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Miller AG, Bartle RM, Feldman A, Mallory P, Reyes E, Scott B, Rotta AT. A narrative review of advanced ventilator modes in the pediatric intensive care unit. Transl Pediatr 2021; 10:2700-2719. [PMID: 34765495 PMCID: PMC8578787 DOI: 10.21037/tp-20-332] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/26/2020] [Indexed: 01/29/2023] Open
Abstract
Respiratory failure is a common reason for pediatric intensive care unit admission. The vast majority of children requiring mechanical ventilation can be supported with conventional mechanical ventilation (CMV) but certain cases with refractory hypoxemia or hypercapnia may require more advanced modes of ventilation. This paper discusses what we have learned about the use of advanced ventilator modes [e.g., high-frequency oscillatory ventilation (HFOV), high-frequency percussive ventilation (HFPV), high-frequency jet ventilation (HFJV) airway pressure release ventilation (APRV), and neurally adjusted ventilatory assist (NAVA)] from clinical, animal, and bench studies. The evidence supporting advanced ventilator modes is weak and consists of largely of single center case series, although a few RCTs have been performed. Animal and bench models illustrate the complexities of different modes and the challenges of applying these clinically. Some modes are proprietary to certain ventilators, are expensive, or may only be available at well-resourced centers. Future efforts should include large, multicenter observational, interventional, or adaptive design trials of different rescue modes (e.g., PROSpect trial), evaluate their use during ECMO, and should incorporate assessments through volumetric capnography, electric impedance tomography, and transpulmonary pressure measurements, along with precise reporting of ventilator parameters and physiologic variables.
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Affiliation(s)
- Andrew G Miller
- Duke University Medical Center, Durham, NC, USA.,Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Renee M Bartle
- Duke University Medical Center, Durham, NC, USA.,Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Alexandra Feldman
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Palen Mallory
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Edith Reyes
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Briana Scott
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Alexandre T Rotta
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
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Leiphrakpam PD, Weber HR, McCain A, Matas RR, Duarte EM, Buesing KL. A novel large animal model of smoke inhalation-induced acute respiratory distress syndrome. Respir Res 2021; 22:198. [PMID: 34233680 PMCID: PMC8261975 DOI: 10.1186/s12931-021-01788-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/28/2021] [Indexed: 12/31/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is multifactorial and can result from sepsis, trauma, or pneumonia, amongst other primary pathologies. It is one of the major causes of death in critically ill patients with a reported mortality rate up to 45%. The present study focuses on the development of a large animal model of smoke inhalation-induced ARDS in an effort to provide the scientific community with a reliable, reproducible large animal model of isolated toxic inhalation injury-induced ARDS. Methods Animals (n = 21) were exposed to smoke under general anesthesia for 1 to 2 h (median smoke exposure = 0.5 to 1 L of oak wood smoke) after the ultrasound-guided placement of carotid, pulmonary, and femoral artery catheters. Peripheral oxygen saturation (SpO2), vital signs, and ventilator parameters were monitored throughout the procedure. Chest x-ray, carotid, femoral and pulmonary artery blood samples were collected before, during, and after smoke exposure. Animals were euthanized and lung tissue collected for analysis 48 h after smoke inhalation. Results Animals developed ARDS 48 h after smoke inhalation as reflected by a decrease in SpO2 by approximately 31%, PaO2/FiO2 ratio by approximately 208 (50%), and development of bilateral, diffuse infiltrates on chest x-ray. Study animals also demonstrated a significant increase in IL-6 level, lung tissue injury score and wet/dry ratio, as well as changes in other arterial blood gas (ABG) parameters. Conclusions This study reports, for the first time, a novel large animal model of isolated smoke inhalation-induced ARDS without confounding variables such as cutaneous burn injury. Use of this unique model may be of benefit in studying the pathophysiology of inhalation injury or for development of novel therapeutics.
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Affiliation(s)
- Premila D Leiphrakpam
- Department of Surgery, College of Medicine, University of Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Hannah R Weber
- Department of Surgery, College of Medicine, University of Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Andrea McCain
- Department of Mechanical and Materials Engineering, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Roser Romaguera Matas
- Department of Mechanical and Materials Engineering, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Ernesto Martinez Duarte
- Department of Pathology and Microbiology, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Keely L Buesing
- Department of Surgery, College of Medicine, University of Nebraska Medical Center, Omaha, NE, 68198-3280, USA.
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Miller AC, Ferrada PA, Kadri SS, Nataraj-Bhandari K, Vahedian-Azimi A, Quraishi SA. High-Frequency Ventilation Modalities as Salvage Therapy for Smoke Inhalation-Associated Acute Lung Injury: A Systematic Review. J Intensive Care Med 2017. [PMID: 28651475 DOI: 10.1177/0885066617714770] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Smoke inhalation-associated acute lung injury (SI-ALI) is a major cause of morbidity and mortality in victims of fire tragedies. To date, there are no evidence-based guidelines on ventilation strategies in acute respiratory distress syndrome (ARDS) after smoke inhalation. We reviewed the existing literature for clinical studies of salvage mechanical ventilation (MV) strategies in patients with SI-ALI, focusing on mortality and pneumonia as outcomes. METHODS A systematic search was designed in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Risk of bias assessment was performed using the Newcastle-Ottawa Quality Assessment Scale (NOS; 0 to 9 stars), with a score ≥7 being the threshold for inclusion in the meta-analysis. A systematic search strategy was used to search 10 databases. Clinical studies were included in which patients: (1) experienced smoke inhalation, (2) treated with MV, and (3) described a concurrent or historical control group. RESULTS A total of 226 potentially relevant studies were identified, of which 7 studies on high-frequency percussive ventilation (HFPV) met inclusion criteria. No studies met inclusion for meta-analysis (NOS ≥ 7). In studies comparing HFPV to conventional mechanical ventilation (CMV), mortality and pneumonia incidence improved in 3 studies and remained unchanged in 3 others. No change in ventilator days or ICU length of stay was observed; however, oxygenation and work of breathing improved with HFPV. CONCLUSIONS Mechanical ventilation in patients with SI-ALI has not been well studied. High-frequency percussive ventilation may decrease in-hospital mortality and pneumonia incidence when compared to CMV. The absence of "good" quality evidence precluded meta-analysis. Based upon low-quality evidence, there was a very weak recommendation that HFPV use may be associated with lower mortality and pneumonia rates in patients with SI-ALI. Given SI-ALI's unique underlying pathophysiology, and its potential implications on therapy, randomized controlled studies are required to ensure that patients receive the safest and most effective care. TRIAL REGISTRATION The study was registered with PROSPERO International prospective register of systematic reviews (#47015).
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Affiliation(s)
- Andrew C Miller
- 1 Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA.,2 Department of Emergency Medicine, West Virginia University, Morgantown, WV, USA
| | - Paula A Ferrada
- 3 Division of Trauma and Critical Care, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Sameer S Kadri
- 1 Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | | | - Amir Vahedian-Azimi
- 4 Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Sadeq A Quraishi
- 5 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.,6 Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
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Herndon DN. Southern Surgical Association: A Tradition of Mentorship in Translational Research. J Am Coll Surg 2017; 224:381-395. [PMID: 28088599 DOI: 10.1016/j.jamcollsurg.2016.12.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 12/23/2016] [Indexed: 12/11/2022]
Affiliation(s)
- David N Herndon
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, Galveston, TX.
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Zhang C, Wang G, Wang J, Ji Z, Liu Z, Pi X, Chen C. Characterization and comparative analyses of muscle transcriptomes in Dorper and small-tailed Han sheep using RNA-Seq technique. PLoS One 2013; 8:e72686. [PMID: 24023632 PMCID: PMC3758325 DOI: 10.1371/journal.pone.0072686] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 07/17/2013] [Indexed: 02/02/2023] Open
Abstract
The sheep is an important domestic animal and model for many types of medically relevant research. An investigation of gene expression in ovine muscle would significantly advance our understanding of muscle growth. RNA-seq is a recently developed analytical approach for transcriptome profiling via high-throughput sequencing. Although RNA-seq has been recently applied to a wide variety of organisms, few RNA-seq studies have been conducted in livestock, particularly in sheep. In this study, two cDNA libraries were constructed from the biceps brachii of one Small-tailed Han sheep (SH) and one Dorper sheep (DP). The Illumina high-throughput sequencing technique and bioinformatics were used to determine transcript abundances and characteristics. For the SH and DP libraries, we obtained a total of 50,264,608 and 52,794,216 high quality reads, respectively. Approximately two-thirds of the reads could be mapped to the sheep genome. In addition, 40,481 and 38,851 potential coding single nucleotide polymorphisms (cSNPs) were observed, respectively, of which a total of 59,139 cSNP coordinates were different between the two samples. Up to 5,116 and 5,265 respective reference genes had undergone 13,827 and 15,684 alternative splicing events. A total of 6,989 reference genes were extended at the 5’, 3’ or both ends, and 123,678 novel transcript units were found. A total of 1,300 significantly differentially expressed genes were identified between the two libraries. These results suggest that there are many differences in the muscle transcriptomes between these two animals. This study addresses a preliminary analysis and offers a foundation for future genomic research in the sheep.
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Affiliation(s)
- Chunlan Zhang
- Shandong Provincial Key Laboratory of Animal Biotechnology and Disease Control and Prevention, College of Animal Science and Veterinary Medicine, Shandong Agricultural University, Taian, Shandong Province, China
| | - Guizhi Wang
- Shandong Provincial Key Laboratory of Animal Biotechnology and Disease Control and Prevention, College of Animal Science and Veterinary Medicine, Shandong Agricultural University, Taian, Shandong Province, China
| | - Jianmin Wang
- Shandong Provincial Key Laboratory of Animal Biotechnology and Disease Control and Prevention, College of Animal Science and Veterinary Medicine, Shandong Agricultural University, Taian, Shandong Province, China
- * E-mail:
| | - Zhibin Ji
- Shandong Provincial Key Laboratory of Animal Biotechnology and Disease Control and Prevention, College of Animal Science and Veterinary Medicine, Shandong Agricultural University, Taian, Shandong Province, China
| | - Zhaohuan Liu
- Shandong Provincial Key Laboratory of Animal Biotechnology and Disease Control and Prevention, College of Animal Science and Veterinary Medicine, Shandong Agricultural University, Taian, Shandong Province, China
| | - Xiushuang Pi
- Shandong Provincial Key Laboratory of Animal Biotechnology and Disease Control and Prevention, College of Animal Science and Veterinary Medicine, Shandong Agricultural University, Taian, Shandong Province, China
| | - Cunxian Chen
- Shandong Provincial Key Laboratory of Animal Biotechnology and Disease Control and Prevention, College of Animal Science and Veterinary Medicine, Shandong Agricultural University, Taian, Shandong Province, China
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Reducing time on for extra-corporeal membrane oxygenation for adults with H1N1 pneumonia with the use of the Volume Diffusive Respirator. Am J Surg 2013; 205:500-4. [DOI: 10.1016/j.amjsurg.2013.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 01/16/2013] [Accepted: 01/17/2013] [Indexed: 01/19/2023]
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Arazawa DT, Oh HI, Ye SH, Johnson CA, Woolley JR, Wagner WR, Federspiel WJ. Immobilized Carbonic Anhydrase on Hollow Fiber Membranes Accelerates CO(2) Removal from Blood. J Memb Sci 2012; 404-404:25-31. [PMID: 22962517 DOI: 10.1016/j.memsci.2012.02.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Current artificial lungs and respiratory assist devices designed for carbon dioxide removal (CO(2)R) are limited in their efficiency due to the relatively small partial pressure difference across gas exchange membranes. To offset this underlying diffusional challenge, bioactive hollow fiber membranes (HFMs) increase the carbon dioxide diffusional gradient through the immobilized enzyme carbonic anhydrase (CA), which converts bicarbonate to CO(2) directly at the HFM surface. In this study, we tested the impact of CA-immobilization on HFM CO(2) removal efficiency and thromboresistance in blood. Fiber surface modification with radio frequency glow discharge (RFGD) introduced hydroxyl groups, which were activated by 1M CNBr while 1.5M TEA was added drop wise over the activation time course, then incubation with a CA solution covalently linked the enzyme to the surface. The bioactive HFMs were then potted in a model gas exchange device (0.0084 m(2)) and tested in a recirculation loop with a CO(2) inlet of 50mmHg under steady blood flow. Using an esterase activity assay, CNBr chemistry with TEA resulted in 0.99U of enzyme activity, a 3.3 fold increase in immobilized CA activity compared to our previous method. These bioactive HFMs demonstrated 108 ml/min/m(2) CO(2) removal rate, marking a 36% increase compared to unmodified HFMs (p < 0.001). Thromboresistance of CA-modified HFMs was assessed in terms of adherent platelets on surfaces by using lactate dehydrogenase (LDH) assay as well as scanning electron microscopy (SEM) analysis. Results indicated HFMs with CA modification had 95% less platelet deposition compared to unmodified HFM (p < 0.01). Overall these findings revealed increased CO(2) removal can be realized through bioactive HFMs, enabling a next generation of more efficient CO(2) removal intravascular and paracorporeal respiratory assist devices.
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Affiliation(s)
- David T Arazawa
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, PA 15219 USA
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Large-animal models of acute respiratory distress syndrome. Ann Thorac Surg 2012; 93:1331-9. [PMID: 22244649 DOI: 10.1016/j.athoracsur.2011.06.107] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 06/16/2011] [Accepted: 06/21/2011] [Indexed: 11/23/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by an acute inflammatory response that compromises alveolar-capillary membrane integrity. Clinical symptoms include refractory hypoxemia, noncardiogenic edema, and decreased lung compliance. The purpose of this review is to summarize the different ARDS large-animal models in terms of similarity to the clinical disease and underlying pathophysiology. The repeated lavage, oleic acid, endotoxin, and smoke/burn ARDS models will be discussed in this review. While each model has significant benefits, none is without weaknesses. Thus, the choice of large-animal ARDS model must be carefully considered based upon the study focus and investigative team experience.
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Jäger M, Ott CE, Grünhagen J, Hecht J, Schell H, Mundlos S, Duda GN, Robinson PN, Lienau J. Composite transcriptome assembly of RNA-seq data in a sheep model for delayed bone healing. BMC Genomics 2011; 12:158. [PMID: 21435219 PMCID: PMC3074554 DOI: 10.1186/1471-2164-12-158] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 03/24/2011] [Indexed: 11/28/2022] Open
Abstract
Background The sheep is an important model organism for many types of medically relevant research, but molecular genetic experiments in the sheep have been limited by the lack of knowledge about ovine gene sequences. Results Prior to our study, mRNA sequences for only 1,556 partial or complete ovine genes were publicly available. Therefore, we developed a composite de novo transcriptome assembly method for next-generation sequence data to combine known ovine mRNA and EST sequences, mRNA sequences from mouse and cow, and sequences assembled de novo from short read RNA-Seq data into a composite reference transcriptome, and identified transcripts from over 12 thousand previously undescribed ovine genes. Gene expression analysis based on these data revealed substantially different expression profiles in standard versus delayed bone healing in an ovine tibial osteotomy model. Hundreds of transcripts were differentially expressed between standard and delayed healing and between the time points of the standard and delayed healing groups. We used the sheep sequences to design quantitative RT-PCR assays with which we validated the differential expression of 26 genes that had been identified by RNA-seq analysis. A number of clusters of characteristic expression profiles could be identified, some of which showed striking differences between the standard and delayed healing groups. Gene Ontology (GO) analysis showed that the differentially expressed genes were enriched in terms including extracellular matrix, cartilage development, contractile fiber, and chemokine activity. Conclusions Our results provide a first atlas of gene expression profiles and differentially expressed genes in standard and delayed bone healing in a large-animal model and provide a number of clues as to the shifts in gene expression that underlie delayed bone healing. In the course of our study, we identified transcripts of 13,987 ovine genes, including 12,431 genes for which no sequence information was previously available. This information will provide a basis for future molecular research involving the sheep as a model organism.
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Affiliation(s)
- Marten Jäger
- Institute for Medical Genetics, Charité-Universitätsmedizin Berlin, Augustenburgerplatz 1, 13353 Berlin, Germany
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Abstract
Mechanical ventilation and ventilator-associated lung injury could be avoided by decreasing the ventilatory needs of the patient by extracorporeal carbon dioxide removal. The reasons for the increased ventilatory needs of the patients with acute respiratory distress syndrome are outlined, as well as some of the mechanisms of continuing damage. Extracorporeal gas exchange has been used mainly as a rescue procedure for severely hypoxic patients. Although this indication remains valid, we propose that extracorporeal carbon dioxide removal could control the ventilatory needs of the patient and allow the maintenance of spontaneous breathing while avoiding intubation and decreasing the concurrent sedation needs. A scenario is depicted whereby an efficient carbon dioxide removal device can maintain blood gas homeostasis of the patient with invasiveness comparable to hemodialysis. High carbon dioxide removal efficiency may be achieved by combinations of hemofiltration and metabolizable acid loads.
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Lynch JE, Zwischenberger JB. Turning the dial to futility. Chest 2011; 139:230-1; author reply 231-2. [PMID: 21208891 DOI: 10.1378/chest.10-1994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Abstract
High-frequency percussive ventilation (HFPV) has demonstrated a potential role as a rescue option for refractory acute respiratory distress syndrome and as a method for improving inhalation injury outcomes. Nevertheless, there is a lack of literature examining the practical application of HFPV theory toward either improving gas exchange or preventing possible ventilator-induced lung injury. This article will discuss the clinically pertinent aspects of HFPV, inclusive of high- and low-frequency ventilation.
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Ballard-Croft C, Sumpter LR, Broaddus R, Alexander J, Wang D, Zwischenberger JB. Ovine smoke/burn ARDS model: a new ventilator-controlled smoke delivery system. J Surg Res 2010; 164:e155-62. [PMID: 20828741 DOI: 10.1016/j.jss.2010.05.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 05/06/2010] [Accepted: 05/17/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Our current ovine smoke/burn acute respiratory distress syndrome (ARDS) model utilizes a manual bee smoker. This smoke delivery system lacks standardization and reproducibility, with 20% of sheep failing to meet ARDS criteria. Time to reach ARDS criteria and survival time are also variable. The mild volutrauma (15 mL/kg) applied after smoke/burn injury may also fail to induce ARDS within 24 h. We hypothesized that these inconsistencies were associated with the bee smoker and the mild volutrauma. In the current study, we addressed these problems to improve the consistency of the smoke/burn ARDS model. METHODS Adult female sheep (n = 10) were given a 40% total body surface area third degree cutaneous burn and 48 breaths (4 × 12) of cotton smoke under general anesthesia. A modified ventilator was then used to deliver a precise and consistent smoke volume (tidal volume) to the sheep. Additional barotrauma was induced by pressure control ventilation (40 cm H(2)0). When ARDS criteria (PaO(2)/FiO(2) < 200) were met, the ARDS Network low tidal volume ventilation protocol (6-8 mL/kg ideal body weight) was used. RESULTS Carboxyhemoglobin levels were 81.4% ± 5.6% immediately following smoke injury. All sheep met ARDS criteria within 24 h (12.5 ± 4.9 h). Mean survival time post-injury was 62.1 ± 26.4 h. White blood cells and granulocytes were significantly elevated at 24 h post-smoke/burn injury. Lung tissue at necropsy was consistent with ARDS. CONCLUSIONS The refinements made to the original ovine smoke/burn ARDS model produce a more reliable time to ARDS onset, injury severity, and time of death.
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Ricci Z, Cruz DN, Ronco C. Intensive care. Nephrol Dial Transplant 2010; 25:678-83. [PMID: 20185413 DOI: 10.1093/ndt/gfq005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Zaccaria Ricci
- Department of Pediatric Cardiosurgery, Bambino Gesù Hospital, Rome, Italy.
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Abstract
This review article describes the pathophysiological aspects of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), induced by combined burn and smoke inhalation and examines various therapeutic approaches. The injury results in a fall in arterial oxygenation as a result of airway obstruction, increased pulmonary transvascular fluid flux and loss of hypoxic pulmonary vasoconstriction. The changes in cardiopulmonary function are mediated by reactive oxygen and nitrogen species. Nitric oxide (NO) is generated by both inducible and constitutive isoforms of nitric oxide synthase (NOS). Recently, neuronal NOS emerged as a major component within the pathogenesis of ARDS. NO rapidly combines with the oxygen radical superoxide to form reactive and highly toxic nitrogen species such as peroxynitrite. The control of NO formation involves poly(ADP-ribose) polymerase and its ability to up-regulate the activity of nuclear transcription factors through ribosylation. In addition, present data support a major role of the bronchial circulation in the injury, as blockage of bronchial blood flow will also minimize the pulmonary injury. Current data suggest that cytotoxins and activated cells are formed in the airway and carried to the parenchyma.
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Rehberg S, Maybauer MO, Enkhbaatar P, Maybauer DM, Yamamoto Y, Traber DL. Pathophysiology, management and treatment of smoke inhalation injury. Expert Rev Respir Med 2009; 3:283-297. [PMID: 20161170 PMCID: PMC2722076 DOI: 10.1586/ers.09.21] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Smoke inhalation injury continues to increase morbidity and mortality in burn patients in both the third world and industrialized countries. The lack of uniform criteria for the diagnosis and definition of smoke inhalation injury contributes to the fact that, despite extensive research, mortality rates have changed little in recent decades. The formation of reactive oxygen and nitrogen species, as well as the procoagulant and antifibrinolytic imbalance of alveolar homeostasis, all play a central role in the pathogenesis of smoke inhalation injury. Further hallmarks include massive airway obstruction owing to cast formation, bronchospasm, the increase in bronchial circulation and transvascular fluid flux. Therefore, anticoagulants, antioxidants and bronchodilators, especially when administered as an aerosol, represent the most promising treatment strategies. The purpose of this review article is to provide an overview of the pathophysiological changes, management and treatment options of smoke inhalation injury based on the current literature.
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Affiliation(s)
- Sebastian Rehberg
- Department of Anesthesiology, The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA, Tel.: +1 409 772 6405, ,
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