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Krewulak KD, Knight G, Irwin A, Morrissey J, Stelfox HT, Bagshaw SM, Zuege D, Roze des Ordons A, Fiest K, Parhar KKS. Acceptability of the Venting Wisely pathway for use in critically ill adults with hypoxaemic respiratory failure and acute respiratory distress syndrome (ARDS): a qualitative study protocol. BMJ Open 2024; 14:e075086. [PMID: 38806421 PMCID: PMC11138268 DOI: 10.1136/bmjopen-2023-075086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/03/2024] [Indexed: 05/30/2024] Open
Abstract
INTRODUCTION Hypoxaemic respiratory failure (HRF) affects nearly 15% of critically ill adults admitted to an intensive care unit (ICU). An evidence-based, stakeholder-informed multidisciplinary care pathway (Venting Wisely) was created to standardise the diagnosis and management of patients with HRF and acute respiratory distress syndrome. Successful adherence to the pathway requires a coordinated team-based approach by the clinician team. The overall aim of this study is to describe the acceptability of the Venting Wisely pathway among critical care clinicians. Specifically, this will allow us to (1) better understand the user's experience with the intervention and (2) determine if the intervention was delivered as intended. METHODS AND ANALYSIS This qualitative study will conduct focus groups with nurse practitioners, physicians, registered nurses and registered respiratory therapists from 17 Alberta ICUs. We will use template analysis to describe the acceptability of a multicomponent care pathway according to seven constructs of acceptability: (1) affective attitude;,(2) burden, (3) ethicality, (4) intervention coherence, (5) opportunity costs, (6) perceived effectiveness and (7) self-efficacy. This study will contribute to a better understanding of the acceptability of the Venting Wisely pathway. Identification of areas of poor acceptability will be used to refine the pathway and implementation strategies as ways to improve adherence to the pathway and promote its sustainability. ETHICS AND DISSEMINATION The study was approved by the University of Calgary Conjoint Health Research Ethics Board. The results will be submitted for publication in a peer-reviewed journal and presented at a scientific conference. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT04744298.
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Affiliation(s)
- Karla D Krewulak
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Gwen Knight
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Andrea Irwin
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Jeanna Morrissey
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Henry Thomas Stelfox
- University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Sean M Bagshaw
- University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Danny Zuege
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | | | - Kirsten Fiest
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Ken Kuljit Singh Parhar
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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2
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Estenssoro E, González I, Plotnikow GA. Post-pandemic acute respiratory distress syndrome: A New Global Definition with extension to lower-resource regions. Med Intensiva 2024; 48:272-281. [PMID: 38644108 DOI: 10.1016/j.medine.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 04/23/2024]
Abstract
Acute respiratory distress syndrome (ARDS), first described in 1967, is characterized by acute respiratory failure causing profound hypoxemia, decreased pulmonary compliance, and bilateral CXR infiltrates. After several descriptions, the Berlin definition was adopted in 2012, which established three categories of severity according to hypoxemia (mild, moderate and severe), specified temporal aspects for diagnosis, and incorporated the use of non-invasive ventilation. The COVID-19 pandemic led to changes in ARDS management, focusing on continuous monitoring of oxygenation and on utilization of high-flow oxygen therapy and lung ultrasound. In 2021, a New Global Definition based on the Berlin definition of ARDS was proposed, which included a category for non-intubated patients, considered the use of SpO2, and established no particular requirement for oxygenation support in regions with limited resources. Although debates persist, the continuous evolution seeks to adapt to clinical and epidemiological needs, and to the search of personalized treatments.
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Affiliation(s)
- Elisa Estenssoro
- Escuela de Gobierno en Salud, Ministerio de Salud, Buenos Aires, Argentina; Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Buenos Aires, Argentina.
| | - Iván González
- Servicio de Rehabilitación, Área de Kinesiología Crítica, Hospital Británico de Buenos Aires, CABA, Argentina
| | - Gustavo A Plotnikow
- Servicio de Rehabilitación, Área de Kinesiología Crítica, Hospital Británico de Buenos Aires, CABA, Argentina; Facultad de Medicina y Ciencias de la Salud, Universidad Abierta Interamericana, Argentina
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3
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Chen L, Rackley CR. Diagnosis and Epidemiology of Acute Respiratory Failure. Crit Care Clin 2024; 40:221-233. [PMID: 38432693 DOI: 10.1016/j.ccc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Acute respiratory failure is a common clinical finding caused by insufficient oxygenation (hypoxemia) or ventilation (hypocapnia). Understanding the pathophysiology of acute respiratory failure can help to facilitate recognition, diagnosis, and treatment. The cause of acute respiratory failure can be identified through utilization of physical examination findings, laboratory analysis, and chest imaging.
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Affiliation(s)
- Lingye Chen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Craig R Rackley
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
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4
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Tongyoo S, Naorungroj T, Laikitmongkhon J. Predictive factors and outcomes of respiratory syncytial virus infection among patients with respiratory failure. Front Med (Lausanne) 2023; 10:1148531. [PMID: 37051214 PMCID: PMC10084925 DOI: 10.3389/fmed.2023.1148531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 03/10/2023] [Indexed: 03/28/2023] Open
Abstract
IntroductionRespiratory syncytial virus (RSV) infection is an emerging infectious disease. However, the impacts of RSV infection among patients with respiratory failure have not been identified.ObjectiveThis study investigated the 28-day mortality and clinical outcomes of RSV infection in patients with respiratory failure.MethodsThis retrospective study enrolled patients admitted with respiratory failure and requiring mechanical ventilator support for more than 24 h at Siriraj Hospital, Bangkok, Thailand, between January 2014 and July 2019. Respiratory samples of the patients were examined to identify RSV infections. The primary outcome was 28-day mortality.ResultsRespiratory syncytial virus infection was identified in 67 of the 335 patients with respiratory failure enrolled in this study. There were no significant differences in the following baseline characteristics of the patients with and without RSV infection: mean age (72.7 ± 12.7 years vs. 71 ± 14.8 years), sex (male: 46.3% vs. 47.4%), comorbidities, and initial Murray lung injury scores (1.1 ± 0.8 vs. 1.1 ± 0.9). The 28-day mortality was 38.8% (26/67) for the RSV group and 37.1% (99/268) for the non-RSV group (p = 0.79). However, the RSV group had significantly higher proportions of bronchospasm (98.5% vs. 60.8%; p < 0.001), ventilator-associated pneumonia (52.2% vs. 33.8%; p = 0.005), and lung atelectasis (10.4% vs. 3.0%; p = 0.009) than the non-RSV group.ConclusionAmong the patients with respiratory failure, the 28-day mortality of patients with and without RSV infection did not differ. However, patients with RSV infection had an increased risk of complications, such as bronchospasm, ventilation-associated pneumonia, and lung atelectasis.
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Affiliation(s)
- Surat Tongyoo
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Critical Care, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- *Correspondence: Surat Tongyoo,
| | - Thummaporn Naorungroj
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Critical Care, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jakkrit Laikitmongkhon
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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5
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Acute Respiratory Distress Syndrome in Pregnancy: Updates in Principles and Practice. Clin Obstet Gynecol 2023; 66:208-222. [PMID: 36657055 DOI: 10.1097/grf.0000000000000763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Acute respiratory failure occurs in 0.05% to 0.3% of pregnancies and is precipitated by pulmonary and nonpulmonary insults. Acute respiratory distress syndrome (ARDS) is the rapid onset of hypoxemic respiratory failure associated with bilateral pulmonary opacities on chest imaging attributed to noncardiogenic pulmonary edema. The pathophysiological features of ARDS include hypoxemia, diminished lung volumes, and decreased lung compliance. While there is a paucity of data concerning ARDS in the pregnant individual, management principles do not vary significantly between pregnant and nonpregnant patients. The following review will discuss the diagnosis and management of the pregnant patient with ARDS.
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Newly Proposed Diagnostic Criteria for Acute Respiratory Distress Syndrome: Does Inclusion of High Flow Nasal Cannula Solve the Problem? J Clin Med 2023; 12:jcm12031043. [PMID: 36769691 PMCID: PMC9917973 DOI: 10.3390/jcm12031043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 02/03/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a common life-threatening clinical syndrome which accounts for 10% of intensive care unit admissions. Since the Berlin definition was developed, the clinical diagnosis and therapy have changed dramatically by adding a minimum positive end-expiratory pressure (PEEP) to the assessment of hypoxemia compared to the American-European Consensus Conference (AECC) definition in 1994. High-flow nasal cannulas (HFNC) have become widely used as an effective respiratory support for hypoxemia to the extent that their use was proposed in the expansion of the ARDS criteria. However, there would be problems if the diagnosis of a specific disease or clinical syndrome occurred, based on therapeutic strategies.
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7
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Sadeghi B, Ringdén O, Gustafsson B, Castegren M. Mesenchymal stromal cells as treatment for acute respiratory distress syndrome. Case Reports following hematopoietic cell transplantation and a review. Front Immunol 2022; 13:963445. [PMID: 36426365 PMCID: PMC9680556 DOI: 10.3389/fimmu.2022.963445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/18/2022] [Indexed: 11/09/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening lung disease. It may occur during the pancytopenia phase following allogeneic hematopoietic cell transplantation (HCT). ARDS is rare following HCT. Mesenchymal stromal cells (MSCs) have strong anti-inflammatory effect and first home to the lung following intravenous infusion. MSCs are safe to infuse and have almost no side effects. During the Covid-19 pandemic many patients died from ARDS. Subsequently MSCs were evaluated as a therapy for Covid-19 induced ARDS. We report three patients, who were treated with MSCs for ARDS following HCT. Two were treated with MSCs derived from the bone marrow (BM). The third patient was treated with MSCs obtained from the placenta, so-called decidua stromal cells (DSCs). In the first patient, the pulmonary infiltrates cleared after infusion of BM-MSCs, but he died from multiorgan failure. The second patient treated with BM-MSCs died of aspergillus infection. The patient treated with DSCs had a dramatic response and survived. He is alive after 7 years with a Karnofsky score of 100%. We also reviewed experimental and clinical studies using MSCs or DSCs for ARDS. Several positive reports are using MSCs for sepsis and ARDS in experimental animals. In man, two prospective randomized placebo-controlled studies used adipose and BM-MSCs, respectively. No difference in outcome was seen compared to placebo. Some pilot studies used MSCs for Covid-19 ARDS. Positive results were achieved using umbilical cord and DSCs however, optimal source of MSCs remains to be elucidated using randomized trials.
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Affiliation(s)
- Behnam Sadeghi
- Translational Cell Therapy Research (TCR), Division of Paediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- *Correspondence: Behnam Sadeghi,
| | - Olle Ringdén
- Translational Cell Therapy Research (TCR), Division of Paediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Britt Gustafsson
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Markus Castegren
- Center for Clinical Research, Sörmland, Uppsala University, Uppsala, Sweden
- Department of Anesthesiology and Intensive Care, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Section of Infectious Diseases, Department of Medical Science, Uppsala University, Uppsala, Sweden
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8
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Meng L, Liao X, Wang Y, Chen L, Gao W, Wang M, Dai H, Yan N, Gao Y, Wu X, Wang K, Liu Q. Pharmacologic therapies of ARDS: From natural herb to nanomedicine. Front Pharmacol 2022; 13:930593. [PMID: 36386221 PMCID: PMC9651133 DOI: 10.3389/fphar.2022.930593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/03/2022] [Indexed: 12/15/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a common critical illness in respiratory care units with a huge public health burden. Despite tremendous advances in the prevention and treatment of ARDS, it remains the main cause of intensive care unit (ICU) management, and the mortality rate of ARDS remains unacceptably high. The poor performance of ARDS is closely related to its heterogeneous clinical syndrome caused by complicated pathophysiology. Based on the different pathophysiology phases, drugs, protective mechanical ventilation, conservative fluid therapy, and other treatment have been developed to serve as the ARDS therapeutic methods. In recent years, there has been a rapid development in nanomedicine, in which nanoparticles as drug delivery vehicles have been extensively studied in the treatment of ARDS. This study provides an overview of pharmacologic therapies for ARDS, including conventional drugs, natural medicine therapy, and nanomedicine. Particularly, we discuss the unique mechanism and strength of nanomedicine which may provide great promises in treating ARDS in the future.
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Affiliation(s)
- Linlin Meng
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Ximing Liao
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Yuanyuan Wang
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Liangzhi Chen
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Wei Gao
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Muyun Wang
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Huiling Dai
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Na Yan
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Yixuan Gao
- Department of Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xu Wu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Kun Wang
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
- *Correspondence: Kun Wang, ; Qinghua Liu,
| | - Qinghua Liu
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
- *Correspondence: Kun Wang, ; Qinghua Liu,
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9
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Piazza O, Scarpati G, Boccia G, Boffardi M, Pagliano P. KL-6 in ARDS and COVID-19 Patients. Transl Med UniSa 2022; 24:12-15. [PMID: 36447946 PMCID: PMC9673987 DOI: 10.37825/2239-9754.1035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/20/2022] [Indexed: 01/25/2023] Open
Abstract
The Acute Respiratory Distress Syndrome (ARDS) is a common, devastating clinical pattern characterized by life-threatening respiratory failure. In ARDS there is an uncontrolled inflammatory response that results in alveolar damage, with the exudation of protein-rich pulmonary-edema fluid in the alveolar space. Although severe COVID-19 lung failure (CARDS) often meets diagnostic criteria of traditional ARDS, additional features have been reported, such as delayed onset, binary pulmonary compliant states, and hypercoagulable profile. Increased levels of Krebs von den Lungen 6 (KL-6, also known as MUC1) have been reported in both ARDS and CARDS. KL-6 is a transmembrane protein expressed on the apical membrane of most mucosal epithelial cells and it plays a critical role in lining the airway lumen. Abnormalities in mucus production contribute to severe pulmonary complications and death from respiratory failure in patients with diseases such as cystic fibrosis, chronic obstructive pulmonary disease, and acute lung injury due to viral pathogens. Nevertheless, it is not clear what role KL-6 plays in ARDS/CARDS pathophysiology. KL-6 may exert anti-inflammatory effects through the intracellular segment, as proven in animal models of ARDS, while its extracellular segment will enter the blood circulation through the alveolar space when the alveolar epithelial cells are damaged. Therefore, changes in plasma KL-6 levels may be useful in ARDS and CARDS phenotyping, and KL-6 might guide future clinical trials in 'personalized medicine' settings.
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Affiliation(s)
- Ornella Piazza
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Via Salvatore Allende, 84081, Baronissi Salerno,
Italy,Corresponding author at: E-mail address: (O. Piazza)
| | - Giuliana Scarpati
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Via Salvatore Allende, 84081, Baronissi Salerno,
Italy
| | - Giovanni Boccia
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Via Salvatore Allende, 84081, Baronissi Salerno,
Italy
| | - Massimo Boffardi
- AOU San Giovanni di Dio e Ruggi d’Aragona, P.O. Cava de’ Tirreni (SA), Salerno,
Italy
| | - Pasquale Pagliano
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Via Salvatore Allende, 84081, Baronissi Salerno,
Italy
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10
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Bastia L, Rozé H, Brochard L. Asymmetrical Lung Injury: Management and Outcome. Semin Respir Crit Care Med 2022; 43:369-378. [PMID: 35785812 DOI: 10.1055/s-0042-1744303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Among mechanically ventilated patients, asymmetrical lung injury is probably extremely frequent in the intensive care unit but the lack of standardized measurements does not allow to describe any prevalence among mechanically ventilated patients. Many past studies have focused only on unilateral injury and have mostly described the effect of lateral positioning. The good lung put downward might receive more perfusion while the sick lung placed upward receive more ventilation than supine. This usually results in better oxygenation but can also promote atelectasis in the healthy lung and no consensus has emerged on the clinical indication of this posture. Recently, electrical impedance tomography (EIT) has allowed for the first time to precisely describe the distribution of ventilation in each lung and to better study asymmetrical lung injury. At low positive-end-expiratory pressure (PEEP), a very heterogeneous ventilation exists between the two lungs and the initial increase in PEEP first helps to recruit the sick lung and protect the healthier lung. However, further increasing PEEP distends the less injured lung and must be avoided. The right level can be found using EIT and transpulmonary pressure. In addition, EIT can show that in the two lungs, airway closure is present but with very different airway opening pressures (AOPs) which cannot be identified on a global assessment. This may suggest a very different PEEP level than on a global assessment. Lastly, epidemiological studies suggest that in hypoxemic patients, the number of quadrants involved has a strong prognostic value. The number of quadrants is more important than the location of the unilateral or bilateral nature of the involvement for the prognosis, and hypoxemic patients with unilateral lung injury should probably be considered as requiring lung protective ventilation as classical acute respiratory distress syndrome.
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Affiliation(s)
- Luca Bastia
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Hadrien Rozé
- Thoracic Surgery and Lung Transplant Unit, Department of Anesthesiology and Critical Care, Bordeaux University Hospital, Haut Leveque Hospital, Pessac, France.,Centre de Recherche Cardio Thoracique INSERM 1045, Pessac, France
| | - Laurent Brochard
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Canada
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11
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Hanley C, Giacomini C, Brennan A, McNicholas B, Laffey JG. Insights Regarding the Berlin Definition of ARDS from Prospective Observational Studies. Semin Respir Crit Care Med 2022; 43:379-389. [PMID: 35679873 DOI: 10.1055/s-0042-1744306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The definition of acute respiratory distress syndrome (ARDS), has evolved since it was first described in 1967 by Ashbaugh and Petty to the current "Berlin" definition of ARDS developed in 2012 by an expert panel, that provided clarification on the definition of "acute," and on the cardiac failure criteria. It expanded the definition to include patients receiving non-invasive ventilation, and removed the term "acute lung injury" and added a requirement of patients to be receiving a minimum 5 cmH2O expiratory pressure.Since 2012, a series of observational cohort studies have generated insights into the utility and robustness of this definition. This review will examine novel insights into the epidemiology of ARDS, failures in ARDS diagnosis, the role of lung imaging in ARDS, the novel ARDS cohort that is not invasively ventilated, lung compliance profiles in patients with ARDS, sex differences that exist in ARDS management and outcomes, the progression of ARDS following initial diagnosis, and the clinical profile and outcomes of confirmed versus resolved ARDS. Furthermore, we will discuss studies that challenge the utility of distinguishing ARDS from other causes of acute hypoxemic respiratory failure (AHRF) and identify issues that may need to be addressed in a revised definition.
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Affiliation(s)
- Ciara Hanley
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - Camilla Giacomini
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - Aoife Brennan
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - Bairbre McNicholas
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - John G Laffey
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland.,Regenerative Medicine Institute, National University of Ireland, Galway, Ireland
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12
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Fang Y, Zhang X. A propensity score-matching analysis of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker exposure on in-hospital mortality in patients with acute respiratory failure. Pharmacotherapy 2022; 42:387-396. [PMID: 35344607 PMCID: PMC9322533 DOI: 10.1002/phar.2677] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 02/05/2023]
Abstract
STUDY OBJECTIVE To explore the impact of pre-hospital ACEI and ARB exposure on the prognosis of ARF patients. DESIGN A single-center retrospective cohort study. SETTING Medical Information Mart for Intensive Care-III (MIMIC-III) database. PATIENTS The patients meeting ICD-9 code of acute respiratory failure were enrolled. INTERVENTION The primary exposure was the pre-hospital exposure of ACEI and ARB. MEASUREMENT AND MAIN RESULTS The primary outcome was in-hospital mortality. Multiple logistic regression analysis was conducted to determine the independent effect of ACEI/ARB exposure on mortality. Propensity score matching (PSM) method was adopted to reduce bias of the confounders. Subgroup analysis and sensitivity analysis were used to test the stability of the conclusion. 5335 adult ARF patients were enrolled. Mortality was significantly decreased in patients with ACEI/ARB exposure before and after PSM, and the adjusted odds ratio (OR) of ACEI/ARB exposure was 0.56 (95% CI 0.43-0.72). In the subgroup analysis, ACEI/ARB lost its protective effect in young subgroup, but no significant interaction was found between ACEI/ARB exposure and age (p = 0.082). The point estimation and lower 95% limit of E-value was 2.97 and 2.12. In sensitivity analysis, ACEI/ARB exposure showed similar effect in ARDS cohort, but no significantly difference was found in the MIMIC-IV database, which may be explained by small sample size of the ACEI/ARB group. CONCLUSIONS Among patients with acute respiratory failure, pre-hospital ACEI/ARB exposure was associated with better outcomes and acted as an independent factor. The relationship between ACEI/ARB and prognosis of ARF is worth investigating further.
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Affiliation(s)
- Yi‐Peng Fang
- Laboratory of Molecular CardiologyThe First Affiliated Hospital of Shantou University Medical CollegeShantouChina
- Laboratory of Medical Molecular ImagingThe First Affiliated Hospital of Shantou University Medical CollegeShantouChina
- Shantou University Medical CollegeShantouChina
| | - Xin Zhang
- Laboratory of Molecular CardiologyThe First Affiliated Hospital of Shantou University Medical CollegeShantouChina
- Laboratory of Medical Molecular ImagingThe First Affiliated Hospital of Shantou University Medical CollegeShantouChina
- Shantou University Medical CollegeShantouChina
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13
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The PANDORA Study: Prevalence and Outcome of Acute Hypoxemic Respiratory Failure in the Pre-COVID-19 Era. Crit Care Explor 2022; 4:e0684. [PMID: 35510152 PMCID: PMC9061169 DOI: 10.1097/cce.0000000000000684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES: To establish the epidemiological characteristics, ventilator management, and outcomes in patients with acute hypoxemic respiratory failure (AHRF), with or without acute respiratory distress syndrome (ARDS), in the era of lung-protective mechanical ventilation (MV). DESIGN: A 6-month prospective, epidemiological, observational study. SETTING: A network of 22 multidisciplinary ICUs in Spain. PATIENTS: Consecutive mechanically ventilated patients with AHRF (defined as Pao2/Fio2 ≤ 300 mm Hg on positive end-expiratory pressure [PEEP] ≥ 5 cm H2O and Fio2 ≥ 0.3) and followed-up until hospital discharge. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were prevalence of AHRF and ICU mortality. Secondary outcomes included prevalence of ARDS, ventilatory management, and use of adjunctive therapies. During the study period, 9,803 patients were admitted: 4,456 (45.5%) received MV, 1,271 (13%) met AHRF criteria (1,241 were included into the study: 333 [26.8%] met Berlin ARDS criteria and 908 [73.2%] did not). At baseline, tidal volume was 6.9 ± 1.1 mL/kg predicted body weight, PEEP 8.4 ± 3.1 cm H2O, Fio2 0.63 ± 0.22, and plateau pressure 21.5 ± 5.4 cm H2O. ARDS patients received higher Fio2 and PEEP than non-ARDS (0.75 ± 0.22 vs 0.59 ± 0.20 cm H2O and 10.3 ± 3.4 vs 7.7 ± 2.6 cm H2O, respectively [p < 0.0001]). Adjunctive therapies were rarely used in non-ARDS patients. Patients without ARDS had higher ventilator-free days than ARDS (12.2 ± 11.6 vs 9.3 ± 9.7 d; p < 0.001). All-cause ICU mortality was similar in AHRF with or without ARDS (34.8% [95% CI, 29.7–40.2] vs 35.5% [95% CI, 32.3–38.7]; p = 0.837). CONCLUSIONS: AHRF without ARDS is a very common syndrome in the ICU with a high mortality that requires specific studies into its epidemiology and ventilatory management. We found that the prevalence of ARDS was much lower than reported in recent observational studies.
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Do Mechanically Ventilated COVID-19 Patients Present a Higher Case-Fatality Rate Compared With Other Infectious Respiratory Pandemics? A Systematic Review and Meta-Analysis. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2022. [DOI: 10.1097/ipc.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Laake JH, Småstuen MC, Møller MH, Larsson A, Aslam TN, Hofsø K, Pham T, Fan E, Bellani G, Laffey JG. Patient characteristics, management and outcomes in a Nordic subset of the "large observational study to understand the global impact of severe acute respiratory failure" (LUNG SAFE) study. Acta Anaesthesiol Scand 2022; 66:684-695. [PMID: 35398892 PMCID: PMC9322410 DOI: 10.1111/aas.14069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 02/07/2022] [Accepted: 03/28/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The "Large observational study to understand the global impact of severe acute respiratory failure" (LUNG SAFE) study described the worldwide epidemiology and management of patients with acute hypoxaemic respiratory failure (AHRF). Here, we present the Nordic subset of data from the LUNG SAFE cohort. METHODS We extracted LUNG SAFE data for adults fulfilling criteria for AHRF in intensive care units (ICU) in Denmark, Norway and Sweden, including demographics, co-morbidities, clinical assessment and management characteristics, 90-day survival and length-of-stay (LOS). We analysed ICU LOS with linear regression, and associations between risk factors and mortality were quantified using Cox regression. RESULTS We included 192 patients, with a median age of 64 years (IQR 55, 72), and a male-to-female ratio of 2:1. The majority had one or more co-morbidities, and clinicians identified pneumonia as the primary cause of respiratory failure in 56% and acute respiratory distress syndrome (ARDS) in 21%. Median ICU LOS and duration of invasive mechanical ventilation (IMV) were 5 and 3 days. Tidal volumes (TV) were frequently larger than that supported by evidence and IMV allowing for spontaneous ventilation was common. Younger age, co-morbidity, surgical admission and ARDS were associated with ICU LOS. Sixty-one patients (32%) were dead at 90 days. Age and a non-surgical cause of admission were associated with death. CONCLUSIONS In this subset of LUNG SAFE, ARDS was often not recognised in patients with AHRF and management frequently deviated from evidence-based practices. ICU LOS was generally short, and mortality was attributable to known risk factors.
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Affiliation(s)
- Jon Henrik Laake
- Department of Anaesthesiology and Intensive Care Medicine, Division of Emergencies and Critical Care, Rikshospitalet Medical Centre Oslo University Hospital Oslo Norway
- Department of Research and Development, Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
| | - Milada Cvancarova Småstuen
- Faculty of Health Sciences, Department of Nursing and Health Promotion Oslo Metropolitan University Oslo Norway
| | - Morten Hylander Møller
- Department of Intensive Care Rigshospitalet, University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care Copenhagen Denmark
| | - Anders Larsson
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Uppsala University Hospital Uppsala Sweden
| | - Tayyba Naz Aslam
- Department of Anaesthesiology and Intensive Care Medicine, Division of Emergencies and Critical Care, Rikshospitalet Medical Centre Oslo University Hospital Oslo Norway
- Department of Research and Development, Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
| | - Kristin Hofsø
- Department of Research and Development, Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
- Lovisenberg Diaconal University College Oslo Norway
| | - Tài Pham
- Service de médecine intensive‐réanimation, AP‐HP, Hôpital de Bicêtre Hôpitaux Universitaires Paris‐Saclay Le Kremlin‐Bicêtre France
- Université Paris‐Saclay, UVSQ, Univ. Paris‐Sud, Inserm U1018, Equipe d'Epidémiologie respiratoire intégrative, CESP Villejuif France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine and the Institute of Health Policy, Management and Evaluation University of Toronto Toronto Canada
| | - Giacomo Bellani
- Department of Medicine and Surgery University of Milan‐Bicocca and Department of Emercengy, ASST Monza Monza Italy
| | - John G. Laffey
- School of Medicine, National University of Ireland Galway and Dept of Anaesthesia and Intensive Care Medicine Galway University Hospitals Galway Ireland
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Cagle LA, Hopper K, Epstein SE. Indications and outcome associated with positive-pressure ventilation in dogs and cats: 127 cases. J Vet Emerg Crit Care (San Antonio) 2022; 32:365-375. [PMID: 35043547 DOI: 10.1111/vec.13176] [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: 08/11/2020] [Revised: 12/31/2020] [Accepted: 01/14/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the indications and outcomes of positive-pressure ventilation (PPV) and identify factors associated with successful weaning. DESIGN Retrospective study from October 2009 to September 2013. SETTING University teaching hospital. ANIMALS One hundred and eleven dogs and 16 cats. MEASUREMENTS AND MAIN RESULTS Medical records were retrospectively reviewed; signalment, indication for PPV, patient characteristics, blood gas, and ventilator variables during PPV, duration of PPV, and outcome were recorded. Dogs were most commonly ventilated for pneumonia (36/111; 32%) and cats for multiple pulmonary diseases (8/16; 50%). The median duration of PPV for all animals was 25.7 h (range, 0.1-957 h). Long-term PPV (≥24 h) was performed in 53% of cases. No differences were noted in successful weaning rates between cases ventilated for pulmonary etiologies (23/99; 23%) versus nonpulmonary etiologies (9/28; 32%). Overall, 32 of 127 (25%; 30 dogs, 2 cats) animals were successfully weaned from PPV and 28 of 127 (22%; 26 dogs, 2 cats) survived to hospital discharge. Long-term ventilation had a higher likelihood of successful weaning (26/67 [39%] vs 6/60 [10%], P = 0.0002) and higher rates of survival to discharge (23/67 [34%] vs 5/60 [8%], P = 0.0005) than short-term ventilation. Animals with higher Pao2 /Fio2 and Spo2 /Fio2 and lower APPLE and SOFA scores on day 1 of PPV were more likely to be weaned (P < 0.03). CONCLUSIONS The outcome of PPV appears to be most heavily determined by the underlying disease process and no clear improvement in outcome could be demonstrated in this study, despite advances in veterinary critical care and ventilator management strategies since previous studies. Dogs and cats receiving PPV for more than 24 h in this study had a higher likelihood of a positive outcome. Several indices of oxygenation and illness severity at the onset of PPV were predictive of outcome and maybe useful when considering prognosis of these cases.
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Affiliation(s)
- Laura A Cagle
- William R. Pritchard Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Steven E Epstein
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
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Rashid M, Ramakrishnan M, Muthu DS, Chandran VP, Thunga G, Kunhikatta V, Shanbhag V, Acharya RV, Nair S. Factors affecting the outcomes in patients with acute respiratory distress syndrome in a tertiary care setting. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2022; 13:100972. [PMID: 37309426 PMCID: PMC10250822 DOI: 10.1016/j.cegh.2022.100972] [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: 11/12/2021] [Revised: 12/27/2021] [Accepted: 01/12/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose The clinical profile and factors affecting outcomes in acute respiratory distress syndrome (ARDS) from adequately sample-sized Indian studies are still lacking. We aimed to investigate the clinical profile, treatment pattern, outcomes; and to assess factors affecting non-recovery in ARDS patients. Patients and methods A retrospective observational study was conducted among adult ARDS patients admitted during five year period (January 2014-December 2018) in a South Indian tertiary care setting. The relevant data were collected from the medical records to the data collection form. The univariate and multivariate logistic regression analyses were conducted to identify the predictors of outcomes using SPSS v20. Results A total of 857 participants including 496 males and 361 females with a mean age of 46.86 ± 15.81 years were included in this study. Fever (70.9%), crepitation (58.3%), breathlessness (56.9%), and cough (45%) were the major clinical presentation. Hypertension (25.2%), kidney disease (23.8%), and diabetes (22.3%) were the major comorbidities; and sepsis (37.6%), pneumonia (33.3%), and septic shock (27.5%) were the major etiological factors observed. Antibiotics and steroids were administered to 97.9% and 52.3% of the population, respectively. The recovery rate was 47.49%. The patients with scrub typhus, dengue, pancreatitis, and oxygen supplementation had significantly lower mortality. The factors such as advanced age, sepsis, septic shock, liver diseases, and ventilation requirements were observed to be the independent predictors of non-recovery in ARDS patients. Conclusion A comparable recovery rate was observed in our population. Advanced age, sepsis, septic shock, liver diseases, and ventilation requirements were the independent predictors of non-recovery.
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Affiliation(s)
- Muhammed Rashid
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, 576104, India
| | - Manasvini Ramakrishnan
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, 576104, India
| | - Deepa Sudalai Muthu
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, 576104, India
| | - Viji Pulikkel Chandran
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, 576104, India
| | - Girish Thunga
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, 576104, India
| | - Vijayanarayana Kunhikatta
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, 576104, India
| | - Vishal Shanbhag
- Department of Critical Care Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, 576104, India
| | - Raviraja V Acharya
- Department of Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Sreedharan Nair
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, 576104, India
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Acute Respiratory Distress Syndrome in an African Intensive Care Unit Setting: A Prospective Study of Prevalence and Outcomes. Ann Am Thorac Soc 2021; 19:691-694. [PMID: 34666632 DOI: 10.1513/annalsats.202103-270rl] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Sharma R, Zhou M, Tiba MH, McCracken BM, Dickson RP, Gillies CE, Sjoding MW, Nemzek JA, Ward KR, Stringer KA, Fan X. Breath analysis for detection and trajectory monitoring of acute respiratory distress syndrome in swine. ERJ Open Res 2021; 8:00154-2021. [PMID: 35174248 PMCID: PMC8841990 DOI: 10.1183/23120541.00154-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 09/19/2021] [Indexed: 12/29/2022] Open
Abstract
Despite the enormous impact on human health, acute respiratory distress syndrome (ARDS) is poorly defined, and its timely diagnosis is difficult, as is tracking the course of the syndrome. The objective of this pilot study was to explore the utility of breath collection and analysis methodologies to detect ARDS through changes in the volatile organic compound (VOC) profiles present in breath. Five male Yorkshire mix swine were studied and ARDS was induced using both direct and indirect lung injury. An automated portable gas chromatography device developed in-house was used for point of care breath analysis and to monitor swine breath hourly, starting from initiation of the experiment until the development of ARDS, which was adjudicated based on the Berlin criteria at the breath sampling points and confirmed by lung biopsy at the end of the experiment. A total of 67 breath samples (chromatograms) were collected and analysed. Through machine learning, principal component analysis and linear discrimination analysis, seven VOC biomarkers were identified that distinguished ARDS. These represent seven of the nine biomarkers found in our breath analysis study of human ARDS, corroborating our findings. We also demonstrated that breath analysis detects changes 1–6 h earlier than the clinical adjudication based on the Berlin criteria. The findings provide proof of concept that breath analysis can be used to identify early changes associated with ARDS pathogenesis in swine. Its clinical application could provide intensive care clinicians with a noninvasive diagnostic tool for early detection and continuous monitoring of ARDS. ARDS, confirmed by lung biopsy, was induced in swine, with breath monitored hourly. Seven VOC markers distinguish ARDS, which are the same as those in human ARDS and can predict ARDS onset ∼3 h earlier than clinical adjudication.https://bit.ly/3zIIIMQ
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Petersen AG, Lind PC, Mogensen S, Jensen ASB, Granfeldt A, Simonsen U. Treatment with senicapoc, a KCa3.1 channel blocker, alleviates hypoxemia in a mouse model for acute respiratory distress syndrome. Br J Pharmacol 2021; 179:2175-2192. [PMID: 34623632 DOI: 10.1111/bph.15704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 08/30/2021] [Accepted: 09/02/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND AND PURPOSE Acute respiratory distress syndrome (ARDS) is characterized by pulmonary oedema and severe hypoxaemia. We investigated whether genetic deficit or blockade of calcium-activated potassium (KCa3.1) channels would counteract pulmonary oedema and hypoxaemia in ventilator-induced lung injury, an experimental model for ARDS. EXPERIMENTAL APPROACH KCa3.1 channel knockout mice were exposed to ventilator-induced lung injury. Control mice exposed to ventilator-induced lung injury were treated with the KCa3.1 channel inhibitor, senicapoc. The outcomes were oxygenation (PaO2 /FiO2 ratio), lung compliance, lung wet-to-dry weight, and protein and cytokines in bronchoalveolar lavage fluid (BALF). KEY RESULTS Ventilator-induced lung injury resulted in lung oedema, decreased lung compliance, a severe drop in PaO2 /FiO2 ratio, increased protein, neutrophils, and tumor necrosis factor-alpha (TNFα) in BALF from wild-type mice compared to KCa3.1 knockout mice. Pre-treatment with senicapoc (10-70 mg/kg) prevented the reduction in PaO2 /FiO2 ratio, decrease in lung compliance, increased protein, and TNFα. Senicapoc (30 mg/kg) reduced histopathological lung injury score and neutrophils in BALF. After injurious ventilation, administration of 30 mg/kg senicapoc also improved the PaO2 /FiO2 ratio and reduced lung injury score and neutrophils in the BALF compared to vehicle-treated mice. In human lung epithelial cells, senicapoc decreased TNFα-induced permeability. CONCLUSIONS AND IMPLICATIONS Genetic deficiency of KCa3.1 channels and senicapoc improved the PaO2 /FiO2 ratio and decreased the cytokines after a ventilator-induced lung injury. Moreover, senicapoc directly affects lung epithelial cells and blocks neutrophil infiltration of the injured lung. These findings open the perspective that blocking KCa3.1 channels is a potential treatment in ARDS-like disease.
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Affiliation(s)
- Asbjørn Graver Petersen
- Department of Biomedicine, Pulmonary and Cardiovascular Pharmacology, Aarhus University, Aarhus, Denmark
| | - Peter Carøe Lind
- Department of Biomedicine, Pulmonary and Cardiovascular Pharmacology, Aarhus University, Aarhus, Denmark
| | - Susie Mogensen
- Department of Biomedicine, Pulmonary and Cardiovascular Pharmacology, Aarhus University, Aarhus, Denmark
| | - Anne-Sophie Bonde Jensen
- Department of Biomedicine, Pulmonary and Cardiovascular Pharmacology, Aarhus University, Aarhus, Denmark
| | - Asger Granfeldt
- Department of Clinical Medicine, Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark.,Intensive care, Aarhus University Hospital, Aarhus, Denmark.,Department of Intensive Care Medicine, Randers Regional Hospital, Randers, Denmark
| | - Ulf Simonsen
- Department of Biomedicine, Pulmonary and Cardiovascular Pharmacology, Aarhus University, Aarhus, Denmark
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Hendrickson KW, Peltan ID, Brown SM. The Epidemiology of Acute Respiratory Distress Syndrome Before and After Coronavirus Disease 2019. Crit Care Clin 2021; 37:703-716. [PMID: 34548129 PMCID: PMC8449138 DOI: 10.1016/j.ccc.2021.05.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Kathryn W Hendrickson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, 26 North 1900 East, Salt Lake City, UT 84112, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center
| | - Ithan D Peltan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, 26 North 1900 East, Salt Lake City, UT 84112, USA; Pulmonary Division, Department of Medicine, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT 84107, USA
| | - Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, 26 North 1900 East, Salt Lake City, UT 84112, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center.
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Identification of persistent and resolving subphenotypes of acute hypoxemic respiratory failure in two independent cohorts. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:336. [PMID: 34526076 PMCID: PMC8442814 DOI: 10.1186/s13054-021-03755-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/31/2021] [Indexed: 01/02/2023]
Abstract
Background Acute hypoxemic respiratory failure (HRF) is associated with high morbidity and mortality, but its heterogeneity challenges the identification of effective therapies. Defining subphenotypes with distinct prognoses or biologic features can improve therapeutic trials, but prior work has focused on ARDS, which excludes many acute HRF patients. We aimed to characterize persistent and resolving subphenotypes in the broader HRF population.
Methods In this secondary analysis of 2 independent prospective ICU cohorts, we included adults with acute HRF, defined by invasive mechanical ventilation and PaO2-to-FIO2 ratio ≤ 300 on cohort enrollment (n = 768 in the discovery cohort and n = 1715 in the validation cohort). We classified patients as persistent HRF if still requiring mechanical ventilation with PaO2-to-FIO2 ratio ≤ 300 on day 3 following ICU admission, or resolving HRF if otherwise. We estimated relative risk of 28-day hospital mortality associated with persistent HRF, compared to resolving HRF, using generalized linear models. We also estimated fold difference in circulating biomarkers of inflammation and endothelial activation on cohort enrollment among persistent HRF compared to resolving HRF. Finally, we stratified our analyses by ARDS to understand whether this was driving differences between persistent and resolving HRF.
Results Over 50% developed persistent HRF in both the discovery (n = 386) and validation (n = 1032) cohorts. Persistent HRF was associated with higher risk of death relative to resolving HRF in both the discovery (1.68-fold, 95% CI 1.11, 2.54) and validation cohorts (1.93-fold, 95% CI 1.50, 2.47), after adjustment for age, sex, chronic respiratory illness, and acute illness severity on enrollment (APACHE-III in discovery, APACHE-II in validation). Patients with persistent HRF displayed higher biomarkers of inflammation (interleukin-6, interleukin-8) and endothelial dysfunction (angiopoietin-2) than resolving HRF after adjustment. Only half of persistent HRF patients had ARDS, yet exhibited higher mortality and biomarkers than resolving HRF regardless of whether they qualified for ARDS. Conclusion Patients with persistent HRF are common and have higher mortality and elevated circulating markers of lung injury compared to resolving HRF, and yet only a subset are captured by ARDS definitions. Persistent HRF may represent a clinically important, inclusive target for future therapeutic trials in HRF. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03755-7.
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Barr J, Paulson SS, Kamdar B, Ervin JN, Lane-Fall M, Liu V, Kleinpell R. The Coming of Age of Implementation Science and Research in Critical Care Medicine. Crit Care Med 2021; 49:1254-1275. [PMID: 34261925 PMCID: PMC8549627 DOI: 10.1097/ccm.0000000000005131] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Juliana Barr
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Shirley S Paulson
- Regional Adult Patient Care Services, Kaiser Permanente, Northern California, Oakland, CA
| | - Biren Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego School of Medicine, La Jolla, CA
| | - Jennifer N Ervin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Meghan Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Vincent Liu
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
- Regional Adult Patient Care Services, Kaiser Permanente, Northern California, Oakland, CA
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego School of Medicine, La Jolla, CA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Division of Research, Kaiser Permanente Northern California, Santa Clara, CA
- Kaiser Permanente Medical Center, Santa Clara, CA
- Stanford University, Stanford, CA
- Hospital Advanced Analytics, Kaiser Permanente Northern California, Santa Clara, CA
- Vanderbilt University School of Nursing, Nashville, TN
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Zhang XJ, Zheng JY, Li X, Liang YJ, Zhang ZD. Usefulness of metagenomic next-generation sequencing in adenovirus 7-induced acute respiratory distress syndrome: A case report. World J Clin Cases 2021; 9:6067-6072. [PMID: 34368328 PMCID: PMC8316940 DOI: 10.12998/wjcc.v9.i21.6067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/26/2021] [Accepted: 05/07/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Direct metagenomic next-generation sequencing (mNGS) of clinical samples is an effective method for the molecular diagnosis of infection. However, its role in the diagnosis of patients with acute respiratory distress syndrome (ARDS) of an unknown infectious etiology remains unclear.
CASE SUMMARY A 33-year-old man was admitted to our center for a cough and febrile sensation. Shortly after admission, the patient was diagnosed with ARDS and treated in the intensive care unit. Subsequently, chest computed tomography features suggested an infection. mNGS was performed and the results were indicative of an infection caused by adenovirus type 7. The patient recovered after receiving appropriate treatment.
CONCLUSION mNGS is a promising tool for the diagnosis of ARDS caused by infectious agents. However, further studies are required to develop strategies for incorporating mNGS into the current diagnostic process for the disease.
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Affiliation(s)
- Xiao-Juan Zhang
- Department of Intensive Care Unit, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Jia-Yin Zheng
- Department of Intensive Care Unit, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Xin Li
- Department of Infectious Disease, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Ying-Jian Liang
- Department of Intensive Care Unit, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Zhi-Dan Zhang
- Department of Infectious Disease, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
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Meikle CKS, Creeden JF, McCullumsmith C, Worth RG. SSRIs: Applications in inflammatory lung disease and implications for COVID-19. Neuropsychopharmacol Rep 2021; 41:325-335. [PMID: 34254465 PMCID: PMC8411309 DOI: 10.1002/npr2.12194] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 05/17/2021] [Accepted: 07/02/2021] [Indexed: 12/15/2022] Open
Abstract
Selective serotonin reuptake inhibitors (SSRIs) have anti-inflammatory properties that may have clinical utility in treating severe pulmonary manifestations of COVID-19. SSRIs exert anti-inflammatory effects at three mechanistic levels: (a) inhibition of proinflammatory transcription factor activity, including NF-κB and STAT3; (b) downregulation of lung tissue damage and proinflammatory cell recruitment via inhibition of cytokines, including IL-6, IL-8, TNF-α, and IL-1β; and (c) direct suppression inflammatory cells, including T cells, macrophages, and platelets. These pathways are implicated in the pathogenesis of COVID-19. In this review, we will compare the pathogenesis of lung inflammation in pulmonary diseases including COVID-19, ARDS, and chronic obstructive pulmonary disease (COPD), describe the anti-inflammatory properties of SSRIs, and discuss the applications of SSRIS in treating COVID-19-associated inflammatory lung disease.
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Affiliation(s)
- Claire Kyung Sun Meikle
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Justin Fortune Creeden
- Department of Neurosciences, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA.,Department of Psychiatry, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Cheryl McCullumsmith
- Department of Psychiatry, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Randall G Worth
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
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26
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Pham T, Pesenti A, Bellani G, Rubenfeld G, Fan E, Bugedo G, Lorente JA, Fernandes ADV, Van Haren F, Bruhn A, Rios F, Esteban A, Gattinoni L, Larsson A, McAuley DF, Ranieri M, Thompson BT, Wrigge H, Brochard LJ, Laffey JG. Outcome of acute hypoxaemic respiratory failure: insights from the LUNG SAFE Study. Eur Respir J 2021; 57:13993003.03317-2020. [PMID: 33334944 DOI: 10.1183/13993003.03317-2020] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/21/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Current incidence and outcome of patients with acute hypoxaemic respiratory failure requiring mechanical ventilation in the intensive care unit (ICU) are unknown, especially for patients not meeting criteria for acute respiratory distress syndrome (ARDS). METHODS An international, multicentre, prospective cohort study of patients presenting with hypoxaemia early in the course of mechanical ventilation, conducted during four consecutive weeks in the winter of 2014 in 459 ICUs from 50 countries (LUNG SAFE). Patients were enrolled with arterial oxygen tension/inspiratory oxygen fraction ratio ≤300 mmHg, new pulmonary infiltrates and need for mechanical ventilation with a positive end-expiratory pressure of ≥5 cmH2O. ICU prevalence, causes of hypoxaemia, hospital survival and factors associated with hospital mortality were measured. Patients with unilateral versus bilateral opacities were compared. FINDINGS 12 906 critically ill patients received mechanical ventilation and 34.9% with hypoxaemia and new infiltrates were enrolled, separated into ARDS (69.0%), unilateral infiltrate (22.7%) and congestive heart failure (CHF; 8.2%). The global hospital mortality was 38.6%. CHF patients had a mortality comparable to ARDS (44.1% versus 40.4%). Patients with unilateral-infiltrate had lower unadjusted mortality, but similar adjusted mortality compared to those with ARDS. The number of quadrants on chest imaging was associated with an increased risk of death. There was no difference in mortality comparing patients with unilateral-infiltrate and ARDS with only two quadrants involved. INTERPRETATION More than one-third of patients receiving mechanical ventilation have hypoxaemia and new infiltrates with a hospital mortality of 38.6%. Survival is dependent on the degree of pulmonary involvement whether or not ARDS criteria are reached.
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Affiliation(s)
- Tài Pham
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Heath Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France.,Université Paris-Saclay, UVSQ, Université Paris-Sud, Inserm, Equipe d'Epidémiologie respiratoire intégrative, CESP, Villejuif, France
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Dept of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Gordon Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto and Program in Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Eddy Fan
- Dept of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - José Angel Lorente
- Critical Care Dept, Hospital Universitario de Getafe, Madrid, Spain.,CIBER Enfermedades Respiratorias, Madrid, Spain.,Universidad Europea, Madrid, Spain
| | | | - Frank Van Haren
- Intensive Care Unit, Canberra Hospital, Garran, Australia.,Australian National University Medical School, Canberra Hospital, Garran, Australia.,University of Canberra, Faculty of Health, Canberra, Australia
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Fernando Rios
- Intensive Care Unit, Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - Andres Esteban
- Hospital Universitario de Getafe, Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Luciano Gattinoni
- University of Göttingen, Dept of Anaesthesiology, Emergency and Intensive Care Medicine, Göttingen, Germany
| | - Anders Larsson
- Dept of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Daniel F McAuley
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK.,Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | - Marco Ranieri
- Alma Mater Studiorum-Università di Bologna, Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Bologna, Italy
| | - B Taylor Thompson
- Massachusetts General Hospital, Harvard School of Medicine, Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Boston, MA, USA
| | - Hermann Wrigge
- Dept of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany.,Dept of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Laurent J Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Heath Toronto, Toronto, ON, Canada .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Co-senior authors
| | - John G Laffey
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Heath Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Dept of Anesthesia, St Michael's Hospital and University of Toronto, Toronto, ON, Canada.,School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.,Co-senior authors
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27
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Yen JS, Hu CC, Huang WH, Hsu CW, Yen TH, Weng CH. An artificial intelligence algorithm for analyzing acetaminophen-associated toxic hepatitis. Hum Exp Toxicol 2021; 40:1947-1954. [PMID: 33955253 DOI: 10.1177/09603271211014587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Very little artificial intelligence (AI) work has been performed to investigate acetaminophen-associated hepatotoxicity. The objective of this study was to develop an AI algorithm for analyzing weighted features for toxic hepatitis after acetaminophen poisoning. METHODS The medical records of 187 patients with acetaminophen poisoning treated at Chang Gung Memorial Hospital were reviewed. Patients were sorted into two groups according to their status of toxic hepatitis. A total of 40 clinical and laboratory features recorded on the first day of admission were selected for algorithm development. The random forest classifier (RFC) and logistic regression (LR) were used for artificial intelligence algorithm development. RESULTS The RFC-based AI model achieved the following results: accuracy = 92.5 ± 2.6%; sensitivity = 100%; specificity = 60%; precision = 92.3 ± 3.4%; and F1 = 96.0 ± 1.8%. The area under the receiver operating characteristic curve (AUROC) was approximately 0.98. The LR-based AI model achieved the following results: accuracy = 92.00 ± 2.9%; sensitivity = 100%; specificity = 20%; precision = 92.8 ± 3.4%; recall = 98.8 ± 3.4%; and F1 = 95.6 ± 1.5%. The AUROC was approximately 0.68. The weighted features were calculated, and the 10 most important weighted features for toxic hepatitis were aspartate aminotransferase (ALT), prothrombin time, alanine aminotransferase (AST), time to hospital, platelet count, lymphocyte count, albumin, total bilirubin, body temperature and acetaminophen level. CONCLUSION The top five weighted features for acetaminophen-associated toxic hepatitis were ALT, prothrombin time, AST, time to hospital and platelet count.
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Affiliation(s)
- J-S Yen
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou
| | - C-C Hu
- College of Medicine, Chang Gung University, Taoyuan.,Department of Hepatogastroenterology and Liver Research Unit, Chang Gung Memorial Hospital, Keelung
| | - W-H Huang
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou
| | - C-W Hsu
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou
| | - T-H Yen
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou
| | - C-H Weng
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou
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28
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Matthay MA, Thompson BT, Ware LB. The Berlin definition of acute respiratory distress syndrome: should patients receiving high-flow nasal oxygen be included? THE LANCET RESPIRATORY MEDICINE 2021; 9:933-936. [PMID: 33915103 PMCID: PMC8075801 DOI: 10.1016/s2213-2600(21)00105-3] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 12/12/2022]
Abstract
The 2012 Berlin definition of acute respiratory distress syndrome (ARDS) provided validated support for three levels of initial arterial hypoxaemia that correlated with mortality in patients receiving ventilatory support. Since 2015, high-flow nasal oxygen (HFNO) has become widely used as an effective therapeutic support for acute respiratory failure, most recently in patients with severe COVID-19. We propose that the Berlin definition of ARDS be broadened to include patients treated with HFNO of at least 30 L/min who fulfil the other criteria for the Berlin definition of ARDS. An expanded definition would make the diagnosis of ARDS more widely applicable, allowing patients at an earlier stage of the syndrome to be recognised, independent of the need for endotracheal intubation or positive-pressure ventilation, with benefits for the testing of early interventions and the study of factors associated with the course of ARDS. We identify key questions that could be addressed in refining an expanded definition of ARDS, the implementation of which could lead to improvements in clinical practice and clinical outcomes for patients.
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Affiliation(s)
- Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, CA, USA.
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
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29
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Optimal Sedation in Patients Who Receive Neuromuscular Blocking Agent Infusions for Treatment of Acute Respiratory Distress Syndrome-A Retrospective Cohort Study From a New England Health Care Network. Crit Care Med 2021; 49:1137-1148. [PMID: 33710031 DOI: 10.1097/ccm.0000000000004951] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Two previously published trials (ARDS et Curarisation Systematique [ACURASYS] and Reevaluation of Systemic Early Neuromuscular Blockade [ROSE]) presented equivocal evidence on the effect of neuromuscular blocking agent infusions in patients with acute respiratory distress syndrome (acute respiratory distress syndrome). The sedation regimen differed between these trials and also within the ROSE trial between treatment and control groups. We hypothesized that the proportion of deeper sedation is a mediator of the effect of neuromuscular blocking agent infusions on mortality. DESIGN Retrospective cohort study. SETTING Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). PATIENTS Intubated and mechanically ventilated ICU patients with acute respiratory distress syndrome (Berlin definition) admitted between January 2008 until June 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The proportion of deeper sedation was defined as days with nonlight sedation as a fraction of mechanical ventilation days in the ICU after acute respiratory distress syndrome diagnosis. Using clinical data obtained from a hospital network registry, 3,419 patients with acute respiratory distress syndrome were included, of whom 577 (16.9%) were treated with neuromuscular blocking agent infusions, for a mean (sd) duration of 1.8 (±1.9) days. The duration of deeper sedation was prolonged in patients receiving neuromuscular blocking agent infusions (4.6 ± 2.2 d) compared with patients without neuromuscular blocking agent infusions (2.4 ± 2.2 d; p < 0.001). The proportion of deeper sedation completely mediated the negative effect of neuromuscular blocking agent infusions on in-hospital mortality (p < 0.001). Exploratory analysis in patients who received deeper sedation revealed a beneficial effect of neuromuscular blocking agent infusions on mortality (49% vs 51%; adjusted odds ratio, 0.80; 95% CI, 0.63-0.99, adjusted absolute risk difference, -0.05; p = 0.048). CONCLUSIONS In acute respiratory distress syndrome patients who receive neuromuscular blocking agent infusions, a prolonged, high proportion of deeper sedation is associated with increased mortality. Our data support the view that clinicians should minimize the duration of deeper sedation after recovery from neuromuscular blocking agent infusion.
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30
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Fuller GW, Keating S, Goodacre S, Herbert E, Perkins GD, Rosser A, Gunson I, Miller J, Ward M, Bradburn M, Thokala P, Harris T, Marsh MM, Scott AJ, Cooper C. Prehospital continuous positive airway pressure for acute respiratory failure: the ACUTE feasibility RCT. Health Technol Assess 2021; 25:1-92. [PMID: 33538686 DOI: 10.3310/hta25070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Acute respiratory failure is a life-threatening emergency. Standard prehospital management involves controlled oxygen therapy. Continuous positive airway pressure is a potentially beneficial alternative treatment; however, it is uncertain whether or not this treatment could improve outcomes in NHS ambulance services. OBJECTIVES To assess the feasibility of a large-scale pragmatic trial and to update an existing economic model to determine cost-effectiveness and the value of further research. DESIGN (1) An open-label, individual patient randomised controlled external pilot trial. (2) Cost-effectiveness and value-of-information analyses, updating an existing economic model. (3) Ancillary substudies, comprising an acute respiratory failure incidence study, an acute respiratory failure diagnostic agreement study, clinicians perceptions of a continuous positive airway pressure mixed-methods study and an investigation of allocation concealment. SETTING Four West Midlands Ambulance Service hubs, recruiting between August 2017 and July 2018. PARTICIPANTS Adults with respiratory distress and peripheral oxygen saturations below the British Thoracic Society's target levels were included. Patients with limited potential to benefit from, or with contraindications to, continuous positive airway pressure were excluded. INTERVENTIONS Prehospital continuous positive airway pressure (O-Two system, O-Two Medical Technologies Inc., Brampton, ON, Canada) was compared with standard oxygen therapy, titrated to the British Thoracic Society's peripheral oxygen saturation targets. Interventions were provided in identical sealed boxes. MAIN OUTCOME MEASURES Feasibility objectives estimated the incidence of eligible patients, the proportion recruited and allocated to treatment appropriately, adherence to allocated treatment, and retention and data completeness. The primary clinical end point was 30-day mortality. RESULTS Seventy-seven patients were enrolled (target 120 patients), including seven patients with a diagnosis for which continuous positive airway pressure could be ineffective or harmful. Continuous positive airway pressure was fully delivered to 74% of participants (target 75%). There were no major protocol violations/non-compliances. Full data were available for all key outcomes (target ≥ 90%). Thirty-day mortality was 27.3%. Of the 21 deceased participants, 14 (68%) either did not have a respiratory condition or had ceiling-of-treatment decision implemented that excluded hospital non-invasive ventilation and critical care. The base-case economic evaluation indicated that standard oxygen therapy was probably cost-effective (incremental cost-effectiveness ratio £5685 per quality-adjusted life-year), but there was considerable uncertainty (population expected value of perfect information of £16.5M). Expected value of partial perfect information analyses indicated that effectiveness of prehospital continuous positive airway pressure was the only important variable. The incidence rate of acute respiratory failure was 17.4 (95% confidence interval 16.3 to 18.5) per 100,000 persons per year. There was moderate agreement between the primary prehospital and final hospital diagnoses (Gwet's AC1 coefficient 0.56, 95% confidence interval 0.43 to 0.69). Lack of hospital awareness of the Ambulance continuous positive airway pressure (CPAP): Use, Treatment Effect and economics (ACUTE) trial, limited time to complete trial training and a desire to provide continuous positive airway pressure treatment were highlighted as key challenges by participating clinicians. LIMITATIONS During week 10 of recruitment, the continuous positive airway pressure arm equipment boxes developed a 'rattle'. After repackaging and redistribution, no further concerns were noted. A total of 41.4% of ambulance service clinicians not participating in the ACUTE trial indicated a difference between the control and the intervention arm trial boxes (115/278); of these clinician 70.4% correctly identified box contents. CONCLUSIONS Recruitment rate was below target and feasibility was not demonstrated. The economic evaluation results suggested that a definitive trial could represent value for money. However, limited compliance with continuous positive airway pressure and difficulty in identifying patients who could benefit from continuous positive airway pressure indicate that prehospital continuous positive airway pressure is unlikely to materially reduce mortality. FUTURE WORK A definitive clinical effectiveness trial of continuous positive airway pressure in the NHS is not recommended. TRIAL REGISTRATION Current Controlled Trials ISRCTN12048261. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 7. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gordon W Fuller
- Centre for Urgent and Emergency Care Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Samuel Keating
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- Centre for Urgent and Emergency Care Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Esther Herbert
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Andy Rosser
- West Midlands Ambulance Service, Brierley Hill, UK
| | | | | | - Matthew Ward
- West Midlands Ambulance Service, Brierley Hill, UK
| | - Mike Bradburn
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Praveen Thokala
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Tim Harris
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Margaret M Marsh
- Sheffield Emergency Care Forum, Royal Hallamshire Hospital, Sheffield, UK
| | - Alexander J Scott
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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31
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Serazin NA, Edem B, Williams SR, Ortiz JR, Kawade A, Das MK, Šubelj M, Edwards KM, Parida SK, Wartel TA, Munoz FM, Bastero P. Acute respiratory distress syndrome (ARDS) as an adverse event following immunization: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2021; 39:3028-3036. [PMID: 33583673 PMCID: PMC7843093 DOI: 10.1016/j.vaccine.2021.01.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/20/2021] [Indexed: 02/08/2023]
Abstract
This is a Brighton Collaboration Case Definition of the term “Acute Respiratory Distress Syndrome – ARDS” to be utilized in the evaluation of adverse events following immunization. The Case Definition was developed by a group of experts convened by the Coalition for Epidemic Preparedness Innovations (CEPI) in the context of active development of vaccines for SARS-CoV-2 vaccines and other emerging pathogens. The case definition format of the Brighton Collaboration was followed to develop a consensus definition and defined levels of certainty, after an exhaustive review of the literature and expert consultation. The document underwent peer review by the Brighton Collaboration Network and by selected Expert Reviewers prior to submission. The comments of the reviewers were taken into consideration and edits incorporated in this final manuscript.
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Affiliation(s)
- Nathan A Serazin
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Bassey Edem
- Department of Vaccines and Immunity, Medical Research Council the Gambia Unit at the London School of Hygiene and Tropical Medicine, UK
| | - Sarah R Williams
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Justin R Ortiz
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anand Kawade
- King Edward Memorial Hospital Research Centre, Vadu Rural Health Program Pune, India
| | | | - Maja Šubelj
- National Institute of Public Health, University of Ljubljana, Slovenia
| | - Kathryn M Edwards
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - T Anh Wartel
- International Vaccine Institute, Seoul, Republic of Korea
| | - Flor M Munoz
- Departments of Pediatrics, Section of Infectious Diseases, and Molecular Virology and Microbiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Patricia Bastero
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.
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Kwizera A, Nakibuuka J, Nakiyingi L, Sendagire C, Tumukunde J, Katabira C, Ssenyonga R, Kiwanuka N, Kateete DP, Joloba M, Kabatoro D, Atwine D, Summers C. Acute hypoxaemic respiratory failure in a low-income country: a prospective observational study of hospital prevalence and mortality. BMJ Open Respir Res 2020; 7:7/1/e000719. [PMID: 33148779 PMCID: PMC7643509 DOI: 10.1136/bmjresp-2020-000719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/24/2020] [Accepted: 09/18/2020] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Limited data exist on the epidemiology of acute hypoxaemic respiratory failure (AHRF) in low-income countries (LICs). We sought to determine the prevalence of AHRF in critically ill adult patients admitted to a Ugandan tertiary referral hospital; determine clinical and treatment characteristics as well as assess factors associated with mortality. MATERIALS AND METHODS We conducted a prospective observational study at the Mulago National Referral and Teaching Hospital in Uganda. Critically ill adults who were hospitalised at the emergency department and met the criteria for AHRF (acute shortness of breath for less than a week) were enrolled and followed up for 90 days. Multivariable analyses were conducted to determine the risk factors for death. RESULTS A total of 7300 patients was screened. Of these, 327 (4.5%) presented with AHRF. The majority (60 %) was male and the median age was 38 years (IQR 27-52). The mean plethysmographic oxygen saturation (SpO2) was 77.6% (SD 12.7); mean SpO2/FiO2 ratio 194 (SD 32) and the mean Lung Injury Prediction Score (LIPS) 6.7 (SD 0.8). Pneumonia (80%) was the most common diagnosis. Only 6% of the patients received mechanical ventilatory support. In-hospital mortality was 77% with an average length of hospital stay of 9.2 days (SD 7). At 90 days after enrolment, the mortality increased to 85%. Factors associated with mortality were severity of hypoxaemia (risk ratio (RR) 1.29 (95% CI 1.15 to 1.54), p=0.01); a high LIPS (RR 1.79 (95% CI 1.79 1.14 to 2.83), p=0.01); thrombocytopenia (RR 1.23 (95% CI 1.11 to 1.38), p=0.01); anaemia (RR 1.15 (95% CI 1.01 to 1.31), p=0.03) ; HIV co-infection (RR 0.84 (95% CI 0.72 to 0.97), p=0.019) and male gender (RR 1.15 (95% CI 1.01 to 1.31) p=0.04). CONCLUSIONS The prevalence of AHRF among emergency department patients in a tertiary hospital in an LIC was low but was associated with very high mortality. Pneumonia was the most common cause of AHRF. Mortality was associated with higher severity of hypoxaemia, high LIPS, anaemia, HIV co-infection, thrombocytopenia and being male.
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Affiliation(s)
- Arthur Kwizera
- Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jane Nakibuuka
- Intensive Care, Mulago National Referral Hospital, Kampala, Uganda
| | - Lydia Nakiyingi
- Internal Medicine, Makerere University Faculty of Medicine, Kampala, Uganda
| | - Cornelius Sendagire
- Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Janat Tumukunde
- Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Catherine Katabira
- Respiratory medicine department, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Ronald Ssenyonga
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Noah Kiwanuka
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - David Patrick Kateete
- Immunology and Molecular Biology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Moses Joloba
- Immunology and Molecular Biology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daphne Kabatoro
- Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diana Atwine
- Office of the permanent secretary, Republic of Uganda Ministry of Health, Kampala, Uganda
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Kopczynska M, Sharif B, Pugh R, Otahal I, Havalda P, Groblewski W, Lynch C, George D, Sutherland J, Pandey M, Jones P, Murdoch M, Hatalyak A, Jones R, Kacmarek RM, Villar J, Szakmany T. Prevalence and Outcomes of Acute Hypoxaemic Respiratory Failure in Wales: The PANDORA-WALES Study. J Clin Med 2020; 9:E3521. [PMID: 33142837 PMCID: PMC7692809 DOI: 10.3390/jcm9113521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND We aimed to identify the prevalence of acute hypoxaemic respiratory failure (AHRF) in the intensive care unit (ICU) and its associated mortality. The secondary aim was to describe ventilatory management as well as the use of rescue therapies. METHODS Multi-centre prospective study in nine hospitals in Wales, UK, over 2-month periods. All patients admitted to an ICU were screened for AHRF and followed-up until discharge from the ICU. Data were collected from patient charts on patient demographics, clinical characteristics, management and outcomes. RESULTS Out of 2215 critical care admissions, 886 patients received mechanical ventilation. A total of 197 patients met inclusion criteria and were recruited. Seventy (35.5%) were non-survivors. Non-survivors were significantly older, had higher SOFA scores and received more vasopressor support than survivors. Twenty-five (12.7%) patients who fulfilled the Berlin definition of acute respiratory distress syndrome (ARDS) during the ICU stay without impact on overall survival. Rescue therapies were rarely used. Analysis of ventilation showed that median Vt was 7.1 mL/kg PBW (IQR 5.9-9.1) and 21.3% of patients had optimal ventilation during their ICU stay. CONCLUSIONS One in four mechanically ventilated patients have AHRF. Despite advances of care and better, but not optimal, utilisation of low tidal volume ventilation, mortality remains high.
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Affiliation(s)
- Maja Kopczynska
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Heath Park Campus, Cardiff University, Cardiff CF14 4XN, UK; (M.K.); (B.S.)
- Salford Royal NHS Trust, Stott Lane, Manchester M6 8HD, UK
| | - Ben Sharif
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Heath Park Campus, Cardiff University, Cardiff CF14 4XN, UK; (M.K.); (B.S.)
- Anaesthetic Department, Royal Glamorgan Hospital, Cwm Taf Morgannwg University Health Board, Llantrisant CF72 8XR, UK;
| | - Richard Pugh
- Anaesthetic Department, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Bodelwyddan, Rhyl LL18 5UJ, UK;
| | - Igor Otahal
- Anaesthetic Department, Glangwili Hospital, Hywel Dda University Health Board, Carmarthen SA31 2AF, UK; (I.O.); (P.H.)
| | - Peter Havalda
- Anaesthetic Department, Glangwili Hospital, Hywel Dda University Health Board, Carmarthen SA31 2AF, UK; (I.O.); (P.H.)
| | - Wojciech Groblewski
- Anaesthetic Department, Withybush Hospital, Hywel Dda University Health Board, Haverfordwest SA61 2PZ, UK;
| | - Ceri Lynch
- Anaesthetic Department, Royal Glamorgan Hospital, Cwm Taf Morgannwg University Health Board, Llantrisant CF72 8XR, UK;
| | - David George
- Anaesthetic Department, Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, Wrexham LL13 7TD, UK;
| | - Jayne Sutherland
- Ed Major Critical Care Unit, Morriston Hospital, Swansea Bay, University Health Board, Swansea SA6 6NL, UK;
| | - Manish Pandey
- Critical Care Department, University Hospital Wales, Cardiff and Vale University Health Board, Cardiff CF14 4XW, UK;
| | - Phillippa Jones
- Critical Care Directorate, Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, Gwent NP20 2UB, UK; (P.J.); (M.M.)
| | - Maxene Murdoch
- Critical Care Directorate, Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, Gwent NP20 2UB, UK; (P.J.); (M.M.)
| | - Adam Hatalyak
- Critical Care Directorate, Nevill Hall Hospital, Aneurin Bevan University Health Board, Abergavenny NP7 7EG, UK;
| | - Rhidian Jones
- Anaesthetic Department, Princess of Wales Hospital, Cwm Taf Morgannwg University Health Board, Bridgend CF31 1RQ, UK;
| | - Robert M. Kacmarek
- Department of Respiratory Care, Massachusetts General Hospital, Boston, MA 02114, USA;
- Department of Anesthesia, Harvard University, Boston, MA 02115, USA
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029 Madrid, Spain;
- Research Unit, Hospital Universitario Dr. Negrín, 35010 Las Palmas de Gran Canaria, Spain
| | - Tamas Szakmany
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Heath Park Campus, Cardiff University, Cardiff CF14 4XN, UK; (M.K.); (B.S.)
- Critical Care Directorate, Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, Gwent NP20 2UB, UK; (P.J.); (M.M.)
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Fernando SM, Fan E, Rochwerg B, Burns KEA, Brochard LJ, Cook DJ, Walkey AJ, Ferguson ND, Hough CL, Brodie D, Seely AJE, Thiruganasambandamoorthy V, Perry JJ, Tran A, Tanuseputro P, Kyeremanteng K. Lung-Protective Ventilation and Associated Outcomes and Costs Among Patients Receiving Invasive Mechanical Ventilation in the ED. Chest 2020; 159:606-618. [PMID: 32966812 DOI: 10.1016/j.chest.2020.09.100] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/22/2020] [Accepted: 09/06/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Invasive mechanical ventilation is often initiated in the ED, and mechanically ventilated patients may be kept in the ED for hours before ICU transfer. Although lung-protective ventilation is beneficial, particularly in ARDS, it remains uncertain how often lung-protective tidal volumes are used in the ED, and whether lung-protective ventilation in this setting impacts patient outcomes. RESEARCH QUESTION What is the association between the use of lung-protective ventilation in the ED and outcomes among invasively ventilated patients? STUDY DESIGN AND METHODS A retrospective analysis (2011-2017) of a prospective registry from eight EDs enrolling consecutive adult patients (≥ 18 years) who received invasive mechanical ventilation in the ED was performed. Lung-protective ventilation was defined by use of tidal volumes ≤ 8 mL/kg predicted body weight. The primary outcome was hospital mortality. Secondary outcomes included development of ARDS, hospital length of stay, and total hospital costs. RESULTS The study included 4,174 patients, of whom 2,437 (58.4%) received lung-protective ventilation in the ED. Use of lung-protective ventilation was associated with decreased odds of hospital death (adjusted OR [aOR], 0.91; 95% CI, 0.84-0.96) and development of ARDS (aOR, 0.87; 95% CI, 0.81-0.92). Patients who received lung-protective ventilation in the ED had shorter median duration of mechanical ventilation (4 vs 5 days; P < 0.01), shorter median hospital length of stay (11 vs 14 days; P < .001), and reduced total hospital costs (Can$44,348 vs Can$52,484 [US$34,153 vs US$40,418]; P = .03) compared with patients who received higher tidal volumes. INTERPRETATION Use of lung-protective ventilation in the ED was associated with important patient- and system-centered outcomes, including lower hospital mortality, decreased incidence of ARDS, lower hospital length of stay, and decreased total costs. Protocol development promoting the regular use of lung-protective ventilation in the ED may be of value.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Deborah J Cook
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Allan J Walkey
- Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA; Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA
| | - Niall D Ferguson
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY
| | - Andrew J E Seely
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Surgery, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexandre Tran
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Surgery, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Peter Tanuseputro
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Bruyére Research Institute, Ottawa, ON, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada
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Δ9-Tetrahydrocannabinol Prevents Mortality from Acute Respiratory Distress Syndrome through the Induction of Apoptosis in Immune Cells, Leading to Cytokine Storm Suppression. Int J Mol Sci 2020; 21:ijms21176244. [PMID: 32872332 PMCID: PMC7503745 DOI: 10.3390/ijms21176244] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 08/22/2020] [Accepted: 08/26/2020] [Indexed: 02/06/2023] Open
Abstract
Acute Respiratory Distress Syndrome (ARDS) causes up to 40% mortality in humans and is difficult to treat. ARDS is also one of the major triggers of mortality associated with coronavirus-induced disease (COVID-19). We used a mouse model of ARDS induced by Staphylococcal enterotoxin B (SEB), which triggers 100% mortality, to investigate the mechanisms through which Δ9-tetrahydrocannabinol (THC) attenuates ARDS. SEB was used to trigger ARDS in C3H mice. These mice were treated with THC and analyzed for survival, ARDS, cytokine storm, and metabolome. Additionally, cells isolated from the lungs were used to perform single-cell RNA sequencing and transcriptome analysis. A database analysis of human COVID-19 patients was also performed to compare the signaling pathways with SEB-mediated ARDS. The treatment of SEB-mediated ARDS mice with THC led to a 100% survival, decreased lung inflammation, and the suppression of cytokine storm. This was associated with immune cell apoptosis involving the mitochondrial pathway, as suggested by single-cell RNA sequencing. A transcriptomic analysis of immune cells from the lungs revealed an increase in mitochondrial respiratory chain enzymes following THC treatment. In addition, metabolomic analysis revealed elevated serum concentrations of amino acids, lysine, n-acetyl methionine, carnitine, and propionyl L-carnitine in THC-treated mice. THC caused the downregulation of miR-185, which correlated with an increase in the pro-apoptotic gene targets. Interestingly, the gene expression datasets from the bronchoalveolar lavage fluid (BALF) of human COVID-19 patients showed some similarities between cytokine and apoptotic genes with SEB-induced ARDS. Collectively, this study suggests that the activation of cannabinoid receptors may serve as a therapeutic modality to treat ARDS associated with COVID-19.
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Corcoran JP, Laursen CB. COUNTERPOINT: Should Point-of-Care Ultrasound Examination Be Routine Practice in the Evaluation of the Acutely Breathless Patient? No. Chest 2020; 156:426-428. [PMID: 31511149 DOI: 10.1016/j.chest.2019.04.119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/16/2019] [Indexed: 12/27/2022] Open
Affiliation(s)
- John P Corcoran
- Interventional Pulmonology Service, Department of Respiratory Medicine, University Hospitals Plymouth NHS Trust, Plymouth, England.
| | - Christian B Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
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Balakrishnan N, Thabah MM, Dineshbabu S, Sistla S, Kadhiravan T, Venkateswaran R. Aetiology and Short-Term Outcome of Acute Respiratory Distress Syndrome: A Real-World Experience from a Medical Intensive Care Unit in Southern India. J R Coll Physicians Edinb 2020. [DOI: 10.4997/jrcpe.2020.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is a highly fatal syndrome especially in resource constrained settings. In this study we prospectively studied the aetiology of ARDS and its short-term outcome. Methods Consecutive adults with suspected ARDS were screened. ARDS was diagnosed by the Berlin criteria. Aetiology was determined clinically, and by imaging and microbiological investigations. Patients presenting with fever, prominent cough and expectoration had a throat swab tested for influenza H1N1 virus. Outcome was discharge from hospital or death. Results A total of 42 patients, mean age 42.6 years, were studied. All received mechanical ventilation. Thirteen (31%) had pulmonary ARDS: H1N1 virus infection (n = 5), pneumonia (n = 7) and tuberculosis (n = 1). Twenty nine (69%) had extrapulmonary ARDS: sepsis (n = 16) and scrub typhus (n = 8). Thirty three (79%) died, of the nine survivors scrub typhus was diagnosed in seven patients. Conclusion The aetiology of ARDS in tropical medical setting is infection related. ARDS due to scrub typhus appeared to be mild with good outcome.
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Affiliation(s)
| | - Molly Mary Thabah
- Additional Professor, Department of Medicine, JIPMER, Puducherry, India
| | - Sekar Dineshbabu
- Senior Resident, Department of Medicine, JIPMER, Puducherry, India
| | - Sujatha Sistla
- Professor, Department of Microbiology, JIPMER, Puducherry, India
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Zhu X, Wang B, Zhang X, Chen X, Zhu J, Zou Y, Li J. Alpha-linolenic acid protects against lipopolysaccharide-induced acute lung injury through anti-inflammatory and anti-oxidative pathways. Microb Pathog 2020; 142:104077. [PMID: 32084579 DOI: 10.1016/j.micpath.2020.104077] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 02/17/2020] [Accepted: 02/17/2020] [Indexed: 12/20/2022]
Abstract
Alpha-linolenic acid (ALA), an important component of polyunsaturated fatty acids (PUFAs), possesses potent anti-inflammatory properties. To date, the effects of ALA on acute lung injury (ALI) remains unknown. This study was designed to investigate the potential protective effects of ALA on LPS-induced ALI and the underpinning mechanisms. An animal model of ALI was established via intratracheally injection of lipopolysaccharide (LPS, 1 mg/kg). We found that lung wet/dry weight ratio and protein concentration in Bronchoalveolar lavage fluid (BALF) were dramatically decreased by ALA pretreatment. Treatment with ALA significantly alleviated the infiltration of total cells and neutrophils, while increased the number of the macrophages. ALA significantly inhibited the secretion of proinflammatory cytokines including tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) and interleukin-1β (IL-1β) and increased anti-inflammatory cytokine. Moreover, we found that the levels of myeloperoxidase (MPO) and malondialdehyde (MDA) were highly increased in LPS-induced ALI, while the activities of glutathione (GSH) and superoxide dismutase (SOD) were decreased, which were reversed by ALA. ALA attenuated LPS-induced histopathological changes and apoptosis. Furthermore, ALA significantly inhibited the phosphorylation of IκBα and NF-κB (p65) activation in ALI. ALA showed anti-inflammatory effects in mice with LPS-induced ALI. NF-κB pathway may be involved in ALA mediated protective effects.
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Affiliation(s)
- Xuejiao Zhu
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, Jiangsu, 215004, China.
| | - Bing Wang
- Department of Anesthesiology, The 950th Hospital of CPLA Ground Force, Yecheng, Xinjiang Uygur Autonomous Region, 844900, China.
| | - Xinyi Zhang
- Department of Anesthesiology, Weifang Medical University, Weifang, Shandong, 261000, China; Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, 200080, China.
| | - Xia Chen
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, 200080, China.
| | - Jiali Zhu
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, 200080, China.
| | - Yun Zou
- Department of Anesthesiology, The 950th Hospital of CPLA Ground Force, Yecheng, Xinjiang Uygur Autonomous Region, 844900, China.
| | - Jinbao Li
- Department of Anesthesiology, The 950th Hospital of CPLA Ground Force, Yecheng, Xinjiang Uygur Autonomous Region, 844900, China.
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Schaefer MS, Serpa Neto A, Pelosi P, Gama de Abreu M, Kienbaum P, Schultz MJ, Meyer-Treschan TA. Temporal Changes in Ventilator Settings in Patients With Uninjured Lungs: A Systematic Review. Anesth Analg 2020; 129:129-140. [PMID: 30222649 DOI: 10.1213/ane.0000000000003758] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In patients with uninjured lungs, increasing evidence indicates that tidal volume (VT) reduction improves outcomes in the intensive care unit (ICU) and in the operating room (OR). However, the degree to which this evidence has translated to clinical changes in ventilator settings for patients with uninjured lungs is unknown. To clarify whether ventilator settings have changed, we searched MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science for publications on invasive ventilation in ICUs or ORs, excluding those on patients <18 years of age or those with >25% of patients with acute respiratory distress syndrome (ARDS). Our primary end point was temporal change in VT over time. Secondary end points were changes in maximum airway pressure, mean airway pressure, positive end-expiratory pressure, inspiratory oxygen fraction, development of ARDS (ICU studies only), and postoperative pulmonary complications (OR studies only) determined using correlation analysis and linear regression. We identified 96 ICU and 96 OR studies comprising 130,316 patients from 1975 to 2014 and observed that in the ICU, VT size decreased annually by 0.16 mL/kg (-0.19 to -0.12 mL/kg) (P < .001), while positive end-expiratory pressure increased by an average of 0.1 mbar/y (0.02-0.17 mbar/y) (P = .017). In the OR, VT size decreased by 0.09 mL/kg per year (-0.14 to -0.04 mL/kg per year) (P < .001). The change in VTs leveled off in 1995. Other intraoperative ventilator settings did not change in the study period. Incidences of ARDS (ICU studies) and postoperative pulmonary complications (OR studies) also did not change over time. We found that, during a 39-year period, from 1975 to 2014, VTs in clinical studies on mechanical ventilation have decreased significantly in the ICU and in the OR.
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Affiliation(s)
- Maximilian S Schaefer
- From the Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Program of Post-Graduation, Innovation and Research, Faculdade de Medicina do ABC, Santo Andre, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Peter Kienbaum
- From the Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
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Beltramo F, Khemani RG. Definition and global epidemiology of pediatric acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:502. [PMID: 31728355 DOI: 10.21037/atm.2019.09.31] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute respiratory distress syndrome (ARDS) has been known to occur in children since early descriptions of the disease, but pediatric specific diagnostic criteria were first established in 2015 with the Pediatric Acute Lung Injury Consensus Conference (PALICC) definition of pediatric ARDS (PARDS). There were substantial changes proposed with the PALICC definition, including simplification of radiographic criteria, use of pulse oximetry based metrics to define PARDS, specific criteria for non-invasive ventilation, and the use of oxygenation index (OI) instead of PaO2/FiO2 ratio for those on invasive ventilation. While these changes could potentially result in major changes in the reported incidence and outcome of PARDS, review of the recent literature since publication of the PALICC definitions highlight that major elements regarding the contemporary epidemiology of PARDS have remained stable over the past 20 years. This highlights that the PARDS definition is likely catching up to changes in clinical practice, and suggests that this new definition should be used moving forward as it is more reflective of current practice than historical definitions. However, it is also clear that PARDS severity alone (as measured by the PALICC) criteria insufficiently characterizes the risk for mortality or other important clinical outcomes amongst PARDS patients, although there appears to be some association between PARDS severity and outcome, particularly when hypoxemia is severe.
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Affiliation(s)
- Fernando Beltramo
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Robinder G Khemani
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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Oxygen Exposure Resulting in Arterial Oxygen Tensions Above the Protocol Goal Was Associated With Worse Clinical Outcomes in Acute Respiratory Distress Syndrome. Crit Care Med 2019; 46:517-524. [PMID: 29261565 DOI: 10.1097/ccm.0000000000002886] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES High fractions of inspired oxygen may augment lung damage to exacerbate lung injury in patients with acute respiratory distress syndrome. Participants enrolled in Acute Respiratory Distress Syndrome Network trials had a goal partial pressure of oxygen in arterial blood range of 55-80 mm Hg, yet the effect of oxygen exposure above this arterial oxygen tension range on clinical outcomes is unknown. We sought to determine if oxygen exposure that resulted in a partial pressure of oxygen in arterial blood above goal (> 80 mm Hg) was associated with worse outcomes in patients with acute respiratory distress syndrome. DESIGN Longitudinal analysis of data collected in these trials. SETTING Ten clinical trials conducted at Acute Respiratory Distress Syndrome Network hospitals between 1996 and 2013. SUBJECTS Critically ill patients with acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We defined above goal oxygen exposure as the difference between the fraction of inspired oxygen and 0.5 whenever the fraction of inspired oxygen was above 0.5 and when the partial pressure of oxygen in arterial blood was above 80 mm Hg. We then summed above goal oxygen exposures in the first five days to calculate a cumulative above goal oxygen exposure. We determined the effect of a cumulative 5-day above goal oxygen exposure on mortality prior to discharge home at 90 days. Among 2,994 participants (mean age, 51.3 yr; 54% male) with a study-entry partial pressure of oxygen in arterial blood/fraction of inspired oxygen that met acute respiratory distress syndrome criteria, average cumulative above goal oxygen exposure was 0.24 fraction of inspired oxygen-days (interquartile range, 0-0.38). Participants with above goal oxygen exposure were more likely to die (adjusted interquartile range odds ratio, 1.20; 95% CI, 1.11-1.31) and have lower ventilator-free days (adjusted interquartile range mean difference of -0.83; 95% CI, -1.18 to -0.48) and lower hospital-free days (adjusted interquartile range mean difference of -1.38; 95% CI, -2.09 to -0.68). We observed a dose-response relationship between the cumulative above goal oxygen exposure and worsened clinical outcomes for participants with mild, moderate, or severe acute respiratory distress syndrome, suggesting that the observed relationship is not primarily influenced by severity of illness. CONCLUSIONS Oxygen exposure resulting in arterial oxygen tensions above the protocol goal occurred frequently and was associated with worse clinical outcomes at all levels of acute respiratory distress syndrome severity.
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Agrinier N, Monnier A, Argaud L, Bemer M, Virion JM, Alleyrat C, Charpentier C, Ziegler L, Louis G, Bruel C, Jamme M, Quenot JP, Badie J, Schneider F, Bollaert PE. Effect of fluid balance control in critically ill patients: Design of the stepped wedge trial POINCARE-2. Contemp Clin Trials 2019; 83:109-116. [PMID: 31260794 DOI: 10.1016/j.cct.2019.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/21/2019] [Accepted: 06/27/2019] [Indexed: 01/28/2023]
Abstract
A high number of recent studies have shown that a positive fluid balance is independently associated with impaired prognosis in specific populations of patients hospitalized in intensive care unit (ICU): acute kidney injury, acute respiratory distress syndrome (ARDS), sepsis, high risk surgery. However, to date, there is no evidence that control of fluid overload reduces mortality in critically ill patients. The main objective is to assess the efficacy of a strategy limiting fluid overload on mortality in unselected critically ill patients hospitalized in ICU. We hypothesized that a strategy based on a weight-driven recommendation of restricted fluid intake, diuretics, and ultrafiltration initiated from 48 h up to 14 days after admission in critically ill patients would reduce all-cause mortality as compared to usual care. We use a stepped wedge cluster randomized controlled trial combined with a quasi-experimental (before-and-after) study. Patients under mechanical ventilation, admitted since >48 h and < 72 h in ICU, and with no discharge planned for the next 24 h are eligible. A total of 1440 patients are expected to be enrolled in 12 ICUs. Sociodemographic and clinical data are collected at inclusion, and outcomes are collected during the follow-up. Primary outcome is all-cause mortality at 60 days after admission. Secondary outcomes are patients weight differences between admission and day7 (or day 14), 28-day, in-hospital, and 1-year mortality, end-organ damages, and unintended harmful events. Analyses will be held in intention-to-treat. If POINCARE-2 strategy proves effective, then guidelines on fluid balance control might be extended to all critically ill patients. Trial registration: ClinicalTrials.govNCT02765009.
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Affiliation(s)
- Nelly Agrinier
- CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie Clinique, F-54000 Nancy, France; Université de Lorraine, APEMAC, F-54000 Nancy, France.
| | - Alexandra Monnier
- CHRU Strasbourg, Nouvel Hôpital Civil, Service de Réanimation médicale, F-67000 Strasbourg, France
| | - Laurent Argaud
- Hospices civils de Lyon, Hôpital Edouard Herriot, Service de réanimation médicale, F-69000 Lyon, France
| | - Michel Bemer
- CHR Metz-Thionville, Service de Réanimation polyvalente, F-57000 Thionville, France
| | - Jean-Marc Virion
- CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie Clinique, F-54000 Nancy, France
| | - Camille Alleyrat
- CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie Clinique, F-54000 Nancy, France
| | - Claire Charpentier
- CHRU-Nancy, Université de Lorraine, Service d'Anesthésie Réanimation chirurgicale, F-54000 Nancy, France
| | - Laurent Ziegler
- CH Verdun, Service d'anesthésie réanimation, F-55000 Verdun, France
| | - Guillaume Louis
- CHR Metz-Thionville, Service de Réanimation polyvalente, F-57000 Metz, France
| | - Cédric Bruel
- Groupe hospitalier Paris Saint-Joseph, Service de réanimation polyvalente, F-75000 Paris, France
| | - Matthieu Jamme
- CHI Poissy Saint-Germain, Service de Réanimation, F-78303 Poissy, France
| | - Jean-Pierre Quenot
- CHU Dijon-Bourgogne, Service de Médecine Intensive-Réanimation, F-21000 Dijon, France
| | - Julio Badie
- Hôpital Nord Franche-Comté, Service de Réanimation médicale, F-90015 Belfort, France
| | - Francis Schneider
- CHU Strasbourg, Hôpital de Hautepierre, Service de Médecine Intensive Réanimation, INSERM U 1121, F-67000 Strasbourg, France
| | - Pierre-Edouard Bollaert
- Université de Lorraine, CHRU-Nancy, Service de Médecine Intensive Réanimation, F-54000 Nancy, France
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Kaku S, Nguyen CD, Htet NN, Tutera D, Barr J, Paintal HS, Kuschner WG. Acute Respiratory Distress Syndrome: Etiology, Pathogenesis, and Summary on Management. J Intensive Care Med 2019; 35:723-737. [DOI: 10.1177/0885066619855021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The acute respiratory distress syndrome (ARDS) has multiple causes and is characterized by acute lung inflammation and increased pulmonary vascular permeability, leading to hypoxemic respiratory failure and bilateral pulmonary radiographic opacities. The acute respiratory distress syndrome is associated with substantial morbidity and mortality, and effective treatment strategies are limited. This review presents the current state of the literature regarding the etiology, pathogenesis, and management strategies for ARDS.
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Affiliation(s)
- Shawn Kaku
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Christopher D. Nguyen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Natalie N. Htet
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Dominic Tutera
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Juliana Barr
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Harman S. Paintal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Ware G. Kuschner
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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Shen N, Cheng A, Qiu M, Zang G. Allicin Improves Lung Injury Induced by Sepsis via Regulation of the Toll-Like Receptor 4 (TLR4)/Myeloid Differentiation Primary Response 88 (MYD88)/Nuclear Factor kappa B (NF-κB) Pathway. Med Sci Monit 2019; 25:2567-2576. [PMID: 30957795 PMCID: PMC6467176 DOI: 10.12659/msm.914114] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background The aim of this study was to assess the effects and mechanisms of allicin in a sepsis-induced lung injury in vivo study. Material/Methods The rats (n=54) were divided into 6 groups: Normal, DMSO, LPS, LPS+LD, LPS+MD, and LPS+HD groups. After being treated by different methods, we collected the lung tissues of different groups and evaluated the pathology by HE staining and positive apoptosis cells by TUNEL. We assessed the W/D ratio, inflammatory cytokines (TNF-α, IL-6 and IL-1β), and relative protein expressions (TLR4, MyD88, NF-κB, caspase-3, and caspase-9) by IHC assay. Results Compared with LPS group, the lung injury and positive cell number of allicin treated groups were significantly improved with dose-dependent (P<0.05, respectively) and the W/D ratio and TNF-α, IL-6 and IL-1β concentration were significantly down-regulation compared with those of LPS group with dose-dependent (P<0.05, respectively). By IHC, the TLR4, MyD88, NF-κB, caspase-3 and caspase-9 protein activities of allicin treated groups were significantly suppressed compared with those of LPS group (P<0.05, respectively) in lung tissues. Conclusions This in vivo study shows that allicin improved sepsis-induced lung injury by regulation of TLR4/MyD88/NF-κB.
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Affiliation(s)
- Ning Shen
- Department of Respiratory Medicine, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China (mainland)
| | - Ailing Cheng
- Department of Geriatrics, Jinan Hospital, Jinan, Shandong, China (mainland)
| | - Mengru Qiu
- Department of Respiratory Medicine, Shandong Academy of Occupational Health and Occupational Medicine, Jinan, Shandong, China (mainland)
| | - Guodong Zang
- Department of Respiratory Medicine, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China (mainland)
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Boiron L, Hopper K, Borchers A. Risk factors, characteristics, and outcomes of acute respiratory distress syndrome in dogs and cats: 54 cases. J Vet Emerg Crit Care (San Antonio) 2019; 29:173-179. [PMID: 30861281 DOI: 10.1111/vec.12819] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 05/04/2017] [Accepted: 06/21/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To characterize the clinical features of the acute respiratory distress syndrome (ARDS), risk factors, and outcome in dogs and cats. The study also aimed to evaluate the current veterinary criteria for the diagnosis of ARDS by comparison of clinical diagnostic criteria with necropsy findings. DESIGN Retrospective study. ANIMALS Fifty-four client-owned animals, 46 dogs and 8 cats. INTERVENTIONS Medical records were reviewed for patients with the diagnosis of ARDS based on previously published clinical criteria or necropsy diagnosis. Signalment, clinical findings, and outcome were recorded. MEASUREMENTS AND MAIN RESULTS Animals were grouped according to a clinical or necropsy diagnosis: 43/54 (80%) were diagnosed with ARDS based on clinical criteria (group 1) and 11/54 (20%) were diagnosed with ARDS based on necropsy only (group 2). In group 1, 22/43 (51%) had a necropsy, which confirmed ARDS in 12/22 (54%). Direct (pulmonary) causes of ARDS were more common than indirect causes in dogs, while cats had a similar occurrence of direct and indirect causes. The most common risk factors identified in dogs were aspiration pneumonia (42%), systemic inflammatory response syndrome (SIRS) (29%), and shock (29%). All cats diagnosed clinically with ARDS had SIRS with or without sepsis. Of the animals with a clinical diagnosis of ARDS, 49% received mechanical ventilation and 58% received treatment (with or without mechanical ventilation) for 24 hours or longer. The overall case fatality rate was 84% in dogs and 100% in cats. CONCLUSIONS AND CLINICAL RELEVANCE As described in human literature, pneumonia was the most common risk factor in dogs with ARDS, whereas it was SIRS for the cat population. The high mortality rate and discrepancy between the clinical diagnosis and necropsy findings may highlight limitations in the clinical criteria for the diagnosis of ARDS and treatment in dogs and cats.
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Affiliation(s)
- Ludivine Boiron
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, CA
| | - Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences and School of Veterinary Medicine, University of California, Davis, Davis, CA
| | - Angela Borchers
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, CA
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Chen L, Zhao H, Alam A, Mi E, Eguchi S, Yao S, Ma D. Postoperative remote lung injury and its impact on surgical outcome. BMC Anesthesiol 2019; 19:30. [PMID: 30832647 PMCID: PMC6399848 DOI: 10.1186/s12871-019-0698-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 02/18/2019] [Indexed: 01/06/2023] Open
Abstract
Postoperative remote lung injury is a complication following various surgeries and is associated with short and long-term mortality and morbidity. The release of proinflammatory cytokines, damage-associated molecular patterns such as high-mobility group box-1, nucleotide-biding oligomerization domain (NOD)-like receptor protein 3 and heat shock protein, and cell death signalling activation, trigger a systemic inflammatory response, which ultimately results in organ injury including lung injury. Except high financial burden, the outcome of patients developing postoperative remote lung injury is often not optimistic. Several risk factors had been classified to predict the occurrence of postoperative remote lung injury, while lung protective ventilation and other strategies may confer protective effect against it. Understanding the pathophysiology of this process will facilitate the design of novel therapeutic strategies and promote better outcomes of surgical patients. This review discusses the cause and pathology underlying postoperative remote lung injury. Risk factors, surgical outcomes and potential preventative/treatment strategies against postoperative remote lung injury are also addressed.
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Affiliation(s)
- Lin Chen
- Department of Anaesthesiology, Institute of Anaesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.,Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, SW10 9NH, UK
| | - Hailin Zhao
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, SW10 9NH, UK
| | - Azeem Alam
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, SW10 9NH, UK
| | - Emma Mi
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, SW10 9NH, UK
| | - Shiori Eguchi
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, SW10 9NH, UK
| | - Shanglong Yao
- Department of Anaesthesiology, Institute of Anaesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
| | - Daqing Ma
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, SW10 9NH, UK.
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Zhang Z, Spieth PM, Chiumello D, Goyal H, Torres A, Laffey JG, Hong Y. Declining Mortality in Patients With Acute Respiratory Distress Syndrome: An Analysis of the Acute Respiratory Distress Syndrome Network Trials. Crit Care Med 2019; 47:315-323. [PMID: 30779718 DOI: 10.1097/ccm.0000000000003499] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES There has been multiple advances in the management of acute respiratory distress syndrome, but the temporal trends in acute respiratory distress syndrome-related mortality are not well known. This study aimed to investigate the trends in mortality in acute respiratory distress syndrome patients over time and to explore the roles of daily fluid balance and ventilation variables in those patients. DESIGN Secondary analysis of randomized controlled trials conducted by the Acute Respiratory Distress Syndrome Network from 1996 to 2013. SETTING Multicenter study involving Acute Respiratory Distress Syndrome Network trials. PATIENTS Patients with acute respiratory distress syndrome. INTERVENTIONS None. MEASURES AND MAIN RESULTS Individual patient data from 5,159 acute respiratory distress syndrome patients (excluding the Late Steroid Rescue Study trial) were enrolled in this study. The crude mortality rate decreased from 35.4% (95% CI, 29.9-40.8%) in 1996 to 28.3% (95% CI, 22.0-34.7%) in 2013. By adjusting for the baseline Acute Physiology and Chronic Health Evaluation III, age, ICU type, and admission resource, patients enrolled from 2005 to 2010 (odds ratio, 0.61; 95% CI, 0.50-0.74) and those enrolled after 2010 (odds ratio, 0.73; 95% CI, 0.58-0.92) were associated with lower risk of death as compared to those enrolled before 2000. The effect of year on mortality decline disappeared after adjustment for daily fluid balance, positive end-expiratory pressure, tidal volume, and plateau pressure. There were significant trends of declines in daily fluid balance, tidal volume, and plateau pressure and an increase in positive end-expiratory pressure over the 17 years. CONCLUSIONS Our study shows an improvement in the acute respiratory distress syndrome-related mortality rate in the critically ill patients enrolled in the Acute Respiratory Distress Syndrome Network trials. The effect was probably mediated via decreased tidal volume, plateau pressure, and daily fluid balance and increased positive end-expiratory pressure.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Peter Markus Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital Dresden, Technische Universität Dresden, Germany
| | - Davide Chiumello
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy
- Centro ricerca cordinata di insufficienza respiratoria, Università degli Studi di Milan, Italy
| | - Hemant Goyal
- Department of Internal Medicine, Mercer University School of Medicine, Macon, GA
| | - Antoni Torres
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona - SGR 911- Ciber de Enfermedades Respiratorias (Ciberes) Barcelona, Spain
| | - John G Laffey
- Critical Illness and Injury Research Centre, Keenan Research Centre for Biomedical Science of St Michael's Hospital, Toronto, ON, Canada
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Pfortmueller CA, Barbani MT, Schefold JC, Hage E, Heim A, Zimmerli S. Severe acute respiratory distress syndrome (ARDS) induced by human adenovirus B21: Report on 2 cases and literature review. J Crit Care 2019; 51:99-104. [PMID: 30798099 PMCID: PMC7172394 DOI: 10.1016/j.jcrc.2019.02.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/29/2018] [Accepted: 02/12/2019] [Indexed: 01/01/2023]
Abstract
Severe pneumonia and ARDS caused by human adenovirus B21 infections (HAdV-B21) is a rare, but a devastating disease with rapid progression to multiorgan failure and death. However, only a few cases were reported so far. Infections appear associated with increased disease severity and higher mortality in infected critically ill patients. Possible factors contributing to infection are underlying psychiatric disease resulting in institutionalization of respective patients, and polytoxicomania. Controlled data on the therapy of severe adenovirus infections are lacking and remains experimental. In conclusion, data on HAdV-B21 infections causing severe pneumonia or ARDS are scarce. Controlled clinical trials on the therapy of adenovirus pneumonia are non existent and thus there is no established therapy so far. ICU physicians should be aware of this potentially devastating disease and further studies are needed.
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MESH Headings
- Adenovirus Infections, Human/complications
- Adenovirus Infections, Human/diagnosis
- Adenovirus Infections, Human/diagnostic imaging
- Adenovirus Infections, Human/virology
- Adenoviruses, Human/genetics
- Adenoviruses, Human/isolation & purification
- Adult
- Diagnosis, Differential
- Female
- Humans
- Male
- Middle Aged
- Pneumonia, Viral/complications
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/diagnostic imaging
- Pneumonia, Viral/virology
- Respiratory Distress Syndrome/complications
- Respiratory Distress Syndrome/diagnosis
- Respiratory Distress Syndrome/diagnostic imaging
- Respiratory Distress Syndrome/virology
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Affiliation(s)
- Carmen Andrea Pfortmueller
- Department of Intensive Care, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
| | - Maria Teresa Barbani
- Institute for Infectious Diseases, University of Bern, Friedbuehlstrasse 51, 3010 Bern, Switzerland.
| | - Joerg Christian Schefold
- Department of Intensive Care, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
| | - Elias Hage
- Institute of Virology, Hannover Medical School, Hannover, Germany
| | - Albert Heim
- Institute of Virology, Hannover Medical School, Hannover, Germany.
| | - Stefan Zimmerli
- Institute for Infectious Diseases, University of Bern, Friedbuehlstrasse 51, 3010 Bern, Switzerland; Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
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49
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Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Patients with initial mild acute respiratory distress syndrome are often underrecognized and mistakenly considered to have low disease severity and favorable outcomes. They represent a relatively poorly characterized population that was only classified as having acute respiratory distress syndrome in the most recent definition. Our primary objective was to describe the natural course and the factors associated with worsening and mortality in this population.
Methods
This study analyzed patients from the international prospective Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) who had initial mild acute respiratory distress syndrome in the first day of inclusion. This study defined three groups based on the evolution of severity in the first week: “worsening” if moderate or severe acute respiratory distress syndrome criteria were met, “persisting” if mild acute respiratory distress syndrome criteria were the most severe category, and “improving” if patients did not fulfill acute respiratory distress syndrome criteria any more from day 2.
Results
Among 580 patients with initial mild acute respiratory distress syndrome, 18% (103 of 580) continuously improved, 36% (210 of 580) had persisting mild acute respiratory distress syndrome, and 46% (267 of 580) worsened in the first week after acute respiratory distress syndrome onset. Global in-hospital mortality was 30% (172 of 576; specifically 10% [10 of 101], 30% [63 of 210], and 37% [99 of 265] for patients with improving, persisting, and worsening acute respiratory distress syndrome, respectively), and the median (interquartile range) duration of mechanical ventilation was 7 (4, 14) days (specifically 3 [2, 5], 7 [4, 14], and 11 [6, 18] days for patients with improving, persisting, and worsening acute respiratory distress syndrome, respectively). Admissions for trauma or pneumonia, higher nonpulmonary sequential organ failure assessment score, lower partial pressure of alveolar oxygen/fraction of inspired oxygen, and higher peak inspiratory pressure were independently associated with worsening.
Conclusions
Most patients with initial mild acute respiratory distress syndrome continue to fulfill acute respiratory distress syndrome criteria in the first week, and nearly half worsen in severity. Their mortality is high, particularly in patients with worsening acute respiratory distress syndrome, emphasizing the need for close attention to this patient population.
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Keddissi JI, Youness HA, Jones KR, Kinasewitz GT. Fluid management in Acute Respiratory Distress Syndrome: A narrative review. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2018; 55:1-8. [PMID: 31297439 PMCID: PMC6591787 DOI: 10.29390/cjrt-2018-016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute Respiratory Distress Syndrome remains a major source of morbidity and mortality in the modern intensive care unit (ICU). Major advances in the understanding and management of this condition were made in the last two decades. The use of low tidal ventilation is a well-established therapy. Conservative fluid management is now another cornerstone of management. However, much remains to be understood in this arena. Assessing volume status in these patients may be challenging and the tools available to do so are far from perfect. Several dynamic measures including pulse pressures variation are used. Ultrasound of the lungs and the vascular system may also have a role. In addition, the type of fluid to administer when needed is still open to debate. Finally, supportive measures in these patients, early during their ICU stay and later after discharge continue to be crucial for survival and adequate recovery.
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Affiliation(s)
- Jean I Keddissi
- Section of Pulmonary, Critical Care and Sleep Medicine, The Oklahoma City VA HealthCare System and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Houssein A Youness
- Section of Pulmonary, Critical Care and Sleep Medicine, The Oklahoma City VA HealthCare System and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kellie R Jones
- Section of Pulmonary, Critical Care and Sleep Medicine, The Oklahoma City VA HealthCare System and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Gary T Kinasewitz
- Section of Pulmonary, Critical Care and Sleep Medicine, The Oklahoma City VA HealthCare System and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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