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Dushianthan A, Grocott MPW, Murugan GS, Wilkinson TMA, Postle AD. Pulmonary Surfactant in Adult ARDS: Current Perspectives and Future Directions. Diagnostics (Basel) 2023; 13:2964. [PMID: 37761330 PMCID: PMC10528901 DOI: 10.3390/diagnostics13182964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/10/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a major cause of hypoxemic respiratory failure in adults, leading to the requirement for mechanical ventilation and poorer outcomes. Dysregulated surfactant metabolism and function are characteristic of ARDS. A combination of alveolar epithelial damage leading to altered surfactant synthesis, secretion, and breakdown with increased functional inhibition from overt alveolar inflammation contributes to the clinical features of poor alveolar compliance and alveolar collapse. Quantitative and qualitative alterations in the bronchoalveolar lavage and tracheal aspirate surfactant composition contribute to ARDS pathogenesis. Compared to neonatal respiratory distress syndrome (nRDS), replacement studies of exogenous surfactants in adult ARDS suggest no survival benefit. However, these studies are limited by disease heterogeneity, variations in surfactant preparations, doses, and delivery methods. More importantly, the lack of mechanistic understanding of the exact reasons for dysregulated surfactant remains a significant issue. Moreover, studies suggest an extremely short half-life of replaced surfactant, implying increased catabolism. Refining surfactant preparations and delivery methods with additional co-interventions to counteract surfactant inhibition and degradation has the potential to enhance the biophysical characteristics of surfactant in vivo.
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Affiliation(s)
- Ahilanandan Dushianthan
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton National Health System Foundation Trust, Southampton SO16 6YD, UK; (M.P.W.G.); (T.M.A.W.); (A.D.P.)
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Michael P. W. Grocott
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton National Health System Foundation Trust, Southampton SO16 6YD, UK; (M.P.W.G.); (T.M.A.W.); (A.D.P.)
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | | | - Tom M. A. Wilkinson
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton National Health System Foundation Trust, Southampton SO16 6YD, UK; (M.P.W.G.); (T.M.A.W.); (A.D.P.)
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Anthony D. Postle
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton National Health System Foundation Trust, Southampton SO16 6YD, UK; (M.P.W.G.); (T.M.A.W.); (A.D.P.)
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
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2
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Haslbauer JD, Savic Prince S, Stalder AK, Matter MS, Zinner CP, Jahn K, Obermann E, Hanke J, Leuzinger K, Hirsch HH, Tzankov A. Differential Gene Expression of SARS-CoV-2 Positive Bronchoalveolar Lavages: A Case Series. Pathobiology 2023; 91:158-168. [PMID: 37490884 PMCID: PMC10997241 DOI: 10.1159/000532057] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Transcriptomic data on bronchoalveolar lavage (BAL) from COVID-19 patients are currently scarce. OBJECTIVES This case series seeks to characterize the intra-alveolar immunopathology of COVID-19. METHOD BALs were performed on 14 patients (5 COVID-19, of which 3 mild and 2 largely asymptomatic, 9 controls). Controls included asthma (n = 1), unremarkable BALs (n = 3), infections with respiratory syncytial virus (n = 1), influenza B (n = 1), and infections with other coronaviruses (n = 3). SARS-CoV-2 RNA load was measured by quantitative nucleic acid testing, while the detection of other pathogens was performed by immunofluorescence or multiplex NAT. RESULTS Gene expression profiling showed 71 significantly downregulated and 5 upregulated transcripts in SARS-CoV-2-positive lavages versus controls. Downregulated transcripts included genes involved in macrophage development, polarization, and crosstalk (LGALS3, MARCO, ERG2, BTK, RAC1, CD83), and genes involved in chemokine signaling and immunometabolism (NUPR1, CEBPB, CEBPA, PECAM1, CCL18, PPARG, ALOX5, ALOX5AP). Upregulated transcripts featured genes involved in NK-T cell signaling (GZMA, GZMH, GNLY, PRF1, CD3G). Patients with mild COVID-19 showed a significant upregulation of genes involved in blood mononuclear cell/leukocyte function (G0S2, ANXA6, FCGR2B, ADORA3), coagulation (von Willebrand factor [VWF]), interferon response (IFRD1, IL12RB2), and a zinc metalloprotease elevated in asthma (CPA3) compared to asymptomatic cases. In-silico comparison of the 5 COVID-19 BAL cases to a published cohort of lethal COVID-19 showed a significant upregulation of "antigen processing and presentation" and "lysosome" pathways in lethal cases. CONCLUSIONS These data underscore the heterogeneity of immune response in COVID-19. Further studies with a larger dataset are required to gain a better understanding of the hallmarks of SARS-CoV-2 immunological response.
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Affiliation(s)
- Jasmin D Haslbauer
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Basel, Switzerland,
| | - Spasenija Savic Prince
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Anna K Stalder
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Matthias S Matter
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Carl P Zinner
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Kathleen Jahn
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Ellen Obermann
- Institute of Pathology, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Jasmin Hanke
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Karoline Leuzinger
- Transplantation and Clinical Virology, Department of Biomedicine, University of Basel, Basel, Switzerland
- Clinical Virology, University Hospital Basel, Basel, Switzerland
| | - Hans H Hirsch
- Transplantation and Clinical Virology, Department of Biomedicine, University of Basel, Basel, Switzerland
- Clinical Virology, University Hospital Basel, Basel, Switzerland
- Infectious Diseases and Hospital Epidemiology, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Alexandar Tzankov
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Basel, Switzerland
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Mikacenic C, Fussner LA, Bell J, Burnham EL, Chlan LL, Cook SK, Dickson RP, Almonor F, Luo F, Madan K, Morales-Nebreda L, Mould KJ, Simpson AJ, Singer BD, Stapleton RD, Wendt CH, Files DC. Research Bronchoscopies in Critically Ill Research Participants: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2023; 20:621-631. [PMID: 37125997 PMCID: PMC10174130 DOI: 10.1513/annalsats.202302-106st] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Bronchoscopy for research purposes is a valuable tool to understand lung-specific biology in human participants. Despite published reports and active research protocols using this procedure in critically ill patients, no recent document encapsulates the important safety considerations and downstream applications of this procedure in this setting. The objectives were to identify safe practices for patient selection and protection of hospital staff, provide recommendations for sample procurement to standardize studies, and give guidance on sample preparation for novel research technologies. Seventeen international experts in the management of critically ill patients, bronchoscopy in clinical and research settings, and experience in patient-oriented clinical or translational research convened for a workshop. Review of relevant literature, expert presentations, and discussion generated the findings presented herein. The committee concludes that research bronchoscopy with bronchoalveolar lavage in critically ill patients on mechanical ventilation is valuable and safe in appropriately selected patients. This report includes recommendations on standardization of this procedure and prioritizes the reporting of sample management to produce more reproducible results between laboratories. This document serves as a resource to the community of researchers who endeavor to include bronchoscopy as part of their research protocols and highlights key considerations for the inclusion and safety of research participants.
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Martin TR, Zemans RL, Ware LB, Schmidt EP, Riches DWH, Bastarache L, Calfee CS, Desai TJ, Herold S, Hough CL, Looney MR, Matthay MA, Meyer N, Parikh SM, Stevens T, Thompson BT. New Insights into Clinical and Mechanistic Heterogeneity of the Acute Respiratory Distress Syndrome: Summary of the Aspen Lung Conference 2021. Am J Respir Cell Mol Biol 2022; 67:284-308. [PMID: 35679511 PMCID: PMC9447141 DOI: 10.1165/rcmb.2022-0089ws] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/09/2022] [Indexed: 12/15/2022] Open
Abstract
Clinical and molecular heterogeneity are common features of human disease. Understanding the basis for heterogeneity has led to major advances in therapy for many cancers and pulmonary diseases such as cystic fibrosis and asthma. Although heterogeneity of risk factors, disease severity, and outcomes in survivors are common features of the acute respiratory distress syndrome (ARDS), many challenges exist in understanding the clinical and molecular basis for disease heterogeneity and using heterogeneity to tailor therapy for individual patients. This report summarizes the proceedings of the 2021 Aspen Lung Conference, which was organized to review key issues related to understanding clinical and molecular heterogeneity in ARDS. The goals were to review new information about ARDS phenotypes, to explore multicellular and multisystem mechanisms responsible for heterogeneity, and to review how best to account for clinical and molecular heterogeneity in clinical trial design and assessment of outcomes. The report concludes with recommendations for future research to understand the clinical and basic mechanisms underlying heterogeneity in ARDS to advance the development of new treatments for this life-threatening critical illness.
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Affiliation(s)
- Thomas R. Martin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Rachel L. Zemans
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Program in Cellular and Molecular Biology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine and
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eric P. Schmidt
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - David W. H. Riches
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Program in Cell Biology, Department of Pediatrics, National Jewish Health, Denver, Colorado
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carolyn S. Calfee
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Anesthesia
| | - Tushar J. Desai
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Stem Cell Institute, Stanford University School of Medicine, Stanford, California
| | - Susanne Herold
- Department of Internal Medicine VI and Cardio-Pulmonary Institute (CPI), Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Catherine L. Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Michael A. Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | - Nuala Meyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samir M. Parikh
- Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Division of Nephrology, University of Texas Southwestern, Dallas, Texas
| | - Troy Stevens
- Department of Physiology and Cell Biology, College of Medicine, Center for Lung Biology, University of South Alabama, Mobile, Alabama; and
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Safety and harms of bronchoalveolar lavage (BAL) for acute respiratory failure. Respir Investig 2022; 60:861-862. [PMID: 35970713 DOI: 10.1016/j.resinv.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/22/2022] [Indexed: 10/31/2022]
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Patolia S, Farhat R, Subramaniyam R. Bronchoscopy in intubated and non-intubated intensive care unit patients with respiratory failure. J Thorac Dis 2021; 13:5125-5134. [PMID: 34527353 PMCID: PMC8411155 DOI: 10.21037/jtd-19-3709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/09/2021] [Indexed: 01/18/2023]
Abstract
Bronchoscopy is one of the important tool for the pulmonary and critical care physicians to diagnose and treat various pulmonary conditions. It is increasingly being used by the intensivist due to its safety and portability. The utilization of bronchoscopy in the intensive care unit (ICU) has made the diagnosis and treatment of many conditions more feasible to intensivists. Sedation, topical or intravenous, usually helps better tolerate the procedure. However, the risks and benefits of bronchoscopy should be carefully considered in critically ill patients. The hypoxic patients in ICU pose a challenge as hypoxemia is one of the known complications of bronchoscopy, and this risk is exacerbated in patients with hypoxic respiratory failure. Bronchoscopy is relatively contraindicated in patients with severe hypoxemia and coagulopathy. However, bronchoscopy in hypoxic patients can have diagnostic as well as therapeutic implications. In patients with hypoxic respiratory failure, the use of non-invasive ventilation (NIV) during bronchoscopy has been shown to reduce the risk of intubation. On the other hand, bronchoscopy in mechanically ventilated patients is not contraindicated and has been widely used. Staying focused, monitoring vital signs closely, limiting the scope time in the airway, and understanding patient’s physiology may help decrease risk of complications. In this review, we discuss indications, techniques, complications, and yield associated with bronchoscopy in critically ill hypoxic patients.
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Affiliation(s)
- Setu Patolia
- Pulmonary and Critical Care Medicine, Saint Louis University, School of Medicine, Saint Louis, MO, USA
| | - Rania Farhat
- Pulmonary and Critical Care Medicine, Saint Louis University, School of Medicine, Saint Louis, MO, USA
| | - Rajamurugan Subramaniyam
- Pulmonary and Critical Care Medicine, Saint Louis University, School of Medicine, Saint Louis, MO, USA
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Safety and harms of bronchoalveolar lavage for acute respiratory failure: A systematic review and meta-analysis. Respir Investig 2021; 60:68-81. [PMID: 34489205 DOI: 10.1016/j.resinv.2021.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/01/2021] [Accepted: 07/28/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND This review aimed to investigate whether bronchoalveolar lavage (BAL) is safe in patients with severe acute respiratory failure (ARF). METHODS We searched the MEDLINE, CENTRAL, and other databases up to June 2, 2021 for studies that examined BAL for severe ARF. We included all cohort studies and randomized or non-randomized trials, while we excluded case-control studies, case reports, and case series. We evaluated the quality of the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. RESULTS We included 17 studies (1085 patients) in the meta-analysis. The integrated frequency of death was 0.000% (95% confidence interval [CI]: 0.000-0.045%, I2 = 0.0%). The pooled risk of severe complications of respiratory system, cardiovascular system, and major bleeding was 1.32% (95% CI: 0.000-4.41%, I2 = 84.8%), 0.040% (95% CI: 0.000-0.71%, I2 = 9.3%), and 0.000% (95% CI: 0.000-0.27%, I2 = 0.0%), respectively. In the subgroup analysis with mechanical ventilation during BAL, there were few severe complications of the respiratory system (3/717 patients in 13 studies) and almost no heterogeneity (I2 = 0.0%). CONCLUSIONS Our study suggests that severe complications of BAL for severe ARF are probably rare, particularly in patients receiving mechanical ventilation. After considering the risks and benefits, it would be worthwhile to consider performing BAL in patients with severe ARF of unknown etiology to pursue its cause. TRIAL REGISTRATION The protocol was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000040600).
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8
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Norton DL, Ceppe A, Tune MK, McCravy M, Devlin T, Drummond MB, Carson SS, Vincent BG, Hagan RS, Dang H, Doerschuk CM, Mock JR. Bronchoalveolar Tregs are associated with duration of mechanical ventilation in acute respiratory distress syndrome. J Transl Med 2020; 18:427. [PMID: 33176790 PMCID: PMC7656499 DOI: 10.1186/s12967-020-02595-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/29/2020] [Indexed: 02/02/2023] Open
Abstract
Background Foxp3+ regulatory T cells (Tregs) play essential roles in immune homeostasis and repair of damaged lung tissue. We hypothesized that patients whose lung injury resolves quickly, as measured by time to liberation from mechanical ventilation, have a higher percentage of Tregs amongst CD4+ T cells in either airway, bronchoalveolar lavage (BAL) or peripheral blood samples. Methods We prospectively enrolled patients with ARDS requiring mechanical ventilation and collected serial samples, the first within 72 h of ARDS diagnosis (day 0) and the second 48–96 h later (day 3). We analyzed immune cell populations and cytokines in BAL, tracheal aspirates and peripheral blood, as well as cytokines in plasma, obtained at the time of bronchoscopy. The study cohort was divided into fast resolvers (FR; n = 8) and slow resolvers (SR; n = 5), based on the median number of days until first extubation for all participants (n = 13). The primary measure was the percentage of CD4+ T cells that were Tregs. Results The BAL of FR contained more Tregs than SR. This finding did not extend to Tregs in tracheal aspirates or blood. BAL Tregs expressed more of the full-length FOXP3 than a splice variant missing exon 2 compared to Tregs in simultaneously obtained peripheral blood. Conclusion Tregs are present in the bronchoalveolar space during ARDS. A greater percentage of CD4+ cells were Tregs in the BAL of FR than SR. Tregs may play a role in the resolution of ARDS, and enhancing their numbers or functions may be a therapeutic target.
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Affiliation(s)
- Dustin L Norton
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, USA.,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.,Section of Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Agathe Ceppe
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, USA.,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.,Marsico Lung Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Miriya K Tune
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, USA.,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.,Marsico Lung Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Matthew McCravy
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.,Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Thomas Devlin
- Department of Respiratory Care, University of North Carolina, Chapel Hill, NC, USA
| | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, USA.,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.,Marsico Lung Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Shannon S Carson
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, USA.,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.,Marsico Lung Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Benjamin G Vincent
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.,Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, NC, USA.,Division of Hematology/Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - Robert S Hagan
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, USA.,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.,Marsico Lung Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Hong Dang
- Marsico Lung Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Claire M Doerschuk
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, USA.,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.,Marsico Lung Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Jason R Mock
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, USA. .,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA. .,Marsico Lung Institute, University of North Carolina, Chapel Hill, NC, USA. .,Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Marsico Hall 7203, 125 Mason Farm Road, Chapel Hill, NC, 27599, USA.
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Abdelaal Ahmed Mahmoud A, Mahmoud HE, Mahran MA, Khaled M. Streptokinase Versus Unfractionated Heparin Nebulization in Patients With Severe Acute Respiratory Distress Syndrome (ARDS): A Randomized Controlled Trial With Observational Controls. J Cardiothorac Vasc Anesth 2020; 34:436-443. [DOI: 10.1053/j.jvca.2019.05.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/19/2019] [Accepted: 05/23/2019] [Indexed: 02/08/2023]
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10
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Kamel T, Helms J, Janssen-Langenstein R, Kouatchet A, Guillon A, Bourenne J, Contou D, Guervilly C, Coudroy R, Hoppe MA, Lascarrou JB, Quenot JP, Colin G, Meng P, Roustan J, Cracco C, Nay MA, Boulain T. Benefit-to-risk balance of bronchoalveolar lavage in the critically ill. A prospective, multicenter cohort study. Intensive Care Med 2020; 46:463-474. [PMID: 31912201 PMCID: PMC7223716 DOI: 10.1007/s00134-019-05896-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/05/2019] [Indexed: 12/15/2022]
Abstract
Purpose To assess the benefit-to-risk balance of bronchoalveolar lavage (BAL) in intensive care unit (ICU) patients. Methods In 16 ICUs, we prospectively collected adverse events during or within 24 h after BAL and assessed the BAL input for decision making in consecutive adult patients. The occurrence of a clinical adverse event at least of grade 3, i.e., sufficiently severe to need therapeutic action(s), including modification(s) in respiratory support, defined poor BAL tolerance. The BAL input for decision making was declared satisfactory if it allowed to interrupt or initiate one or several treatments. Results We included 483 BAL in 483 patients [age 63 years (interquartile range (IQR) 53–72); female gender: 162 (33.5%); simplified acute physiology score II: 48 (IQR 37-61); immunosuppression 244 (50.5%)]. BAL was begun in non-intubated patients in 105 (21.7%) cases. Sixty-seven (13.9%) patients reached the grade 3 of adverse event or higher. Logistic regression showed that a BAL performed by a non-experienced physician (non-pulmonologist, or intensivist with less than 10 years in the specialty or less than 50 BAL performed) was the main predictor of poor BAL tolerance in non-intubated patients [OR: 3.57 (95% confidence interval 1.04–12.35); P = 0.04]. A satisfactory BAL input for decision making was observed in 227 (47.0%) cases and was not predictable using logistic regression. Conclusions Adverse events related to BAL in ICU patients are not infrequent nor necessarily benign. Our findings call for an extreme caution, when envisaging a BAL in ICU patients and for a mandatory accompaniment of the less experienced physicians. Electronic supplementary material The online version of this article (10.1007/s00134-019-05896-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Toufik Kamel
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 14 Avenue de l'Hôpital CS 86709, 45067, Orléans Cedex 2, France
| | - Julie Helms
- CHU de Strasbourg-Hôpital Civil, Service de Réanimation Médicale 1, Place de l'Hôpital, BP 426, 67091, Strasbourg Cedex, France
| | - Ralf Janssen-Langenstein
- Médecine intensive Réanimation, Hôpital de Haute pierre, Hôpitaux Universitaires de Strasbourg, Avenue Molière, 67098, Strasbourg Cedex, France
| | - Achille Kouatchet
- CHU d'Angers Service de Réanimation Médicale et de Médecine Hyperbare, 4, Rue Larrey, 49933, Angers Cedex 09, France
| | - Antoine Guillon
- CHRU de Tours-Hôpital Bretonneau Service de Réanimation Polyvalente, 2 bis, Boulevard Tonnelle, 37044, Tours Cedex 09, France
| | - Jeremy Bourenne
- Médecine Intensive Réanimation, Réanimation des Urgences CHU la Timone 2-Pole RUSH, 264 Rue Saint Pierre, 13005, Marseille, France
| | - Damien Contou
- CH d'Argenteuil Service de Réanimation Polyvalente, 69, Rue du Lieutenant-Colonel Prudhon, 95107, Argenteuil Cedex, France
| | - Christophe Guervilly
- Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, 13015, Marseille, France
- Aix-Marseille Université, Faculté de médecine, Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie, EA 3279, 13005, Marseille, France
| | - Rémi Coudroy
- Médecine intensive et Réanimation, CHU de Poitiers, 2 rue de la Milétrie, 86021, Poitiers, France
- INSERM U1402, Groupe ALIVE, Université de Poitiers, 2 rue de la Milétrie, 86021, Poitiers, France
| | - Marie Anne Hoppe
- CH de La Rochelle-Hôpital Saint-Louis Service de Réanimation Polyvalente, Rue du Docteur Schweitzer, 17019, La Rochelle Cedex 01, France
| | - Jean Baptiste Lascarrou
- Service de Médecine Intensive Réanimation, CHU de Nantes-Hôtel Dieu, 30 Bd. Jean Monnet, 44093, Nantes Cedex 1, France
| | - Jean Pierre Quenot
- CHU de Dijon-Complexe du Bocage, Service de Réanimation Médicale, 2 Boulevard Maréchal de Lattre de Tassigny, BP 77908, 21079, Dijon Cedex, France
| | - Gwenhaël Colin
- CHD Vendée-Hôpital de la Roche-sur-Yon, Service de Réanimation Polyvalente Les Oudairies, 85925, La Roche-Sur-Yon Cedex 09, France
| | - Paris Meng
- Hôpital Raymond Poincaré, APHP, Service de Médecine intensive Réanimation, 104 Boulevard Raymond Poincaré, 92380, Garches, France
| | - Jérôme Roustan
- Centre hospitalier de Montauban, service de réanimation polyvalente, 100 rue Léon Cladel, BP 765, 82013, Montauban Cedex, France
| | - Christophe Cracco
- CH d'Angoulême Service de Réanimation Polyvalente, Rond-Point de Girac CS, 55015 Saint-Michel, 16959, Angoulême Cedex 9, France
| | - Mai-Anh Nay
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 14 Avenue de l'Hôpital CS 86709, 45067, Orléans Cedex 2, France
| | - Thierry Boulain
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 14 Avenue de l'Hôpital CS 86709, 45067, Orléans Cedex 2, France.
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11
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Lesur O, Chagnon F, Lebel R, Lepage M. In Vivo Endomicroscopy of Lung Injury and Repair in ARDS: Potential Added Value to Current Imaging. J Clin Med 2019; 8:jcm8081197. [PMID: 31405200 PMCID: PMC6723156 DOI: 10.3390/jcm8081197] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/06/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Standard clinical imaging of the acute respiratory distress syndrome (ARDS) lung lacks resolution and offers limited possibilities in the exploration of the structure-function relationship, and therefore cannot provide an early and clear discrimination of patients with unexpected diagnosis and unrepair profile. The current gold standard is open lung biopsy (OLB). However, despite being able to reveal precise information about the tissue collected, OLB cannot provide real-time information on treatment response and is accompanied with a complication risk rate up to 25%, making longitudinal monitoring a dangerous endeavor. Intravital probe-based confocal laser endomicroscopy (pCLE) is a developing and innovative high-resolution imaging technology. pCLE offers the possibility to leverage multiple and specific imaging probes to enable multiplex screening of several proteases and pathogenic microorganisms, simultaneously and longitudinally, in the lung. This bedside method will ultimately enable physicians to rapidly, noninvasively, and accurately diagnose degrading lung and/or fibrosis without the need of OLBs. OBJECTIVES AND METHODS To extend the information provided by standard imaging of the ARDS lung with a bedside, high-resolution, miniaturized pCLE through the detailed molecular imaging of a carefully selected region-of-interest (ROI). To validate and quantify real-time imaging to validate pCLE against OLB. RESULTS Developments in lung pCLE using fluorescent affinity- or activity-based probes at both preclinical and clinical (first-in-man) stages are ongoing-the results are promising, revealing correlations with OLBs in problematic ARDS. CONCLUSION It can be envisaged that safe, high-resolution, noninvasive pCLE with activatable fluorescence probes will provide a "virtual optical biopsy" and will provide decisive information in selected ARDS patients at the bedside.
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Affiliation(s)
- Olivier Lesur
- Intensive Care and Pneumology Departments, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC J1H 5N4, Canada.
- Sherbrooke Molecular Imaging Center (CIMS), Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC J1H 5N4, Canada.
| | - Frédéric Chagnon
- Intensive Care and Pneumology Departments, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC J1H 5N4, Canada
| | - Réjean Lebel
- Sherbrooke Molecular Imaging Center (CIMS), Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC J1H 5N4, Canada
- Nuclear Medicine and Radiobiology Departments, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC J1H 5N4, Canada
| | - Martin Lepage
- Sherbrooke Molecular Imaging Center (CIMS), Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC J1H 5N4, Canada
- Nuclear Medicine and Radiobiology Departments, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC J1H 5N4, Canada
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12
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Ergan B, Nava S. The use of bronchoscopy in critically ill patients: considerations and complications. Expert Rev Respir Med 2018; 12:651-663. [PMID: 29958019 DOI: 10.1080/17476348.2018.1494576] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Flexible bronchoscopy has been well established for diagnostic and therapeutic purposes in critically ill patients. Areas covered: This review outlines the clinical evidence of the utility and safety of flexible bronchoscopy in the intensive care unit, as well as specific considerations, including practical points and potential complications, in critically ill patients. Expert commentary: Its ease to learn and perform and its capacity for bedside application with relatively few complications make flexible bronchoscopy an indispensable tool in the intensive care unit setting. The main indications for flexible bronchoscopy in the intensive care unit are the visualization of the airways, sampling for diagnostic purposes and management of the artificial airways. The decision to perform flexible bronchoscopy can only be made by trade-offs between potential risks and benefits because of the fragile nature of the critically ill. Flexible bronchoscopy-associated serious adverse events are inevitable in cases of a lack of expertise or appropriate precautions.
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Affiliation(s)
- Begum Ergan
- a Department of Pulmonary and Critical Care , School of Medicine, Dokuz Eylul University , Izmir , Turkey
| | - Stefano Nava
- b Department of Clinical , Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Alma Mater University , Bologna , Italy
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13
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Gupta N, Sachdev A, Gupta D, Gupta S. Safety profile of blind bronchial sampling-A prospective study in pediatric intensive care unit. Pediatr Pulmonol 2018; 53:942-947. [PMID: 29566462 DOI: 10.1002/ppul.23989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 02/24/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To study the safety profile of blind bronchial sampling in mechanically ventilated children. DESIGN Prospective interventional study. SETTING Tertiary level pediatric intensive care unit of a multispecialty hospital. PATIENTS Children aged 1 month to 16 years on mechanical ventilator for ≥48 h, were assessed by clinical pulmonary infection score for ventilator-associated pneumonia (VAP). INTERVENTIONS Blind bronchial sampling was performed following standard procedural guidelines. The hemodynamic, ventilation parameters, and arterial blood gases done before, and in next 24 h post procedure were recorded and compared. MEASUREMENTS AND MAIN RESULTS Among the 40 enrolled children, VAP was suspected at 5.8 ± 3.7 days post intubation with insignificant increase in median (IQR) PELOD score to 15 (11-23) from 13.5 (11-23) (P value 0.29). A statistically significant increase in mean blood pressure (75.5 ± 14.7 to 79.1 ± 14.2, P 0.04) and transient drop in SpO2 (98.2 ± 2.3 to 92.2 ± 9.2, P < 0.001) were noted with insignificant change in heart rate (128.7 ± 25.6 vs 132.0 ± 30.8, P 0.52), though these variations were clinically not significant. There were no major complications like significant airway bleed, arrhythmia, air leaks, edema, and change in pulmonary infiltrates during the procedure. There were no significant (either clinical or statistical) effects of BBS procedure, whether transient or prolonged, on ventilatory requirements or gas exchange parameters. CONCLUSIONS Blind bronchial sampling is a safe procedure in children with no major adverse events related to hemodynamics, oxygenation, and ventilation parameters.
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Affiliation(s)
- Neeraj Gupta
- Consultant, Division of Pediatric Emergency, Critical Care, Pulmonology & Allergic Disorders, Institute of Child Health Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
| | - Anil Sachdev
- Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
| | - Dhiren Gupta
- Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
| | - Suresh Gupta
- Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
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14
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Kalchiem-Dekel O, Shanholtz CB, Jeudy J, Sachdeva A, Pickering EM. Feasibility, safety, and utility of bronchoscopy in patients with ARDS while in the prone position. Crit Care 2018; 22:54. [PMID: 29499729 PMCID: PMC5834861 DOI: 10.1186/s13054-018-1983-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 02/07/2018] [Indexed: 11/18/2022] Open
Affiliation(s)
- Or Kalchiem-Dekel
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Maryland School of Medicine, 110 South Paca Street, Baltimore, MD, 21201, USA.
| | - Carl B Shanholtz
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Maryland School of Medicine, 110 South Paca Street, Baltimore, MD, 21201, USA
| | - Jean Jeudy
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 110 South Paca Street, Baltimore, MD, 21201, USA
| | - Ashutosh Sachdeva
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Maryland School of Medicine, 110 South Paca Street, Baltimore, MD, 21201, USA
| | - Edward M Pickering
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Maryland School of Medicine, 110 South Paca Street, Baltimore, MD, 21201, USA
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15
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16
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Ellekjaer KL, Meyhoff TS, Møller MH. Therapeutic bronchoscopy vs. standard of care in acute respiratory failure: a systematic review. Acta Anaesthesiol Scand 2017; 61:1240-1252. [PMID: 28990179 DOI: 10.1111/aas.13000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 09/04/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND We aimed to assess patient-important benefits and harms of therapeutic bronchoscopy vs. standard of care (no bronchoscopy) in critically ill patients with acute respiratory failure (ARF). METHODS We conducted a systematic review with meta-analysis and trial sequential analysis (TSA) according to the Cochrane Handbook and GRADE methodology, including a predefined protocol (PROSPERO no. CRD42016046235). We included randomized clinical trials (RCTs) comparing therapeutic bronchoscopy to standard of care in critically ill patients with ARF. Two reviewers independently assessed trials for inclusion, extracted data and assessed risk of bias. Risk ratios (RR) with 95% confidence intervals (CI) were estimated by conventional meta-analysis. The risk of random errors was assessed by TSA. Exclusively patient-important outcomes were evaluated. RESULTS We included five trials (n = 212); all were judged as having high risk of bias. There was no difference in all-cause mortality between therapeutic bronchoscopy and standard of care (TSA adjusted RR 0.39; 95% CI 0.14 to 1.07; I2 0%), and only 3% of the required information size had been accrued. There was no difference in ICU length of stay. A shorter duration of mechanical ventilation was suggested by conventional meta-analysis, however TSA highlighted that only 42% of the required information size had been accrued, indicating high risk of random errors. No trials reported data on adverse events, hospital length of stay, quality of life or performance status. CONCLUSIONS The quantity and quality of evidence supporting therapeutic bronchoscopy in critically ill patients with ARF is very low with no firm evidence for benefit or harm.
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Affiliation(s)
- K. L. Ellekjaer
- Department of Intensive Care 4131; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - T. S. Meyhoff
- Department of Intensive Care 4131; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - M. H. Møller
- Department of Intensive Care 4131; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
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17
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Investigation of a cause–effect relationship between flexible bronchoscopy and pneumothorax in patients with severe acute respiratory distress syndrome. Eur J Anaesthesiol 2015; 32:896-8. [DOI: 10.1097/eja.0000000000000290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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18
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Nay MA, Mankikian J, Auvet A, Dequin PF, Guillon A. The effect of fibreoptic bronchoscopy in acute respiratory distress syndrome: experimental evidence from a lung model. Anaesthesia 2015; 71:185-91. [DOI: 10.1111/anae.13274] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2015] [Indexed: 11/27/2022]
Affiliation(s)
- M.-A. Nay
- Centre Hospitalier Régional Universitaire de Tours; Service de Réanimation Polyvalente; Tours France
| | - J. Mankikian
- Centre Hospitalier Régional Universitaire de Tours; Service de Réanimation Polyvalente; Tours France
| | - A. Auvet
- Centre Hospitalier Régional Universitaire de Tours; Service de Réanimation Polyvalente; Tours France
- French Institute of Health and Medical Research; Centre d'Etude des Pathologies Respiratoires; Tours France
| | - P.-F. Dequin
- French Institute of Health and Medical Research; Centre d'Etude des Pathologies Respiratoires; Tours France
- Centre Hospitalier Régional Universitaire de Tours; Service de Réanimation Polyvalente; Tours France
| | - A. Guillon
- Centre Hospitalier Régional Universitaire de Tours; Service de Réanimation Polyvalente; Tours France
- French Institute of Health and Medical Research; Centre d'Etude des Pathologies Respiratoires; Tours France
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19
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Nicholson TT, Mutlu GM. Pneumothorax following bronchoalveolar lavage for the diagnosis of non-tuberculous mycobacterial infection. An «atypical» complication of bronchoscopy? Arch Bronconeumol 2015; 52:278-9. [PMID: 26574159 DOI: 10.1016/j.arbres.2015.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/13/2015] [Accepted: 07/14/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Trevor T Nicholson
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, EE. UU..
| | - Gökhan M Mutlu
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois, EE. UU
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20
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Schnabel RM, van der Velden K, Osinski A, Rohde G, Roekaerts PMHJ, Bergmans DCJJ. Clinical course and complications following diagnostic bronchoalveolar lavage in critically ill mechanically ventilated patients. BMC Pulm Med 2015; 15:107. [PMID: 26420333 PMCID: PMC4588466 DOI: 10.1186/s12890-015-0104-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 09/21/2015] [Indexed: 12/26/2022] Open
Abstract
Background Flexible, fibreoptic bronchoscopy (FFB) and bronchoalveolar lavage (BAL) have been used for diagnostic purposes in critically ill ventilated patients. The additional diagnostic value compared to tracheal aspirations in ventilator-associated pneumonia (VAP) has been questioned. Nevertheless, BAL can provide extra information for the differential diagnosis of respiratory disease and good antibiotic stewardship. These benefits should outweigh potential hazards caused by the invasiveness of this diagnostic technique. The focus of the present study was on the clinical course and complications of patients following BAL procedures up to 24 h. Methods Hundred sixty-four FFB guided BAL procedures for suspected pneumonia were analysed in an observational study. The clinical course of patients was monitored by respiratory and haemodynamic data before BAL, 1 and 24 h after BAL. Complications were defined and registered. Factors associated with complications were analysed by logistic regression. Results Clinical course: a decrease in average pO2/FiO2 ratio 1 h after BAL from 29 kPa (218 mmHg) to 25 kPa (189 mmHg) (p < 0.05) was observed which fully recovered within 24 h. Respiratory complications: the incidence of procedure related hypo-oxygenation (SaO2 ≤ 88 %) and/or bronchospasm was 9 %; a decrease of >25 % PaO2/FiO2 ratio 1 h after BAL was found in 29 % of patients; no bleeding or pneumothorax were registered. Haemodynamic complications: there were no cases of hypertension and cardiac rhythm disturbances; haemodynamic instability within the first 24 h after BAL was recorded in 22 %; this was correlated with a cardiovascular diagnosis at admission (OR 2.9; 95 % CI 1.2 - 6.7) and the presence of cardiovascular co-morbidity (OR 3.5; 95 % CI 1.5 – 8.3). The incidence of bacteraemia was 7 %. There was no case of procedure related death. Discussion Frequently occurring haemodynamic and respiratory instability but no cases of cardiac rhythm disturbances, bleeding, pneumothorax or procedure related death were attributable to diagnostic FFB and BAL. The procedures should be conducted under careful supervision by experienced physicians. Only a randomized controlled trial that compares diagnostic FFB and BAL with a non-invasive strategy could ultimately establish the safety profile and clinical utility of these procedures in critically ill ventilated patients.
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Affiliation(s)
- R M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - K van der Velden
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - A Osinski
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - G Rohde
- Department of Respiratory Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - P M H J Roekaerts
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - D C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
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Abstract
Acute respiratory distress syndrome is a life-threatening condition that is common in critically ill patients. Historically, diagnosis has been difficult and prognosis has been poor, but the Berlin definition and developments in medical therapies provide promise that we can improve outcomes for these patients in the future.
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Affiliation(s)
- Felicity Liew
- Medical Student in the School of Medicine, University College London, London
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22
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Terzi E, Zarogoulidis K, Kougioumtzi I, Dryllis G, Kioumis I, Pitsiou G, Machairiotis N, Katsikogiannis N, Lampaki S, Papaiwannou A, Tsiouda T, Madesis A, Karaiskos T, Zaric B, Branislav P, Zarogoulidis P. Acute respiratory distress syndrome and pneumothorax. J Thorac Dis 2014; 6:S435-42. [PMID: 25337400 DOI: 10.3978/j.issn.2072-1439.2014.08.34] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 08/19/2014] [Indexed: 12/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) can occur during the treatment of several diseases and in several interventional procedures as a complication. It is a difficult situation to handle and special care should be applied to the patients. Mechanical ventilation is used for these patients and several parameters are changed constantly until compliance is achieved. However, a complication that is observed during the application of positive airway pressure is pneumothorax. In our current work we will present definition and causes of pneumothorax in the setting of intensive care unit (ICU). We will identify differences and similarities of this situation and present treatment options.
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Affiliation(s)
- Eirini Terzi
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Konstantinos Zarogoulidis
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Ioanna Kougioumtzi
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Georgios Dryllis
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Ioannis Kioumis
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Georgia Pitsiou
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Nikolaos Machairiotis
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Nikolaos Katsikogiannis
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Sofia Lampaki
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Antonis Papaiwannou
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Theodora Tsiouda
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Athanasios Madesis
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Theodoros Karaiskos
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Bojan Zaric
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Perin Branislav
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Paul Zarogoulidis
- 1 Internal Medicine Department-Unit of Infectious Diseases, "AHEPA" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 5 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 6 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Thoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia
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CHEN YUQING, RONG LING, QIAO JIANOU. Anti-inflammatory effects of Panax notoginseng saponins ameliorate acute lung injury induced by oleic acid and lipopolysaccharide in rats. Mol Med Rep 2014; 10:1400-8. [DOI: 10.3892/mmr.2014.2328] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 01/22/2014] [Indexed: 11/05/2022] Open
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Prebil SEW, Andrews J, Cribbs SK, Martin GS, Esper A. Safety of research bronchoscopy in critically ill patients. J Crit Care 2014; 29:961-4. [PMID: 25092617 DOI: 10.1016/j.jcrc.2014.06.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 05/13/2014] [Accepted: 06/04/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Bronchoscopy and bronchoalveolar lavage (BAL) are common procedures in intensive care units; however, no contemporaneous safety and outcomes data have been reported, particularly for critically ill patients. DESIGN This is a retrospective analysis of prospectively collected data from teaching hospital adult intensive care units. INTERVENTIONS One hundred mechanically ventilated patients with severe sepsis, septic shock, acute lung injury (ALI), and/or acute respiratory distress syndrome underwent bronchoscopy with unilateral BAL. Data collected included demographics, presence of sepsis or ALI, Pao2 to Fio2 ratio, positive end-expiratory pressure, Acute Physiology and Chronic Health Evaluation score, Sequential Organ Failure Assessment score, and peri- or postprocedural complications. RESULTS Men comprised 51% of the patients; 81% of the patients were black, and 15% were white. The mean age was 52 (SD, ±16) years. The mean Acute Physiology and Chronic Health Evaluation score was 22 (±7.5), whereas the median Sequential Organ Failure Assessment score was 9 (interquartile range, 5-12). Ten patients (10%) had complications during or immediately after the procedure. Hypoxemia during or immediately after the BAL was the most common complication. Ninety percent of the complications were related to transient hypoxemia, whereas bradycardia and hypotension each occurred in 1 patient. Age, female sex, and higher positive end-expiratory pressure were associated with complications. CONCLUSIONS Bronchoscopy with BAL in critically ill patients with sepsis and ALI is well tolerated with low risk of complications, primarily related to manageable hypoxemia.
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Affiliation(s)
- Sarah E W Prebil
- University of Minnesota, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Minneapolis, MN
| | - Joel Andrews
- Emory University, Division of Pulmonary, Allergy and Critical Care Medicine, Atlanta, GA
| | - Sushma K Cribbs
- Emory University, Division of Pulmonary, Allergy and Critical Care Medicine, Atlanta, GA; Pulmonary Medicine, Department of Veterans Affairs Medical Center, Atlanta, GA
| | - Greg S Martin
- Emory University, Division of Pulmonary, Allergy and Critical Care Medicine, Atlanta, GA
| | - Annette Esper
- Emory University, Division of Pulmonary, Allergy and Critical Care Medicine, Atlanta, GA.
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Burnham EL, Janssen WJ, Riches DWH, Moss M, Downey GP. The fibroproliferative response in acute respiratory distress syndrome: mechanisms and clinical significance. Eur Respir J 2013; 43:276-85. [PMID: 23520315 DOI: 10.1183/09031936.00196412] [Citation(s) in RCA: 237] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Acute respiratory distress syndrome (ARDS) continues to be a major healthcare problem, affecting >190,000 people in the USA annually, with a mortality of 27-45%, depending on the severity of the illness and comorbidities. Despite advances in clinical care, particularly lung protective strategies of mechanical ventilation, most survivors experience impaired health-related quality of life for years after the acute illness. While most patients survive the acute illness, a subset of ARDS survivors develops a fibroproliferative response characterised by fibroblast accumulation and deposition of collagen and other extracellular matrix components in the lung. Historically, the development of severe fibroproliferative lung disease has been associated with a poor prognosis with high mortality and/or prolonged ventilator dependence. More recent studies also support a relationship between the magnitude of the fibroproliferative response and long-term health-related quality of life. The factors that determine which patients develop fibroproliferative ARDS and the cellular mechanisms responsible for this pathological response are not well understood. This article reviews our current understanding of the contribution of pulmonary dysfunction to mortality and to quality of life in survivors of ARDS, the mechanisms driving pathological fibroproliferation and potential therapeutic approaches to prevent or attenuate fibroproliferative lung disease.
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Affiliation(s)
- Ellen L Burnham
- Dept of Medicine, University of Colorado Health Sciences Center, Aurora, CO
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Effects on respiratory mechanics of bronchoalveolar lavage in mechanically ventilated patients. J Bronchology Interv Pulmonol 2012; 17:228-31. [PMID: 23168888 DOI: 10.1097/lbr.0b013e3181e846ee] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Inconsistent findings have been reported about the effects of bronchoalveolar lavage (BAL) on respiratory mechanics. The aims of this study were to study the effects of BAL on respiratory mechanics in mechanically ventilated patients with suspected pneumonia and to find out whether these effects are related to the extension of radiographic infiltrate and preceding respiratory mechanics measurements. METHODS Bronchoscopy BAL was performed with 150 mL of sterile isotonic saline in 3 aliquots of 50 mL. Respiratory mechanics parameters were measured by the rapid airway occlusion technique, immediately before and after BAL and 90 minutes later. Patients were classified according to unilateral or bilateral radiological infiltrate occurrence. RESULTS Fifty critically ill patients undergoing mechanical ventilation were included. Respiratory system compliance (Crs) decreased from 43.32±13.17 mL/cm H2O to 33.02±9.56 mL/cm H2O (P<0.01) and airway resistance increased from 15.16±7.04 cm H2O/L/s to 17.54±9.40 cm H2O/L/s (P<0.05) immediately after BAL; 90 minutes later both the parameters returned to the pre-BAL values. Patients who showed a greater than 20% decrease in Crs had a higher pre-BAL Crs than patients with a less severe decrease (49.85±10.7 mL/cm H2O vs. 35.65±11.67 mL/cm H2O; P<0.01). However, neither pre-BAL airway resistance nor the extension of the radiographic infiltrates was related to the changes in respiratory mechanics. CONCLUSIONS BAL in mechanically ventilated patients can lead to a significant, although transitory, deterioration in pulmonary mechanics, characterized by a decrease in Crs and by an increase in airway resistance. Patients with better initial Crs showed the most severe affectation.
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Meyer KC, Raghu G, Baughman RP, Brown KK, Costabel U, du Bois RM, Drent M, Haslam PL, Kim DS, Nagai S, Rottoli P, Saltini C, Selman M, Strange C, Wood B. An official American Thoracic Society clinical practice guideline: the clinical utility of bronchoalveolar lavage cellular analysis in interstitial lung disease. Am J Respir Crit Care Med 2012; 185:1004-14. [PMID: 22550210 DOI: 10.1164/rccm.201202-0320st] [Citation(s) in RCA: 663] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The clinical utility of bronchoalveolar lavage fluid (BAL) cell analysis for the diagnosis and management of patients with interstitial lung disease (ILD) has been a subject of debate and controversy. The American Thoracic Society (ATS) sponsored a committee of international experts to examine all relevant literature on BAL in ILD and provide recommendations concerning the use of BAL in the diagnosis and management of patients with suspected ILD. PURPOSE To provide recommendations for (1) the performance and processing of BAL and (2) the interpretation of BAL nucleated immune cell patterns and other BAL characteristics in patients with suspected ILD. METHODS A pragmatic systematic review was performed to identify unique citations related to BAL in patients with ILD that were published between 1970 and 2006. The search was updated during the guideline development process to include published literature through March 2011. This is the evidence upon which the committee's conclusions and recommendations are based. RESULTS Recommendations for the performance and processing of BAL, as well as the interpretation of BAL findings, were formulated by the committee. CONCLUSIONS When used in conjunction with comprehensive clinical information and adequate thoracic imaging such as high-resolution computed tomography of the thorax, BAL cell patterns and other characteristics frequently provide useful information for the diagnostic evaluation of patients with suspected ILD.
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[Fiberoptic bronchoscopy in a respiratory intensive care unit]. Med Intensiva 2011; 36:389-95. [PMID: 22195599 DOI: 10.1016/j.medin.2011.11.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 09/27/2011] [Accepted: 11/04/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe the indications, diagnostic performance and safety of fiberoptic bronchoscopy (FOB) performed in a respiratory intensive care unit (RICU). DESIGN A prospective, observational study was carried out. SETTING A 6-bed RICU in a tertiary university hospital. PATIENTS Patients admitted to RICU who required FOB. INTERVENTIONS None. MAIN MEASUREMENTS FOB indications and complications, endoscopic procedures, time required to perform FOB. RESULTS Sixty-nine out (23%) of the 297 patients admitted to the RICU underwent a total of 107 FOB. Sixty-eight percent of FOB were performed in patients on mechanical ventilation. FOB was performed for diagnostic and therapeutic purposes in 88 (82%) and 19 cases (18%), respectively. The study of pulmonary infiltrates was the main indication for diagnostic FOB (44 cases; 50%), particularly in immunocompromised patients (24 cases; 27%). In immunocompromised patients the diagnostic performance of FOB was significantly higher than in immunocompetent subjects (48% vs 30%; p<0.01). No major complications were recorded. Only a significant drop in PaO(2)/FiO(2) ratio was observed (182 ± 74 vs 163 ± 79; p<0.005) in patients undergoing bronchoalveolar lavage. Overall mortality in patients in the RICU was 14%. In patients requiring a single FOB procedure, mortality was 25%, versus 45% among those requiring more than one FOB procedure. CONCLUSIONS These results show that FOB is used commonly in the RICU. It is a safe and fast procedure that contributes significantly to clinical management. Patients requiring additional FOB during admission to the RICU show high mortality.
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Evaluation of the patient undergoing respiratory endoscopic procedures. REVISTA PORTUGUESA DE PNEUMOLOGIA 2011; 18:48-53. [PMID: 22138432 DOI: 10.1016/j.rppneu.2011.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 10/07/2011] [Accepted: 10/07/2011] [Indexed: 11/22/2022] Open
Abstract
Endoscopic techniques can be considered reasonably safe since they are widely used and the rate of complications is extremely low. Still complications do occur and in order to avoid them, the evaluation of the patient before and after any intervention is of the utmost importance. In this article, issues concerning the preparation of the patient and informed consent, the general assessment - medical history, current medications, physical examination, laboratory tests, radiological evaluation and analysis of the indication and planning will be addressed. The post intervention evaluation will also be discussed, in order to detect and treat complications and decide on the final guidance for the patient after discharge. There are very few up-to-date studies or publications dealing with these areas, the evidence level remains low and most recommendations are based on common sense and expert opinion.
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Budinger GRS, Walley KR. Predicting mortality in patients with acute lung injury. Am J Respir Crit Care Med 2011; 184:394-5. [PMID: 21844512 DOI: 10.1164/rccm.201105-0825ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Medford ARL, Husain SA, Turki HM, Millar AB. Diagnosis of ventilator-associated pneumonia. J Crit Care 2009; 24:473.e1-6. [PMID: 19327300 DOI: 10.1016/j.jcrc.2008.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Revised: 05/24/2008] [Accepted: 06/21/2008] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is difficult to diagnose. Recent data suggest quantitative endotracheal aspirate (ETA) may be noninferior diagnostically to quantitative bronchoalveolar lavage (BAL). We hypothesized this would be the case. METHODS Blind quantitative ETA and BAL were performed on 150 consecutive ventilated patients with suspected VAP in a prospective single-centre medical intensive care unit study over a 2-year inclusion period. Patients were either antibiotic-naive or antibiotic-free for 72 hours. Diagnostic yield, Gram stain and culture results, and impact on antibiotic therapy were assessed. The independent impact of a positive BAL or ETA result on ventilator settings and 28-day mortality was calculated. The BAL/ETA safety was assessed hemodynamically. RESULTS Bronchoalveolar lavage had significantly higher diagnostic yield (49.3% vs 34.0%, P = .01), more frequent impact on antibiotic therapy (usually de-escalation) (48.0% vs 32.7%, P = .01), and greater sensitivity (64.1% vs 42.6%, P = .0003) than ETA. There was moderate intertest agreement and no difference in specificity and positive and negative predictive values. A positive BAL or ETA result did not independently alter the frequency of ventilator changes or 28-day mortality. Both procedures were well tolerated. CONCLUSION Quantitative BAL is safe and has greater diagnostic utility than ETA for VAP facilitates de-escalation. This study provides support for quantitative BAL in VAP diagnosis.
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Affiliation(s)
- Andrew R L Medford
- North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, United Kingdom.
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Colucci G, Domenighetti G, Della Bruna R, Bonilla J, Limoni C, Matthay MA, Martin TR. Comparison of two non-bronchoscopic methods for evaluating inflammation in patients with acute hypoxaemic respiratory failure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R134. [PMID: 19671148 PMCID: PMC2750192 DOI: 10.1186/cc7995] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Revised: 07/28/2009] [Accepted: 08/11/2009] [Indexed: 01/11/2023]
Abstract
Introduction The simple bedside method for sampling undiluted distal pulmonary edema fluid through a normal suction catheter (s-Cath) has been experimentally and clinically validated. However, there are no data comparing non-bronchoscopic bronchoalveolar lavage (mini-BAL) and s-Cath for assessing lung inflammation in acute hypoxaemic respiratory failure. We designed a prospective study in two groups of patients, those with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) and those with acute cardiogenic lung edema (ACLE), designed to investigate the clinical feasibility of these techniques and to evaluate inflammation in both groups using undiluted sampling obtained by s-Cath. To test the interchangeability of the two methods in the same patient for studying the inflammation response, we further compared mini-BAL and s-Cath for agreement of protein concentration and percentage of polymorphonuclear cells (PMNs). Methods Mini-BAL and s-Cath sampling was assessed in 30 mechanically ventilated patients, 21 with ALI/ARDS and 9 with ACLE. To analyse agreement between the two sampling techniques, we considered only simultaneously collected mini-BAL and s-Cath paired samples. The protein concentration and polymorphonuclear cell (PMN) count comparisons were performed using undiluted sampling. Bland-Altman plots were used for assessing the mean bias and the limits of agreement between the two sampling techniques; comparison between groups was performed by using the non-parametric Mann-Whitney-U test; continuous variables were compared by using the Student t-test, Wilcoxon signed rank test, analysis of variance or Student-Newman-Keuls test; and categorical variables were compared by using chi-square analysis or Fisher exact test. Results Using protein content and PMN percentage as parameters, we identified substantial variations between the two sampling techniques. When the protein concentration in the lung was high, the s-Cath was a more sensitive method; by contrast, as inflammation increased, both methods provided similar estimates of neutrophil percentages in the lung. The patients with ACLE showed an increased PMN count, suggesting that hydrostatic lung edema can be associated with a concomitant inflammatory process. Conclusions There are significant differences between the s-Cath and mini-BAL sampling techniques, indicating that these procedures cannot be used interchangeably for studying the lung inflammatory response in patients with acute hypoxaemic lung injury.
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Affiliation(s)
- Giuseppe Colucci
- Multidisciplinary Intensive Care Unit, Regional Hospital EOC, Via Ospedale 14, Locarno 6600, Switzerland.
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[Diagnostic flexible bronchoscopy. Recommendations of the Endoscopy Working Group of the French Society of Pulmonary Medicine]. Rev Mal Respir 2008; 24:1363-92. [PMID: 18216755 DOI: 10.1016/s0761-8425(07)78513-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
These guidelines on flexible bronchoscopy depict important clues to be known and taken into account while practicing flexible bronchoscopy, in adult, except in emergency situations. This is a practical clarification. Safety conditions, complications, anesthesia, infectious risks, cleaning and disinfection are detailed from a review of the literature. Intensive care practice of bronchoscopy requires more attention due to higher risks patients and is discussed extensively. Standards and performances of the various sampling techniques complete this work. Indications for bronchoscopy, therapeutic and paediatric bronchoscopy are not covered in these guidelines.
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Nathani N. ICS Research Gold Medal Abstract Presentations. J Intensive Care Soc 2007. [DOI: 10.1177/175114370700800114] [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)
- Nazim Nathani
- Department of Respiratory Medicine, University Hospitals Birmingham
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Wrigge H, Uhlig U, Baumgarten G, Menzenbach J, Zinserling J, Ernst M, Drömann D, Welz A, Uhlig S, Putensen C. Mechanical ventilation strategies and inflammatory responses to cardiac surgery: a prospective randomized clinical trial. Intensive Care Med 2005; 31:1379-87. [PMID: 16132888 DOI: 10.1007/s00134-005-2767-1] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2004] [Accepted: 07/25/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine whether postoperative mechanical ventilation with lower tidal volumes (V(T)) has protective effects on inflammatory responses induced by cardiopulmonary bypass (CPB) surgery in smokers and nonsmokers. DESIGN AND SETTING Prospective, randomized, controlled clinical trial in the intensive care unit of a university hospital. PATIENTS AND PARTICIPANTS We examined 44 patients (22 smokers, 22 nonsmokers) immediately after uncomplicated CPB surgery. INTERVENTIONS Ventilation was applied for 6 h with either V(T) of either 6 or 12 ml/kg ideal body weight. MEASUREMENTS AND RESULTS The time course of serum tumor necrosis factor (TNF) alpha, interleukin (IL) 6, and IL-8 determined 0, 2, 4, and 6 h after randomization did not differ significantly between the ventilatory strategies. By contrast, in bronchoalveolar lavage fluids sampled after 6 h only TNF-alpha levels were significantly higher in the high V(T) group than the low V(T) group (50+/-111 pg/ml vs. 1+/-7 pg/ml). IL-6 and IL-8 concentrations did not differ between groups. Subgroup analysis of patients with serum TNF-alpha level higher than 0 pg/ml after surgery revealed lower TNF-alpha serum levels during lower V(T) ventilation. All observed effects were small, independent of patients' history of smoking, and were not correlated with duration of ventilation and ICU stay. CONCLUSIONS Ventilation with lower V(T) had no or only minor effect on systemic and pulmonary inflammatory responses in patients with healthy lungs after uncomplicated CPB surgery. Our data do not suggest a clinical benefit of using low V(T) ventilation in these selected patients.
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Affiliation(s)
- Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University of Bonn, Sigmund-Freud-Strasse 25, 53105 Bonn, Germany.
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Perkins GD, Chatterjee S, Giles S, McAuley DF, Quinton S, Thickett DR, Gao F. Safety and Tolerability of Nonbronchoscopic Lavage in ARDS. Chest 2005. [DOI: 10.1016/s0012-3692(15)34488-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ueno H, Matsuda T, Hashimoto S, Amaya F, Kitamura Y, Tanaka M, Kobayashi A, Maruyama I, Yamada S, Hasegawa N, Soejima J, Koh H, Ishizaka A. Contributions of high mobility group box protein in experimental and clinical acute lung injury. Am J Respir Crit Care Med 2004; 170:1310-6. [PMID: 15374839 DOI: 10.1164/rccm.200402-188oc] [Citation(s) in RCA: 297] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
This study was performed to examine the putative role of high mobility group box (HMGB) protein in the pathogenesis of acute lung injury (ALI). Observations were made (1) in 21 patients who were septic with ALI and 15 patients with normal lung function and (2) in a mouse model 24 hours after intratracheal instillation of lipopolysaccharide (LPS). The concentrations of HMGB1 were increased in plasma and lung epithelial lining fluid of patients with ALI and mice instilled with LPS. LPS-induced ALI was mitigated by anti-HMGB1 antibody. Although this protein was not detected in the plasma of control humans or mice, the concentrations of HMGB1 in lung epithelial lining fluid or in bronchoalveolar lavage fluid were unexpectedly high. The nuclear expression of HMGB1 was apparent in epithelial cells surrounding terminal bronchioles in normal mice, whereas its nuclear and cytoplasmic expression was observed in alveolar macrophages in LPS-instilled mice. Lung instillation of HMGB2 did not cause as much inflammation as HMGB1. Extracellular HMGB1 may play a key role in the pathogenesis of clinical and experimental ALI. However, its expression in normal airways is noteworthy and suggests that it also plays a physiologic role in the lung.
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Affiliation(s)
- Hiroshi Ueno
- Department of Intensive Care and Anesthesiology, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto 602-8566, Japan
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Ishizaka A, Matsuda T, Albertine KH, Koh H, Tasaka S, Hasegawa N, Kohno N, Kotani T, Morisaki H, Takeda J, Nakamura M, Fang X, Martin TR, Matthay MA, Hashimoto S. Elevation of KL-6, a lung epithelial cell marker, in plasma and epithelial lining fluid in acute respiratory distress syndrome. Am J Physiol Lung Cell Mol Physiol 2004; 286:L1088-94. [PMID: 12959931 DOI: 10.1152/ajplung.00420.2002] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
KL-6 is a pulmonary epithelial mucin more prominently expressed on the surface membrane of alveolar type II cells when these cells are proliferating, stimulated, and/or injured. We hypothesized that high levels of KL-6 in epithelial lining fluid and plasma would reflect the severity of lung injury in patients with acute lung injury (ALI). Epithelial lining fluid was obtained at onset (day 0) and day 1 of acute respiratory distress syndrome (ARDS)/ALI by bronchoscopic microsampling procedure in 35 patients. On day 0, KL-6 and albumin concentrations in epithelial lining fluid were significantly higher than in normal controls (P < 0.001), and the concentrations of KL-6 in epithelial lining fluid (P < 0.002) and in plasma (P < 0.0001) were higher in nonsurvivors than in survivors of ALI/ARDS. These observations were corroborated by the immunohistochemical localization of KL-6 protein expression in the lungs of nonsurvivors with ALI and KL-6 secretion from cultured human alveolar type II cells stimulated by proinflammatory cytokines. Because injury to distal lung epithelial cells, including alveolar type II cells, is important in the pathogenesis of ALI, the elevation of KL-6 concentrations in plasma and epithelial lining fluid could be valuable indicators for poor prognosis in clinical ALI.
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Affiliation(s)
- Akitoshi Ishizaka
- Department of Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582 Japan.
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Avecillas JF, Mazzone P, Arroliga AC. A rational approach to the evaluation and treatment of the infected patient in the intensive care unit. Clin Chest Med 2003; 24:645-69. [PMID: 14710696 DOI: 10.1016/s0272-5231(03)00099-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Critically ill patients are at increased risk of acquiring nosocomial infections. A thorough clinical evaluation and the selection of appropriate diagnostic techniques are important elements in the evaluation of these patients. Nonetheless, this selection process can be difficult because of the wide spectrum of disease that is seen in the ICU and the lack of standardized studies that have evaluated the different diagnostic methods that are available. Many different antimicrobials are available for the treatment of ICU-acquired infections. Most antimicrobial regimens have not been evaluated in large-scale, prospective, randomized trials. Until this information is available, the clinician must make an effort to be familiar with the different clinical and epidemiologic variables that can be used to stratify patients at the moment of selecting antimicrobial therapy. The information provided in this article, used in association with good clinical judgment, will help the critical care physician provide optimal initial management of the infected patient in the ICU.
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Affiliation(s)
- Jaime F Avecillas
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Mokart D, Guery BP, Bouabdallah R, Martin C, Blache JL, Arnoulet C, Mege JL. Deactivation of alveolar macrophages in septic neutropenic ARDS. Chest 2003; 124:644-52. [PMID: 12907555 DOI: 10.1378/chest.124.2.644] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Neutrophils often have been involved in the pathophysiology of ARDS. However, authentic ARDS has been described in patients with severe neutropenia, suggesting the presence of other potential mechanisms that are responsible of this syndrome. Alveolar macrophages (AMs) could be involved in the development of ARDS, and so we decided to study AM activation in neutropenic patients. PATIENTS We designed a prospective study and enrolled two subgroups of consecutive patients (group A, 18 patients; group B, 22 patients) with septic ARDS. In the first period, 7 of 18 patients were neutropenic, and in the second period 10 of 22 patients were neutropenic. All neutropenic patients were treated with granulocyte colony-stimulating factor (G-CSF). MEASUREMENTS AND RESULTS In group A, BAL fluid samples were analyzed for differential and total cell counts, and alveolar activation marker expression (ie, human leukocyte antigen [HLA]-DR locus) was determined. Basal and lipopolysaccharide (LPS)-stimulated production of tumor necrosis factor, interleukin (IL)-1 beta, IL-6, and IL-10 was evaluated in group B. In neutropenic patients, the BAL fluid total cell count and the neutrophil absolute count was significantly lower compared to those in nonneutropenic patients (p = 0.029 and p = 0.046, respectively). HLA-DR expression on AMs was significantly decreased (p = 0.016), and the percentage of AMs expressing HLA-DR was also significantly lower (p = 0.041). In neutropenic patients, the mean percentage of AMs expressing HLA-DR was significantly lower in deceased patients compared to survivors (30 +/- 7 vs 43 +/- 1, respectively; p = 0.047). Basal AMs released cytokines was comparable between the two groups; however, LPS stimulation yielded a deactivation of AMs in neutropenic patients. CONCLUSION These results suggest a deactivation and/or hypoactivation of AMs in septic ARDS patients. This deactivation/hypoactivation could be linked to the use of G-CSF as this molecule has been shown to generate a down-regulation of HLA-DR expression.
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Affiliation(s)
- Djamel Mokart
- Department of Anesthesiology and Intensive Care Unit, Paoli-Calmette Institute, Marseille, France.
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Jones AT, du Bois RM, Wells AU. The pulmonary physician in critical care. Illustrative case 2: interstitial lung disease. Thorax 2003; 58:361-4. [PMID: 12668805 PMCID: PMC1746654 DOI: 10.1136/thorax.58.4.361] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The case history of a patient admitted to the ICU with interstitial lung disease deteriorating to respiratory failure is presented. Problems in distinguishing between infection and disease progression are discussed and the role of transplantation in ventilated patients is examined.
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Affiliation(s)
- A T Jones
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London SW3 6LR, UK
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Pacht ER, DeMichele SJ, Nelson JL, Hart J, Wennberg AK, Gadek JE. Enteral nutrition with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants reduces alveolar inflammatory mediators and protein influx in patients with acute respiratory distress syndrome. Crit Care Med 2003; 31:491-500. [PMID: 12576957 DOI: 10.1097/01.ccm.0000049952.96496.3e] [Citation(s) in RCA: 159] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Previously, we showed that acute respiratory distress syndrome patients fed an enteral diet containing eicosapentaenoic acid and gamma-linolenic acid and elevated antioxidants (EPA+GLA; Oxepa) had significantly reduced pulmonary inflammation, increased oxygenation, and improved clinical outcomes. In a subset of acute respiratory distress syndrome patients from this trial, we performed a preliminary examination of the potential mechanisms underlying these clinical improvements by retrospectively testing the hypothesis that enteral feeding with EPA+GLA could reduce alveolar-capillary membrane protein permeability and the production of interleukin (IL)-8, IL-6, tumor necrosis factor-alpha, and leukotriene B4 that are responsible, in part, for pulmonary inflammation. DESIGN Prospective, randomized, double-blind, controlled clinical trial. SETTING Intensive Care Unit of the Ohio State University Medical Center. PATIENTS A total of 67 patients were enrolled who met defined criteria for acute lung injury/acute respiratory distress syndrome. INTERVENTIONS A total of 43 of 67 evaluable patients randomly received either EPA+GLA or an isonitrogenous, isocaloric standard diet that was tube fed at a minimum caloric delivery of 75% of basal energy expenditure times 1.33 for at least 4 to 7 days. MEASUREMENTS AND MAIN RESULTS Bronchoalveolar lavage (BAL) was performed at baseline and study days 4 and 7 to obtain BAL fluid (BALF) for measurement of total protein, ceruloplasmin, and transferrin, total neutrophil count, IL-8, IL-6, tumor necrosis factor-alpha, and leukotriene B4. Oxygenation, measured as Pao2/Fio2, was assessed before BAL. Patients fed EPA+GLA had a significant reduction in BALF ceruloplasmin and IL-8 during the study as compared with patients fed the control diet. BALF levels of total protein, neutrophils, and leukotriene B4 tended to decrease in EPA+GLA patients over the course of the study as compared with control patients. BALF levels of IL-6 declined similarly during the study in both groups. A trend toward a reduction in BALF tumor necrosis factor-alpha was observed on study day 7 in the EPA+GLA group as compared with control patients. Significant improvements in oxygenation (Pao2/Fio2) occurred in EPA+GLA patients on study day 4 as compared with controls. Correlation analysis revealed significant relationships between BALF neutrophil counts and indices of alveolar-capillary membrane protein permeability, IL-8, and leukotriene B4. CONCLUSIONS This preliminary investigation showing a decrease in BALF levels of IL-8 and leukotriene B4 and the associated reduction of BALF neutrophils and alveolar membrane protein permeability in acute respiratory distress syndrome patients fed EPA+GLA support, in part, the potential mechanisms underlying the previously described clinical improvements with this diet. Additional controlled studies are needed to confirm these findings.
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Affiliation(s)
- Eric R Pacht
- Pulmonary and Critical Care Division, Ohio State University Medical Center, Columbus, USA
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Lanchou J, Corbel M, Tanguy M, Germain N, Boichot E, Theret N, Clement B, Lagente V, Malledant Y. Imbalance between matrix metalloproteinases (MMP-9 and MMP-2) and tissue inhibitors of metalloproteinases (TIMP-1 and TIMP-2) in acute respiratory distress syndrome patients. Crit Care Med 2003; 31:536-42. [PMID: 12576963 DOI: 10.1097/01.ccm.0000048626.02184.f8] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Matrix metalloproteinases (MMPs) are known to be involved in degradation of extracellular matrix. We aimed to assess the role of MMPs and their natural inhibitors (TIMPs) in the genesis and the evolution of acute respiratory distress syndrome (ARDS). DESIGN Prospective, clinical study. SETTING Intensive care unit of a university hospital. PATIENTS Twenty-one patients were assigned to three different groups: Group 1 patients developed ARDS that rapidly resolved in <4 days; Group 2 patients developed ARDS lasting >8 days; Group 3 (control group) patients had clinical criteria for hospital-acquired pneumonia without ARDS. INTERVENTION Bronchoalveolar lavages were performed on day 0 of the onset of ARDS and on days 4, 8, and 12 for unresolving ARDS. For group 3, the bronchoalveolar lavages were performed on day 0 of the pneumonia. On these bronchoalveolar lavage fluids, we measured the amount of MMP-9 and -2 and their inhibitors TIMP-1 and -2. MEASUREMENTS AND MAIN RESULTS The amount of MMP-9 measured by enzyme-linked immunosorbent assay was significantly lower in the bronchoalveolar lavages from patients with ARDS (group 1 and group 2) compared with the control group (p <.01) throughout the study. The ratio MMP-9/TIMP-1 was also significantly smaller and was less than one in the two ARDS groups (p <.05) compared with the control group (group 3), where this ratio was greater than one. In the second bronchoalveolar lavages, this ratio was greater than one only in the ARDS group that rapidly resolved (group 1), whereas it stayed less than one when the ARDS was lasting (group 2). Concerning the quantity of MMP-2 and the ratio MMP-2/TIMP-2, there was no statistical difference between the three groups throughout the study. Using zymography, there was no significant difference in the amounts of active and latent MMP-9 between the three groups. Moreover, no significant difference in the quantity of latent and active MMP-2 in the three groups was noted. CONCLUSION These results suggest that the MMP-9 level and MMP-9/TIMP-1 ratio play a role in the pathogenesis of ARDS and, namely, the imbalance between MMP-9 and TIMP-1 would participate in airway remodeling leading to either short- or long-course ARDS. The ratio MMP-9/TIMP-1 could be a predictive factor of the ARDS evolution.
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Affiliation(s)
- Jérôme Lanchou
- INSERM U456, Université de Rennes, Service de Réanimation Chirurgicale, CHU de Rennes, Hôpital de Pontchaillou, France
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Rosengart MR, Nathens AB, Arbabi S, Neff MJ, Garcia I, Martin TR, Maier RV. Mitogen-activated protein kinases in the intensive care unit: prognostic potential. Ann Surg 2003; 237:94-100. [PMID: 12496535 PMCID: PMC1513967 DOI: 10.1097/00000658-200301000-00013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the prognostic significance of the activational status of p38, specifically progression to multiple organ dysfunction syndrome (MODS), in a group of severely injured trauma patients. SUMMARY BACKGROUND DATA To date, therapeutic manipulation of the host immunoinflammatory response has not affected the outcome of patients with MODS. A major concern is the inability to identify the patient most at risk so as to enable early intervention. METHODS Nineteen trauma patients underwent bronchoalveolar lavage (BAL). Cells obtained were plated, stimulated with lipopolysaccharide (LPS), and then harvested at varying time points after stimulation. p38 was evaluated by Western blot. RESULTS Nineteen patients were categorized into two groups according to baseline and LPS-stimulated p38 activation in cells obtained by BAL. Group 1 demonstrated a 10-fold increase in p38 activation with LPS treatment over unstimulated controls. Group 2 had high baseline levels of p38 that were unresponsive to subsequent LPS stimulation. Both groups were similar with respect to age, gender, shock (systolic blood pressure < 90), Injury Severity Score, APACHE II, lactate levels, base deficit, blood transfusions, and the cell differential of BAL fluid. However, patients in group 2 had a greater incidence of progression to MODS as defined by the Marshall MOD score, a longer duration of mechanical ventilation, a longer stay in the intensive care unit, and a longer overall hospital stay than group 1. CONCLUSIONS These results demonstrate the prognostic significance of p38 activation in predicting outcome in critically ill trauma patients. Furthermore, these results demonstrate that trauma populations identical by current scoring systems contain a mixture of patients with markedly different outcomes as identified by p38 activation. Measurement of p38 may enable early identification of a subgroup of patients at increased risk for MODS to permit effective therapeutic intervention.
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Nathens AB, Neff MJ, Jurkovich GJ, Klotz P, Farver K, Ruzinski JT, Radella F, Garcia I, Maier RV. Randomized, prospective trial of antioxidant supplementation in critically ill surgical patients. Ann Surg 2002; 236:814-22. [PMID: 12454520 PMCID: PMC1422648 DOI: 10.1097/00000658-200212000-00014] [Citation(s) in RCA: 337] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the effectiveness of early, routine antioxidant supplementation using alpha-tocopherol and ascorbic acid in reducing the rate of pulmonary morbidity and organ dysfunction in critically ill surgical patients. SUMMARY BACKGROUND DATA Oxidative stress has been associated with the development of the acute respiratory distress syndrome (ARDS) and organ failure through direct tissue injury and activation of genes integral to the inflammatory response. In addition, depletion of endogenous antioxidants has been associated with an increased risk of nosocomial infections. The authors postulated that antioxidant supplementation in critically ill surgical patients may reduce the incidence of ARDS, pneumonia, and organ dysfunction. METHODS This randomized, prospective study was conducted to compare outcomes in patients receiving antioxidant supplementation (alpha-tocopherol and ascorbate) versus those receiving standard care. The primary endpoint for analysis was pulmonary morbidity (a composite measure of ARDS and nosocomial pneumonia). Secondary endpoints included the development of multiple organ failure, duration of mechanical ventilation, length of ICU stay, and mortality. RESULTS Five hundred ninety-five patients were enrolled and analyzed, 91% of whom were victims of trauma. The relative risk of pulmonary morbidity was 0.81 (95% confidence interval 0.60-1.1) in patients receiving antioxidant supplementation. Multiple organ failure was significantly less likely to occur in patients receiving antioxidants than in patients receiving standard care, with a relative risk of 0.43 (95% confidence interval 0.19-0.96). Patients randomized to antioxidant supplementation also had a shorter duration of mechanical ventilation and length of ICU stay. CONCLUSIONS The early administration of antioxidant supplementation using alpha-tocopherol and ascorbic acid reduces the incidence of organ failure and shortens ICU length of stay in this cohort of critically ill surgical patients.
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Affiliation(s)
- Avery B Nathens
- Division of Trauma and General Surgery, Harborview Medical Center and the Department of Surgery, University of Washington, Seattle, Washington, USA.
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Abstract
Ventilator-associated pneumonia (VAP) continues to complicate the course of 8 to 28% of patients receiving mechanical ventilation (MV). In contrast to infections of more frequently involved organs (e.g., urinary tract and skin), for which mortality is low, ranging from 1 to 4%, the mortality rate for VAP ranges from 24 to 50% and can reach 76% in some specific settings or when lung infection is caused by high-risk pathogens. The predominant organisms responsible for infection are Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae, but etiologic agents widely differ according to the population of patients in an intensive care unit, duration of hospital stay, and prior antimicrobial therapy. Because appropriate antimicrobial treatment of patients with VAP significantly improves outcome, more rapid identification of infected patients and accurate selection of antimicrobial agents represent important clinical goals. Our personal bias is that using bronchoscopic techniques to obtain protected brush and bronchoalveolar lavage specimens from the affected area in the lung permits physicians to devise a therapeutic strategy that is superior to one based only on clinical evaluation. When fiberoptic bronchoscopy is not available to physicians treating patients clinically suspected of having VAP, we recommend using either a simplified nonbronchoscopic diagnostic procedure or following a strategy in which decisions regarding antibiotic therapy are based on a clinical score constructed from seven variables. Selection of the initial antimicrobial therapy should be based on predominant flora responsible for VAP at each institution, clinical setting, information provided by direct examination of pulmonary secretions, and intrinsic antibacterial activities of antimicrobial agents and their pharmacokinetic characteristics. Further trials will be needed to clarify the optimal duration of treatment and the circumstances in which monotherapy can be safely used.
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Affiliation(s)
- Jean Chastre
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, France.
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Abstract
In this article, an overview on the diagnostic performances of bronchoscopic techniques for the diagnosis of nosocomial pneumonia is given with special emphasis on the inherent problems of the methodology of validation applied to different studies. The current evidence about the importance of bronchoscopic techniques for the outcome is reviewed. It is outlined that future prospects of bronchoscopic investigations mainly include the evaluation of its role in the reassessment of the patient with pneumonia not responding to the initial antimicrobial treatment.
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Affiliation(s)
- S Ewig
- Department of Internal Medicine, Medizinische Universitätsklinik und Poliklinik Bonn, Bonn, Germany
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Abstract
This article gives a broad overview of the increasingly important applications of bronchoscopy, flexible (FOB) and rigid (RB), in a modern medical intensive care unit. Special emphasis is made to bronchoscopy use in mechanically ventilated patients. Therapies such as endobronchial stenting and Nd:YAG laser are being used to improve respiratory failure and facilitate weaning from mechanical ventilation. Practical applications of recent advancements in technology (endobronchial stenting, laser therapy, and so forth), the increasing use of rigid bronchoscopy, and the new generation of flexible bronchoscopes like battery bronchoscopes, and ultra-thin bronchoscopes, are also discussed. The risks, potential benefits, complications, and suggested technique of performing bronchoscopy in mechanically ventilated patients are reviewed.
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Affiliation(s)
- S Raoof
- Interventional Pulmonary Unit, Division of Pulmonary and Critical Care Medicine, Nassau University Medical Center, East Meadow, New York, USA
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Ishizaka A, Watanabe M, Yamashita T, Ogawa Y, Koh H, Hasegawa N, Nakamura H, Asano K, Yamaguchi K, Kotani M, Kotani T, Morisaki H, Takeda J, Kobayashi K, Ogawa S. New bronchoscopic microsample probe to measure the biochemical constituents in epithelial lining fluid of patients with acute respiratory distress syndrome. Crit Care Med 2001; 29:896-8. [PMID: 11373491 DOI: 10.1097/00003246-200104000-00043] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE A noninvasive bronchoscopic microsampling (BMS) probe was developed to sample biochemical constituents of the epithelial lining fluid in small airways. DESIGN Observational, controlled study. SETTING Intensive care unit of academic medical center. PATIENTS AND PROCEDURE: BMS was applied in a control group of seven patients who had hemoptysis or small solitary peripheral nodules but no hypoxemia or other signs of acute inflammation and in four patients with acute respiratory distress syndrome (ARDS), to test whether BMS can ascertain the presence of acute pulmonary inflammation without complications. MEASUREMENTS AND RESULTS Complications, including a significant decrease in arterial oxygen saturation, were observed neither during nor after BMS. In the ARDS group, albumin, lactate dehydrogenase, interleukin-6, basic fibroblast growth factor, and neutrophil elastase concentrations in epithelial lining fluid were significantly higher (p <.0001, p =.012, p <.0001, p <.0001, and p <.0001, respectively) than in the control group. Serial BMS was safely performed in one patient with ARDS, allowing us to observe a correlation between changes in the concentration of inflammation-related biochemical markers and clinical course of the disease. CONCLUSIONS These results suggest that BMS is safe and useful to monitor pulmonary biochemical events in ARDS.
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Affiliation(s)
- A Ishizaka
- Department of Medicine, School of Medicine, Keio University, Tokyo, Japan.
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Bauer TT, Arosio C, Montón C, Filella X, Xaubet A, Torres A. Systemic inflammatory response after bronchoalveolar lavage in critically ill patients. Eur Respir J 2001; 17:274-80. [PMID: 11334131 DOI: 10.1183/09031936.01.17202740] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Bronchoscopic bronchoalveolar lavage (BAL) may be followed by a systemic inflammatory response. Previous reports have suggested pneumonia as a predisposing condition and systemic cytokines as possible mediators. To test this hypothesis, systemic levels of interleukin (IL)-1beta, IL-6 and tumour necrosis factor-alpha (TNF-alpha) were studied before and at 12 h and 24 h after bronchoscopically guided BAL in 30 mechanically ventilated patients (median age 67 (range 54-76) yrs, simplified acute physiology score II (SAPS II) 33 (12-56)), 20 of whom had pneumonia and 10 of whom were control patients without pneumonia. Arterial oxygen partial pressure to inspired oxygen fraction ratio (Pa,O2/FI,O2), body temperature, mean arterial pressure, and cardiac frequency were recorded. The majority of patients (28/30, 93%) received antibiotic treatment prior to the procedure. Pa,O2/FI,O2 ratio was lower at 12 h compared to baseline in patients with pneumonia (baseline median 192 (range 65-256); 12 h 160 (66-190) mmHg, p<0.001) and ventilated controls (baseline 293 (205-473); 12 h 226 (153-330) mm Hg p=0.011), but returned to baseline levels at 24 h (pneumonia: 194 (92-312), p=0.991; controls: 309 (173-487) mmHg, p=0.785). No changes in other clinical variables were observed. Systemic TNF-alpha levels before BAL (pneumonia: 35 (10-88); controls: 17 (0-33) pg x mL(-1)) did not increase at 12 h (pneumonia: 35 (0-64); p=0.735; controls: 16 (0-21) pg x mL(-1), p=0.123 comparison to baseline) or 24 h (pneumonia: 31 (0-36), p=0.464; controls: 19 (0-43) pg x mL(-1), p=0.358). No changes of IL-1beta (baseline: pneumonia 0 (0-13); controls 1 (0-32) pg x mL(-1)) or IL-6 (baseline: pneumonia, 226 (9-4300); controls, 53 (0-346) pg x mL(-1)) were detected. No deterioration of clinical variables and no increase in systemic cytokine release has been observed after bronchoalveolar lavage, in critically ill patients. The potential cytokine increase is probably too small, in relation to the pre-existing inflammatory response, to yield clinical significance in this population otherwise antibiotic therapy may have been protective.
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Affiliation(s)
- T T Bauer
- Institute of Pneumology and Thoracic Surgery, Hospital Clinic de Barcelona, Spain
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