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Muenster S, Zarragoikoetxea I, Moscatelli A, Balcells J, Gaudard P, Pouard P, Marczin N, Janssens SP. Inhaled NO at a crossroads in cardiac surgery: current need to improve mechanistic understanding, clinical trial design and scientific evidence. Front Cardiovasc Med 2024; 11:1374635. [PMID: 38646153 PMCID: PMC11027901 DOI: 10.3389/fcvm.2024.1374635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/27/2024] [Indexed: 04/23/2024] Open
Abstract
Inhaled nitric oxide (NO) has been used in pediatric and adult perioperative cardiac intensive care for over three decades. NO is a cellular signaling molecule that induces smooth muscle relaxation in the mammalian vasculature. Inhaled NO has the unique ability to exert its vasodilatory effects in the pulmonary vasculature without any hypotensive side-effects in the systemic circulation. In patients undergoing cardiac surgery, NO has been reported in numerous studies to exert beneficial effects on acutely lowering pulmonary artery pressure and reversing right ventricular dysfunction and/or failure. Yet, various investigations failed to demonstrate significant differences in long-term clinical outcomes. The authors, serving as an advisory board of international experts in the field of inhaled NO within pediatric and adult cardiac surgery, will discuss how the existing scientific evidence can be further improved. We will summarize the basic mechanisms underlying the clinical applications of inhaled NO and how this translates into the mandate for inhaled NO in cardiac surgery. We will move on to the popular use of inhaled NO and will talk about the evidence base of the use of this selective pulmonary vasodilator. This review will elucidate what kind of clinical and biological barriers and gaps in knowledge need to be solved and how this has impacted in the development of clinical trials. The authors will elaborate on how the optimization of inhaled NO therapy, the development of biomarkers to identify the target population and the definition of response can improve the design of future large clinical trials. We will explain why it is mandatory to gain an international consensus for the state of the art of NO therapy far beyond this expert advisory board by including the different major players in the field, such as the different medical societies and the pharma industry to improve our understanding of the real-life effects of inhaled NO in large scale observational studies. The design for future innovative randomized controlled trials on inhaled NO therapy in cardiac surgery, adequately powered and based on enhanced biological phenotyping, will be crucial to eventually provide scientific evidence of its clinical efficacy beyond its beneficial hemodynamic properties.
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Affiliation(s)
- Stefan Muenster
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Iratxe Zarragoikoetxea
- Department of Anesthesiology and Intensive Care Medicine, Hospital Universitari I Politècnic Fe, Valencia, Spain
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Joan Balcells
- Pediatric Intensive Care Unit, Vall d’Hebron Barcelona Campus Hospitalari, Universitari Vall d'Hebron, Barcelona, Spain
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine Arnaud de Villeneuve, CHU Montpellier, University of Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Philippe Pouard
- Department of Anesthesiology and Critical Care, Assistance Publique-Hopitaux de Paris, Hopital Necker-Enfants Malades, Paris, France
| | - Nandor Marczin
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Stefan P. Janssens
- Cardiac Intensive Care, Department of Cardiovascular Diseases, University Hospital Leuven, Leuven, Belgium
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2
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Trieu M, Qadir N. Adjunctive Therapies in Acute Respiratory Distress Syndrome. Crit Care Clin 2024; 40:329-351. [PMID: 38432699 DOI: 10.1016/j.ccc.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Despite significant advances in understanding acute respiratory distress syndrome (ARDS), mortality rates remain high. The appropriate use of adjunctive therapies can improve outcomes, particularly for patients with moderate to severe hypoxia. In this review, the authors discuss the evidence basis behind prone positioning, recruitment maneuvers, neuromuscular blocking agents, corticosteroids, pulmonary vasodilators, and extracorporeal membrane oxygenation and considerations for their use in individual patients and specific clinical scenarios. Because the heterogeneity of ARDS poses challenges in finding universally effective treatments, an individualized approach and continued research efforts are crucial for optimizing the utilization of adjunctive therapies and improving patient outcomes.
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Affiliation(s)
- Megan Trieu
- Division of Pulmonary Critical Care Sleep Medicine and Physiology, Department of Medicine, University of California San Diego, 9300 Campus Point Drive, #7381, La Jolla, CA 92037-1300, USA
| | - Nida Qadir
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Avenue, Room 43-229 CHS, Los Angeles, CA 90095, USA.
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3
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Velamuri SR, Ali Y, Lanfranco J, Gupta P, Hill DM. Inhalation Injury, Respiratory Failure, and Ventilator Support in Acute Burn Care. Clin Plast Surg 2024; 51:221-232. [PMID: 38429045 DOI: 10.1016/j.cps.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Sustaining an inhalation injury increases the risk of severe complications and mortality. Current evidential support to guide treatment of the injury or subsequent complications is lacking, as studies either exclude inhalation injury or design limit inferences that can be made. Conventional ventilator modes are most commonly used, but there is no consensus on optimal strategies. Settings should be customized to patient tolerance and response. Data for pharmacotherapy adjunctive treatments are limited.
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Affiliation(s)
- Sai R Velamuri
- Department of Surgery, College of Medicine, University of Tennessee, Health Science Center, Memphis, TN 38103, USA.
| | - Yasmin Ali
- Department of Surgery, College of Medicine, University of Tennessee Health Science Center, 910 Madison Avenue, 2nd floor Suite 217, Memphis, TN 38103, USA
| | - Julio Lanfranco
- Division of Pulmonary and Critical Care, University of Tennessee Health Science Center, 965 Court Avenue Room H316B, Memphis, TN 38103, USA
| | - Pooja Gupta
- Pulmonary and Critical Care, University of Tennessee Health Science Center, 965 court avenue, Room H316B, Memphis, TN 38103, USA
| | - David M Hill
- Department of Pharmacy, Regional One Health, University of Tennessee, 80 madison avenue, Memphis TN 38103, USA
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4
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Eleuteri D, Montini L, Antonelli M, Grieco DL. High-Dose Inhaled Nitric Oxide in Acute Hypoxemic Respiratory Failure: Need for Patient Phenotyping? Am J Respir Crit Care Med 2024; 209:459-460. [PMID: 38128106 PMCID: PMC10878385 DOI: 10.1164/rccm.202310-1909le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/20/2023] [Indexed: 12/23/2023] Open
Affiliation(s)
- Davide Eleuteri
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy; and
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Montini
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy; and
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy; and
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico L. Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy; and
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
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5
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Ferraz JFFM, Siuba MT, Krishnan S, Chatburn RL, Mireles-Cabodevila E, Duggal A. Physiologic Markers of Disease Severity in ARDS. Respir Care 2023; 68:1708-1718. [PMID: 37438051 PMCID: PMC10676265 DOI: 10.4187/respcare.11100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/06/2023] [Indexed: 07/14/2023]
Abstract
Despite its significant limitations, the PaO2 /FIO2 remains the standard tool to classify disease severity in ARDS. Treatment decisions and research enrollment have depended on this parameter for over 50 years. In addition, several variables have been studied over the past few decades, incorporating other physiologic considerations such as ventilation efficiency, lung mechanics, and right-ventricular performance. This review describes the strengths and limitations of all relevant parameters, with the goal of helping us better understand disease severity and possible future treatment targets.
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Affiliation(s)
- Joao F F M Ferraz
- Department of Hospital Medicine, Community Care Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Sudhir Krishnan
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Robert L Chatburn
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Eduardo Mireles-Cabodevila
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio.
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6
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Zhao Y, Li C, Zhang S, Cheng J, Liu Y, Han X, Wang Y, Wang Y. Inhaled nitric oxide: can it serve as a savior for COVID-19 and related respiratory and cardiovascular diseases? Front Microbiol 2023; 14:1277552. [PMID: 37849924 PMCID: PMC10577426 DOI: 10.3389/fmicb.2023.1277552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/18/2023] [Indexed: 10/19/2023] Open
Abstract
Nitric oxide (NO), as an important gaseous medium, plays a pivotal role in the human body, such as maintaining vascular homeostasis, regulating immune-inflammatory responses, inhibiting platelet aggregation, and inhibiting leukocyte adhesion. In recent years, the rapid prevalence of coronavirus disease 2019 (COVID-19) has greatly affected the daily lives and physical and mental health of people all over the world, and the therapeutic efficacy and resuscitation strategies for critically ill patients need to be further improved and perfected. Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator, and some studies have demonstrated its potential therapeutic use for COVID-19, severe respiratory distress syndrome, pulmonary infections, and pulmonary hypertension. In this article, we describe the biochemistry and basic characteristics of NO and discuss whether iNO can act as a "savior" for COVID-19 and related respiratory and cardiovascular disorders to exert a potent clinical protective effect.
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Affiliation(s)
- Yifan Zhao
- Department of Cardiovascular Center, The First Hospital of Jilin University, Changchun, China
| | - Cheng Li
- Department of Cardiovascular Center, The First Hospital of Jilin University, Changchun, China
| | - Shuai Zhang
- Department of Cardiovascular Center, The First Hospital of Jilin University, Changchun, China
| | - Jiayu Cheng
- Department of Cardiovascular Center, The First Hospital of Jilin University, Changchun, China
| | - Yucheng Liu
- Department of Family and Community Medicine, Feinberg School of Medicine, McGaw Medical Center of Northwestern University, Chicago, IL, United States
| | - Xiaorong Han
- Department of Special Care Center, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yinghui Wang
- Department of Cardiovascular Center, The First Hospital of Jilin University, Changchun, China
| | - Yonggang Wang
- Department of Cardiovascular Center, The First Hospital of Jilin University, Changchun, China
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Zerikiotis S, Efentakis P, Dapola D, Agapaki A, Seiradakis G, Kostomitsopoulos N, Skaltsounis AL, Tseti I, Triposkiadis F, Andreadou I. Synergistic Pulmonoprotective Effect of Natural Prolyl Oligopeptidase Inhibitors in In Vitro and In Vivo Models of Acute Respiratory Distress Syndrome. Int J Mol Sci 2023; 24:14235. [PMID: 37762537 PMCID: PMC10531912 DOI: 10.3390/ijms241814235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a highly morbid inflammatory lung disease with limited pharmacological interventions. The present study aims to evaluate and compare the potential pulmonoprotective effects of natural prolyl oligopeptidase (POP) inhibitors namely rosmarinic acid (RA), chicoric acid (CA), epigallocatechin-3-gallate (EGCG) and gallic acid (GA), against lipopolysaccharide (LPS)-induced ARDS. Cell viability and expression of pro-inflammatory mediators were measured in RAW264.7 cells and in primary murine lung epithelial and bone marrow cells. Nitric oxide (NO) production was also assessed in unstimulated and LPS-stimulated RAW264.7 cells. For subsequent in vivo experiments, the two natural products (NPs) with the most favorable effects, RA and GA, were selected. Protein, cell content and lipid peroxidation levels in bronchoalveolar lavage fluid (BALF), as well as histopathological changes and respiratory parameters were evaluated in LPS-challenged mice. Expression of key mediators involved in ARDS pathophysiology was detected by Western blotting. RA and GA favorably reduced gene expression of pro-inflammatory mediators in vitro, while GA decreased NO production in macrophages. In LPS-challenged mice, RA and GA co-administration improved respiratory parameters, reduced cell and protein content and malondialdehyde (MDA) levels in BALF, decreased vascular cell adhesion molecule-1 (VCAM-1) and the inducible nitric oxide synthase (iNOS) protein expression, activated anti-apoptotic mechanisms and down-regulated POP in the lung. Conclusively, these synergistic pulmonoprotective effects of RA and GA co-administration could render them a promising prophylactic/therapeutic pharmacological intervention against ARDS.
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Affiliation(s)
- Stelios Zerikiotis
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, 157 71 Athens, Greece; (S.Z.); (P.E.); (D.D.); (G.S.)
| | - Panagiotis Efentakis
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, 157 71 Athens, Greece; (S.Z.); (P.E.); (D.D.); (G.S.)
| | - Danai Dapola
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, 157 71 Athens, Greece; (S.Z.); (P.E.); (D.D.); (G.S.)
| | - Anna Agapaki
- Histochemistry Facility, Biomedical Research Foundation of the Academy of Athens, 115 27 Athens, Greece;
| | - Georgios Seiradakis
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, 157 71 Athens, Greece; (S.Z.); (P.E.); (D.D.); (G.S.)
| | - Nikolaos Kostomitsopoulos
- Laboratory Animal Facility, Centre of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, 115 27 Athens, Greece;
| | - Alexios-Leandros Skaltsounis
- Section of Pharmacognosy and Natural Product Chemistry Faculty of Pharmacy, National and Kapodistrian University of Athens, 157 71 Athens, Greece;
| | | | - Filippos Triposkiadis
- Department of Cardiology, University General Hospital of Larissa, 413 34 Larissa, Greece;
- Faculty of Health Sciences, University of Thessaly, 413 34 Larissa, Greece
| | - Ioanna Andreadou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, 157 71 Athens, Greece; (S.Z.); (P.E.); (D.D.); (G.S.)
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8
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Newman G, Leclerc A, Arditi W, Calzuola ST, Feaugas T, Roy E, Perrault CM, Porrini C, Bechelany M. Challenge of material haemocompatibility for microfluidic blood-contacting applications. Front Bioeng Biotechnol 2023; 11:1249753. [PMID: 37662438 PMCID: PMC10469978 DOI: 10.3389/fbioe.2023.1249753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023] Open
Abstract
Biological applications of microfluidics technology is beginning to expand beyond the original focus of diagnostics, analytics and organ-on-chip devices. There is a growing interest in the development of microfluidic devices for therapeutic treatments, such as extra-corporeal haemodialysis and oxygenation. However, the great potential in this area comes with great challenges. Haemocompatibility of materials has long been a concern for blood-contacting medical devices, and microfluidic devices are no exception. The small channel size, high surface area to volume ratio and dynamic conditions integral to microchannels contribute to the blood-material interactions. This review will begin by describing features of microfluidic technology with a focus on blood-contacting applications. Material haemocompatibility will be discussed in the context of interactions with blood components, from the initial absorption of plasma proteins to the activation of cells and factors, and the contribution of these interactions to the coagulation cascade and thrombogenesis. Reference will be made to the testing requirements for medical devices in contact with blood, set out by International Standards in ISO 10993-4. Finally, we will review the techniques for improving microfluidic channel haemocompatibility through material surface modifications-including bioactive and biopassive coatings-and future directions.
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Affiliation(s)
- Gwenyth Newman
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Milan, Italy
- Eden Tech, Paris, France
| | - Audrey Leclerc
- Institut Européen des Membranes, IEM, UMR 5635, Univ Montpellier, ENSCM, Centre National de la Recherche Scientifique (CNRS), Place Eugène Bataillon, Montpellier, France
- École Nationale Supérieure des Ingénieurs en Arts Chimiques et Technologiques, Université de Toulouse, Toulouse, France
| | - William Arditi
- Eden Tech, Paris, France
- Centrale Supélec, Gif-sur-Yvette, France
| | - Silvia Tea Calzuola
- Eden Tech, Paris, France
- UMR7648—LadHyx, Ecole Polytechnique, Palaiseau, France
| | - Thomas Feaugas
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Milan, Italy
- Eden Tech, Paris, France
| | | | | | | | - Mikhael Bechelany
- Institut Européen des Membranes, IEM, UMR 5635, Univ Montpellier, ENSCM, Centre National de la Recherche Scientifique (CNRS), Place Eugène Bataillon, Montpellier, France
- Gulf University for Science and Technology (GUST), Mubarak Al-Abdullah, Kuwait
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9
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Zhou Y, Feng J, Mei S, Tang R, Xing S, Qin S, Zhang Z, Xu Q, Gao Y, He Z. A deep learning model for predicting COVID-19 ARDS in critically ill patients. Front Med (Lausanne) 2023; 10:1221711. [PMID: 37564041 PMCID: PMC10411521 DOI: 10.3389/fmed.2023.1221711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/06/2023] [Indexed: 08/12/2023] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) is an acute infectious pneumonia caused by a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection previously unknown to humans. However, predictive studies of acute respiratory distress syndrome (ARDS) in patients with COVID-19 are limited. In this study, we attempted to establish predictive models to predict ARDS caused by COVID-19 via a thorough analysis of patients' clinical data and CT images. Method The data of included patients were retrospectively collected from the intensive care unit in our hospital from April 2022 to June 2022. The primary outcome was the development of ARDS after ICU admission. We first established two individual predictive models based on extreme gradient boosting (XGBoost) and convolutional neural network (CNN), respectively; then, an integrated model was developed by combining the two individual models. The performance of all the predictive models was evaluated using the area under receiver operating characteristic curve (AUC), confusion matrix, and calibration plot. Results A total of 103 critically ill COVID-19 patients were included in this research, of which 23 patients (22.3%) developed ARDS after admission; five predictive variables were selected and further used to establish the machine learning models, and the XGBoost model yielded the most accurate predictions with the highest AUC (0.94, 95% CI: 0.91-0.96). The AUC of the CT-based convolutional neural network predictive model and the integrated model was 0.96 (95% CI: 0.93-0.98) and 0.97 (95% CI: 0.95-0.99), respectively. Conclusion An integrated deep learning model could be used to predict COVID-19 ARDS in critically ill patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Yuan Gao
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zhengyu He
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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10
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Cui A, Li S, Li Y, Yang D, Huang J, Wang X, Song N, Chen F, Chen S, Xiang M. Nitric oxide-mediated the therapeutic properties of induced pluripotent stem cell for paraquat-induced acute lung injury. Front Immunol 2023; 14:1136290. [PMID: 37275899 PMCID: PMC10232993 DOI: 10.3389/fimmu.2023.1136290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/09/2023] [Indexed: 06/07/2023] Open
Abstract
The mortality rate associated with acute lung injury (ALI) and its severe form, acute respiratory distress syndrome, is high. Induced pluripotent stem cell (iPSC) therapy is a potential treatment method for ALI, but its therapeutic efficacy is limited in injured lungs. Nitric oxide (NO) has various physiological actions. The current study investigated the effect of iPSCs pretreated with NO donors in paraquat (PQ)-induced ALI mouse model. Male C57BL/6 mice were intraperitoneally injected with PQ, followed by infusion of phosphate-buffered saline, iPSCs, L-arginine pretreated iPSCs, or Nitro-L-arginine methylester (L-NAME) pretreated iPSCs through the tail veins. Histopathological changes, pulmonary microvascular permeability, and inflammatory cytokine levels were analyzed after 3 or 28 d. The effects on iPSC proliferation, migration, and adhesion were evaluated in vitro. More L-arginine-pretreated iPSCs were selectively trafficked into the injured pulmonary tissue of mice with LPS-induced ALI, drastically diminishing the histopathologic changes and inflammatory cytokine levels (IL-1β and IL-6). There was also markedly improved pulmonary microvascular permeability and pulmonary function. The NO inhibitor abolished the protective effects of iPSCs. In addition, the ability of L-arginine to promote the proliferation and migration of iPSCs was decreased by L-NAME pretreatment, suggesting that NO might mediate the therapeutic benefits of iPSC. The improvement of the iPSC physiological changes by the endogenous gaseous molecule NO reduces lung injury severity. L-Arginine represents a pharmacologically important strategy for enhancing the therapeutic potential of iPSCs.
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Affiliation(s)
- Anfeng Cui
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, China
- Department of Pathology, The Second Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Shirui Li
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Yijun Li
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Dawei Yang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital Fudan University, Shanghai, China
| | - Jiongwei Huang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, China
- Health Management Center Department, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xuemeng Wang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Nana Song
- Fudan Zhang Jiang Institute, Shanghai, China
| | - Fuchen Chen
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Sifeng Chen
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Meng Xiang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, China
- Fudan Zhang Jiang Institute, Shanghai, China
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11
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Ramji HF, Hafiz M, Altaq HH, Hussain ST, Chaudry F. Acute Respiratory Distress Syndrome; A Review of Recent Updates and a Glance into the Future. Diagnostics (Basel) 2023; 13:diagnostics13091528. [PMID: 37174920 PMCID: PMC10177247 DOI: 10.3390/diagnostics13091528] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 05/15/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a rapidly progressive form of respiratory failure that accounts for 10% of admissions to the ICU and is associated with approximately 40% mortality in severe cases. Despite significant mortality and healthcare burden, the mainstay of management remains supportive care. The recent pandemic of SARS-CoV-2 has re-ignited a worldwide interest in exploring the pathophysiology of ARDS, looking for innovative ideas to treat this disease. Recently, many trials have been published utilizing different pharmacotherapy targets; however, the long-term benefits of these agents remain unknown. Metabolomics profiling and stem cell transplantation offer strong enthusiasm and may completely change the outlook of ARDS management in the near future.
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Affiliation(s)
- Husayn F Ramji
- University of Oklahoma College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Maida Hafiz
- Department of Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Hiba Hammad Altaq
- Department of Pulmonary, Critical Care & Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Syed Talal Hussain
- Department of Pulmonary, Critical Care & Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Fawad Chaudry
- Department of Pulmonary, Critical Care & Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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12
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Multisystemic involvement of post-traumatic fat embolism at a Pediatric Trauma Center: a clinical series and literature review. Eur J Pediatr 2023; 182:1811-1821. [PMID: 36790485 DOI: 10.1007/s00431-023-04869-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
UNLABELLED Post-traumatic fat embolism syndrome (FES) is a severe complication consequent to bone fractures. The authors describe its clinical features and management in a population of teenagers by detailing demographics, organ involvement, laboratory, and imaging findings, as well as outcome. Moreover, a systematic review of pediatric published case reports of post-traumatic FES is provided. First, a series of eight episodes of post-traumatic FES that occurred in seven patients (median age 16.0 years, IQR 16.0-17.5) admitted to a pediatric intensive care unit (PICU) in an 8-year period was analyzed through a retrospective chart review. Secondly, a systematic research was performed on PUBMED database. Trauma patients ≤ 18 years without comorbidities in a 20-year period (2002-2022) were included in the review. Neurological impairment was present in five out of seven patients, and a patent foramen ovale was found in four cases. Hemodynamic instability requiring vasoactive drugs was recorded in four patients. A severe form of acute respiratory distress syndrome (ARDS) occurred in five cases, with the evidence of hemorrhagic alveolitis in three of them. In the literature review, eighteen cases were examined. Most cases refer to adolescents (median age 17.0 years). More than half of patients experienced two or more long bone fractures (median: 2 fractures). Both respiratory and neurological impairment were common (77.8% and 83.3%, respectively). 88.9% of patients underwent invasive mechanical ventilation and 33.3% of them required vasoactive drugs support. Neurological sequelae were reported in 22.2% of patients. CONCLUSION Post-traumatic FES is an uncommon multi-faceted condition even in pediatric trauma patients, requiring a high level of suspicion. Prognosis of patients who receive prompt support in an intensive care setting is generally favorable. WHAT IS KNOWN •Post-traumatic fat embolism syndrome is a severe condition complicating long bone or pelvic fractures. •Little is known about clinical features and management in pediatric age. WHAT IS NEW •Post-traumatic fat embolism syndrome can cause multiple organ failure, often requiring an intensive care management. •Prompt supportive care contributes to a favorable prognosis.
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Abstract
Aerosolized prostacyclins are frequently used in patients with severe acute respiratory distress syndrome and refractory hypoxia. Previous studies have shown improvement in oxygenation with use of pulmonary vasodilators such as iloprost and epoprostenol; however, there is no head-to-head comparison between these agents. OBJECTIVES To compare the effects of inhaled epoprostenol and inhaled iloprost in critically ill patients with refractory hypoxia. DESIGN SETTING AND PARTICIPANTS We performed a retrospective cohort analysis of patients admitted to the ICUs at the University of Oklahoma Health Sciences Center between 2015 and 2018. Adult patients who received aerosolized epoprostenol or iloprost for more than 4 hours were included in the analysis. MAIN OUTCOMES AND MEASURES The primary endpoint measured was to compare the change in Pao2/Fio2 ratio between patients treated with iloprost compared with epoprostenol. Secondary outcomes measured were 90-day in-hospital mortality and improvement in vasopressor requirements. RESULTS A total of 126 patients were included in the study, 95 of whom received iloprost (75%) and 31 patients (25%) received epoprostenol. There were significant improvements in Pao2/Fio2 ratio in both the iloprost and epoprostenol group. Patients in the epoprostenol group appeared to have a higher 90-day mortality compared with the iloprost group. However, our study was not powered to detect a mortality difference and this finding likely represents a sicker population in the epoprostenol group and prescription bias. The use of iloprost was associated with higher vasopressor requirements in the first 12 hours of administration, an association was not observed in the epoprostenol group. CONCLUSIONS AND RELEVANCE In this retrospective cohort analysis, use of both pulmonary vasodilators was associated with similar improvement in gas exchange. The mortality difference observed likely represents difference in severity of illness. Further studies are needed to corroborate these findings.
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14
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Zhu W, Zhang Y, Wang Y. Immunotherapy strategies and prospects for acute lung injury: Focus on immune cells and cytokines. Front Pharmacol 2022; 13:1103309. [PMID: 36618910 PMCID: PMC9815466 DOI: 10.3389/fphar.2022.1103309] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) is a disastrous condition, which can be caused by a wide range of diseases, such as pneumonia, sepsis, traumas, and the most recent, COVID-19. Even though we have gained an improved understanding of acute lung injury/acute respiratory distress syndrome pathogenesis and treatment mechanism, there is still no effective treatment for acute lung injury/acute respiratory distress syndrome, which is partly responsible for the unacceptable mortality rate. In the pathogenesis of acute lung injury, the inflammatory storm is the main pathological feature. More and more evidences show that immune cells and cytokines secreted by immune cells play an irreplaceable role in the pathogenesis of acute lung injury. Therefore, here we mainly reviewed the role of various immune cells in acute lung injury from the perspective of immunotherapy, and elaborated the crosstalk of immune cells and cytokines, aiming to provide novel ideas and targets for the treatment of acute lung injury.
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Affiliation(s)
- Wenfang Zhu
- Department of Respiratory Medicine, Anhui Chest Hospital, Hefei, China
| | - Yiwen Zhang
- Department of Respiratory Medicine, Anhui Chest Hospital, Hefei, China,*Correspondence: Yiwen Zhang, ; Yinghong Wang,
| | - Yinghong Wang
- Department of Pharmacy, Anhui Provincial Cancer Hospital, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China,*Correspondence: Yiwen Zhang, ; Yinghong Wang,
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15
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Implications of microvascular dysfunction and nitric oxide mediated inflammation in severe COVID-19 infection. Am J Med Sci 2022; 364:251-256. [PMID: 35469768 PMCID: PMC9027037 DOI: 10.1016/j.amjms.2022.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/01/2022] [Accepted: 04/14/2022] [Indexed: 12/12/2022]
Abstract
Infection with COVID-19 has resulted in over 276,000 deaths in the United States and over 1.5 million deaths globally, with upwards of 15% of patients requiring hospitalization. Severe COVID-19 infection is, in essence, a microvascular disease. This contention has been emphasized throughout the course of the pandemic, particularly due to the clinical manifestation of severe infection. In fact, it has been hypothesized and shown in particular instances that microvascular function is a significant prognosticator for morbidity and mortality. Initially thought to be isolated to the pulmonary system and resulting in ARDS, patients with COVID-19 have been observed to have acute cardiac, renal, and thrombolytic complications. Therefore, severe COVID-19 is a vascular disease that has systemic implications. The objective of this review is to provide a mechanistic background for the microvascular nature of severe COVID-19 infection, with a particular emphasis on dysfunction of the endothelial glycocalyx and nitric oxide mediated pathogenesis.
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Redaelli S, Magliocca A, Malhotra R, Ristagno G, Citerio G, Bellani G, Berra L, Rezoagli E. Nitric oxide: Clinical applications in critically ill patients. Nitric Oxide 2022; 121:20-33. [PMID: 35123061 PMCID: PMC10189363 DOI: 10.1016/j.niox.2022.01.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 12/19/2022]
Abstract
Inhaled nitric oxide (iNO) acts as a selective pulmonary vasodilator and it is currently approved by the FDA for the treatment of persistent pulmonary hypertension of the newborn. iNO has been demonstrated to effectively decrease pulmonary artery pressure and improve oxygenation, while decreasing extracorporeal life support use in hypoxic newborns affected by persistent pulmonary hypertension. Also, iNO seems a safe treatment with limited side effects. Despite the promising beneficial effects of NO in the preclinical literature, there is still a lack of high quality evidence for the use of iNO in clinical settings. A variety of clinical applications have been suggested in and out of the critical care environment, aiming to use iNO in respiratory failure and pulmonary hypertension of adults or as a preventative measure of hemolysis-induced vasoconstriction, ischemia/reperfusion injury and as a potential treatment of renal failure associated with cardiopulmonary bypass. In this narrative review we aim to present a comprehensive summary of the potential use of iNO in several clinical conditions with its suggested benefits, including its recent application in the scenario of the COVID-19 pandemic. Randomized controlled trials, meta-analyses, guidelines, observational studies and case-series were reported and the main findings summarized. Furthermore, we will describe the toxicity profile of NO and discuss an innovative proposed strategy to produce iNO. Overall, iNO exhibits a wide range of potential clinical benefits, that certainly warrants further efforts with randomized clinical trials to determine specific therapeutic roles of iNO.
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Affiliation(s)
- Simone Redaelli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Aurora Magliocca
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy
| | - Rajeev Malhotra
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Giuseppe Ristagno
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy; Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Neuroscience Department, NeuroIntensive Care Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, ECMO Center, San Gerardo University Hospital, Monza, Italy
| | - Lorenzo Berra
- Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Respiratory Care Department, Massachusetts General Hospital, Boston, MA, USA
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, ECMO Center, San Gerardo University Hospital, Monza, Italy.
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17
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Zheng P, Jiang D, Liu C, Wei X, Li S. Nitric Oxide Inhalation Therapy Attenuates Postoperative Hypoxemia in Obese Patients with Acute Type A Aortic Dissection. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:9612548. [PMID: 35360551 PMCID: PMC8964131 DOI: 10.1155/2022/9612548] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/21/2022] [Accepted: 02/24/2022] [Indexed: 12/21/2022]
Abstract
Objective To investigate the differences between inhaled nitric oxide (iNO) treatment and conventional therapy in the treatment of postoperative hypoxemia in obese patients with acute type A aortic dissection (ATAAD). Methods ATAAD patients diagnosed and treated with emergency surgery in our hospital from June 2017 to December 2019 were retrospectively analyzed. Patients with postoperative hypoxemia were divided into the iNO group and control group. Propensity score matching was used to analyze clinical characteristics and results of the two groups. Results A total of 218 ATAAD patients with BMI ≥ 25 were treated with surgery. Among them, 115 patients developed refractory hypoxemia (64 in the control group and 51 in the iNO group). Patients in the iNO group had significantly shorter invasive mechanical ventilation time, intensive care unit (ICU) stay, and hospital stay. After 6 h of iNO treatment, the PaO2/FiO2 ratio in the iNO group increased significantly, and this ratio was higher than that in the control group at 6, 12, 24, 48, and 72 h after treatment. Conclusion Low-dose iNO could improve oxygenation and shorten mechanical ventilation and ICU stay in patients with hypoxemia after ATAAD surgery, but without significant side effects or increase in postoperative mortality or morbidity. These findings provide a basis for a randomized multicenter controlled trial to assess the efficacy of iNO in the treatment of hypoxemia after ATAAD surgery.
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Affiliation(s)
- Ping Zheng
- Department of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Dingsheng Jiang
- Department of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Chun Liu
- Department of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Xiang Wei
- Department of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Shiliang Li
- Department of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
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Brown CJ, Rubel N, Lai J, Ward C, McLean J, Wheelock M, Steuerwald M, Cathers A. Initiation of Inhaled Nitric Oxide by Air Transport Team in Adult COVID-19 Respiratory Failure. Air Med J 2022; 41:406-410. [PMID: 35750450 PMCID: PMC8907015 DOI: 10.1016/j.amj.2022.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/28/2022] [Accepted: 03/02/2022] [Indexed: 11/19/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has caused a significant increase in the volume of critical care flight transports between outlying referral hospitals and tertiary care facilities. Because of the tropism of severe acute respiratory syndrome coronavirus 2, flight crews are often asked to transport mechanically ventilated patients in refractory hypoxemic respiratory failure. The authors present a case series of 5 patients with COVID-19 acute respiratory distress syndrome (ARDS) who were initiated on inhaled nitric oxide (iNO) by the transport team before rotor wing transport and survived the journey in stable or improved condition upon arrival. Previously, no case reports have described adults with COVID-19 ARDS transported after iNO initiation by the transport team. This case series shows the feasibility of iNO initiation by trained air medical transport teams and suggests a short-term stabilizing effect of iNO in patients with ARDS from COVID-19.
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Affiliation(s)
- Connor J Brown
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI.
| | - Nicolas Rubel
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Jason Lai
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Christen Ward
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Justin McLean
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Martin Wheelock
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Michael Steuerwald
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Andrew Cathers
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
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19
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Wang Y, Zhong M. Inhaled Nitric Oxide Improved Refractory Hypoxemia Through Attenuation of Intra-Pulmonary Shunt. Am J Respir Crit Care Med 2022; 205:1114. [PMID: 35167413 DOI: 10.1164/rccm.202107-1598im] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Yuxian Wang
- Zhongshan Hospital Fudan University, 92323, Shanghai, China
| | - Ming Zhong
- Zhongshan Hospital Fudan University, 92323, Shanghai, China
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20
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Liu J, Dean DA. Gene Therapy for Acute Respiratory Distress Syndrome. Front Physiol 2022; 12:786255. [PMID: 35111077 PMCID: PMC8801611 DOI: 10.3389/fphys.2021.786255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a devastating clinical syndrome that leads to acute respiratory failure and accounts for over 70,000 deaths per year in the United States alone, even prior to the COVID-19 pandemic. While its molecular details have been teased apart and its pathophysiology largely established over the past 30 years, relatively few pharmacological advances in treatment have been made based on this knowledge. Indeed, mortality remains very close to what it was 30 years ago. As an alternative to traditional pharmacological approaches, gene therapy offers a highly controlled and targeted strategy to treat the disease at the molecular level. Although there is no single gene or combination of genes responsible for ARDS, there are a number of genes that can be targeted for upregulation or downregulation that could alleviate many of the symptoms and address the underlying mechanisms of this syndrome. This review will focus on the pathophysiology of ARDS and how gene therapy has been used for prevention and treatment. Strategies for gene delivery to the lung, such as barriers encountered during gene transfer, specific classes of genes that have been targeted, and the outcomes of these approaches on ARDS pathogenesis and resolution will be discussed.
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Affiliation(s)
- Jing Liu
- Department of Pediatrics, University of Rochester, Rochester, NY, United States
- Department of Pharmacology and Physiology, University of Rochester, Rochester, NY, United States
| | - David A. Dean
- Department of Pediatrics, University of Rochester, Rochester, NY, United States
- Department of Pharmacology and Physiology, University of Rochester, Rochester, NY, United States
- *Correspondence: David A. Dean,
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21
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Fan HC, Chang FW, Pan YR, Yu SI, Chang KH, Chen CM, Liu CA. Approach to the Connection between Meconium Consistency and Adverse Neonatal Outcomes: A Retrospective Clinical Review and Prospective In Vitro Study. CHILDREN (BASEL, SWITZERLAND) 2021; 8:1082. [PMID: 34943278 PMCID: PMC8700184 DOI: 10.3390/children8121082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/18/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022]
Abstract
Whether meconium-stained amniotic fluid (MSAF) serves as an indicator of fetal distress is under debate; however, the presence of MSAF concerns both obstetricians and pediatricians because meconium aspiration is a major contributor to neonatal morbidity and mortality, even with appropriate treatment. The present study suggested that thick meconium in infants might be associated with poor outcomes compared with thin meconium based on chart reviews. In addition, cell survival assays following the incubation of various meconium concentrations with monolayers of human epithelial and embryonic lung fibroblast cell lines were consistent with the results obtained from chart reviews. Exposure to meconium resulted in the significant release of nitrite from A549 and HEL299 cells. Medicinal agents, including dexamethasone, L-Nω-nitro-arginine methylester (L-NAME), and NS-398 significantly reduced the meconium-induced release of nitrite. These results support the hypothesis that thick meconium is a risk factor for neonates who require resuscitation, and inflammation appears to serve as the primary mechanism for meconium-associated lung injury. A better understanding of the relationship between nitrite and inflammation could result in the development of promising treatments for meconium aspiration syndrome (MAS).
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Affiliation(s)
- Hueng-Chuen Fan
- Department of Pediatrics, Tungs’ Taichung Metroharbor Hospital, Wuchi, Taichung 435, Taiwan;
- Department of Medica research, Tungs’ Taichung Metroharbor Hospital, Wuchi, Taichung 435, Taiwan; (Y.-R.P.); (S.-I.Y.); (K.-H.C.)
- Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli 356, Taiwan
- Department of Life Sciences, Agricultural Biotechnology Center, National Chung Hsing University, Taichung 402, Taiwan;
| | - Fung-Wei Chang
- Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan;
| | - Ying-Ru Pan
- Department of Medica research, Tungs’ Taichung Metroharbor Hospital, Wuchi, Taichung 435, Taiwan; (Y.-R.P.); (S.-I.Y.); (K.-H.C.)
| | - Szu-I Yu
- Department of Medica research, Tungs’ Taichung Metroharbor Hospital, Wuchi, Taichung 435, Taiwan; (Y.-R.P.); (S.-I.Y.); (K.-H.C.)
| | - Kuang-Hsi Chang
- Department of Medica research, Tungs’ Taichung Metroharbor Hospital, Wuchi, Taichung 435, Taiwan; (Y.-R.P.); (S.-I.Y.); (K.-H.C.)
| | - Chuan-Mu Chen
- Department of Life Sciences, Agricultural Biotechnology Center, National Chung Hsing University, Taichung 402, Taiwan;
- The iEGG and Animal Biotechnology Center, and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Ching-Ann Liu
- Bioinnovation Center, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan
- Department of Medical Research, Hualien Tzu Chi Hospital, Hualien 970, Taiwan
- Neuroscience Center, Hualien Tzu Chi Hospital, Hualien 970, Taiwan
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22
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Seo H, Lopez CN, Succar L, Donahue KR. Evaluation of Inhaled Alprostadil in Hospitalized Adult Patients. Ann Pharmacother 2021; 56:671-678. [PMID: 34486414 DOI: 10.1177/10600280211042675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Intermittent inhaled alprostadil (iPGE1) may be a viable alternative to inhaled nitric oxide or epoprostenol for management of right ventricular failure, pulmonary hypertension (pHTN) or acute respiratory distress syndrome (ARDS). However, limited evidence exists regarding iPGE1 use in adults, ideal dosing strategies, or optimal use cases. OBJECTIVE To describe the clinical characteristics of patients receiving iPGE1 and identify specific sub-populations warranting further research. METHODS This was a single-center, retrospective, descriptive analysis of inpatients who received at least one dose of iPGE1. The primary outcome was to describe patient characteristics and alprostadil dosing strategies. Secondary outcomes included changes in respiratory support requirements, hemodynamics, and inotropic/vasoactive use. Outcomes were stratified and compared based on primary therapeutic indication (cardiac or pulmonary). RESULTS Fifty-four patients received iPGE1 40 (75%) for pulmonary (pHTN or ARDS) and 14 (25%) for cardiac indications. There was no difference between indications in the number of patients de-escalated from level of respiratory (53% vs 57%, P = 0.76), inotropic (70% vs 57%, P = 0.39), or vasopressor support (78% vs 57%, P = 0.17). Furthermore, there was no significant improvement in cardiopulmonary parameters at multiple time intervals after iPGE1 initiation. CONCLUSION AND RELEVANCE This is the largest study to date on the use of intermittent iPGE1 in adults. Alprostadil was safely utilized in novel populations; however, efficacy as evaluated by clinical or surrogate endpoints could not be demonstrated and further investigation is needed to determine its potential and optimal place in therapy.
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Evolution of practice patterns in the management of acute respiratory distress syndrome: A secondary analysis of two successive randomized controlled trials. J Crit Care 2021; 65:274-281. [PMID: 34280657 PMCID: PMC8255112 DOI: 10.1016/j.jcrc.2021.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 06/25/2021] [Accepted: 06/30/2021] [Indexed: 01/02/2023]
Abstract
Purpose We sought to examine changes in acute respiratory distress syndrome (ARDS) management over a 12-year period of two successive randomized trials. Methods Analyses included baseline data, from eligible patients, prior to influence of trial protocols, and daily study data, from randomized patients, of variables not determined by trial protocols. Mixed linear regressions examined changes in practice year-on-year. Results A total of 2376 patients met the inclusion criteria. Over the 12-year period, baseline tidal volume index decreased (9.0 to 7.0 ml/kg, p < 0.001), plateau pressures decreased (30.8 to 29.0 cmH2O, p < 0.05), and baseline positive end-expiratory pressures increased (10.8 to 13.2 cmH2O, p < 0.001). Volume-controlled ventilation declined from 29.4 to 14.0% (p < 0.01). Use of corticosteroids increased (baseline: 7.7 to 30.3%; on study: 32.6 to 61.2%; both p < 0.001), as did neuromuscular blockade (baseline: 12.3 to 24.5%; on study: 55.5 to 70.0%; both p < 0.01). Inhaled nitric oxide use increased (24.9 to 65.8%, p < 0.05). We observed no significant change in prone positioning (16.2 to 18.9%, p = 0.70). Conclusions Clear trends were apparent in tidal volume, airway pressures, ventilator modes, adjuncts and rescue therapies. With the exception of prone positioning, and outside the context of rescue therapy, these trends appear consistent with the evolving literature on ARDS management.
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Fernando SM, Ferreyro BL, Urner M, Munshi L, Fan E. Diagnostic et traitement du syndrome de détresse respiratoire aiguë. CMAJ 2021; 193:E978-E986. [PMID: 34155054 PMCID: PMC8248466 DOI: 10.1503/cmaj.202661-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Shannon M Fernando
- Division de médecine des soins intensifs (Fernando), Départements de médecine et de médecine d'urgence, Université d'Ottawa, Ottawa, Ont.; Division interdépartementale de médecine des soins intensifs (Ferreyro, Urner, Munshi, Fan), Université de Toronto; Institut pour les politiques, la gestion et l'évaluation de la santé (Ferreyro, Urner, Munshi, Fan), École Dalla Lana de santé publique, Université de Toronto; Faculté de médecine (Ferreyro, Urner, Munshi, Fan), Sinai Health System et Réseau universitaire de santé; Institut de recherche de l'Hôpital général de Toronto (Fan), Réseau universitaire de santé, Toronto, Ont.
| | - Bruno L Ferreyro
- Division de médecine des soins intensifs (Fernando), Départements de médecine et de médecine d'urgence, Université d'Ottawa, Ottawa, Ont.; Division interdépartementale de médecine des soins intensifs (Ferreyro, Urner, Munshi, Fan), Université de Toronto; Institut pour les politiques, la gestion et l'évaluation de la santé (Ferreyro, Urner, Munshi, Fan), École Dalla Lana de santé publique, Université de Toronto; Faculté de médecine (Ferreyro, Urner, Munshi, Fan), Sinai Health System et Réseau universitaire de santé; Institut de recherche de l'Hôpital général de Toronto (Fan), Réseau universitaire de santé, Toronto, Ont
| | - Martin Urner
- Division de médecine des soins intensifs (Fernando), Départements de médecine et de médecine d'urgence, Université d'Ottawa, Ottawa, Ont.; Division interdépartementale de médecine des soins intensifs (Ferreyro, Urner, Munshi, Fan), Université de Toronto; Institut pour les politiques, la gestion et l'évaluation de la santé (Ferreyro, Urner, Munshi, Fan), École Dalla Lana de santé publique, Université de Toronto; Faculté de médecine (Ferreyro, Urner, Munshi, Fan), Sinai Health System et Réseau universitaire de santé; Institut de recherche de l'Hôpital général de Toronto (Fan), Réseau universitaire de santé, Toronto, Ont
| | - Laveena Munshi
- Division de médecine des soins intensifs (Fernando), Départements de médecine et de médecine d'urgence, Université d'Ottawa, Ottawa, Ont.; Division interdépartementale de médecine des soins intensifs (Ferreyro, Urner, Munshi, Fan), Université de Toronto; Institut pour les politiques, la gestion et l'évaluation de la santé (Ferreyro, Urner, Munshi, Fan), École Dalla Lana de santé publique, Université de Toronto; Faculté de médecine (Ferreyro, Urner, Munshi, Fan), Sinai Health System et Réseau universitaire de santé; Institut de recherche de l'Hôpital général de Toronto (Fan), Réseau universitaire de santé, Toronto, Ont
| | - Eddy Fan
- Division de médecine des soins intensifs (Fernando), Départements de médecine et de médecine d'urgence, Université d'Ottawa, Ottawa, Ont.; Division interdépartementale de médecine des soins intensifs (Ferreyro, Urner, Munshi, Fan), Université de Toronto; Institut pour les politiques, la gestion et l'évaluation de la santé (Ferreyro, Urner, Munshi, Fan), École Dalla Lana de santé publique, Université de Toronto; Faculté de médecine (Ferreyro, Urner, Munshi, Fan), Sinai Health System et Réseau universitaire de santé; Institut de recherche de l'Hôpital général de Toronto (Fan), Réseau universitaire de santé, Toronto, Ont
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25
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Griffiths M, Meade S, Summers C, McAuley DF, Proudfoot A, Baladia MM, Dark PM, Diomede K, Finney SJ, Forni LG, Meadows C, Naldrett IA, Patel B, Perkins GD, Samaan MA, Sharifi L, Suntharalingam G, Tarmey NT, Young HF, Wise MP, Irving PM. RAND appropriateness panel to determine the applicability of UK guidelines on the management of acute respiratory distress syndrome (ARDS) and other strategies in the context of the COVID-19 pandemic. Thorax 2021; 77:129-135. [PMID: 34045363 DOI: 10.1136/thoraxjnl-2021-216904] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/25/2021] [Accepted: 04/08/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND COVID-19 has become the most common cause of acute respiratory distress syndrome (ARDS) worldwide. Features of the pathophysiology and clinical presentation partially distinguish it from 'classical' ARDS. A Research and Development (RAND) analysis gauged the opinion of an expert panel about the management of ARDS with and without COVID-19 as the precipitating cause, using recent UK guidelines as a template. METHODS An 11-person panel comprising intensive care practitioners rated the appropriateness of ARDS management options at different times during hospital admission, in the presence or absence of, or varying severity of SARS-CoV-2 infection on a scale of 1-9 (where 1-3 is inappropriate, 4-6 is uncertain and 7-9 is appropriate). A summary of the anonymised results was discussed at an online meeting moderated by an expert in RAND methodology. The modified online survey comprising 76 questions, subdivided into investigations (16), non-invasive respiratory support (18), basic intensive care unit management of ARDS (20), management of refractory hypoxaemia (8), pharmacotherapy (7) and anticoagulation (7), was completed again. RESULTS Disagreement between experts was significant only when addressing the appropriateness of diagnostic bronchoscopy in patients with confirmed or suspected COVID-19. Adherence to existing published guidelines for the management of ARDS for relevant evidence-based interventions was recommended. Responses of the experts to the final survey suggested that the supportive management of ARDS should be the same, regardless of a COVID-19 diagnosis. For patients with ARDS with COVID-19, the panel recommended routine treatment with corticosteroids and a lower threshold for full anticoagulation based on a high index of suspicion for venous thromboembolic disease. CONCLUSION The expert panel found no reason to deviate from the evidence-based supportive strategies for managing ARDS outlined in recent guidelines.
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Affiliation(s)
- Mark Griffiths
- NHLI, Imperial College London, London, UK .,Barts Heart Centre, St Bartholomews Hospital, London, UK.,William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Susanna Meade
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Charlotte Summers
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Daniel Francis McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, UK.,Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | | | | | - Paul M Dark
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Kate Diomede
- East Kent Hospitals NHS Foundation Trust, London, UK
| | - Simon J Finney
- Perioperative Medicine, Barts Health NHS Trust, London, UK
| | - Lui G Forni
- Intensive Care, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK.,University of Surrey Faculty of Health and Medical Sciences, Guildford, Surrey, UK
| | - Chris Meadows
- Department of Critical Care, Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Ian A Naldrett
- University of West London, Ealing, UK.,Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Brijesh Patel
- AICU, Royal Brompton & Harefield NHS Foundation Trust, London, UK.,Anaesthetics, Imperial College London, London, UK
| | | | - Mark A Samaan
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | | - Nicholas T Tarmey
- Academic Department of Critical Care, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | | | - Matt P Wise
- Adult Critical Care, University Hopsital of Wales, Cardiff, UK
| | - Peter M Irving
- Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Immunology and Microbial Sciences, King's College London, London, UK
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26
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Fernando SM, Ferreyro BL, Urner M, Munshi L, Fan E. Diagnosis and management of acute respiratory distress syndrome. CMAJ 2021; 193:E761-E768. [PMID: 34035056 PMCID: PMC8177922 DOI: 10.1503/cmaj.202661] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Shannon M Fernando
- Division of Critical Care (Fernando), Departments of Medicine and of Emergency Medicine, University of Ottawa, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Ferreyro, Urner, Munshi, Fan), University of Toronto; Institute of Health Policy, Management and Evaluation (Ferreyro, Urner, Munshi, Fan), Dalla Lana School of Public Health, University of Toronto; Department of Medicine (Ferreyro, Urner, Munshi, Fan), Sinai Health System and University Health Network; Toronto General Hospital Research Institute (Fan), University Health Network, Toronto, Ont.
| | - Bruno L Ferreyro
- Division of Critical Care (Fernando), Departments of Medicine and of Emergency Medicine, University of Ottawa, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Ferreyro, Urner, Munshi, Fan), University of Toronto; Institute of Health Policy, Management and Evaluation (Ferreyro, Urner, Munshi, Fan), Dalla Lana School of Public Health, University of Toronto; Department of Medicine (Ferreyro, Urner, Munshi, Fan), Sinai Health System and University Health Network; Toronto General Hospital Research Institute (Fan), University Health Network, Toronto, Ont
| | - Martin Urner
- Division of Critical Care (Fernando), Departments of Medicine and of Emergency Medicine, University of Ottawa, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Ferreyro, Urner, Munshi, Fan), University of Toronto; Institute of Health Policy, Management and Evaluation (Ferreyro, Urner, Munshi, Fan), Dalla Lana School of Public Health, University of Toronto; Department of Medicine (Ferreyro, Urner, Munshi, Fan), Sinai Health System and University Health Network; Toronto General Hospital Research Institute (Fan), University Health Network, Toronto, Ont
| | - Laveena Munshi
- Division of Critical Care (Fernando), Departments of Medicine and of Emergency Medicine, University of Ottawa, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Ferreyro, Urner, Munshi, Fan), University of Toronto; Institute of Health Policy, Management and Evaluation (Ferreyro, Urner, Munshi, Fan), Dalla Lana School of Public Health, University of Toronto; Department of Medicine (Ferreyro, Urner, Munshi, Fan), Sinai Health System and University Health Network; Toronto General Hospital Research Institute (Fan), University Health Network, Toronto, Ont
| | - Eddy Fan
- Division of Critical Care (Fernando), Departments of Medicine and of Emergency Medicine, University of Ottawa, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Ferreyro, Urner, Munshi, Fan), University of Toronto; Institute of Health Policy, Management and Evaluation (Ferreyro, Urner, Munshi, Fan), Dalla Lana School of Public Health, University of Toronto; Department of Medicine (Ferreyro, Urner, Munshi, Fan), Sinai Health System and University Health Network; Toronto General Hospital Research Institute (Fan), University Health Network, Toronto, Ont
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27
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Henry R, Ghafil C, Piccinini A, Liasidis PK, Matsushima K, Golden A, Lewis M, Inaba K, Strumwasser A. Extracorporeal support for trauma: A trauma quality improvement project (TQIP) analysis in patients with acute respiratory distress syndrome. Am J Emerg Med 2021; 48:170-176. [PMID: 33962131 DOI: 10.1016/j.ajem.2021.04.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION The use of extracorporeal membrane oxygenation (ECMO) in trauma patients with severe acute respiratory distress syndrome (ARDS) continues to evolve. The objective of this study was to perform a comparative analysis of trauma patients with ARDS who received ECMO to a propensity matched cohort of patients who underwent conventional management. METHODS The Trauma Quality Improvement Program (TQIP) database was queried from 2013 to 2016 for all patients with ARDS and those who received ECMO. Demographics, as well as clinical, injury, intervention, and outcome data were collected and analyzed. Patients with ARDS were divided into two groups, those who received ECMO and those who did not. A propensity score analysis was performed using the following criteria: age, gender, vital signs (HR, SBP) and GCS on admission, Injury Severity Score (ISS), and Abbreviated Injury Scale (AIS) score in several body regions. Outcomes between the groups were subsequently compared using univariate as well as Cox regression analyses. Secondary outcomes such as hospitalization (HLOS), ICU length-of-stay (LOS) and ventilation days stratified for patient demographics, timing of ECMO and anticoagulation status were compared. RESULTS Over the 3-year study period, 8990 patients with ARDS were identified from the TQIP registry. Following exclusion, 3680 were included in the final analysis, of which 97 (2.6%) received ECMO. On univariate analysis following matching, patients who underwent ECMO had lower overall hospital mortality (23 vs 50%, p < 0.001) with higher rates of complications (p < 0.005), including longer HLOS. In those undergoing ECMO, early initiation (<7 days) was associated with shorter HLOS, ICU LOS, and fewer ventilator days. No difference was observed between the two groups with regard to anticoagulation. CONCLUSION Extracorporeal membrane oxygenation use in trauma patients with ARDS may be associated with improved survival, especially for young patients with thoracic injuries, early in the course of ARDS. Anticoagulation while on circuit was not associated with increased risk of hemorrhage or mortality, even in the setting of head injuries. The mortality benefit suggested with ECMO comes at the expense of a potential increase in complication rate and prolonged hospitalization.
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Affiliation(s)
- Reynold Henry
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, United States of America.
| | - Cameron Ghafil
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, United States of America
| | - Alice Piccinini
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, United States of America
| | - Panagiotis K Liasidis
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, United States of America
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, United States of America
| | - Adam Golden
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, United States of America
| | - Meghan Lewis
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, United States of America
| | - Kenji Inaba
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, United States of America
| | - Aaron Strumwasser
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, United States of America
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28
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Implications of SARS-Cov-2 infection on eNOS and iNOS activity: Consequences for the respiratory and vascular systems. Nitric Oxide 2021; 111-112:64-71. [PMID: 33831567 PMCID: PMC8021449 DOI: 10.1016/j.niox.2021.04.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/18/2021] [Accepted: 04/03/2021] [Indexed: 02/07/2023]
Abstract
Symptoms of COVID-19 range from asymptomatic/mild symptoms to severe illness and death, consequence of an excessive inflammatory process triggered by SARS-CoV-2 infection. The diffuse inflammation leads to endothelium dysfunction in pulmonary blood vessels, uncoupling eNOS activity, lowering NO production, causing pulmonary physiological alterations and coagulopathy. On the other hand, iNOS activity is increased, which may be advantageous for host defense, once NO plays antiviral effects. However, overproduction of NO may be deleterious, generating a pro-inflammatory effect. In this review, we discussed the role of endogenous NO as a protective or deleterious agent of the respiratory and vascular systems, the most affected in COVID-19 patients, focusing on eNOS and iNOS roles. We also reviewed the currently available NO therapies and pointed out possible alternative treatments targeting NO metabolism, which could help mitigate health crises in the present and future CoV's spillovers.
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29
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Kotsiou OS, Gourgoulianis KI, Zarogiannis SG. The role of nitric oxide in pleural disease. Respir Med 2021; 179:106350. [PMID: 33662805 DOI: 10.1016/j.rmed.2021.106350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 11/25/2022]
Abstract
Nitric oxide (NO) regulates various physiological and pathophysiological functions in the lungs. However, there is much less information about the effects of NO in the pleura. The present review aimed to explore the available evidence regarding the role of NO in pleural disease. NO, has a double-edged role in the pleural cavity. It is an essential signaling molecule mediating various physiological cell functions such as lymphatic drainage of the serous cavities, the immune response to intracellular multiplication of pathogens, and downregulation of neutrophil migration, but also induces genocytotoxic and mutagenic effects when present in excess. NO is implicated in the pathogenesis of asbestos-related or exudative pleural disease and mesothelioma. From a clinical point of view, the fraction of exhaled NO has been suggested as a potential non-invasive tool for the diagnosis of benign asbestos-related disorders. Under experimental conditions, NO-mimetics were found to attenuate hypoxia-induced therapy resistance in mesothelioma. Similarly, hybrid agents consisting of an NO donor coupled with a parent anti-inflammatory drug showed an enhancement of the anti-inflammatory activity of anti-inflammatory drugs. However, given the paucity of research work performed over the last years in this area, further research should be undertaken to establish reliable conclusions with respect to the feasibility of determining or targeting the NO signaling pathway for pleural disease diagnosis and therapeutic management.
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Affiliation(s)
- Ourania S Kotsiou
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, BIOPOLIS, 41110, Larissa, Greece; Department of Physiology, Faculty of Medicine, University of Thessaly, BIOPOLIS, 41500, Larissa, Greece.
| | - Konstantinos I Gourgoulianis
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, BIOPOLIS, 41110, Larissa, Greece
| | - Sotirios G Zarogiannis
- Department of Physiology, Faculty of Medicine, University of Thessaly, BIOPOLIS, 41500, Larissa, Greece
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30
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Al Sulaiman KA, Aljuhani O, Eljaaly K, Alharbi AA, Al Shabasy AM, Alsaeedi AS, Al Mutairi M, Badreldin HA, Al Harbi SA, Al Haji HA, Al Zumai OI, Vishwakarma RK, Alkatheri A. Clinical features and outcomes of critically ill patients with coronavirus disease 2019 (COVID-19): A multicenter cohort study. Int J Infect Dis 2021; 105:180-187. [PMID: 33601030 PMCID: PMC7882917 DOI: 10.1016/j.ijid.2021.02.037] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/27/2021] [Accepted: 02/07/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Coronavirus disease-19 (COVID-19) manifested by a broad spectrum of symptoms, ranging from asymptomatic manifestations to severe illness and death. The purpose of the study was to extensively describe the clinical features and outcomes in critically ill patients with COVID-19 in Saudi Arabia. METHOD This was a multicenter, non-interventional cohort study for all critically ill patients aged 18 years or older, admitted to intensive care units (ICUs) between March 1 to August 31, 2020, with an objectively confirmed diagnosis of COVID-19. The diagnosis of COVID-19 was confirmed by Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) on nasopharyngeal and/or throat swabs. Multivariate logistic regression and generalized linear regression were used. We considered a P value of <0.05 statistically significant. RESULTS A total of 560 patients met the inclusion criteria. An extensive list of clinical features was associated with higher 30-day ICU mortality rates, such as requiring mechanical ventilation (MV) or developing acute kidney injury within 24 hours of ICU admission, higher body temperature, white blood cells, blood glucose level, serum creatinine, fibrinogen, procalcitonin, creatine phosphokinase, aspartate aminotransferase, and total iron-binding capacity. During ICU stay, the most common complication was respiratory failure that required MV (71.4%), followed by acute kidney injury (AKI) and thrombosis with a proportion of 46.8% and 11.4%, respectively. CONCLUSION Among patients with COVID-19 who were admitted to the ICU, several variables were associated with an increased risk of ICU mortality at 30 days. Respiratory failure that required MV, AKI, and thrombosis were the most common complications during ICU stay.
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Affiliation(s)
- Khalid A Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia; College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khalid Eljaaly
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia; College of Pharmacy, University of Arizona, Tucson, AZ, United States
| | - Aisha A Alharbi
- Pharmaceutical Care Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Adel M Al Shabasy
- Department of Anesthesia and Intensive Care, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Anesthesia and Intensive Care, Ain Shams University, Faculty of Medicine, Cairo, Egypt
| | - Alawi S Alsaeedi
- Department of Intensive Care, King Abdulaziz Medical City, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mashael Al Mutairi
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Hisham A Badreldin
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia; College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Shmeylan A Al Harbi
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia; College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Hussain A Al Haji
- Department of Respiratory Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Omar I Al Zumai
- Department of Respiratory Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ramesh K Vishwakarma
- Biostatistics and Bioinformatics Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdulmalik Alkatheri
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia; College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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31
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Moreira DR, Uberti ACMG, Gomes ARQ, Ferreira MES, da Silva Barbosa A, Varela ELP, Dolabela MF, Percário S. Dexamethasone increased the survival rate in Plasmodium berghei-infected mice. Sci Rep 2021; 11:2623. [PMID: 33514836 PMCID: PMC7846581 DOI: 10.1038/s41598-021-82032-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/11/2021] [Indexed: 01/30/2023] Open
Abstract
The present study aimed to evaluate the effects of dexamethasone on the redox status, parasitemia evolution, and survival rate of Plasmodium berghei-infected mice. Two-hundred and twenty-five mice were infected with Plasmodium berghei and subjected to stimulation or inhibition of NO synthesis. The stimulation of NO synthesis was performed through the administration of L-arginine, while its inhibition was made by the administration of dexamethasone. Inducible NO synthase (iNOS) inhibition by dexamethasone promoted an increase in the survival rate of P. berghei-infected mice, and the data suggested the participation of oxidative stress in the brain as a result of plasmodial infection, as well as the inhibition of brain NO synthesis, which promoted the survival rate of almost 90% of the animals until the 15th day of infection, with possible direct interference of ischemia and reperfusion syndrome, as seen by increased levels of uric acid. Inhibition of brain iNOS by dexamethasone caused a decrease in parasitemia and increased the survival rate of infected animals, suggesting that NO synthesis may stimulate a series of compensatory redox effects that, if overstimulated, may be responsible for the onset of severe forms of malaria.
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Affiliation(s)
- Danilo Reymão Moreira
- grid.271300.70000 0001 2171 5249Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Av. Augusto Corrêa, 01, Belém, PA 66075-110 Brazil
| | - Ana Carolina Musa Gonçalves Uberti
- grid.271300.70000 0001 2171 5249Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Av. Augusto Corrêa, 01, Belém, PA 66075-110 Brazil
| | - Antonio Rafael Quadros Gomes
- grid.271300.70000 0001 2171 5249Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Av. Augusto Corrêa, 01, Belém, PA 66075-110 Brazil
| | - Michelli Erica Souza Ferreira
- grid.411204.20000 0001 2165 7632Laboratory of Pathophysiology and Therapeutic Research, Centro de Ciências Sociais Saúde e Tecnologia – CCSST, Federal University of Maranhão, Campus Avançado - Bom Jesus, Prédio de Medicina, Av. da Universidade, S/N, Imperatriz, MA 65915-240 Brazil
| | - Aline da Silva Barbosa
- grid.271300.70000 0001 2171 5249Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Av. Augusto Corrêa, 01, Belém, PA 66075-110 Brazil
| | - Everton Luiz Pompeu Varela
- grid.271300.70000 0001 2171 5249Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Av. Augusto Corrêa, 01, Belém, PA 66075-110 Brazil
| | - Maria Fani Dolabela
- grid.271300.70000 0001 2171 5249Institute of Health Sciences, Federal University of Pará, Av. Augusto Corrêa, 01, Belém, PA 66075-110 Brazil
| | - Sandro Percário
- grid.271300.70000 0001 2171 5249Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Av. Augusto Corrêa, 01, Belém, PA 66075-110 Brazil
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32
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Wang J, Cong X, Miao M, Yang Y, Zhang J. Inhaled nitric oxide and acute kidney injury risk: a meta-analysis of randomized controlled trials. Ren Fail 2021; 43:281-290. [PMID: 33494652 PMCID: PMC7850389 DOI: 10.1080/0886022x.2021.1873805] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Purpose There are conflicting results as to the effect of inhaled nitric oxide (iNO) therapy on the risk of acute kidney injury (AKI). The aim of this study was to perform a meta-analysis to assess the updated data. Methods We systematically searched Web of Science, the Cochrane Library, Wanfang, and PubMed for relevant randomized control trials between database inception and 9/07/2020. Relative risks (RRs) with 95% confidence intervals (CIs) predicting the risk of AKI were extracted to obtain summary estimates using fixed-effects models. The Trim and Fill method was used to evaluate the sensitivity of the results and adjust for publication bias in meta-analysis. Results 15 randomized controlled studies from 14 articles involving 1853 patients were included in the study. Analyzing the eligible studies we found: (1) iNO therapy significantly increased the risk of AKI in acute respiratory distress syndrome patients (RR 1.55, 95% CI 1.15–2.10, p = 0.004; I2 for heterogeneity 0%; Phet = 0.649). (2) The use of iNO was associated with reduced AKI risk in patients undergoing cardiac surgery (RR 0.80, 95% CI 0.64–0.99, p = 0.037; I2 for heterogeneity 0%; Phet = 0.528). (3) For organ transplantation recipients, there was no effect of iNO administration on the risk of AKI (RR 0.50, 95% CI 0.16–1.56, p = 0.233; I2 for heterogeneity 0%; Phet = 0.842). The Trim and Fill analysis showed that the overall effect of this meta-analysis was stable. Conclusions The effect of iNO on AKI risk might be disease-specific. Future RCTs with larger patient populations should aim to validate our findings.
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Affiliation(s)
- Junqiu Wang
- Journal Editorial Department, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Xuhui Cong
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Mengrong Miao
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Yitian Yang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiaqiang Zhang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
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33
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Friebe A, Englert N. NO-sensitive guanylyl cyclase in the lung. Br J Pharmacol 2020; 179:2328-2343. [PMID: 33332689 DOI: 10.1111/bph.15345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 12/21/2022] Open
Abstract
In the late 1960s, several labatories identified guanylyl cyclase (GC) as the cGMP-producing enzyme. Subsequently, two different types of GC were described that differed in their cellular localization. Primarily found in the cytosol, nitric oxide (NO)-sensitive guanylyl cyclase (NO-GC) acts as receptor for the signalling molecule NO, in contrast the membrane-bound isoenzyme is activated by natriuretic peptides. The lung compared with other tissues exhibits the highest expression of NO-GC. The enzyme has been purified from lung for biochemical analysis. Although expressed in smooth muscle cells (SMCs) and in pericytes, the function of NO-GC in lung, especially in pericytes, is still not fully elucidated. However, pharmacological compounds that target NO-GC are available and have been implemented for the therapy of pulmonary arterial hypertension. In addition, NO-GC has been suggested as drug target for the therapy of asthma, acute respiratory distress syndrome and pulmonary fibrosis.
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Affiliation(s)
- Andreas Friebe
- Physiological Institute, Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Nils Englert
- Physiological Institute, Julius Maximilian University of Würzburg, Würzburg, Germany
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Sonti R, Pike CW, Cobb N. Responsiveness of Inhaled Epoprostenol in Respiratory Failure due to COVID-19. J Intensive Care Med 2020; 36:327-333. [PMID: 33234007 PMCID: PMC7724253 DOI: 10.1177/0885066620976525] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Inhaled pulmonary vasodilators are used as adjunctive therapies for the treatment of refractory hypoxemia. Available evidence suggest they improve oxygenation in a subset of patients without changing long-term trajectory. Given the differences in respiratory failure due to COVID-19 and "traditional" ARDS, we sought to identify their physiologic impact. METHODS This is a retrospective observational study of patients mechanically ventilated for COVID-19, from the ICUs of 2 tertiary care centers, who received inhaled epoprostenol (iEpo) for the management of hypoxemia. The primary outcome is change in PaO2/FiO2. Additionally, we measured several patient level features to predict iEpo responsiveness (or lack thereof). RESULTS Eighty patients with laboratory confirmed SARS-CoV2 received iEpo while mechanically ventilated and had PaO2/FiO2 measured before and after. The median PaO2/FiO2 prior to receiving iEpo was 92 mmHg and interquartile range (74 - 122). The median change in PaO2/FiO2 was 9 mmHg (-9 - 37) corresponding to a 10% improvement (-8 - 41). Fifty-percent (40 / 80) met our a priori definition of a clinically significant improvement in PaO2/FiO2 (increase in 10% from the baseline value). Prone position and lower PaO2/FiO2 when iEpo was started predicted a more robust response, which held after multivariate adjustment. For proned individuals, improvement in PaO2/FiO2 was 14 mmHg (-6 to 45) vs. 3 mmHg (-11 - 20), p = 0.04 for supine individuals; for those with severe ARDS (PaO2/FiO2 < 100, n = 49) the median improvement was 16 mmHg (-2 - 46). CONCLUSION Fifty percent of patients have a clinically significant improvement in PaO2/FiO2 after the initiation of iEpo. This suggests it is worth trying as a rescue therapy; although generally the benefit was modest with a wide variability. Those who were prone and had lower PaO2/FiO2 were more likely to respond.
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Affiliation(s)
- Rajiv Sonti
- Division of Pulmonary, Critical Care and Sleep Medicine, 12230Georgetown University Medical Center, Washington, DC, USA
| | - C William Pike
- 12230Georgetown University School of Medicine, Washington, DC, USA
| | - Nathan Cobb
- Division of Pulmonary, Critical Care and Sleep Medicine, 12230Georgetown University Medical Center, Washington, DC, USA
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Vassiliou AG, Kotanidou A, Dimopoulou I, Orfanos SE. Endothelial Damage in Acute Respiratory Distress Syndrome. Int J Mol Sci 2020; 21:ijms21228793. [PMID: 33233715 PMCID: PMC7699909 DOI: 10.3390/ijms21228793] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 01/01/2023] Open
Abstract
The pulmonary endothelium is a metabolically active continuous monolayer of squamous endothelial cells that internally lines blood vessels and mediates key processes involved in lung homoeostasis. Many of these processes are disrupted in acute respiratory distress syndrome (ARDS), which is marked among others by diffuse endothelial injury, intense activation of the coagulation system and increased capillary permeability. Most commonly occurring in the setting of sepsis, ARDS is a devastating illness, associated with increased morbidity and mortality and no effective pharmacological treatment. Endothelial cell damage has an important role in the pathogenesis of ARDS and several biomarkers of endothelial damage have been tested in determining prognosis. By further understanding the endothelial pathobiology, development of endothelial-specific therapeutics might arise. In this review, we will discuss the underlying pathology of endothelial dysfunction leading to ARDS and emerging therapies. Furthermore, we will present a brief overview demonstrating that endotheliopathy is an important feature of hospitalised patients with coronavirus disease-19 (COVID-19).
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Affiliation(s)
- Alice G. Vassiliou
- 1st Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.); (I.D.)
| | - Anastasia Kotanidou
- 1st Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.); (I.D.)
| | - Ioanna Dimopoulou
- 1st Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.); (I.D.)
| | - Stylianos E. Orfanos
- 1st Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.); (I.D.)
- 2nd Department of Critical Care, School of Medicine, National and Kapodistrian University of Athens, Attikon Hospital, 124 62 Athens, Greece
- Correspondence: or ; Tel.: +30-2107-235-521
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Franco V, Bradley EA, Badagliacca R, Sabanayagam A, Rajpal S, Lastinger LT, Daniels CJ, Smith JS, Benza RL. Pulmonary vasodilators: beyond the bounds of pulmonary arterial hypertension therapy in COVID-19. Pulm Circ 2020; 10:2045894020970369. [PMID: 33282201 PMCID: PMC7686637 DOI: 10.1177/2045894020970369] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/10/2020] [Indexed: 01/03/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) and novel coronavirus (SARS-CoV-2) disease COVID-19
are characterized by extensive endothelial dysfunction and inflammation leading to
vascular remodeling and severe microthrombi and microvascular obliterative disease. It is
hypothesized that those patients with underlying lung disease, like PAH, represent a
high-risk cohort in this pandemic. However, reports of COVID-19 in this cohort of patient
have been scaring and an observational survey showed that the disease was relatively well
tolerated. We postulate that specific PAH vasodilator may offer some protection and/or
advantage in the case of concomitant COVID-19. Here we review the literature describing
mechanisms of action for each of the broad categories of PAH therapy, and offer potential
hypothesis about why this therapy may impact outcomes in COVID-19.
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Affiliation(s)
- Veronica Franco
- Division of Cardiovascular Disease, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Elisa A Bradley
- Division of Cardiovascular Disease, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, Rome, Italy
| | - Aarthi Sabanayagam
- Division of Cardiovascular Disease, University of California San Francisco, USA
| | - Saurabh Rajpal
- Division of Cardiovascular Disease, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lauren T Lastinger
- Division of Cardiovascular Disease, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Curt J Daniels
- Division of Cardiovascular Disease, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - J Shaun Smith
- Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Raymond L Benza
- Division of Cardiovascular Disease, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Adusumilli NC, Zhang D, Friedman JM, Friedman AJ. Harnessing nitric oxide for preventing, limiting and treating the severe pulmonary consequences of COVID-19. Nitric Oxide 2020; 103:4-8. [PMID: 32681986 PMCID: PMC7362842 DOI: 10.1016/j.niox.2020.07.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/22/2020] [Accepted: 07/13/2020] [Indexed: 01/30/2023]
Abstract
The ongoing outbreak of COVID-19 has quickly become a daunting challenge to global health. In the absence of targeted therapy and a reported 5.5% case fatality rate in the United States, treatments preventing rapid cardiopulmonary failure are urgently needed. Clinical features, pathology and homology to better understood pathogens suggest that uncontrolled inflammation and a cytokine storm likely drive COVID-19's unrelenting disease process. Interventions that are protective against acute lung injury and ARDS can play a critical role for patients and health systems during this pandemic. Nitric oxide is an antimicrobial and anti-inflammatory molecule with key roles in pulmonary vascular function in the context of viral infections and other pulmonary disease states. This article reviews the rationale for exogenous nitric oxide use for the pathogenesis of COVID-19 and highlights its potential for contributing to better clinical outcomes and alleviating the rapidly rising strain on healthcare capacity.
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Affiliation(s)
- Nagasai C. Adusumilli
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - David Zhang
- Department of Physiology and Biophysics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Joel M. Friedman
- Department of Physiology and Biophysics, Albert Einstein College of Medicine, Bronx, NY, USA,Corresponding author
| | - Adam J. Friedman
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA,Corresponding author
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Kim SH, Sul YH, Lee JY, Ye JB, Lee JS, Yoon SY, Kim JS. Veno-Veno Extracorporeal Membrane Oxygenation in Post-Traumatic Acute Lung Injury. JOURNAL OF ACUTE CARE SURGERY 2020. [DOI: 10.17479/jacs.2020.10.2.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Wood C, Kataria V, Modrykamien AM. The acute respiratory distress syndrome. Proc (Bayl Univ Med Cent) 2020; 33:357-365. [PMID: 32675953 DOI: 10.1080/08998280.2020.1764817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/27/2020] [Accepted: 04/06/2020] [Indexed: 12/18/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a prevalent cause of acute respiratory failure with high rates of mortality, as well as short- and long-term complications, such as physical and cognitive impairment. Therefore, early recognition of this syndrome and application of well-demonstrated therapeutic interventions are essential to change the natural course of this entity and bring about positive clinical outcomes. In this article, we review updated concepts in ARDS. Specifically, we discuss the current definition of ARDS, its risk factors, and the evidence supporting ventilation management, adjunctive therapies, and interventions required in refractory hypoxemia.
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Affiliation(s)
- Christopher Wood
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Baylor University Medical CenterDallasTexas
| | - Vivek Kataria
- Department of Pharmacy, Baylor University Medical CenterDallasTexas
| | - Ariel M Modrykamien
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Baylor University Medical CenterDallasTexas
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Barnes M, Brisbois EJ. Clinical use of inhaled nitric oxide: Local and systemic applications. Free Radic Biol Med 2020; 152:422-431. [PMID: 31785330 DOI: 10.1016/j.freeradbiomed.2019.11.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/15/2019] [Accepted: 11/21/2019] [Indexed: 12/26/2022]
Abstract
Upon the FDA approval for inhaled nitric oxide (iNO) in 1999 to treat persistent pulmonary hypertension in neonates, iNO has proven to be a beneficial therapeutic in multiple diseases. We aim to review applications of iNO that have modeled its protective and therapeutic attributes, as well as highlight preliminary studies that could allude to future avenues of use. Numerous publications have reported specific incidences where iNO therapy has proved advantageous, while some applications have potential after further validation. Establishing guidelines on dosing, duration, and defined clinical uses are crucial for the future of iNO. Delivery of iNO has been controlled by a sole distributor, and comes with high cost, and lack of portability. A shift in patents has allowed for new designs for iNO device synthesis, with many new developments of iNO medical devices that will likely change the future of iNO in a medical setting.
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Affiliation(s)
- Megan Barnes
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Elizabeth J Brisbois
- Department of Materials Science & Engineering, University of Central Florida, Orlando, FL, USA.
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COUNTERPOINT: Does Persistent or Worsening ARDS Refractory to Optimized Ventilation and Proning Deserve a Trial of Prostacyclin? No. Chest 2020; 155:665-668. [PMID: 30955569 DOI: 10.1016/j.chest.2018.11.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 11/20/2018] [Indexed: 11/22/2022] Open
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Silva PL, Pelosi P, Rocco PRM. Personalized pharmacological therapy for ARDS: a light at the end of the tunnel. Expert Opin Investig Drugs 2019; 29:49-61. [PMID: 31778609 DOI: 10.1080/13543784.2020.1699531] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Pharmacotherapy for the acute respiratory distress syndrome (ARDS) has been tested in preclinical and clinical studies. However, to date, no pharmacological interventions have proven effective. This may be attributed to lack of proper identification of different ARDS phenotypes.Areas covered: We designed inclusive search strings and searched four bibliographic databases (Cochrane Database of Systematic Reviews, PubMed, Web of Science, and clinicaltrials.gov) to identify relevant research. Search results were mainly restricted to papers published from 2009 through 2019. ARDS is a heterogeneous syndrome, and its different phenotypes - defined according to clinical, radiological, and biological parameters - may affect response to therapy. The most promising pharmacological approaches to date have been based on ARDS pathophysiology. They focus on reducing inflammation and pulmonary edema, promoting selective vasodilation, and repairing alveolar epithelial and endothelial cells.Expert opinion: Pharmacotherapeutic approaches targeting ARDS pathophysiology have failed to exert beneficial effects. Personalized medicine targeting the different ARDS phenotypes has emerged as an option to improve survival. Identification of specific ARDS patient phenotypes that respond to specific therapies seems to be the most important challenge for the next decade. Additional research is warranted before personalized medicine approaches can be applied at bedside for ARDS patients.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Rio de Janeiro, Brazil
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Allareddy V, Cheifetz IM. Clinical trials and future directions in pediatric acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:514. [PMID: 31728367 DOI: 10.21037/atm.2019.09.14] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The pediatric acute respiratory distress syndrome (PARDS), a description specific for children with acute respiratory distress syndrome (ARDS), was proposed in the recent Pediatric Acute Lung Injury Consensus Conference (PALICC, 2015). This recent standardization of PARDS diagnosis is expected to aid in uniform earlier recognition of the entity, enable use of consistent management strategies and potentially increase the ease of enrollment in future PARDS clinical trials-all of which are expected to optimize outcomes in PARDS. Clinical trials in PARDS are few but ongoing studies are expected to lay the foundation for future clinical studies. The Randomized Evaluation of Sedation Titration for Respiratory Failure trial (RESTORE) trial has revealed that a goal directed sedation protocol does not reduce the duration of invasive ventilation in critically ill children. PROSpect trial is a large multi-institute clinical trial that is expected to reveal optimal ventilation strategies and patient positioning (supine vs. prone) in patients with severe PARDS. The PARDS neuromuscular blockade (NMB) study is expected to yield important information about the impact of active NMB on PARDS outcomes. Information from these studies could be used to design future clinical trials in PARDS and to lessen the anecdotal or extrapolated experiences from adult clinical studies that often guide clinical practices in PARDS management. Finally, it is expected that these definitions and management strategies will be revised periodically as our understanding of PARDS evolves. Emerging data on PARDS subtypes suggest that patient heterogeneity is an important factor in designing these clinical trials.
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Affiliation(s)
- Veerajalandhar Allareddy
- Section Chief Pediatric Cardiac ICU, Duke Children's Hospital, Duke University Medical Center, Durham, NC, USA
| | - Ira M Cheifetz
- Section Chief Pediatric Cardiac ICU, Duke Children's Hospital, Duke University Medical Center, Durham, NC, USA
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Reid A, Ha JF. Inhalational injury and the larynx: A review. Burns 2019; 45:1266-1274. [DOI: 10.1016/j.burns.2018.10.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 09/01/2018] [Accepted: 10/31/2018] [Indexed: 12/13/2022]
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Spina S, Lei C, Pinciroli R, Berra L. Hemolysis and Kidney Injury in Cardiac Surgery: The Protective Role of Nitric Oxide Therapy. Semin Nephrol 2019; 39:484-495. [DOI: 10.1016/j.semnephrol.2019.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Griffiths MJD, McAuley DF, Perkins GD, Barrett N, Blackwood B, Boyle A, Chee N, Connolly B, Dark P, Finney S, Salam A, Silversides J, Tarmey N, Wise MP, Baudouin SV. Guidelines on the management of acute respiratory distress syndrome. BMJ Open Respir Res 2019; 6:e000420. [PMID: 31258917 PMCID: PMC6561387 DOI: 10.1136/bmjresp-2019-000420] [Citation(s) in RCA: 257] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/01/2019] [Indexed: 12/16/2022] Open
Abstract
The Faculty of Intensive Care Medicine and Intensive Care Society Guideline Development Group have used GRADE methodology to make the following recommendations for the management of adult patients with acute respiratory distress syndrome (ARDS). The British Thoracic Society supports the recommendations in this guideline. Where mechanical ventilation is required, the use of low tidal volumes (<6 ml/kg ideal body weight) and airway pressures (plateau pressure <30 cmH2O) was recommended. For patients with moderate/severe ARDS (PF ratio<20 kPa), prone positioning was recommended for at least 12 hours per day. By contrast, high frequency oscillation was not recommended and it was suggested that inhaled nitric oxide is not used. The use of a conservative fluid management strategy was suggested for all patients, whereas mechanical ventilation with high positive end-expiratory pressure and the use of the neuromuscular blocking agent cisatracurium for 48 hours was suggested for patients with ARDS with ratio of arterial oxygen partial pressure to fractional inspired oxygen (PF) ratios less than or equal to 27 and 20 kPa, respectively. Extracorporeal membrane oxygenation was suggested as an adjunct to protective mechanical ventilation for patients with very severe ARDS. In the absence of adequate evidence, research recommendations were made for the use of corticosteroids and extracorporeal carbon dioxide removal.
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Affiliation(s)
| | - Danny Francis McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, West Midlands, UK
| | | | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Andrew Boyle
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Nigel Chee
- Academic Department of Critical Care, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, NIHR Biomedical Research Centre, University of Manchester, Manchester, Greater Manchester, UK
| | - Simon Finney
- Peri-Operative Medicine, Barts Health NHS Trust, London, UK
| | - Aemun Salam
- Peri-Operative Medicine, Barts Health NHS Trust, London, UK
| | - Jonathan Silversides
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Nick Tarmey
- Academic Department of Critical Care, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - Simon V Baudouin
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Al-Saiedy M, Gunasekara L, Green F, Pratt R, Chiu A, Yang A, Dennis J, Pieron C, Bjornson C, Winston B, Amrein M. Surfactant Dysfunction in ARDS and Bronchiolitis is Repaired with Cyclodextrins. Mil Med 2019; 183:207-215. [PMID: 29635617 DOI: 10.1093/milmed/usx204] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 01/16/2018] [Indexed: 12/22/2022] Open
Abstract
Objectives Acute respiratory distress syndrome (ARDS) is caused by many factors including inhalation of toxicants, acute barotrauma, acid aspiration, and burns. Surfactant function is impaired in ARDS and acute airway injury resulting in high surface tension with alveolar and small airway collapse, edema, hypoxemia, and death. In this study, we explore the mechanisms whereby surfactant becomes dysfunctional in ARDS and bronchiolitis and its repair with a cyclodextrin drug that sequesters cholesterol. Methods We used in vitro model systems, a mouse model of ARDS, and samples from patients with acute bronchiolitis. Surface tension was measured by captive bubble surfactometry. Results Patient samples showed severe surfactant inhibition even in the absence of elevated cholesterol levels. Surfactant was also impaired in ARDS mice where the cholesterol to phospholipid ratio (W/W%) was increased. Methyl-β-cyclodextrin (MβCD) restored surfactant function to normal in both human and animal samples. Model studies showed that the inhibition of surfactant was due to both elevated cholesterol and an interaction between cholesterol and oxidized phospholipids. MβCD was also shown to have anti-inflammatory effects. Conclusions Inhaled cyclodextrins have potential for the treatment of ARDS. They could be delivered in a portable device carried in combat and used following exposure to toxic gases and fumes or shock secondary to hemorrhage and burns.
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Affiliation(s)
- Mustafa Al-Saiedy
- Snyder Institute of Chronic Diseases, University of Calgary, Calgary, Alberta, Canada T2N 4Z6
| | - Lasantha Gunasekara
- Snyder Institute of Chronic Diseases, University of Calgary, Calgary, Alberta, Canada T2N 4Z6
| | - Francis Green
- Snyder Institute of Chronic Diseases, University of Calgary, Calgary, Alberta, Canada T2N 4Z6.,SolAeroMed Inc., Calgary, Alberta, Canada T2L 2K8
| | - Ryan Pratt
- Snyder Institute of Chronic Diseases, University of Calgary, Calgary, Alberta, Canada T2N 4Z6
| | - Andrea Chiu
- Snyder Institute of Chronic Diseases, University of Calgary, Calgary, Alberta, Canada T2N 4Z6.,SolAeroMed Inc., Calgary, Alberta, Canada T2L 2K8
| | - Ailian Yang
- Snyder Institute of Chronic Diseases, University of Calgary, Calgary, Alberta, Canada T2N 4Z6
| | - John Dennis
- SolAeroMed Inc., Calgary, Alberta, Canada T2L 2K8
| | - Cora Pieron
- SolAeroMed Inc., Calgary, Alberta, Canada T2L 2K8
| | - Candice Bjornson
- Department of Pediatrics, Pediatric Cystic Fibrosis Clinic, Alberta Children's Hospital, Calgary, Alberta, Canada T3B 6A8
| | - Brent Winston
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada T2N 4Z6
| | - Matthias Amrein
- Snyder Institute of Chronic Diseases, University of Calgary, Calgary, Alberta, Canada T2N 4Z6
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Moralesa D, Tapia P, Mercado P, Ortiz C. ¿QUÉ HEMOS APRENDIDO DE FALLA RESPIRATORIA CATASTRÓFICA? REVISTA MÉDICA CLÍNICA LAS CONDES 2019. [DOI: 10.1016/j.rmclc.2019.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Buckley MS, Dzierba AL, Muir J, Gonzales JP. Moderate to Severe Acute Respiratory Distress Syndrome Management Strategies: A Narrative Review. J Pharm Pract 2019; 32:347-360. [PMID: 30791860 DOI: 10.1177/0897190019830504] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) remains a common complication associated with significant negative outcomes in critically ill patients. Lung-protective mechanical ventilation strategies remain the cornerstone in the management of ARDS. Several therapeutic options are currently available including fluid management, neuromuscular blocking agents, prone positioning, extracorporeal membrane oxygenation, corticosteroids, and inhaled pulmonary vasodilating agents (prostacyclins and nitric oxide). Unfortunately, an evidence-based, standard-of-care approach in managing ARDS beyond lung-protective ventilation remains elusive, contributing to significant variability in clinical practice. Although the optimal therapeutic strategy for managing moderate to severe ARDS remains extremely controversial, therapies supported with more robust clinical evidence should be considered first. The purpose of this narrative review is to discuss the published clinical evidence for both pharmacologic and nonpharmacologic management strategies in adult patients with moderate to severe ARDS as well as to discuss practical considerations for implementation.
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Affiliation(s)
- Mitchell S Buckley
- 1 Department of Pharmacy, Banner University Medical Center, Phoenix, AZ, USA
| | - Amy L Dzierba
- 2 Department of Pharmacy, New York-Presbyterian Hospital, NY, USA
| | - Justin Muir
- 2 Department of Pharmacy, New York-Presbyterian Hospital, NY, USA
| | - Jeffrey P Gonzales
- 3 Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Ma GG, Hao GW, Lai H, Yang XM, Liu L, Wang CS, Tu GW, Luo Z. Initial clinical impact of inhaled nitric oxide therapy for refractory hypoxemia following type A acute aortic dissection surgery. J Thorac Dis 2019; 11:495-504. [PMID: 30962993 PMCID: PMC6409278 DOI: 10.21037/jtd.2019.01.42] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND To evaluate the effect of inhaled nitric oxide (iNO) therapy on oxygenation and clinical outcomes in patients with refractory hypoxemia after surgical reconstruction for acute type A aortic dissection (TAAD). METHODS A before-and-after interventional study was conducted in patients with refractory hypoxemia after surgical reconstruction for TAAD. Postoperative refractory hypoxemia was defined as a persistent PaO2/FiO2 ratio ≤100 mmHg despite conventional therapy. From January to November 2016, conventional treatment was carried out for refractory hypoxemia. From December 2016 to October 2017, on the basis of conventional therapy, we explored the use of iNO to treat refractory hypoxemia. RESULTS Fifty-three TAAD patients with refractory hypoxemia were enrolled in this study. Twenty-seven patients received conventional treatment (conventional group), while the remaining 26 patients received iNO therapy. The PaO2/FiO2 ratio was significantly higher in the iNO group after treatment than in the conventional group when analyzed over the entire 72 hours. The duration of invasive mechanical ventilation was significantly reduced in the iNO group (69.19 vs. 104.56 hours; P=0.003). Other outcomes, such as mortality (3.85% vs. 7.41%, P=1.000), intensive care unit (ICU) duration (9.88 vs. 12.36 days, P=0.059) and hospital stay (16.88 vs. 20.76 days, P=0.060), were not significantly different between the two groups. CONCLUSIONS iNO therapy might play an ameliorative role in patients with refractory hypoxemia after surgical reconstruction for TAAD. This therapy may lead to sustained improvement in oxygenation and reduce the duration of invasive mechanical ventilation.
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Affiliation(s)
- Guo-Guang Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Hao Lai
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Xiao-Mei Yang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Lan Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Chun-Sheng Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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