Advances: The current ARDS definition relies on clinical characteristics that fail to capture the diversity of disease pathology, severity, and mortality risk. We undertook a comprehensive survey of the available ARDS literature to identify genes and genetic variants (candidate gene and limited genome-wide association study approaches) implicated in susceptibility to developing ARDS in hopes of uncovering novel biomarkers for ARDS risk and mortality and potentially novel therapeutic targets in ARDS. We further attempted to address the well-known health disparities that exist in susceptibility to and mortality from ARDS. Critical Issues: Bioinformatic analyses identified 201 ARDS candidate genes with pathway analysis indicating a strong predominance in key evolutionarily conserved inflammatory pathways, including reactive oxygen species, innate immunity-related inflammation, and endothelial vascular signaling pathways. Future Directions: Future studies employing a system biology approach that combines clinical characteristics, genomics, transcriptomics, and proteomics may allow for a better definition of biologically relevant pathways and genotype-phenotype connections and result in improved strategies for the sub-phenotyping of diverse ARDS patients via molecular signatures. These efforts should facilitate the potential for successful clinical trials in ARDS and yield a better fundamental understanding of ARDS pathobiology.
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Affiliation(s)
- Heather Lynn
- Department of Physiological Sciences and University of Arizona, Tucson, Arizona.,Department of Health Sciences, University of Arizona, Tucson, Arizona
| | - Xiaoguang Sun
- Department of Health Sciences, University of Arizona, Tucson, Arizona
| | - Nancy Casanova
- Department of Health Sciences, University of Arizona, Tucson, Arizona
| | | | - Christian Bime
- Department of Health Sciences, University of Arizona, Tucson, Arizona
| | - Joe G N Garcia
- Department of Health Sciences, University of Arizona, Tucson, Arizona
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16
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Diet-Induced Pulmonary Inflammation and Incipient Fibrosis in Mice: a Possible Role of Neutrophilic Inflammation. Inflammation 2019; 42:1886-1900. [DOI: 10.1007/s10753-019-01051-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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17
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Rojas-Quintero J, Wang X, Tipper J, Burkett PR, Zuñiga J, Ashtekar AR, Polverino F, Rout A, Yambayev I, Hernández C, Jimenez L, Ramírez G, Harrod KS, Owen CA. Matrix metalloproteinase-9 deficiency protects mice from severe influenza A viral infection. JCI Insight 2018; 3:99022. [PMID: 30568032 DOI: 10.1172/jci.insight.99022] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 11/06/2018] [Indexed: 02/06/2023] Open
Abstract
Matrix metalloproteinase-9 (MMP-9) cleaves various proteins to regulate inflammatory and injury responses. However, MMP-9's activities during influenza A viral (IAV) infections are incompletely understood. Herein, plasma MMP-9 levels were increased in patients with pandemic H1N1 and seasonal IAV infections. MMP-9 lung levels were increased and localized to airway epithelial cells and leukocytes in H1N1-infected WT murine lungs. H1N1-infected Mmp-9-/- mice had lower mortality rates, reduced weight loss, lower lung viral titers, and reduced lung injury, along with lower E-cadherin shedding in bronchoalveolar lavage fluid (BALF) samples than WT mice. H1N1-infected Mmp-9-/- mice had an altered immune response to IAV with lower BALF PMN and macrophage counts, higher Th1-like CD4+ and CD8+ T cell subsets, lower T regulatory cell counts, reduced lung type I interferon levels, and higher lung interferon-γ levels. Mmp-9 bone marrow-chimera studies revealed that Mmp-9 deficiency in lung parenchymal cells protected mice from IAV-induced mortality. H1N1-infected Mmp-9-/- lung epithelial cells had lower viral titers than H1N1-infected WT cells in vitro. Thus, H1N1-infected Mmp-9-/- mice are protected from IAV-induced lung disease due to a more effective adaptive immune response to IAV and reduced epithelial barrier injury due partly to reduced E-cadherin shedding. Thus, we believe that MMP-9 is a novel therapeutic target for IAV infections.
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Affiliation(s)
- Joselyn Rojas-Quintero
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Xiaoyun Wang
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer Tipper
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular and Translational Biomedicine, School of Medicine, University of Alabama-Birmingham, Birmingham, Alabama, USA
| | - Patrick R Burkett
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Joaquin Zuñiga
- Laboratory of Immunobiology and Genetics, and Intensive Care Unit, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Amit R Ashtekar
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular and Translational Biomedicine, School of Medicine, University of Alabama-Birmingham, Birmingham, Alabama, USA
| | - Francesca Polverino
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA.,Lovelace Respiratory Research Institute, Albuquerque, New Mexico, USA
| | - Amit Rout
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Ilyas Yambayev
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Carmen Hernández
- Laboratory of Immunobiology and Genetics, and Intensive Care Unit, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico.,Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Mexico City, Mexico
| | - Luis Jimenez
- Laboratory of Immunobiology and Genetics, and Intensive Care Unit, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Gustavo Ramírez
- Laboratory of Immunobiology and Genetics, and Intensive Care Unit, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Kevin S Harrod
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular and Translational Biomedicine, School of Medicine, University of Alabama-Birmingham, Birmingham, Alabama, USA
| | - Caroline A Owen
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA.,Lovelace Respiratory Research Institute, Albuquerque, New Mexico, USA
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18
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Bashar FR, Vahedian-Azimi A, Farzanegan B, Goharani R, Shojaei S, Hatamian S, Mosavinasab SMM, Khoshfetrat M, Khatir MAK, Tomdio A, Miller AC. Comparison of non-invasive to invasive oxygenation ratios for diagnosing acute respiratory distress syndrome following coronary artery bypass graft surgery: a prospective derivation-validation cohort study. J Cardiothorac Surg 2018; 13:123. [PMID: 30482210 PMCID: PMC6260696 DOI: 10.1186/s13019-018-0804-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 11/05/2018] [Indexed: 01/11/2023] Open
Abstract
Objective To determine if non-invasive oxygenation indices, namely peripheral capillary oxygen saturation (SpO2)/fraction of inspired oxygen (FiO2) and partial pressure of alveolar oxygen (PAO2)/FiO2 may be used as effective surrogates for the partial pressure of arterial oxygen (PaO2)/FiO2. Also, to determine the SpO2/FiO2 and PAO2/FiO2 values that correspond to PaO2/FiO2 thresholds for identifying acute respiratory distress syndrome (ARDS) in patients following coronary artery bypass graft (CABG) surgery. Methods A prospective derivation-validation cohort study in the Open-Heart ICU of an academic teaching hospital. Recorded variables included patient demographics, ventilator settings, chest radiograph results, and SPO2, PaO2, PAO2, SaO2, and FiO2. Linear regression modeling was used to quantify the relationship between indices. Receiver operating characteristic (ROC) curves were used to determine the sensitivity and specificity of the threshold values. Results One-hundred seventy-five patients were enrolled in the derivation cohort, and 358 in the validation cohort. The SPO2/FiO2 and PAO2/FiO2 ratios could be predicted well from PaO2/FiO2, described by the linear regression models SPO2/FiO2 = 71.149 + 0.8PF and PAO2/FiO2 = 38.098 + 2.312PF, respectively. According to the linear regression equation, a PaO2/FiO2 ratio of 300 equaled an SPO2/FiO2 ratio of 311 (R2 0.857, F 1035.742, < 0.0001) and a PAO2/FiO2 ratio of 732 (R2 0.576, F 234.887, < 0.0001). The SPO2/FiO2 threshold of 311 had 90% sensitivity, 80% specificity, LR+ 4.50, LR- 0.13, PPV 98, and NPV 42.1 for the diagnosis of mild ARDS. The PAO2/FiO2 threshold of 732 had 86% sensitivity, 90% specificity, LR+ 8.45, LR- 0.16, PPV 98.9, and NPV 36 for the diagnosis of mild ARDS. SPO2/FiO2 had excellent discrimination ability for mild ARDS (AUC ± SE = 0.92 ± 0.017; 95% CI 0.889 to 0.947) as did PAO2/FiO2 (AUC ± SE = 0.915 ± 0.018; 95% CI 0.881 to0.942). Conclusions PaO2 and SaO2 correlated in the diagnosis of ARDS, with a PaO2/FiO2 of 300 correlating to an SPO2/ FiO2 of 311 (Sensitivity 90%, Specificity 80%). The SPO2/ FiO2 ratio may allow for early real-time rapid identification of ARDS, while decreasing the cost, phlebotomy, blood loss, pain, skin breaks, and vascular punctures associated with serial arterial blood gas measurements.
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Affiliation(s)
- Farshid R Bashar
- Anesthesia and Critical Care Department, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Amir Vahedian-Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Behrooz Farzanegan
- Tracheal Diseases Research Center, Anesthesia and Critical Care Department, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Goharani
- Anesthesiology Research Center, Anesthesia and Critical Care Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyedpouzhia Shojaei
- Anesthesiology Research Center, Anesthesia and Critical Care Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sevak Hatamian
- Anesthesia and Critical Care Department, Alborz University of Medical Sciences, Karaj, Iran
| | - Seyed M M Mosavinasab
- Anesthesiology Research Center, Anesthesia and Critical Care Department, Modares Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoum Khoshfetrat
- Anesthesiology Research Center, Anesthesia and Critical Care Department, Khatam-o-anbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Mohammad A K Khatir
- Anesthesiology Research Center, Anesthesia and Critical Care Department, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Anna Tomdio
- Department of Internal Medicine, Vident Medical Center, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Andrew C Miller
- Department of Emergency Medicine, Vident Medical Center, East Carolina University Brody School of Medicine, 600 Moye Blvd, Greenville, NC, 27834, USA.
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19
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DesPrez K, McNeil JB, Wang C, Bastarache JA, Shaver CM, Ware LB. Oxygenation Saturation Index Predicts Clinical Outcomes in ARDS. Chest 2017; 152:1151-1158. [PMID: 28823812 PMCID: PMC5812755 DOI: 10.1016/j.chest.2017.08.002] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/02/2017] [Accepted: 08/01/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Traditional measures of ARDS severity such as Pao2/Fio2 may not reliably predict clinical outcomes. The oxygenation index (OI [Fio2 × mean airway pressure × 100)/Pao2]) may more accurately reflect ARDS severity but requires arterial blood gas measurement. We hypothesized that the oxygenation saturation index (OSI [Fio2 × mean airway pressure × 100)/oxygen saturation by pulse oximetry (Spo2)]) is a reliable noninvasive surrogate for the OI that is associated with hospital mortality and ventilator-free days (VFDs) in patients with ARDS. METHODS Critically ill patients enrolled in a prospective cohort study were eligible if they developed ARDS (Berlin criteria) during the first 4 ICU days and had mean airway pressure, Spo2/Fio2, and Pao2/Fio2 values recorded on the first day of ARDS (N = 329). The highest mean airway pressure and lowest Spo2/Fio2 and Pao2/Fio2 values were used to calculate OI and OSI. The association between OI or OSI and hospital mortality or VFD was analyzed by using logistic regression and linear regression, respectively. The area under the receiver-operating characteristic curve (AUC) for mortality was compared among OI, OSI, Spo2/Fio2, Pao2/Fio2, and Acute Physiology and Chronic Health Evaluation II scores. RESULTS OI and OSI were strongly correlated (rho = 0.862; P < .001). OSI was independently associated with hospital mortality (OR per 5-point increase in OSI, 1.228 [95% CI, 1.056-1.429]; P = .008). OI and OSI were each associated with a reduction in VFD (OI, P = .023; OSI, P = .005). The AUC for mortality prediction was greatest for Acute Physiology and Chronic Health Evaluation II scores (AUC, 0.695; P < .005) and OSI (AUC, 0.602; P = .007). The AUC for OSI was substantially better in patients aged < 40 years (AUC, 0.779; P < .001). CONCLUSIONS In patients with ARDS, the OSI was correlated with the OI. The OSI on the day of ARDS diagnosis was significantly associated with increased mortality and fewer VFDs. The findings suggest that OSI is a reliable surrogate for OI that can noninvasively provide prognostic information and assessment of ARDS severity.
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Affiliation(s)
- Katherine DesPrez
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - J. Brennan McNeil
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Chunxue Wang
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Julie A. Bastarache
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ciara M. Shaver
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN,CORRESPONDENCE TO: Lorraine B. Ware, MD, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, 1161 21st Ave S, T1218 Medical Center N, Nashville, TN 37232Division of AllergyPulmonary, and Critical Care MedicineVanderbilt University Medical Center1161 21st Ave S, T1218 Medical Center NNashvilleTN 37232
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20
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Zhao Z, Wickersham N, Kangelaris KN, May AK, Bernard GR, Matthay MA, Calfee CS, Koyama T, Ware LB. External validation of a biomarker and clinical prediction model for hospital mortality in acute respiratory distress syndrome. Intensive Care Med 2017; 43:1123-1131. [PMID: 28593401 PMCID: PMC5978765 DOI: 10.1007/s00134-017-4854-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 05/25/2017] [Indexed: 01/11/2023]
Abstract
PURPOSE Mortality prediction in ARDS is important for prognostication and risk stratification. However, no prediction models have been independently validated. A combination of two biomarkers with age and APACHE III was superior in predicting mortality in the NHLBI ARDSNet ALVEOLI trial. We validated this prediction tool in two clinical trials and an observational cohort. METHODS The validation cohorts included 849 patients from the NHLBI ARDSNet Fluid and Catheter Treatment Trial (FACTT), 144 patients from a clinical trial of sivelestat for ARDS (STRIVE), and 545 ARDS patients from the VALID observational cohort study. To evaluate the performance of the prediction model, the area under the receiver operating characteristic curve (AUC), model discrimination, and calibration were assessed, and recalibration methods were applied. RESULTS The biomarker/clinical prediction model performed well in all cohorts. Performance was better in the clinical trials with an AUC of 0.74 (95% CI 0.70-0.79) in FACTT, compared to 0.72 (95% CI 0.67-0.77) in VALID, a more heterogeneous observational cohort. The AUC was 0.73 (95% CI 0.70-0.76) when FACTT and VALID were combined. CONCLUSION We validated a mortality prediction model for ARDS that includes age, APACHE III, surfactant protein D, and interleukin-8 in a variety of clinical settings. Although the model performance as measured by AUC was lower than in the original model derivation cohort, the biomarker/clinical model still performed well and may be useful for risk assessment for clinical trial enrollment, an issue of increasing importance as ARDS mortality declines, and better methods are needed for selection of the most severely ill patients for inclusion.
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Affiliation(s)
- Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
- The Institution for Medicine and Public Health, Vanderbilt University, Nashville, TN, USA
| | - Nancy Wickersham
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, T1218 MCN, 1161 21st Avenue S., Nashville, TN, 37232-2650, USA
| | - Kirsten N Kangelaris
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Addison K May
- Division of Trauma and Surgical Critical Care, Vanderbilt University, Nashville, TN, USA
| | - Gordon R Bernard
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, T1218 MCN, 1161 21st Avenue S., Nashville, TN, 37232-2650, USA
| | - Michael A Matthay
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Department of Anesthesia and Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Carolyn S Calfee
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Department of Anesthesia and Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, T1218 MCN, 1161 21st Avenue S., Nashville, TN, 37232-2650, USA.
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA.
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21
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Balzer F, Menk M, Ziegler J, Pille C, Wernecke KD, Spies C, Schmidt M, Weber-Carstens S, Deja M. Predictors of survival in critically ill patients with acute respiratory distress syndrome (ARDS): an observational study. BMC Anesthesiol 2016; 16:108. [PMID: 27821065 PMCID: PMC5100178 DOI: 10.1186/s12871-016-0272-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 10/14/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Currently there is no ARDS definition or classification system that allows optimal prediction of mortality in ARDS patients. This study aimed to examine the predictive values of the AECC and Berlin definitions, as well as clinical and respiratory parameters obtained at onset of ARDS and in the course of the first seven consecutive days. METHODS The observational study was conducted at a 14-bed intensive care unit specialized on treatment of ARDS. Predictive validity of the AECC and Berlin definitions as well as PaO2/FiO2 and FiO2/PaO2*Pmean (oxygenation index) on mortality of ARDS patients was assessed and statistically compared. RESULTS Four hundred forty two critically-ill patients admitted for ARDS were analysed. Multivariate Cox regression indicated that the oxygenation index was the most accurate parameter for mortality prediction. The third day after ARDS criteria were met at our hospital was found to represent the best compromise between earliness and accuracy of prognosis of mortality regarding the time of assessment. An oxygenation index of 15 or greater was associated with higher mortality, longer length of stay in ICU and hospital and longer duration of mechanical ventilation. In addition, non-survivors had a significantly longer length of stay and duration of mechanical ventilation in referring hospitals before admitted to the national reference centre than survivors. CONCLUSIONS The oxygenation index is suggested to be the most suitable parameter to predict mortality in ARDS, preferably assessed on day 3 after admission to a specialized centre. Patients might benefit when transferred to specialized ICU centres as soon as possible for further treatment.
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Affiliation(s)
- Felix Balzer
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum / Campus Charité Mitte, Augustenburger Platz 1, D-13353, Berlin, Germany
| | - Mario Menk
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum / Campus Charité Mitte, Augustenburger Platz 1, D-13353, Berlin, Germany
| | - Jannis Ziegler
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Christian Pille
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum / Campus Charité Mitte, Augustenburger Platz 1, D-13353, Berlin, Germany
| | | | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum / Campus Charité Mitte, Augustenburger Platz 1, D-13353, Berlin, Germany
| | - Maren Schmidt
- Department of Anaesthesiology and Intensive Care Medicine, Werner Forßmann Krankenhaus, 16225, Eberswalde, Germany
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum / Campus Charité Mitte, Augustenburger Platz 1, D-13353, Berlin, Germany.
| | - Maria Deja
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum / Campus Charité Mitte, Augustenburger Platz 1, D-13353, Berlin, Germany. .,Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
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22
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deBacker J, Hart N, Fan E. Neuromuscular Blockade in the 21st Century Management of the Critically Ill Patient. Chest 2016; 151:697-706. [PMID: 27818334 DOI: 10.1016/j.chest.2016.10.040] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Neuromuscular blockings agents (NMBAs) have a controversial role in the ventilatory and medical management of critical illness. The clinical concern surrounding NMBA-induced complications stems from evidence presented in the 2002 clinical practice guidelines, but new evidence from subsequent randomized trials and studies provides a more optimistic outlook about the application of NMBAs in the ICU. Furthermore, changes in the delivery of critical care, such as protocolized care pathways, minimizing or interrupting sedation, increased monitoring techniques, and overall improvements in reducing immobility, have created a modern, 21st century ICU environment whereby NMBAs may be administered safely. In this article we start with a review of the mechanism of action, side effects, and pharmacology of commonly used NMBAs. We then address the rationale for NMBA use for an expanding number of indications (endotracheal intubation, acute respiratory distress syndrome, status asthmaticus, increased intracranial and intra-abdominal pressure, and therapeutic hypothermia after cardiac arrest), with an emphasis on NMBA use in facilitating lung-protective ventilation for respiratory failure. We end with an appraisal over the importance of monitoring depth of paralysis and the concerns of complications, such as prolonged skeletal muscle weakness. In the context of adequate sedation and analgesia, monitored NMBA use (continuous or bolus administration) can be considered for the small number of clinical indications in critically ill patients for which evidence currently exists.
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Affiliation(s)
- Julian deBacker
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH; Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Nicholas Hart
- Lane Fox Respiratory Service, St. Thomas' Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada.
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23
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Differential Regulation of the Extracellular Cysteine/Cystine Redox State (EhCySS) by Lung Fibroblasts from Young and Old Mice. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2016; 2016:1561305. [PMID: 27642492 PMCID: PMC5014973 DOI: 10.1155/2016/1561305] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 08/07/2016] [Indexed: 12/21/2022]
Abstract
Aging is associated with progressive oxidation of plasma cysteine (Cys)/cystine (CySS) redox state, expressed as EhCySS. Cultured cells condition their media to reproduce physiological EhCySS, but it is unknown whether aged cells produce a more oxidized extracellular environment reflective of that seen in vivo. In the current study, we isolated primary lung fibroblasts from young and old female mice and measured the media EhCySS before and after challenge with Cys or CySS. We also measured expression of genes related to redox regulation and fibroblast function. These studies revealed that old fibroblasts produced a more oxidizing extracellular EhCySS than young fibroblasts and that old fibroblasts had a decreased capacity to recover from an oxidative challenge due to a slower rate of reduction of CySS to Cys. These defects were associated with 10-fold lower expression of the Slc7a11 subunit of the xCT cystine-glutamate transporter. Extracellular superoxide dismutase (Sod3) was the only antioxidant or thiol-disulfide regulating enzyme among 36 examined that was downregulated in old fibroblasts by more than 2-fold, but there were numerous changes in extracellular matrix components. Thus, aging fibroblasts not only contribute to remodeling of the extracellular matrix but also have a profound effect on the extracellular redox environment.
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24
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Yehya N, Thomas NJ, Margulies SS. Circulating nucleosomes are associated with mortality in pediatric acute respiratory distress syndrome. Am J Physiol Lung Cell Mol Physiol 2016; 310:L1177-84. [PMID: 27130528 DOI: 10.1152/ajplung.00067.2016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 04/21/2016] [Indexed: 12/17/2022] Open
Abstract
Mechanisms underlying pediatric acute respiratory distress syndrome (PARDS) are poorly understood. The recent implication of circulating nucleosomes as pathogenic in sepsis and trauma-associated ARDS in adults led us to investigate the significance of nucleosomes in PARDS. We conducted a prospective, observational study on children with PARDS at the Children's Hospital of Philadelphia between July 2014 and September 2015. Plasma was collected within 48 h of PARDS onset and nucleosomes quantified by enzyme-linked immunosorbent assay. Samples from 76 children with PARDS (11 deaths, 14%) were collected early [median 15 (IQR 7, 21) h] after PARDS onset. Nucleosome levels were higher in nonsurvivors [0.59 AU (IQR 0.46, 0.84)] relative to survivors [0.21 AU (IQR 0.08, 0.33), rank sum P < 0.001]. Nucleosome levels were not associated with either Berlin (P = 0.845) or PALICC (P = 0.886) oxygenation categories, nor with etiology of PARDS (P = 0.527). Nucleosomes were correlated with increasing numbers of nonpulmonary organ failures (P = 0.009 for trend), and were higher in patients whose PaO2 /FiO2 worsened (P = 0.012) over the first 72 h of PARDS. In regression analysis, nucleosome levels were independently associated with mortality after adjusting for either age, severity of illness score, number of nonpulmonary organ failures, vasopressor score, or PaO2 /FiO2 (all P < 0.05). In conclusion, plasma nucleosome levels in early PARDS were associated with increased mortality, correlated with number of nonpulmonary organ failures, and preceded worsening oxygenation. The potential utility of this biomarker for prognostication, risk stratification, and mechanistic insight should be investigated further.
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Affiliation(s)
- Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia;
| | - Neal J Thomas
- Department of Pediatrics and Public Health Science, Division of Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey
| | - Susan S Margulies
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania
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25
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Yehya N, Thomas NJ, Meyer NJ, Christie JD, Berg RA, Margulies SS. Circulating markers of endothelial and alveolar epithelial dysfunction are associated with mortality in pediatric acute respiratory distress syndrome. Intensive Care Med 2016; 42:1137-45. [PMID: 27101828 DOI: 10.1007/s00134-016-4352-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 04/05/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE Angiopoietin 2 (Ang2) and soluble receptor for advanced glycation end products (sRAGE) are markers of endothelial and pulmonary epithelial damage with prognostic implications in adult acute respiratory distress syndrome (ARDS), but unclear significance in pediatric ARDS (PARDS). METHODS This was a prospective, observational study in children with PARDS (2012 Berlin and 2015 PALICC definitions) at the Children's Hospital of Philadelphia. Plasma was collected within 48 h of PARDS onset and biomarkers quantified by enzyme-linked immunosorbent assay. RESULTS In 82 children with PARDS (12 deaths, 15 %), Ang2 and sRAGE were higher in non-survivors than survivors (p < 0.01 for both). Mortality was highest in patients with Ang2 and sRAGE levels both above median values. Ang2 and sRAGE correlated with the number of non-pulmonary organ failures (both p < 0.001). Ang2 was higher in indirect lung injury and in immunocompromised children. In stratified analysis, both Ang2 and sRAGE were associated with mortality only in direct lung injury and in immunocompetent children, with no association evident in indirect lung injury or in immunocompromised children. CONCLUSIONS Ang2 and sRAGE in early PARDS were higher in non-survivors than survivors and strongly correlated with number of non-pulmonary organ failures. When stratified by type of lung injury, Ang2 and sRAGE were associated with mortality only in direct lung injury. Similarly, when stratified by immunocompromised status, Ang2 and sRAGE were associated with mortality only in immunocompetent children. The utility of these biomarkers for prognostication and risk stratification requires investigation.
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Affiliation(s)
- Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Suite 7C-26, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, 3600 Spruce Street, Philadelphia, PA, 19104, USA.
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, 500 University Drive, Hershey, PA, 17033, USA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, 3600 Spruce Street, Philadelphia, PA, 19104, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, 3600 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, 717 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Suite 7C-26, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Susan S Margulies
- Department of Bioengineering, University of Pennsylvania, 240 Skirkanich Hall, 210 South 33rd Street, Philadelphia, PA, 19104, USA
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26
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Bartko J, Stiebellehner L, Derhaschnig U, Schoergenhofer C, Schwameis M, Prosch H, Jilma B. Dissociation between systemic and pulmonary anti-inflammatory effects of dexamethasone in humans. Br J Clin Pharmacol 2016; 81:865-77. [PMID: 26647918 PMCID: PMC4834593 DOI: 10.1111/bcp.12857] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 11/23/2015] [Accepted: 12/01/2015] [Indexed: 12/14/2022] Open
Abstract
Aims The local pulmonary inflammatory response has a different temporal and qualitative profile compared with the systemic inflammatory response. Although glucocorticoids substantially downregulate the systemic release of acute‐phase mediators, it is not clear whether they have comparable inhibitory effects in the human lung compartment. Therefore, we compared the anti‐inflammatory effects of a pure glucocorticoid agonist, dexamethasone, on bronchoalveolar lavage and blood cytokine concentrations in response to bronchially instilled endotoxin. Methods In this randomized, double‐blind and placebo‐controlled trial, 24 volunteers received dexamethasone or placebo and had endotoxin instilled into a lung segment and saline instilled into a contralateral segment, followed by bronchoalveolar lavage. Results Bronchially instilled endotoxin induced a local and systemic inflammatory response. Dexamethasone strongly blunted the systemic interleukin (IL) 6 and C‐reactive protein release. In sharp contrast, dexamethasone left the local release of acute‐phase mediators in the lungs virtually unchanged: bronchoalveolar lavage levels of IL‐6 were only 18% lower and levels of IL‐8 were even higher with dexamethasone compared with placebo, although the differences between treatments were not statistically significant (P = 0.07 and P = 0.08, respectively). However, dexamethasone had inhibitory effects on pulmonary protein extravasation and neutrophil migration. Conclusions The present study demonstrated a remarkable dissociation between the systemic anti‐inflammatory effects of glucocorticoids and its protective effects on capillary leak on the one hand and surprisingly low anti‐inflammatory effects in the lungs on the other.
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Affiliation(s)
- Johann Bartko
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Ulla Derhaschnig
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Michael Schwameis
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Helmut Prosch
- Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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27
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Bhatraju P, Crawford J, Hall M, Lang JD. Inhaled nitric oxide: Current clinical concepts. Nitric Oxide 2015; 50:114-128. [DOI: 10.1016/j.niox.2015.08.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 07/31/2015] [Accepted: 08/26/2015] [Indexed: 12/12/2022]
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28
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Seo DJ, Yoo JS, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW. Venovenous Extracorporeal Membrane Oxygenation for Postoperative Acute Respiratory Distress Syndrome. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 48:180-6. [PMID: 26078924 PMCID: PMC4463224 DOI: 10.5090/kjtcs.2015.48.3.180] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 10/22/2014] [Accepted: 10/27/2014] [Indexed: 01/11/2023]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) has recently attracted interest as a treatment for severe acute respiratory distress syndrome (ARDS). However, the outcomes of this procedure in post-surgical settings have not yet been characterized. In this study, we evaluated the outcomes of ECMO in patients with severe postoperative ARDS. Methods From January 2007 to December 2012, a total of 69 patients (aged 58.3±11.5 years, 23 females) who underwent venovenous ECMO to treat severe postoperative ARDS were reviewed. Of these patients, 22 (31.9%) had undergone cardiothoracic surgery, 32 (46.4%) had undergone liver transplantation, and 15 (21.7%) had undergone other procedures. Results Thirty-four patients (49.3%) were successfully weaned from ECMO, while the other 35 patients (50.7%) died on ECMO support. Among the 34 patients who were successfully weaned from ECMO, 21 patients (30.4%) eventually died before discharge from the hospital, resulting in 13 hospital survivors (18.8%). Multivariable analysis showed that the duration of pre-ECMO ventilation was a significant independent predictor of death (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.29 to 3.90; p=0.004), whereas the concomitant use of continuous venovenous hemodialysis (CVVHD) was associated with improved survival (OR, 0.55; 95% CI, 0.31 to 0.97; p=0.038). Conclusion Although the overall survival rate of patients treated with ECMO for postoperative ARDS was unfavorable, ECMO offered an invaluable opportunity for survival to patients who would not have been expected to survive using conventional therapy. CVVHD may be beneficial in improving the outcomes of such patients, whereas a prolonged duration of pre-ECMO ventilator support was associated with poor survival.
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Affiliation(s)
- Dong Ju Seo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jae Suk Yoo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
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Abstract
This review documents important progress made in 2013 in the field of critical care respirology, in particular with regard to acute respiratory failure and acute respiratory distress syndrome. Twenty-five original articles published in the respirology and critical care sections of Critical Care are discussed in the following categories: pre-clinical studies, protective lung ventilation – how low can we go, non-invasive ventilation for respiratory failure, diagnosis and prognosis in acute respiratory distress syndrome and respiratory failure, and promising interventions for acute respiratory distress syndrome.
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30
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He DK, Shao YR, Zhang L, Shen J, Zhong ZY, Wang J, Xu G. Adenovirus-delivered angiopoietin-1 suppresses NF-κB and p38 MAPK and attenuates inflammatory responses in phosgene-induced acute lung injury. Inhal Toxicol 2014; 26:185-92. [PMID: 24517841 DOI: 10.3109/08958378.2013.872213] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Animals exposed to phosgene (Psg) result in acute lung injury (ALI). We have recently reported that angiopoietin-1 (Ang1) reduces inflammation and vascular hyperpermeability in ALI animals. In this study, we examined whether the beneficial effects of adenovirus-delivered Ang1 (Ad/Ang1) on inflammatory responses in Psg-induced ALI rats are due to the suppression of the nuclear factor-kappa B (NF-κB) and p38 mitogen-activated protein kinase (MAPK) pathways, which play crucial roles in inflammatory responses in ALI. We demonstrated that Psg increased Ang2 and inflammatory cytokines, such as tumor necrosis factor-α (TNF-α), interleukin (IL)-4 (IL-4), IL-6, IL-8, and IL-10, in the serum and bronchoalveolar lavage fluid of ALI rats, determined by ELISA. Ang1 inhibits pro-inflammatory mediators (TNF-α, IL-6 and IL-8) and has no effect on anti-inflammatory mediators (IL-4 and IL-10). Furthermore, the inhibitory action of Ang1 was mediated by the suppression of the NF-κB and p38 MAPK pathways, leading to the attenuation of inflammatory responses of ALI. Thus, Ad/Ang1 may provide a useful tool for the effective treatment in Psg-induced ALI.
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Affiliation(s)
- Dai-Kun He
- Center of Emergency & Intensive Care Unit
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Bellingan G, Maksimow M, Howell DC, Stotz M, Beale R, Beatty M, Walsh T, Binning A, Davidson A, Kuper M, Shah S, Cooper J, Waris M, Yegutkin GG, Jalkanen J, Salmi M, Piippo I, Jalkanen M, Montgomery H, Jalkanen S. The effect of intravenous interferon-beta-1a (FP-1201) on lung CD73 expression and on acute respiratory distress syndrome mortality: an open-label study. THE LANCET RESPIRATORY MEDICINE 2013; 2:98-107. [PMID: 24503265 DOI: 10.1016/s2213-2600(13)70259-5] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pulmonary vascular leakage occurs early in acute respiratory distress syndrome (ARDS). Mortality is high (35-45%), but no effective pharmacotherapy exists. Production of anti-inflammatory adenosine by ecto-5'-nucleotidase (CD73) helps maintain endothelial barrier function. We tested whether interferon-beta-1a (IFN-beta-1a), which increases CD73 synthesis, can reduce vascular leakage and mortality in patients with ARDS. METHODS In ex-vivo studies, we first established that IFN-beta-1a induced CD73 up-regulation in cultured human lung tissue samples. We then tested the safety, tolerability, and efficacy of intravenous human recombinant IFN-beta-1a (FP-1201) in patients with ARDS in an open-label study (comprising dose-escalation and expansion phases). We recruited patients from eight intensive care units in the UK. Eligible patients were aged 18 years or older, had ARDS, and were being treated with assisted ventilation. We established an optimal tolerated dose (OTD) in the first, dose-escalation phase. Once established, we gave all subsequently enrolled patients the OTD of intravenous FP-1201 for 6 days. We assessed 28-day mortality (our primary endpoint) in all patients receiving the OTD versus 28-day mortality in a group of patients who did not receive treatment (this control group comprised patients in the study but who did not receive treatment because they were screened during the safety windows after dose escalation). This trial is registered with ClinicalTrials.gov, number NCT00789685, and the EU Clinical Trials Register EudraCT, number 2008-000140-13. FINDINGS IFN-beta-1a increased the number of CD73-positive vessels in lung culture by four times on day 1 (p=0·04) and by 14·3 times by day 4 (p=0·004). For the clinical trial, between Feb 23, 2009, and April 7, 2011, we identified 150 patients, of whom 37 were enrolled into the trial and given treatment. The control group consisted of 59 patients who were recruited to take part in the study, but who did not receive treatment. Demographic characteristics and severity of illness did not differ between treatment and control groups. The optimal tolerated FP-1201 dose was 10 μg per day for 6 days. By day 28, 3 (8%) of 37 patients in the treatment cohort and 19 (32%) of 59 patients in the control cohort had died-thus, treatment with FP-1201 was associated with an 81% reduction in odds of 28-day mortality (odds ratio 0·19 [95% CI 0·03-0·72]; p=0·01). INTERPRETATION FP-1201 up-regulates human lung CD73 expression, and is associated with a reduction in 28-day mortality in patients with ARDS. Our findings need to be substantiated in large, prospective randomised trials, but suggest that FP-1201 could be the first effective, mechanistically targeted, disease-specific pharmacotherapy for patients with ARDS.
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Affiliation(s)
- Geoff Bellingan
- Critical Care, University College Hospital, London, UK; Department of Medicine, University College London and NIHR University College London Hospitals Biomedical Research Centre, UK
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- Centre for Cardiovascular Genetics, Institute of Cardiovascular Science, University College London, UK
| | - Matti Waris
- Department of Virology, University of Turku, Finland
| | - Gennady G Yegutkin
- MediCity Research Laboratory, University of Turku, Finland; Department of Medical Microbiology, University of Turku, Finland
| | - Juho Jalkanen
- Department of Vascular Surgery, Turku University Hospital, Finland
| | - Marko Salmi
- MediCity Research Laboratory, University of Turku, Finland; Department of Medical Biochemistry and Genetics, University of Turku, Finland
| | | | | | - Hugh Montgomery
- Department of Medicine, University College London and NIHR University College London Hospitals Biomedical Research Centre, UK; Whittington Hospital London, UK
| | - Sirpa Jalkanen
- MediCity Research Laboratory, University of Turku, Finland; Department of Medical Microbiology, University of Turku, Finland.
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Fröhlich S, Murphy N, Boylan JF. ARDS: progress unlikely with non-biological definition. Br J Anaesth 2013; 111:696-9. [PMID: 24108727 DOI: 10.1093/bja/aet165] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- S Fröhlich
- Department of Anaesthesia and Intensive Care Medicine, St Vincent's University Hospital, Dublin, Ireland
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Fioretto JR, Carvalho WB. Temporal evolution of acute respiratory distress syndrome definitions. J Pediatr (Rio J) 2013; 89:523-30. [PMID: 24035871 DOI: 10.1016/j.jped.2013.02.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 02/14/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE to review the evolution of acute respiratory distress syndrome (ARDS) definitions and present the current definition for the syndrome. DATA SOURCE a literature review and selection of the most relevant articles on ARDS definitions was performed using the MEDLINE®/PubMed® Resource Guide database (last ten years), in addition to including the most important articles (classic articles) that described the disease evolution. DATA SYNTHESIS the review included the following subjects: introduction; importance of definition; description of the first diagnostic criterion and subsequently used definitions, such as acute lung injury score; definition by the American-European Consensus Conference, and its limitations; description of the definition by Delphi, and its problems; accuracy of the aforementioned definitions; description of most recent definition (the Berlin definition), and its limitations; and practical importance of the new definition. CONCLUSIONS ARDS is a serious disease that remains an ongoing diagnostic and therapeutic challenge. The evolution of definitions used to describe the disease shows that studies are needed to validate the current definition, especially in pediatrics, where the data are very scarce.
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Affiliation(s)
- José R Fioretto
- Pediatrics Department, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, São Paulo, SP, Brazil; Sociedade Paulista de Terapia Intensiva, São Paulo, SP, Brazil.
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Temporal evolution of acute respiratory distress syndrome definitions. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2013. [DOI: 10.1016/j.jpedp.2013.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Sinha P, Singh S, Hardman JG, Bersten AD, Soni N. Evaluation of the physiological properties of ventilatory ratio in a computational cardiopulmonary model and its clinical application in an acute respiratory distress syndrome population. Br J Anaesth 2013; 112:96-101. [PMID: 24067330 PMCID: PMC9585654 DOI: 10.1093/bja/aet283] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Owing to complexities of measuring dead space, ventilatory failure is difficult to quantify in critical care. A simple, novel index called ventilatory ratio (VR) can quantify ventilatory efficiency at the bedside. The study objectives were to evaluate physiological properties of VR and examine its clinical applicability in acute respiratory distress syndrome (ARDS) patients. METHODS A validated computational model of cardiopulmonary physiology [Nottingham Physiology Simulator (NPS)] was used to evaluate VR ex vivo in three virtual patients with varying degrees of gas exchange defects. Arterial P(CO₂) and mixed expired P(CO₂) were obtained from the simulator while either dead space or CO₂ production was altered in isolation. VR and deadspace fraction was calculated using these values. A retrospective analysis of a previously presented prospective ARDS database was then used to evaluate the clinical utility of VR. Basic characteristics of VR and its association with mortality were examined. RESULTS The NPS showed that VR behaved in an intuitive manner as would be predicted by its physiological properties. When CO₂ production was constant, there was strong positive correlation between dead space and VR (modified Pearson's r 0.98, P<0.01). The ARDS database had a mean VR of 1.47 (standard deviation 0.58). Non-survivors had a significantly higher VR compared with survivors [1.70 vs 1.34, mean difference 0.35, 95% confidence interval (CI) 0.16-0.56, P<0.01]. VR was an independent predictor of mortality (odds ratio 3.05, CI 1.35-6.91, P<0.01). CONCLUSIONS VR is influenced by dead space and CO₂ production. In ARDS, high VR was associated with increased mortality.
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Affiliation(s)
- P Sinha
- Magill Department of Anaesthesia, Intensive Care Medicine and Pain Management Chelsea and Westminster Hospital, 369 Fulham Road, London, UK
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Sinha P, Fauvel NJ, Singh P, Soni N. Analysis of ventilatory ratio as a novel method to monitor ventilatory adequacy at the bedside. Crit Care 2013; 17:R34. [PMID: 23445563 PMCID: PMC4057449 DOI: 10.1186/cc12541] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 02/05/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Due to complexities in its measurement, adequacy of ventilation is seldom used to categorize disease severity and guide ventilatory strategies. Ventilatory ratio (VR) is a novel index to monitor ventilatory adequacy at the bedside. VR=(VEmeasured × PaCO₂measured)/(VEpredicted × PaCO₂ideal). VEpredicted is 100 mL.Kg-1.min-1 and PaCO₂ideal is 5 kPa. Physiological analysis shows that VR is influenced by dead space (VD/VT) and CO₂ production (VCO₂). Two studies were conducted to explore the physiological properties of VR and assess its use in clinical practice. METHODS Both studies were conducted in adult mechanically ventilated ICU patients. In Study 1, volumetric capnography was used to estimate daily VD/VT and measure VCO₂ in 48 patients. Simultaneously, ventilatory ratio was calculated using arterial blood gas measurements alongside respiratory and ventilatory variables. This data was used to explore the physiological properties of VR. In Study 2, 224 ventilated patients had daily VR and other respiratory variables, baseline characteristics, and outcome recorded. The database was used to examine the prognostic value of VR. RESULTS Study 1 showed that there was significant positive correlation between VR and VD/VT (modified r = 0.71) and VCO₂ (r = 0.14). The correlation between VR and VD/VT was stronger in mandatory ventilation compared to spontaneous ventilation. Linear regression analysis showed that VD/VT had a greater influence on VR than VCO₂ (standardized regression coefficient 1/1-VD/VT: 0.78, VCO₂: 0.44). Study 2 showed that VR was significantly higher in non-survivors compared to survivors (1.55 vs. 1.32; P < 0.01). Univariate logistic regression showed that higher VR was associated with mortality (OR 2.3, P < 0.01), this remained the case after adjusting for confounding variables (OR 2.34, P = 0.04). CONCLUSIONS VR is an easy to calculate bedside index of ventilatory adequacy and appears to yield clinically useful information.
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A universal definition of ARDS: the PaO2/FiO2 ratio under a standard ventilatory setting—a prospective, multicenter validation study. Intensive Care Med 2013; 39:583-92. [DOI: 10.1007/s00134-012-2803-x] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 10/23/2012] [Indexed: 12/14/2022]
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Ventilatory strategies in septic patients. Results from a nationwide observational trial. Anaesthesist 2013; 62:27-33. [PMID: 23319272 DOI: 10.1007/s00101-012-2121-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 10/19/2012] [Accepted: 11/25/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND Mortality in intensive care unit (ICU) patients is affected by multiple variables. The possible impact of the mode of ventilation has not yet been clarified; therefore, a secondary analysis of the "epidemiology of sepsis in Germany" study was performed. The aims were (1) to describe the ventilation strategies currently applied in clinical practice, (2) to analyze the association of the different modes of ventilation with mortality and (3) to investigate whether the ratio between arterial partial pressure of oxygen and inspired fraction of oxygen (PF ratio) and/or other respiratory variables are associated with mortality in septic patients needing ventilatory support. METHODS A total of 454 ICUs in 310 randomly selected hospitals participated in this national prospective observational 1-day point prevalence of sepsis study including 415 patients with severe sepsis or septic shock according to the American College of Chest Physicians/Society of Critical Care Medicine criteria. RESULTS Of the 415 patients, 331 required ventilatory support. Pressure controlled ventilation (PCV) was the most frequently used ventilatory mode (70.6 %) followed by assisted ventilation (AV 21.7 %) and volume controlled ventilation (VCV 7.7 %). Hospital mortality did not differ significantly among patients ventilated with PCV (57 %), VCV (71 %) or AV (51 %, p=0.23). A PF ratio equal or less than 300 mmHg was found in 83.2 % of invasively ventilated patients (n=316). In AV patients there was a clear trend to a higher PF ratio (204±70 mmHg) than in controlled ventilated patients (PCV 179±74 mmHg, VCV 175±75 mmHg, p=0.0551). Multiple regression analysis identified the tidal volume to pressure ratio (tidal volume divided by peak inspiratory airway pressure, odds ratio OR=0.94, 95 % confidence interval 95% CI=0.89-0.99), acute renal failure (OR=2.15, 95% CI=1.01-4.55) and acute physiology and chronic health evaluation (APACHE) II score (OR=1.09, 95% CI=1.03-1.15) but not the PF ratio (univariate analysis OR=0.998, 95 % CI=0.995-1.001) as independent risk factors for in-hospital mortality. CONCLUSIONS This representative survey revealed that severe sepsis or septic shock was frequently associated with acute lung injury. Different ventilatory modes did not affect mortality. The tidal volume to inspiratory pressure ratio but not the PF ratio was independently associated with mortality.
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Acute respiratory distress syndrome after trauma: development and validation of a predictive model. Crit Care Med 2012; 40:2295-303. [PMID: 22809905 DOI: 10.1097/ccm.0b013e3182544f6a] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine early clinical predictors of acute respiratory distress syndrome after major traumatic injury and characterize the performance of this acute respiratory distress syndrome prediction model, and two previously published acute respiratory distress syndrome prediction models, in an independent cohort of severely injured patients. DESIGN Prospective cohort study. SETTING University-affiliated level I trauma center in Seattle, WA, and nine hospitals participating in the Inflammation and Host Response to Injury Consortium. PATIENTS Model derivation utilized data from 224 patients participating in a randomized controlled trial. All models were validated in an independent cohort of 1,762 trauma patients. MEASUREMENTS AND MAIN RESULTS Variables strongly associated with acute respiratory distress syndrome in bivariate analysis (p<.01) were entered into a multiple logistic regression equation to generate an acute respiratory distress syndrome predictive model. We evaluated the performance of all models using the area under the receiver operator characteristic curve. Acute respiratory distress syndrome occurred in 79 subjects (35%) belonging to the development cohort and in 423 subjects (24%) from the validation cohort. Multivariable predictors of acute respiratory distress syndrome after trauma included subject age, Acute Physiology and Chronic Health Evaluation II Score, injury severity score, and the presence of blunt traumatic injury, pulmonary contusion, massive transfusion, and flail chest injury (area under the receiver operator characteristic curve 0.79 [95% confidence interval 0.73, 0.85]). Validation of the prediction model resulted in an area under the receiver operator characteristic curve of 0.71 (95% confidence interval 0.68, 0.74). Our model's performance in the validation cohort was superior to that of two other published acute respiratory distress syndrome prediction models (0.65 [95% confidence interval 0.63, 0.68] and 0.66 [95% confidence interval 0.64, 0.69], p<.01 for all comparisons). CONCLUSIONS Using routinely available clinical data, our prediction model identifies patients at high risk for acute respiratory distress syndrome early after severe traumatic injury. This predictive model could facilitate enrollment of subjects into future clinical trials designed to prevent this serious complication.
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Finigan JH, Mishra R, Vasu VT, Silveira LJ, Nethery DE, Standiford TJ, Burnham EL, Moss M, Kern JA. Bronchoalveolar lavage neuregulin-1 is elevated in acute lung injury and correlates with inflammation. Eur Respir J 2012; 41:396-401. [PMID: 22599357 DOI: 10.1183/09031936.00004912] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Shedding of neuregulin (NRG)-1 from the pulmonary epithelium leads to activation of the epithelial human epidermal growth factor receptor (HER)2 receptor, increased pulmonary epithelial permeability and acute lung injury (ALI). We sought to determine whether NRG-1 was detectable and elevated in bronchoalveolar lavage (BAL) and plasma from patients with ALI compared with controls and to determine whether a correlation exists between NRG-1 and inflammation and outcome in ALI. Matched BAL and plasma samples were obtained from 23 ALI patients requiring intubation and mechanical ventilation. Control patients (n=5) included healthy volunteers. NRG-1 and indices of inflammation were measured in BAL and plasma via ELISA. The mean±sd BAL NRG-1 concentration in ALI patients was 187.0±21.35 pg·mL(-1) compared with 85.50±9.2 pg·mL(-1) in controls (p=0.001). Increased BAL NRG-1 was associated with markers of inflammation, and inversely correlated with ventilator-free days (VFDs; r= -0.51, p=0.015). Plasma NRG-1 was elevated in ALI patients compared with controls (611.7±354.2 versus 25.17±19.33 pg·mL(-1), p<0.001) and inversely correlated with VFDs (r= -0.51, p=0.04). These results confirm shedding of NRG-1 in ALI and suggest that the NRG-1-HER2 pathway is active in patients with ALI.
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Affiliation(s)
- James H Finigan
- Dept. of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA.
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Kordonowy LL, Burg E, Lenox CC, Gauthier LM, Petty JM, Antkowiak M, Palvinskaya T, Ubags N, Rincón M, Dixon AE, Vernooy JHJ, Fessler MB, Poynter ME, Suratt BT. Obesity is associated with neutrophil dysfunction and attenuation of murine acute lung injury. Am J Respir Cell Mol Biol 2012; 47:120-7. [PMID: 22427537 DOI: 10.1165/rcmb.2011-0334oc] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Although obesity is implicated in numerous health complications leading to increased mortality, the relationship between obesity and outcomes for critically ill patients appears paradoxical. Recent studies have reported better outcomes and lower levels of inflammatory cytokines in obese patients with acute lung injury (ALI)/acute respiratory distress syndrome, suggesting that obesity may ameliorate the effects of this disease. We investigated the effects of obesity in leptin-resistant db/db obese and diet-induced obese mice using an inhaled LPS model of ALI. Obesity-associated effects on neutrophil chemoattractant response were examined in bone marrow neutrophils using chemotaxis and adoptive transfer; neutrophil surface levels of chemokine receptor CXCR2 were determined by flow cytometry. Airspace neutrophilia, capillary leak, and plasma IL-6 were all decreased in obese relative to lean mice in established lung injury (24 h). No difference in airspace inflammatory cytokine levels was found between obese and lean mice in both obesity models during the early phase of neutrophil recruitment (2-6 h), but early airspace neutrophilia was reduced in db/db obese mice. Neutrophils from uninjured obese mice demonstrated diminished chemotaxis to the chemokine keratinocyte cytokine compared with lean control mice, and adoptive transfer of obese mouse neutrophils into injured lean mice revealed a defect in airspace migration of these cells. Possibly contributing to this defect, neutrophil CXCR2 expression was significantly lower in obese db/db mice, and a similar but nonsignificant decrease was seen in diet-induced obese mice. ALI is attenuated in obese mice, and this blunted response is in part attributable to an obesity-associated abnormal neutrophil chemoattractant response.
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Affiliation(s)
- Lauren L Kordonowy
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT 05405, USA
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Acute lung injury: can the fibrocyte of today turn into the fibroguide of the future? Crit Care Med 2012; 40:300-1. [PMID: 22179347 DOI: 10.1097/ccm.0b013e318236e7c8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Alveolar fibrocyte percentage is an independent predictor of poor outcome in patients with acute lung injury. Crit Care Med 2012; 40:21-8. [PMID: 21926612 DOI: 10.1097/ccm.0b013e31822d718b] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Fibrocytes are mesenchymal progenitors involved in normal and pathologic repair. The aims of this study were: 1) to quantify fibrocytes in bronchoalveolar lavage fluid from patients with or without acute lung injury and acute respiratory distress syndrome; and 2) to evaluate the prognostic value of bronchoalveolar lavage fibrocyte percentage in patients with acute lung injury and acute respiratory distress syndrome. DESIGN Prospective cohort study. SETTING Three intensive care units of a large tertiary referral center. PATIENTS One hundred twenty-two ventilated patients requiring bronchoalveolar lavage were enrolled (62 acute respiratory distress syndrome, 30 acute lung injury, 30-ventilated patients without acute lung injury and acute respiratory distress syndrome). INTERVENTIONS After bronchoalveolar lavage collection during standard care, the patients were followed up for 28 days and clinical outcome was recorded. Fibrocytes (CD45+/collagen 1+) were quantified in bronchoalveolar lavage by flow cytometry. Comparison of bronchoalveolar lavage fibrocyte percentage from patients with or without acute lung injury and acute respiratory distress syndrome was performed using a Wilcoxon test. A multivariate analysis using a Cox model was performed to study the independent predictors of survival. MEASUREMENTS AND MAIN RESULTS Fibrocytes were detected in 90 of 92 (98%) bronchoalveolar lavages from patients with acute lung injury and acute respiratory distress syndrome. The median percentage of bronchoalveolar lavage fibrocytes was significantly higher in patients with acute lung injury and acute respiratory distress syndrome (5.0%) in comparison with ventilated control subjects (0.9%, p < .0001). After adjustment for age, comorbidity of malignancy, and severity of illness, a bronchoalveolar lavage fibrocyte percentage >6% was independently associated with a higher 28-day mortality in patients with acute lung injury and acute respiratory distress syndrome (hazard ratio [95% confidence interval] 6.15 [2.78-13.64], p ≤ .0001). Addition of bronchoalveolar lavage fibrocyte percentage in a clinical model predicting mortality in patients with acute lung injury and acute respiratory distress syndrome improved global fit and discriminatory capacity (c-statistic, 0.78-0.85; p = .007). CONCLUSIONS Fibrocytes are detectable in bronchoalveolar lavage during acute lung injury and acute respiratory distress syndrome. A bronchoalveolar lavage fibrocyte percentage >6% provides an additive prognostic value to clinical predictors and may be useful to identify patients with acute lung injury and acute respiratory distress syndrome at highest risk of an adverse outcome.
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A simple classification model for hospital mortality in patients with acute lung injury managed with lung protective ventilation. Crit Care Med 2012; 39:2645-51. [PMID: 21725235 DOI: 10.1097/ccm.0b013e3182266779] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Despite improvements in the care of critically ill patients, hospital mortality rate for acute lung injury remains high at approximately 40%. We developed a classification rule to stratify mechanically ventilated patients with acute lung injury according to hospital mortality and compared this rule with the Acute Physiology and Chronic Health Evaluation III prediction. PATIENTS We used data of 2,022 participants in Acute Respiratory Distress Syndrome Network trials to build a classification rule based on 54 variables collected before randomization. DESIGN We used a classification tree approach to stratify patients according to hospital mortality using a training subset of 1800 participants and estimated expected prediction errors using tenfold crossvalidation. We validated our classification tree using a subset of 222 participants not included in model building and calculated areas under the receiver operating characteristic curves. MEASUREMENTS AND MAIN RESULTS We identified combinations of age (>63 yrs), blood urea nitrogen (>15 mg/dL), shock, respiratory rate (>21 breaths/min), and minute ventilation (>13.9 L/min) as important predictors of hospital mortality at 90 days. The classification tree had a similar expected prediction error in the training set (28% vs. 26%; p = .18) and areas under the receiver operating characteristic curve in the validation set (0.71 vs. 0.73; p = .71) as did a model based on Acute Physiology and Chronic Health Evaluation III. CONCLUSIONS Our tree-based classification rule performed similarly to Acute Physiology and Chronic Health Evaluation III in stratifying patients according to hospital mortality, is simpler to use, contains risk factors that may be specific to acute lung injury, and identified minute ventilation as a potential novel predictor of death in patients with acute lung injury.
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Abstract
Acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) are distinctly modern clinical entities. Recent epidemiologic research has taken advantage of large cohorts in efforts to better describe these highly lethal syndromes with a focus on differentiation of clinically meaningful subtypes and early prediction in an effort to improve treatment and prevention. This article identifies the most significant studies and systematic reviews of recent years, defining the incidence, mortality, risk and prognostic factors, and etiologic classes of ARDS/ALI.
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Affiliation(s)
- Ross Blank
- Division of Critical Care, Department of Anesthesiology, University of Michigan Health System, 1500 East Medical Center Drive, SPC 5861, Ann Arbor, MI 48109-5861, USA.
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Abstract
A 41-year-old woman presents with severe community-acquired pneumococcal pneumonia. Chest radiography reveals diffuse bilateral infiltrates, and hypoxemic respiratory failure develops despite appropriate antibiotic therapy. She is intubated and mechanical ventilation is initiated with a volume- and pressure-limited approach for the acute respiratory distress syndrome (ARDS). Over the ensuing 24 hours, her partial pressure of arterial oxygen (Pao2) decreases to 40 mm Hg, despite ventilatory support with a fraction of inspired oxygen (Fio2) of 1.0 and a positive end-expiratory pressure (PEEP) of 20 cm of water. She is placed in the prone position and a neuromuscular blocking agent is administered, without improvement in her Pao2. An intensive care specialist recommends the initiation of extracorporeal membrane oxygenation (ECMO).
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Affiliation(s)
- Daniel Brodie
- Columbia University College of Physicians and Surgeons, and New York-Presbyterian Hospital, New York, NY 10032, USA.
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Stamm JA, McVerry BJ, Mathier MA, Donahoe MP, Saul MI, Gladwin MT. Doppler-defined pulmonary hypertension in medical intensive care unit patients: Retrospective investigation of risk factors and impact on mortality. Pulm Circ 2011; 1:95-102. [PMID: 22034595 PMCID: PMC3198625 DOI: 10.4103/2045-8932.78104] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Pulmonary hypertension (PH) is poorly characterized in the critically ill. No prior studies describe the burden of or outcomes associated with PH in a general medical intensive care unit population. We hypothesize that PH is an important comorbidity prevalent in the modern medical intensive care unit. We undertook a preliminary investigation to define the consequences of Doppler-defined PH in the critically ill. A single-center retrospective case–control study of medical intensive care patients admitted over a 1-year period was conducted. Eligible patients had an echocardiogram within 4 days of admission. PH was defined to include both pulmonary arterial and venous hypertension and required a tricuspid regurgitant jet velocity ≥3 m/sec. Cases and controls were compared for comorbidities, illness severity, diagnoses, and mortality. Multivariable regression was performed to identify clinical features associated with PH and mortality. 299 (21% of admissions) patients had an eligible echocardiogram. Patients with PH (N=126) had a higher unadjusted mortality than did controls (N=173) (37% vs. 25%, P=0.04) and PH remained significantly associated with mortality after controlling for other clinical factors (HR=1.59, 95% CI=1.03–2.44, P=0.036). Low ejection fraction (OR=2.21, 95% CI=1.19–4.11, P=0.012) and pulmonary embolism (OR=4.28, 95% CI=1.59–11.5, P=0.004) were independently associated with PH. Doppler-defined PH is associated with mortality in the critically ill. Prospective studies are needed to define the prevalence of pulmonary venous hypertension versus pulmonary arterial hypertension, and the clinical consequences of each, in a general medical intensive care unit population.
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Affiliation(s)
- Jason A Stamm
- Department of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Outcome prediction in pneumonia induced ALI/ARDS by clinical features and peptide patterns of BALF determined by mass spectrometry. PLoS One 2011; 6:e25544. [PMID: 21991318 PMCID: PMC3184998 DOI: 10.1371/journal.pone.0025544] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 09/05/2011] [Indexed: 01/11/2023] Open
Abstract
Background Peptide patterns of bronchoalveolar lavage fluid (BALF) were assumed to reflect the complex pathology of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) better than clinical and inflammatory parameters and may be superior for outcome prediction. Methodology/Principal Findings A training group of patients suffering from ALI/ARDS was compiled from equal numbers of survivors and nonsurvivors. Clinical history, ventilation parameters, Murray's lung injury severity score (Murray's LISS) and interleukins in BALF were gathered. In addition, samples of bronchoalveolar lavage fluid were analyzed by means of hydrophobic chromatography and MALDI-ToF mass spectrometry (MALDI-ToF MS). Receiver operating characteristic (ROC) analysis for each clinical and cytokine parameter revealed interleukin-6>interleukin-8>diabetes mellitus>Murray's LISS as the best outcome predictors. Outcome predicted on the basis of BALF levels of interleukin-6 resulted in 79.4% accuracy, 82.7% sensitivity and 76.1% specificity (area under the ROC curve, AUC, 0.853). Both clinical parameters and cytokines as well as peptide patterns determined by MALDI-ToF MS were analyzed by classification and regression tree (CART) analysis and support vector machine (SVM) algorithms. CART analysis including Murray's LISS, interleukin-6 and interleukin-8 in combination was correct in 78.0%. MALDI-ToF MS of BALF peptides did not reveal a single identifiable biomarker for ARDS. However, classification of patients was successfully achieved based on the entire peptide pattern analyzed using SVM. This method resulted in 90% accuracy, 93.3% sensitivity and 86.7% specificity following a 10-fold cross validation (AUC = 0.953). Subsequent validation of the optimized SVM algorithm with a test group of patients with unknown prognosis yielded 87.5% accuracy, 83.3% sensitivity and 90.0% specificity. Conclusions/Significance MALDI-ToF MS peptide patterns of BALF, evaluated by appropriate mathematical methods can be of value in predicting outcome in pneumonia induced ALI/ARDS.
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Seiberlich E, Santana JA, Chaves RDA, Seiberlich RC. Protective Mechanical Ventilation, Why Use It? Braz J Anesthesiol 2011; 61:659-67, 361-5. [DOI: 10.1016/s0034-7094(11)70076-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Accepted: 01/31/2011] [Indexed: 11/17/2022] Open
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