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Wieruszewski PM, Coleman PJ, Levine AR, Davison D, Smischney NJ, Kethireddy S, Guo Y, Hecht J, Mazzeffi MA, Chow JH. Trajectory of PaO 2/FiO 2 Ratio in Shock After Angiotensin II. J Intensive Care Med 2023; 38:939-948. [PMID: 37161301 DOI: 10.1177/08850666231174870] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
INTRODUCTION High-dose catecholamines can impair hypoxic pulmonary vasoconstriction and increase shunt fraction. We aimed to determine if Angiotensin II (Ang-2) is associated with improved PaO2/FiO2 and SpO2/FiO2 in patients in shock. METHODS Adult patients at four tertiary care centers and one community hospital in the United States who received Ang-2 from July 2018-September 2020 were included in this retrospective, observational cohort study. PaO2, SpO2, and FiO2 were measured at 13 timepoints during the 48-h before and after Ang-2 initiation. Piecewise linear mixed models of PaO2/FiO2 and SpO2/FiO2 were created to evaluate hourly changes in oxygenation after Ang-2 initiation. The difference in the proportion of patients with PaO2/FiO2 ≤ 300 mm Hg at the time of Ang-2 initiation and 48 h after was also examined. RESULTS The study included 254 patients. In the 48 h prior to Ang-2 initiation, oxygenation was significantly declining (hourly PaO2/FiO2 change -4.7 mm Hg/hr, 95% CI - 6.0 to -3.5, p < .001; hourly SpO2/FiO2 change -3.1/hr, 95% CI-3.7 to -2.4, p < .001). Ang-2 treatment was associated with significant improvements in PaO2/FiO2 and SpO2/FiO2 in the 48-h after initiation (hourly PaO2/FiO2 change +1.5 mm Hg/hr, 95% CI 0.5-2.5, p = .003; hourly SpO2/FiO2 change +0.9/hr, 95% CI 0.5-1.2, p < .001). The difference in the hourly change in oxygenation before and after Ang-2 initiation was also significant (pinteraction < 0.001 for both PaO2/FiO2 and SpO2/FiO2). This improvement was associated with significantly fewer patients having a PaO2/FiO2 ≤ 300 mm Hg at 48 h compared to baseline (mean difference -14.9%, 95% CI -25.3% to -4.6%, p = .011). Subgroup analysis found that patients with either a baseline PaO2/FiO2 ≤ 300 mm Hg or a norepinephrine-equivalent dose requirement >0.2 µg/kg/min had the greatest associations with oxygenation improvement. CONCLUSIONS Ang-2 is associated with improved PaO2/FiO2 and SpO2/FiO2. The mechanisms for this improvement are not entirely clear but may be due to catecholamine-sparing effect or may also be related to improved ventilation-perfusion matching, intrapulmonary shunt, or oxygen delivery.
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Affiliation(s)
- Patrick M Wieruszewski
- Department of Anesthesiology and Pharmacy, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Patrick J Coleman
- Department of Anesthesiology, Walter Reed National Military Medical Center, Baltimore, MD, USA
| | - Andrea R Levine
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Danielle Davison
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Nathan J Smischney
- Department of Anesthesiology, Division of Critical Care Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Shravan Kethireddy
- Department of Medicine, Division of Pulmonary and Critical Care, Cleveland Clinic, Cleveland, OH, USA
| | - Yanglin Guo
- Department of Medicine, Division of Pulmonary & Critical Care, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jason Hecht
- Department of Pharmacy, St. Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, USA
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Jonathan H Chow
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Blot PL, DE Roquetaillade C, Deniau B, Gaugain S, Kindermans M, Julian N, LE Dorze M, Mebazaa A, Chousterman BG, Barthélémy R. Efficacy of almitrine as a rescue therapy for refractory hypoxemia in COVID and non-COVID acute respiratory distress syndrome. A retrospective monocenter study. Minerva Anestesiol 2023; 89:157-165. [PMID: 36287391 DOI: 10.23736/s0375-9393.22.16736-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Almitrine, a drug enhancing hypoxic pulmonary vasoconstriction, has been proposed as a rescue therapy for refractory hypoxemia in COVID related acute respiratory distress syndrome (C-ARDS). We aimed at investigating the response to almitrine depending on the cause of ARDS (COVID vs. non-COVID). METHODS Monocenter retrospective study from 2014 to 2021. All patients diagnosed with moderate to severe ARDS and treated with almitrine as rescue therapy for refractory hypoxemia were studied. Factor independently associated with oxygenation response to almitrine infusion were determined. RESULTS Sixty patients with ARDS and treated with almitrine were analyzed, 36 (60%) due to SARS-CoV-2 infection and 24 (40%) due to other causes. Baseline PaO2/FiO2 was 78 [61-101] mmHg, 76% had at least one prone positioning before the start of almitrine infusion. Median PaO2/FiO2 increased by +38 [7-142] mmHg (+61% [10-151]) after almitrine infusion. PaO2/FiO2 increased by +134 [12-186] mmHg in non-COVID ARDS (NC-ARDS) and by +19 [8-87] mmHg in C-ARDS. The increase in PaO2/FiO2 was lower in C-ARDS than in NC-ARDS (P=0.013). In multivariable analysis, C-ARDS, non-invasive ventilation and concomitant use of norepinephrine were independently associated with a decreased oxygenation response to almitrine infusion. CONCLUSIONS Our study reports a highly variable response to almitrine infusion in ARDS patients with refractory hypoxemia. Independent factors associated with a reduced oxygenation response to almitrine infusion were: COVID ARDS, concomitant use of norepinephrine, and non-invasive ventilatory strategy.
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Affiliation(s)
- Pierre-Louis Blot
- Department of Anesthesia and Critical Care, Lariboisière Hospital, Paris, France.,Université Paris-Cité, Inserm UMRS 942 Mascot, Paris, France
| | - Charles DE Roquetaillade
- Department of Anesthesia and Critical Care, Lariboisière Hospital, Paris, France.,Université Paris-Cité, Inserm UMRS 942 Mascot, Paris, France
| | - Benjamin Deniau
- Department of Anesthesia and Critical Care, Lariboisière Hospital, Paris, France.,Université Paris-Cité, Inserm UMRS 942 Mascot, Paris, France
| | - Samuel Gaugain
- Department of Anesthesia and Critical Care, Lariboisière Hospital, Paris, France
| | - Manuel Kindermans
- Department of Anesthesia and Critical Care, Lariboisière Hospital, Paris, France.,Université Paris-Cité, Inserm UMRS 942 Mascot, Paris, France
| | - Nathan Julian
- Department of Anesthesia and Critical Care, Lariboisière Hospital, Paris, France.,Université Paris-Cité, Inserm UMRS 942 Mascot, Paris, France
| | - Matthieu LE Dorze
- Department of Anesthesia and Critical Care, Lariboisière Hospital, Paris, France.,Université Paris-Cité, Inserm UMRS 942 Mascot, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesia and Critical Care, Lariboisière Hospital, Paris, France.,Université Paris-Cité, Inserm UMRS 942 Mascot, Paris, France
| | - Benjamin G Chousterman
- Department of Anesthesia and Critical Care, Lariboisière Hospital, Paris, France.,Université Paris-Cité, Inserm UMRS 942 Mascot, Paris, France
| | - Romain Barthélémy
- Department of Anesthesia and Critical Care, Lariboisière Hospital, Paris, France - .,Université Paris-Cité, Inserm UMRS 942 Mascot, Paris, France
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Roy D, Thakare RP, Chopra S, Panda G. Aromatic or Hetero-aromatic Directly Attached Tri and Tetrasubstituted Methanes: New Chemical Entities as Anti-Infectives. Curr Med Chem 2023; 30:974-998. [PMID: 36017850 DOI: 10.2174/0929867329666220823111812] [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: 04/29/2022] [Accepted: 05/12/2022] [Indexed: 11/22/2022]
Abstract
Tri and Tetra-substituted Methanes (TRSMs) are a significant structural motif in many approved drugs and prodrugs. There is increasing use of TRSM units in medicinal chemistry, and many derivatives are specifically designed to make drug-target interactions through new chemical space around TRSM moiety. In this perspective, we describe synthetic challenges for accessing a range of functionalized selective TRSMs and their molecular mechanism of action, especially as anti-infectives. Natural anti-infectives like (+)-Bionectin A, B, (+)-Gliocladine C, Balanocarpol having TRSMs selectively and effectively bind to target proteins in comparison to planar motif having more sp2 carbons perhaps due to conformation which reduces the penalty for conformational entropy with the enhancement of three-dimensionality. Properties of repurposed TRSMs like Almitrine, Ifenprodil, Baricitinib and Remdesivir with their recent progress in COVID-19 therapeutics with their mode of action are also delineated. This perspective is expected to deliver a user guide and reference source for scientists, researchers and academicians in pursuing newly designed TRSMs as therapeutics.
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Affiliation(s)
- Deblina Roy
- Medicinal & Process Chemistry Division, Gautam Panda, CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Lucknow 226031, UP, India
| | - Ritesh P Thakare
- Division of Microbiology, Sidharth Chopra, CSIRCentral Drug Research Institute, Sector 10, Jankipuram Extension, Lucknow 226031, UP, India
| | - Sidharth Chopra
- Division of Microbiology, Sidharth Chopra, CSIRCentral Drug Research Institute, Sector 10, Jankipuram Extension, Lucknow 226031, UP, India.,Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Gautam Panda
- Medicinal & Process Chemistry Division, Gautam Panda, CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Lucknow 226031, UP, India.,Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
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Bagate F, Tuffet S, Masi P, Perier F, Razazi K, de Prost N, Carteaux G, Payen D, Mekontso Dessap A. Rescue therapy with inhaled nitric oxide and almitrine in COVID-19 patients with severe acute respiratory distress syndrome. Ann Intensive Care 2020; 10:151. [PMID: 33150525 PMCID: PMC7641257 DOI: 10.1186/s13613-020-00769-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 10/24/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In COVID-19 patients with severe acute respiratory distress syndrome (ARDS), the relatively preserved respiratory system compliance despite severe hypoxemia, with specific pulmonary vascular dysfunction, suggests a possible hemodynamic mechanism for VA/Q mismatch, as hypoxic vasoconstriction alteration. This study aimed to evaluate the capacity of inhaled nitric oxide (iNO)-almitrine combination to restore oxygenation in severe COVID-19 ARDS (C-ARDS) patients. METHODS We conducted a monocentric preliminary pilot study in intubated patients with severe C-ARDS. Respiratory mechanics was assessed after a prone session. Then, patients received iNO (10 ppm) alone and in association with almitrine (10 μg/kg/min) during 30 min in each step. Echocardiographic and blood gases measurements were performed at baseline, during iNO alone, and iNO-almitrine combination. The primary endpoint was the variation of oxygenation (PaO2/FiO2 ratio). RESULTS Ten severe C-ARDS patients were assessed (7 males and 3 females), with a median age of 60 [52-72] years. Combination of iNO and almitrine outperformed iNO alone for oxygenation improvement. The median of PaO2/FiO2 ratio varied from 102 [89-134] mmHg at baseline, to 124 [108-146] mmHg after iNO (p = 0.13) and 180 [132-206] mmHg after iNO and almitrine (p < 0.01). We found no correlation between the increase in oxygenation caused by iNO-almitrine combination and that caused by proning. CONCLUSION In this pilot study of severe C-ARDS patients, iNO-almitrine combination was associated with rapid and significant improvement of oxygenation. These findings highlight the role of pulmonary vascular function in COVID-19 pathophysiology.
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Affiliation(s)
- François Bagate
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France
| | - Samuel Tuffet
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France
| | - Paul Masi
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France
| | - François Perier
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France
| | - Keyvan Razazi
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France
| | - Nicolas de Prost
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France
| | - Guillaume Carteaux
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France
| | - Didier Payen
- UFR de Médecine Villemin, Université Paris 7 Paris Cité Sorbonne, Paris, France
| | - Armand Mekontso Dessap
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France. .,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France. .,Univ Paris Est Créteil, INSERM, IMRB, 94 010, Créteil, France.
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6
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Bendjelid K, Raphaël G. Treating hypoxemic patients with SARS-COV-2 pneumonia: Back to applied physiology. Anaesth Crit Care Pain Med 2020; 39:389-390. [PMID: 32305591 PMCID: PMC7161523 DOI: 10.1016/j.accpm.2020.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/07/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Karim Bendjelid
- Intensive care division, university hospitals, Geneva, Switzerland; Geneva haemodynamic research group, Geneva, Switzerland; Faculty of medicine, Geneva, Switzerland.
| | - Giraud Raphaël
- Intensive care division, university hospitals, Geneva, Switzerland; Geneva haemodynamic research group, Geneva, Switzerland; Faculty of medicine, Geneva, Switzerland
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7
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Voelker MT, Bergmann A, Busch T, Jahn N, Laudi S, Noreikat K, Simon P, Bercker S. The effects of hemoglobin glutamer-200 and iNO on pulmonary vascular tone and arterial oxygenation in an experimental acute respiratory distress syndrome. Pulm Pharmacol Ther 2018; 49:130-133. [DOI: 10.1016/j.pupt.2018.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 12/16/2017] [Accepted: 01/25/2018] [Indexed: 11/17/2022]
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8
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Radermacher P, Maggiore SM, Mercat A. FiftyYears ofResearch inARDS.Gas Exchange in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 196:964-984. [DOI: 10.1164/rccm.201610-2156so] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Peter Radermacher
- Institute of Anaesthesiological Pathophysiology and Process Engineering, University Medical School, Ulm, Germany
| | - Salvatore Maurizio Maggiore
- Section of Anesthesia, Analgesia, Perioperative, and Intensive Care, Department of Medical, Oral, and Biotechnological Sciences, School of Medicine and Health Sciences, “SS. Annunziata” Hospital, “Gabriele d’Annunzio” University of Chieti-Pescara, Chieti, Italy; and
| | - Alain Mercat
- Department of Medical Intensive Care and Hyperbaric Medicine, Angers University Hospital, Angers, France
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9
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Abstract
Hypoxic pulmonary vasoconstriction (HPV) represents a fundamental difference between the pulmonary and systemic circulations. HPV is active in utero, reducing pulmonary blood flow, and in adults helps to match regional ventilation and perfusion although it has little effect in healthy lungs. Many factors affect HPV including pH or PCO2, cardiac output, and several drugs, including antihypertensives. In patients with lung pathology and any patient having one-lung ventilation, HPV contributes to maintaining oxygenation, so anesthesiologists should be aware of the effects of anesthesia on this protective reflex. Intravenous anesthetic drugs have little effect on HPV, but it is attenuated by inhaled anesthetics, although less so with newer agents. The reflex is biphasic, and once the second phase becomes active after about an hour of hypoxia, this pulmonary vasoconstriction takes hours to reverse when normoxia returns. This has significant clinical implications for repeated periods of one-lung ventilation.
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10
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Vasoconstrictor responses to vasopressor agents in human pulmonary and radial arteries: an in vitro study. Anesthesiology 2014; 121:930-6. [PMID: 25198173 DOI: 10.1097/aln.0000000000000430] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Vasopressor drugs, commonly used to treat systemic hypotension and maintain organ perfusion, may also induce regional vasoconstriction in specialized vascular beds such as the lung. An increase in pulmonary vascular tone may adversely affect patients with pulmonary hypertension or right heart failure. While sympathomimetics constrict pulmonary vessels, and vasopressin does not, a direct comparison between these drugs has not been made. This study investigated the effects of clinically used vasopressor agents on human isolated pulmonary and radial arteries. METHODS Isolated pulmonary and radial artery ring segments, mounted in organ baths, were used to study the contractile responses of each vasopressor agent. Concentration-response curves to norepinephrine, phenylephrine, metaraminol, and vasopressin were constructed. RESULTS The sympathomimetics norepinephrine, phenylephrine, and metaraminol caused concentration-dependent vasoconstriction in the radial (pEC50: 6.99 ± 0.06, 6.14 ± 0.09, and 5.56 ± 0.07, respectively, n = 4 to 5) and pulmonary arteries (pEC50: 6.86 ± 0.11, 5.94 ± 0.05 and 5.56 ± 0.09, respectively, n = 3 to 4). Vasopressin was a potent vasoconstrictor of the radial artery (pEC50 9.13 ± 0.20, n = 3), whereas in the pulmonary artery, it had no significant effect. CONCLUSIONS Sympathomimetic-based vasopressor agents constrict both human radial and pulmonary arteries with similar potency in each. In contrast, vasopressin, although a potent vasoconstrictor of radial vessels, had no effect on pulmonary vascular tone. These findings provide some support for the use of vasopressin in patients with pulmonary hypertension.
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Abstract
This article describes the gas exchange abnormalities occurring in the acute respiratory distress syndrome seen in adults and children and in the respiratory distress syndrome that occurs in neonates. Evidence is presented indicating that the major gas exchange abnormality accounting for the hypoxemia in both conditions is shunt, and that approximately 50% of patients also have lungs regions in which low ventilation-to-perfusion ratios contribute to the venous admixture. The various mechanisms by which hypercarbia may develop and by which positive end-expiratory pressure improves gas exchange are reviewed, as are the effects of vascular tone and airway narrowing. The mechanisms by which surfactant abnormalities occur in the two conditions are described, as are the histological findings that have been associated with shunt and low ventilation-to-perfusion.
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Affiliation(s)
- Richard K Albert
- Chief of Medicine, Denver Health, Professor of Medicine, University of Colorado, Adjunct Professor of Engineering and Computer Science, University of Denver, Denver, Colorado, USA.
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12
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Roch A, Hraiech S, Dizier S, Papazian L. Pharmacological interventions in acute respiratory distress syndrome. Ann Intensive Care 2013; 3:20. [PMID: 23822630 PMCID: PMC3701581 DOI: 10.1186/2110-5820-3-20] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 06/14/2013] [Indexed: 01/11/2023] Open
Abstract
Pharmacological interventions are commonly considered in acute respiratory distress syndrome (ARDS) patients. Inhaled nitric oxide (iNO) and neuromuscular blockers (NMBs) are used in patients with severe hypoxemia. No outcome benefit has been observed with the systematic use of iNO. However, a sometimes important improvement in oxygenation can occur shortly after starting administration. Therefore, its ease of use and its good tolerance justify iNO optionally combined with almitirne as a rescue therapy on a trial basis. Recent data from the literature support the use of a 48-h infusion of NMBs in patients with a PaO2 to FiO2 ratio <120 mmHg. No strong evidence exists on the increase of ICU-acquired paresis after a short course of NMBs. Fluid management with the goal to obtain zero fluid balance in ARDS patients without shock or renal failure significantly increases the number of days without mechanical ventilation. On the other hand, patients with hemodynamic failure must receive early and adapted fluid resuscitation. Liberal and conservative fluid strategies therefore are complementary and should ideally follow each other in time in the same patient whose hemodynamic state progressively stabilizes. At present, albumin treatment does not appear to be justified for limitation of pulmonary edema and respiratory morbidity. Aerosolized β2-agonists do not improve outcome in patients with ARDS and one study strongly suggests that intravenous salbutamol may worsen outcome in those patients. The early use of high doses of corticosteroids for the prevention of ARDS in septic shock patients or in patients with confirmed ARDS significantly reduced the duration of mechanical ventilation but had no effect or even increased mortality. In patients with persistent ARDS after 7 to 28 days, a randomized trial showed no reduction in mortality with moderate doses of corticosteroids but an increased PaO2 to FiO2 ratio and thoracopulmonary compliance were found, as well as shorter durations of mechanical ventilation and of ICU stay. Conflicting data exist on the interest of low doses of corticosteroids (200 mg/day of hydrocortisone) in ARDS patients. In the context of a persistent ARDS with histological proof of fibroproliferation, a corticosteroid treatment with a progressive decrease of doses can be proposed.
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Affiliation(s)
- Antoine Roch
- URMITE, UM63, CNRS 7278, Aix Marseille Université, IRD 198, Inserm 1095, Marseille, 13005, France
- APHM, CHU Nord, Réanimation, Marseille, 13015, France
- Intensive Care Unit, CHU Nord, Chemin des Bourrely, Marseille, 13015, France
| | - Sami Hraiech
- URMITE, UM63, CNRS 7278, Aix Marseille Université, IRD 198, Inserm 1095, Marseille, 13005, France
- APHM, CHU Nord, Réanimation, Marseille, 13015, France
| | | | - Laurent Papazian
- URMITE, UM63, CNRS 7278, Aix Marseille Université, IRD 198, Inserm 1095, Marseille, 13005, France
- APHM, CHU Nord, Réanimation, Marseille, 13015, France
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Abstract
It has been known for more than 60 years, and suspected for over 100, that alveolar hypoxia causes pulmonary vasoconstriction by means of mechanisms local to the lung. For the last 20 years, it has been clear that the essential sensor, transduction, and effector mechanisms responsible for hypoxic pulmonary vasoconstriction (HPV) reside in the pulmonary arterial smooth muscle cell. The main focus of this review is the cellular and molecular work performed to clarify these intrinsic mechanisms and to determine how they are facilitated and inhibited by the extrinsic influences of other cells. Because the interaction of intrinsic and extrinsic mechanisms is likely to shape expression of HPV in vivo, we relate results obtained in cells to HPV in more intact preparations, such as intact and isolated lungs and isolated pulmonary vessels. Finally, we evaluate evidence regarding the contribution of HPV to the physiological and pathophysiological processes involved in the transition from fetal to neonatal life, pulmonary gas exchange, high-altitude pulmonary edema, and pulmonary hypertension. Although understanding of HPV has advanced significantly, major areas of ignorance and uncertainty await resolution.
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Affiliation(s)
- J. T. Sylvester
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and Division of Asthma, Allergy and Lung Biology, School of Medicine, King's College, London, United Kingdom
| | - Larissa A. Shimoda
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and Division of Asthma, Allergy and Lung Biology, School of Medicine, King's College, London, United Kingdom
| | - Philip I. Aaronson
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and Division of Asthma, Allergy and Lung Biology, School of Medicine, King's College, London, United Kingdom
| | - Jeremy P. T. Ward
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and Division of Asthma, Allergy and Lung Biology, School of Medicine, King's College, London, United Kingdom
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Raoof S, Goulet K, Esan A, Hess DR, Sessler CN. Severe Hypoxemic Respiratory Failure. Chest 2010; 137:1437-48. [DOI: 10.1378/chest.09-2416] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Abstract
PURPOSE OF REVIEW Studies of the pharmacologic management of acute respiratory distress syndrome (ARDS) have yielded conflicting results. The purpose of this review is to discuss recent pharmacologic trials in ARDS, using the conceptual framework of ARDS as a heterogeneous disease. RECENT FINDINGS Whereas most drug trials in ARDS have been negative, some studies suggest that targeting therapies at subgroups of patients may be successful. Proposed subgroups include early versus late-phase ARDS, direct versus indirect lung injury, and patients with altered coagulation. Corticosteroids have beneficial short-term effects when given at low or moderate doses sooner than 2 weeks but appear to be harmful if initiated later and are of unclear benefit if lung protective ventilation is also used. Surfactant may be helpful in patients with direct lung injury. Anticoagulants and vasodilators may have a greater chance for success in the subset of patients with vascular disease and a high dead-space fraction may identify such a population. SUMMARY ARDS is a heterogeneous syndrome. Failure to target subgroups more likely to benefit from specific therapies may be one explanation for largely disappointing trial results so far.
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Abstract
Acute right ventricular (RV) failure has until recently received relatively little attention in the cardiology, critical care or anaesthesia literature. However, it is frequently encountered in cardiac surgical cases and is a significant cause of mortality in patients with severe pulmonary hypertension who undergo non-cardiac surgery. RV dysfunction may be primarily due to impaired RV contractility, or volume or pressure overload. In these patients, an increased pulmonary vascular resistance (PVR) or a decreased aortic root pressure may lead to RV ischaemia, resulting in a rapid, downward haemodynamic spiral. The key aspects of 'RV protection' in patients who are at risk of perioperative decompensation are prevention, detection and treatment aimed at reversing the underlying pathophysiology. Minimising PVR and maintaining systemic blood pressure are of central importance in the prevention of RV decompensation, which is characterised by a rising central venous pressure and a falling cardiac output. Although there are no outcome data to support any therapeutic strategy for RV failure when PVR is elevated, the combination of inhaled iloprost or intravenous milrinone with oral sildenafil produces a synergistic reduction in PVR, while sparing systemic vascular resistance. Levosimendan is a promising new inotrope for the treatment of RV failure, although its role in comparison to older agents such as dobutamine, adrenaline and milrinone has yet to be determined. This is also the case for the use of vasopressin as an alternative pressor to noradrenaline. If all else has failed, mechanical support of the RV should be considered in selected cases.
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Affiliation(s)
- P Forrest
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Trachsel S, Deby-Dupont G, Maurenbrecher E, Nys M, Lamy M, Hedenstierna G. Association between inflammatory mediators and response to inhaled nitric oxide in a model of endotoxin-induced lung injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R131. [PMID: 18954441 PMCID: PMC2592770 DOI: 10.1186/cc7099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 09/16/2008] [Accepted: 10/27/2008] [Indexed: 11/10/2022]
Abstract
Introduction Inhaled nitric oxide (INO) allows selective pulmonary vasodilation in acute respiratory distress syndrome and improves PaO2 by redistribution of pulmonary blood flow towards better ventilated parenchyma. One-third of patients are nonresponders to INO, however, and it is difficult to predict who will respond. The aim of the present study was to identify, within a panel of inflammatory mediators released during endotoxin-induced lung injury, specific mediators that are associated with a PaO2 response to INO. Methods After animal ethics committee approval, pigs were anesthetized and exposed to 2 hours of endotoxin infusion. Levels of cytokines, prostanoid, leucotriene and endothelin-1 (ET-1) were sampled prior to endotoxin exposure and hourly thereafter. All animals were exposed to 40 ppm INO: 28 animals were exposed at either 4 hours or 6 hours and a subgroup of nine animals was exposed both at 4 hours and 6 hours after onset of endotoxin infusion. Results Based on the response to INO, the animals were retrospectively placed into a responder group (increase in PaO2 ≥ 20%) or a nonresponder group. All mediators increased with endotoxin infusion although no significant differences were seen between responders and nonresponders. There was a mean difference in ET-1, however, with lower levels in the nonresponder group than in the responder group, 0.1 pg/ml versus 3.0 pg/ml. Moreover, five animals in the group exposed twice to INO switched from responder to nonresponder and had decreased ET-1 levels (3.0 (2.5 to 7.5) pg/ml versus 0.1 (0.1 to 2.1) pg/ml, P < 0.05). The pulmonary artery pressure and ET-1 level were higher in future responders to INO. Conclusions ET-1 may therefore be involved in mediating the response to INO.
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Affiliation(s)
- Sebastien Trachsel
- Department of Medical Sciences, Clinical Physiology, Uppsala University, S-75185 Uppsala, Sweden
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18
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Chiche L, Forel JM, Papazian L. Low-tidal-volume ventilation. N Engl J Med 2007; 357:2518-9; author reply 2519-20. [PMID: 18077819 DOI: 10.1056/nejmc072900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Hsu CW, Lee DL, Lin SL, Sun SF, Chang HW. The initial response to inhaled nitric oxide treatment for intensive care unit patients with acute respiratory distress syndrome. ACTA ACUST UNITED AC 2007; 75:288-95. [PMID: 17396026 DOI: 10.1159/000101478] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2006] [Accepted: 01/15/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND Inhaled nitric oxide (INO) can improve hypoxemia and reduce pulmonary hypertension, but there is a wide range of response to INO. OBJECTIVES The aim of this study was to evaluate the effect of different INO concentrations in acute respiratory distress syndrome (ARDS) patients. METHODS Thirty-two adult ARDS patients who were supported by mechanical ventilator were included. INO was given at a concentration of 1, 5, 10, 20 and 40 ppm, sequentially. Arterial blood gas and mean pulmonary artery pressure (MPAP) were measured 30 min after INO concentrations changed. RESULTS There was a significant increase in PaO(2)/FiO(2) (p < 0.0001) and a decrease in pulmonary vascular resistance index and MPAP (p < 0.0001) after INO use. INO concentrations required for improving oxygenation were in the range of 1-20 ppm, whereas concentrations required for decreasing MPAP were in the range of 1-40 ppm. PaO(2)/FiO(2) worsened when the INO dose was adjusted above 20 ppm. Sixty-nine percent of ARDS patients were responders; 31% of them were nonresponders. Among responders, 64% of patients responded at 1 ppm, 36% at 5 ppm. CONCLUSIONS The optimal doses for improving oxygenation and reducing PAP differ. The maximum PaO(2)/FiO(2) was observed at a lower INO concentration than that required for the minimal MPAP. There was no further improvement in PaO(2)/FiO(2) when the INO dose was adjusted above 20 ppm. Higher doses of INO treatment worsened oxygenation.
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Affiliation(s)
- Chien-Wei Hsu
- Intensive Care Unit, Internal Medicine Department, Veterans General Hospital Kaohsiung, Kaoshiung, Taiwan, ROC.
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Maeder M, Fehr T, Rickli H, Ammann P. Sepsis-associated myocardial dysfunction: diagnostic and prognostic impact of cardiac troponins and natriuretic peptides. Chest 2006; 129:1349-66. [PMID: 16685029 DOI: 10.1378/chest.129.5.1349] [Citation(s) in RCA: 202] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Myocardial dysfunction, which is characterized by transient biventricular impairment of intrinsic myocardial contractility, is a common complication in patients with sepsis. Left ventricular systolic dysfunction is reflected by a reduced left ventricular stroke work index or, less accurately, by an impaired left ventricular ejection fraction (LVEF). Early recognition of myocardial dysfunction is crucial for the administration of the most appropriate therapy. Cardiac troponins and natriuretic peptides are biomarkers that were previously introduced for diagnosis and risk stratification in patients with acute coronary syndrome and congestive heart failure, respectively. However, their prognostic and diagnostic impact in critically ill patients warrants definition. The elevation of cardiac troponin levels in patients with sepsis, severe sepsis, or septic shock has been shown to indicate left ventricular dysfunction and a poor prognosis. Troponin release in this population occurs in the absence of flow-limiting coronary artery disease, suggesting the presence of mechanisms other than thrombotic coronary artery occlusion, probably a transient loss in membrane integrity with subsequent troponin leakage or microvascular thrombotic injury. In contrast to the rather uniform results of studies dealing with cardiac troponins, the impact of raised B-type natriuretic peptide (BNP) levels in patients with sepsis is less clear. The relationship between BNP and both LVEF and left-sided filling pressures is weak, and data on the prognostic impact of high BNP levels in patients with sepsis are conflicting. Mechanisms other than left ventricular wall stress may contribute to BNP release, including right ventricular overload, catecholamine therapy, renal failure, diseases of the CNS, and cytokine up-regulation. Whereas cardiac troponins may be integrated into the monitoring of myocardial dysfunction in patients with severe sepsis or septic shock to identify those patients requiring early and aggressive supportive therapy, the routine use of BNP and other natriuretic peptides in this setting is discouraged at the moment.
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Affiliation(s)
- Micha Maeder
- Division of Cardiology, University Hospital, Petersgraben 4, CH-4031 Basel, Switzerland.
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Hermans GM, Wilmer A, Knockaert DC, Bobbaers H. Acute intracardiac right-to-left shunt in a patient with acute respiratory distress syndrome and shock successfully treated with nitric oxide. Br J Anaesth 2006; 96:268-9. [PMID: 16415323 DOI: 10.1093/bja/aei636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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22
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Silva-Costa-Gomes T, Gallart L, Vallès J, Trillo L, Minguella J, Puig MM. Low- vs high-dose almitrine combined with nitric oxide to prevent hypoxia during open-chest one-lung ventilation. Br J Anaesth 2005; 95:410-6. [PMID: 16024585 DOI: 10.1093/bja/aei194] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Almitrine combined with inhaled nitric oxide (NO) can prevent hypoxia during one-lung ventilation (OLV). The optimal dose of almitrine that would provide therapeutic advantage with few side-effects during open-chest OLV has not been established. METHODS Forty-two patients undergoing thoracotomy were randomly allocated to three groups: placebo, almitrine 4 microg kg(-1) min(-1) and inhaled NO 10 p.p.m. (ALM4+NO), and almitrine 16 microg kg(-1) min(-1) and inhaled NO 10 p.p.m. (ALM16+NO). Gas exchange, haemodynamic and respiratory variables and plasma concentrations of almitrine and lactate were monitored. Measurements were obtained with the patient awake (baseline), after induction of anaesthesia with two-lung ventilation (control 2LV), 20 min after treatment (2LV+T), and then at 10, 20 and 30 min of OLV (OLV10', OLV20' and OLV30') with FI(O2)1. RESULTS In the placebo group, OLV impaired Pa(O2) and increased pulmonary shunt [16 (SD 7) kPa and 42 (10)% respectively]. These improved with ALM4+NO [26 (10) kPa and 31 (7)%; P<0.001]. ALM16+NO further improved PaO2) to 36 (13) kPa (P<0.0001) but gave no improvement in the shunt. Mean pulmonary artery pressure was similar in the placebo and ALM4+NO groups [20 (4) vs 23 (5) mm Hg], whereas it was increased in the ALM16+NO group to 28 (8) mm Hg (P<0.01). Plasma concentrations of almitrine and lactate were unaltered by the treatments. CONCLUSIONS Low-dose almitrine (4 microg kg(-1) min(-1)) together with inhaled NO significantly improves oxygenation during open-chest OLV, without modifying pulmonary haemodynamics. An increased dose of almitrine (16 microg kg(-1) min(-1)) with inhaled NO further improves arterial oxygenation, but also increases mean pulmonary artery pressure.
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Affiliation(s)
- T Silva-Costa-Gomes
- Department of Anesthesiology, Hospital Universitari del Mar, Institut Municipal d'Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, Spain
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Crimi E, Slutsky AS. Inflammation and the acute respiratory distress syndrome. Best Pract Res Clin Anaesthesiol 2004; 18:477-92. [PMID: 15212340 DOI: 10.1016/j.bpa.2003.12.007] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is a clinical syndrome of non-cardiogenic pulmonary oedema associated with bilateral pulmonary infiltrates, stiff lungs and refractory hypoxaemia. ARDS is characterized by an explosive acute inflammatory response in the lung parenchyma, leading to alveolar oedema, decreased lung compliance and, ultimately, hypoxaemia. Although our understanding of the causes and pathophysiology of ARDS has increased, the mortality rate remains in the range of 30-50%. No major advances in pharmacological therapy have been achieved. Mechanical ventilation is the main therapeutic intervention in the management of ARDS. The only approach that has been shown to reduce the inflammatory response and mortality is the use of lung-protective ventilatory strategy with a low tidal volume and high positive-end expiratory pressure. This chapter will review the current state of the literature on the pathogenesis of ARDS and ventilatory and pharmacotherapy approaches to its management.
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Affiliation(s)
- Ettore Crimi
- Division of Respiratory Medicine, Department of Critical Care Medicine, St Michael's Hospital, University of Toronto, Toronto, Ont., Canada
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24
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Abstract
The ability of alveolar gas composition to influence pulmonary vascular tone has been appreciated for over 50 years. In particular, it has been proposed that both O2 and CO2 could play a role in the matching of perfusion to ventilation within the lung, improving the overall efficiency of gas exchange. A wide variety of experimental approaches has been used to investigate pulmonary vascular effects of the respiratory gases in a range of mammalian species. In this article, we review experiments performed in healthy humans, identify particular difficulties in the interpretation of such experiments, and discuss possible approaches to future study.
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Affiliation(s)
- K L Dorrington
- University Laboratory of Physiology, Parks Road, Oxford OX1 3PT, United Kingdom.
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25
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Abstract
Cyclic adenosine 3',5'-monophosphate (cAMP) and cyclic guanosine 3',5'-monophosphate (cGMP) are second messengers involved in the intracellular signal transduction of a variety of extracellular stimuli in several tissues. In the vascular system, these nucleotides play important roles in the regulation of vascular tone and in the maintenance of the mature contractile phenotype in smooth muscle cells. Given that cyclic nucleotide signaling regulates a wide variety of cellular functions, it is not surprising that cyclic nucleotide phosphodiesterases (PDEs). In paticular, the accumulating data showing that there are a large number of different PDE isozymes have triggered an equally large increase in interest about these enzymes. At least 11 different gene families of PDEs are currently known to exist in mammalian tissues. Most families contain several distinct genes, and many of these genes are expressed in different tissues as functionally unique alternative splice variants. This article reviews many of the important aspects about the structure, cellular localization, and regulation of each family of PDEs. Particular emphasis is placed on new information obtained in the last few years about vascular disease. The development of novel methods to deliver more potent and selective PDE inhibitors to individual cell types and subcellular locations will lead to new therapeutic uses for this class of drugs in diseases of the vascular system.
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Affiliation(s)
- Takayuki Matsumoto
- Department of Physiology and Morphology, Institute of Medicinal Chemistry, Hoshi University, Shinagawa-ku, Tokyo 142-8501, Japan
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26
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Dalibon N, Moutafis M, Liu N, Law-Koune JD, Monsel S, Fischler M. Treatment of Hypoxemia During One-Lung Ventilation Using Intravenous Almitrine. Anesth Analg 2004; 98:590-4, table of contents. [PMID: 14980903 DOI: 10.1213/01.ane.0000099715.40831.2a] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED We performed this prospective randomized double-blinded study to assess the ability of almitrine to treat hypoxemia during one-lung ventilation (OLV). Twenty-eight patients were anesthetized with propofol, sufentanil, and atracurium; lung separation was achieved with a double-lumen tube. A transesophageal Doppler probe was inserted to evaluate cardiac index. If SpO(2) was equal to or decreased to <95% during OLV (inspired fraction of oxygen of 0.6), patients were included in the study and received a placebo or almitrine (12 microg x kg(-1) x min(-1) for 10 min followed by 4 microg x kg(-1) x min(-1)) infusion until SpO(2) reached 90% or decreased to <90% (exclusion from the study). Eighteen of the 28 patients were included and received either almitrine (n = 9) or a placebo (n = 9). Treatment was discontinued in 1 patient in the almitrine group and 6 in the placebo group (P < 0.05). Treatment was successful (SpO(2) remaining >or=95% during OLV) in 8 patients in the almitrine group and 1 in the placebo group (P < 0.01). Heart rate, arterial blood pressure, and cardiac index did not change throughout the study, but we could obtain an adequate aortic blood flow signal in only half of the patients. Almitrine could be used to treat hypoxemia during OLV. IMPLICATIONS IV almitrine improves oxygenation during one-lung ventilation without hemodynamic modification. Such treatment could be used when conventional ventilatory strategy fails to treat hypoxemia or cannot be used.
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Affiliation(s)
- Nicolas Dalibon
- Department of Anesthesiology, Hôpital Foch, Université Paris-Ouest, Suresnes, France
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27
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Fischer LG, Aken HV, Bürkle H. Management of pulmonary hypertension: physiological and pharmacological considerations for anesthesiologists. Anesth Analg 2003; 96:1603-1616. [PMID: 12760982 DOI: 10.1213/01.ane.0000062523.67426.0b] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lars G Fischer
- Department of Anesthesiology and Intensive Care, Universita[Combining Diaeresis]tsklinikum Mu[Combining Diaeresis]nster, Mu[Combining Diaeresis]nster, Germany
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28
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Groeneveld ABJ. Vascular pharmacology of acute lung injury and acute respiratory distress syndrome. Vascul Pharmacol 2002; 39:247-56. [PMID: 12747964 DOI: 10.1016/s1537-1891(03)00013-2] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) following sepsis, major trauma and surgery are leading causes of respiratory insufficiency, warranting artificial ventilation in the intensive care unit. It is caused by an inflammatory reaction in the lung upon exogenous or endogenous etiologies eliciting proinflammatory factors, and results in increased alveolocapillary permeability and protein-rich alveolar edema. The interstitial and alveolar inflammation and edema alter ventilation perfusion matching, gas exchange and mechanical properties of the lung. The current therapy of the condition is supportive, paying careful attention to fluid balance, relieving the increased work of breathing and improving gas exchange by mechanical ventilation, but in vitro, animal and some clinical research is done to evaluate the value of anti-inflammatory therapies on morbidity and outcome, including inflammatory cell-stabilizing corticosteroids, xanthine derivates, prostanoids and inhibitors, O(2) radical scavenging factors such as N-acetylcysteine, surfactant replacement, vasodilators including inhaled nitric oxide, vasoconstrictors such as almitrine, and others. None of these compounds has been proven to benefit survival in patients, however, even though carrying a physiologic benefit, except perhaps for steroids that may improve outcome in the later stage of ARDS. This partly relates to the difficulty to assess the lung injury at the bedside, to the multifactorial pathogenesis and the severity of comorbidity, adversely affecting survival.
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Affiliation(s)
- A B Johan Groeneveld
- Department of Intensive Care, Vrije Universiteit Medical Centre, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
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29
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Abstract
The acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is a clinical syndrome that affects both medical and surgical patients. To date, despite improved understanding of the pathogenesis of ALI/ARDS, pharmacological modalities have been unsuccessful in decreasing mortality. However, several pharmacological agents for ARDS are in development and have shown great promise. In addition to the anti-inflammatory category including late corticosteroids, inhaled nitric oxide, alveolar surfactant, and vasodilators are being evaluated. Replacements of anticoagulation mediators have also suggested beneficial effects on the patient outcome. This article provides an overview of pharmacological treatments of ALI/ARDS.
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Affiliation(s)
- Sadatomo Tasaka
- Department of Medicine, Keio University School of Medicine, Tokyo, Japan
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30
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dos Santos CC, Chant C, Slutsky AS. Pharmacotherapy of acute respiratory distress syndrome. Expert Opin Pharmacother 2002; 3:875-88. [PMID: 12083988 DOI: 10.1517/14656566.3.7.875] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
To date, the only therapeutic option that has convincingly been shown to decrease mortality in acute respiratory distress syndrome (ARDS) has been to use a lung-protective strategy that minimises the iatrogenic consequences of providing adequate life support through the use of mechanical ventilation. In terms of the pharmacological options for ARDS, no single drug or treatment has been shown to be the magic bullet in this disease. The search for novel therapies and pharmacological agents is active and relentless. Important pathophysiological areas of focus are preventative therapy, supportive care and treatment of the underlying inflammatory process. In this paper we will review current and experimental approaches to the management of ARDS. In addition, the pathophysiological basis for their putative modes of action, the current state of the literature and the potential for future clinical development will be discussed.
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Affiliation(s)
- C C dos Santos
- Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
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31
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Schermuly RT, Roehl A, Weissmann N, Ghofrani HA, Leuchte H, Grimminger F, Seeger W, Walmrath D. Combination of nonspecific PDE inhibitors with inhaled prostacyclin in experimental pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2001; 281:L1361-8. [PMID: 11704531 DOI: 10.1152/ajplung.2001.281.6.l1361] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Inhalation of aerosolized prostacyclin (PGI(2)) exerts selective pulmonary vasodilation, but its effect is rapidly lost after termination of nebulization. Amplification of the vasodilatory response to inhaled PGI(2) might be achieved by phosphodiesterase (PDE) inhibitors to stabilize its second messenger, cAMP. We established stable pulmonary hypertension in perfused rabbit lungs by continuous infusion of U-46619. Short-term (10-min) aerosolization maneuvers of PGI(2) effected a rapid, moderate decrease in pulmonary arterial pressure, with post-PGI(2) vasorelaxation being lost within 10-15 min, accompanied by a marginal reduction in shunt flow. Preceding administration of subthreshold doses of the PDE inhibitors theophylline, dipyridamole, and pentoxifylline via the intravascular or inhalational route, which per se did not influence pulmonary hemodynamics, caused more than doubling of the immediate pulmonary arterial pressure drop in response to PGI(2) and marked prolongation of the post-PGI(2) vasorelaxation to >60 min (all PDE inhibitors via both routes of application). This was accompanied by a reduction in shunt flow in the case of aerosolized theophylline (27.5%), pentoxifylline (30.5%), and dipyridamole (33.4%). Coaerosolization of PGI(2) and PDE inhibitors may be considered as a therapeutic strategy in pulmonary hypertension.
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Affiliation(s)
- R T Schermuly
- Department of Internal Medicine, Justus-Liebig-University Giessen, D-35392 Giessen, Germany.
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Naeije R, Brimioulle S. Physiology in medicine: importance of hypoxic pulmonary vasoconstriction in maintaining arterial oxygenation during acute respiratory failure. Crit Care 2001; 5:67-71. [PMID: 11299064 PMCID: PMC137269 DOI: 10.1186/cc989] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2001] [Accepted: 02/19/2001] [Indexed: 11/13/2022] Open
Abstract
Hypoxic pulmonary vasoconstriction continues to attract interest more than half a century after its original report because of persistent mystery about its biochemical mechanism and its exact physiological function. Recent work suggests an important role for pulmonary arteriolar smooth muscle cell oxygen-sensitive voltage-dependent potassium channels. Inhibition of these channels by decreased PO2 inhibits outward potassium current, causing membrane depolarization, and calcium entry through voltage-dependent calcium channels. Endothelium-derived vasoconstricting and vasodilating mediators modulate this intrinsic smooth muscle cell reactivity to hypoxia. However, refined modeling of hypoxic pulmonary vasoconstriction operating as a feedback mechanism in inhomogeneous lungs, using more realistic stimulus-response curves and confronted with direct measurements of regional blood flow distribution, shows a more effective than previously assessed ability of this remarkable intrapulmonary reflex to improve gas exchange and arterial oxygenation. Further studies could show clinical benefit of pharmacological manipulation of hypoxic pulmonary vasoconstriction, in circumstances of life-threatening hypoxemia.
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Affiliation(s)
- R Naeije
- Department of Physiology, Erasme Campus of the Free University of Brussels, Belgium.
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Affiliation(s)
- B A Markewitz
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah Health Sciences Center, Salt Lake City 84132, USA
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Abstract
Remarkable progress has been made in the past 10 years with regard to understanding the interplay of potent physiologic mediators in patients with acute lung injury. Because there are so many mediators and the interaction of these agents is complex, true insight into the process has been slow in coming. Clinical studies in ARDS, as well as sepsis, the leading cause of ARDS, have increased in number, size, and quality over this same period. Although none of these studies has produced an accepted new therapy for ARDS, each has laid the groundwork for more efficient and more elegant studies of the problem. The stage is now set for the real advances to be brought forward and put to rigorous, efficient clinical testing.
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Affiliation(s)
- B D Conner
- Center for Lung Research, Vanderbilt University, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Suter PM. Increasing arterial oxygenation with knobs and tricks: lipstick cosmetics or real improvement of outcome? Crit Care Med 2000; 28:3083-4. [PMID: 10966303 DOI: 10.1097/00003246-200008000-00071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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