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Bluth T, Güldner A, Spieth PM. [Ventilation concepts under extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS)]. DIE ANAESTHESIOLOGIE 2024; 73:352-362. [PMID: 38625538 DOI: 10.1007/s00101-024-01407-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) is often the last resort for escalation of treatment in patients with severe acute respiratory distress syndrome (ARDS). The success of treatment is mainly determined by patient-specific factors, such as age, comorbidities, duration and invasiveness of the pre-existing ventilation treatment as well as the expertise of the treating ECMO center. In particular, the adjustment of mechanical ventilation during ongoing ECMO treatment remains controversial. Although a reduction of invasiveness of mechanical ventilation seems to be reasonable due to physiological considerations, no improvement in outcome has been demonstrated so far for the use of ultraprotective ventilation regimens.
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Affiliation(s)
- Thomas Bluth
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Andreas Güldner
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Peter M Spieth
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.
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2
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Golino G, Forin E, Boni E, Martin M, Perbellini G, Rizzello V, Toniolo A, Danzi V. Secondary pneumomediastinum in COVID-19 patient: A case managed with VV-ECMO. IDCases 2024; 36:e01956. [PMID: 38681081 PMCID: PMC11047182 DOI: 10.1016/j.idcr.2024.e01956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/10/2024] [Accepted: 04/14/2024] [Indexed: 05/01/2024] Open
Abstract
Air leak syndrome, including pneumomediastinum (PM), pneumopericardium, pneumothorax, or subcutaneous emphysema, is primarily caused by chest trauma, cardiothoracic surgery, esophageal perforation, and mechanical ventilation. Secondary pneumomediastinum (SP) is a rare complication, with a much lower incidence reported in patients with coronavirus disease 2019 (COVID-19). Our patient was a 44-year-old nonsmoker male with a previous history of obesity (Body Mass Index [BMI] 35 kg/m2), hyperthyroidism, hypokinetic cardiopathy and atrial fibrillation in treatment with flecainide, who presented to the emergency department with 6 days of fever, cough, dyspnea, and respiratory distress. The COVID-19 diagnosis was confirmed based on a polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). After initiation of mechanical ventilation, a chest computed tomography (CT) on the first day revealed bilateral multifocal ground-glass opacities, consolidation and an extensive SP and pneumoperitoneum. Our therapeutic strategy was initiation of veno-venous extracorporeal membrane oxygenation (VV-ECMO) as a bridge to recovery after positioning 2 drains (mediastinal and pleural), for both oxygenation and carbon dioxide clearance, to allow protective and ultra-protective ventilation to limit ventilator-induced lung injury (VILI) and the intensity of mechanical power for lung recovery. After another chest CT scan which showed a clear reduction of the PM, 2 pronation and neuromuscular relaxation cycles were also required, with improvement of gas exchange and respiratory mechanics. On the 15th day, lung function recovered and the patient was then weaned from VV-ECMO, and ultimately made a good recovery and was discharged. In conclusion, SP may be a reflection of extensive alveolar damage and should be considered as a potential predictive factor for adverse outcome in critically ill SARS-CoV2 patients.
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Affiliation(s)
- Gianlorenzo Golino
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Edoardo Forin
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Elisa Boni
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Marina Martin
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Guido Perbellini
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Veronica Rizzello
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Anna Toniolo
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Vinicio Danzi
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
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Fernandez-Sarmiento J, Perez MC, Bustos JD, Acevedo L, Sarta-Mantilla M, Guijarro J, Santacruz C, Pardo DF, Castro D, Rosero YV, Mulett H. Association between mechanical ventilation parameters and mortality in children with respiratory failure on ECMO: a systematic review and meta-analysis. Front Pediatr 2024; 12:1302049. [PMID: 38292212 PMCID: PMC10824827 DOI: 10.3389/fped.2024.1302049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/04/2024] [Indexed: 02/01/2024] Open
Abstract
Background In refractory respiratory failure (RF), extracorporeal membrane oxygenation (ECMO) is a salvage therapy that seeks to reduce lung injury induced by mechanical ventilation. The parameters of optimal mechanical ventilation in children during ECMO are not known. Pulmonary ventilatory management during this therapy may impact mortality. The objective of this study was to evaluate the association between ventilatory parameters in children during ECMO therapy and in-hospital mortality. Methods A systematic search of PubMed/MEDLINE, Embase, Cochrane, and Google Scholar from January 2013 until May 2022 (PROSPERO 450744), including studies in children with ECMO-supported RF assessing mechanical ventilation parameters, was conducted. Risk of bias was assessed using the Newcastle-Ottawa scale; heterogeneity, with absence <25% and high >75%, was assessed using I2. Sensitivity and subgroup analyses using the Mantel-Haenszel random-effects model were performed to explore the impact of methodological quality on effect size. Results Six studies were included. The median age was 3.4 years (IQR: 3.2-4.2). Survival in the 28-day studies was 69%. Mechanical ventilation parameters associated with higher mortality were a very low tidal volume ventilation (<4 ml/kg; OR: 4.70; 95% CI: 2.91-7.59; p < 0.01; I2: 38%), high plateau pressure (mean Dif: -0.70 95% CI: -0.18, -0.22; p < 0.01), and high driving pressure (mean Dif: -0.96 95% CI: -1.83, -0.09: p = 0.03). The inspired fraction of oxygen (p = 0.09) and end-expiratory pressure (p = 0.69) were not associated with higher mortality. Patients who survived had less multiple organ failure (p < 0.01). Conclusion The mechanical ventilation variables associated with higher mortality in children with ECMO-supported respiratory failure are high plateau pressures, high driving pressure and very low tidal volume ventilation. No association between mortality and other parameters of the mechanical ventilator, such as the inspired fraction of oxygen or end-expiratory pressure, was found. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023450744, PROSPERO 2023 (CRD42023450744).
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Affiliation(s)
- Jaime Fernandez-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Maria Camila Perez
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Juan David Bustos
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Lorena Acevedo
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Mauricio Sarta-Mantilla
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Jennifer Guijarro
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Carlos Santacruz
- Department of Anesthesia and Cardiovascular Surgery, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Daniel Felipe Pardo
- Department of Anesthesia and Cardiovascular Surgery, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Daniel Castro
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Yinna Villa Rosero
- Department of Critical Care Medicine and Pediatrics, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Hernando Mulett
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
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Dankhara N, Holla I, Ramarao S, Kalikkot Thekkeveedu R. Bronchopulmonary Dysplasia: Pathogenesis and Pathophysiology. J Clin Med 2023; 12:4207. [PMID: 37445242 DOI: 10.3390/jcm12134207] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Bronchopulmonary dysplasia (BPD), also known as chronic lung disease, is the most common respiratory morbidity in preterm infants. "Old" or "classic" BPD, as per the original description, is less common now. "New BPD", which presents with distinct clinical and pathological features, is more frequently observed in the current era of advanced neonatal care, where extremely premature infants are surviving because of medical advancements. The pathogenesis of BPD is complex and multifactorial and involves both genetic and environmental factors. This review provides an overview of the pathology of BPD and discusses the influence of several prenatal and postnatal factors on its pathogenesis, such as maternal factors, genetic susceptibility, ventilator-associated lung injury, oxygen toxicity, sepsis, patent ductus arteriosus (PDA), and nutritional deficiencies. This in-depth review draws on existing literature to explore these factors and their potential contribution to the development of BPD.
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Affiliation(s)
- Nilesh Dankhara
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Ira Holla
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Sumana Ramarao
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
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Assouline B, Combes A, Schmidt M. Setting and Monitoring of Mechanical Ventilation During Venovenous ECMO. Crit Care 2023; 27:95. [PMID: 36941722 PMCID: PMC10027594 DOI: 10.1186/s13054-023-04372-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2023 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Benjamin Assouline
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alain Combes
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.
- Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
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Lim MJ, Lakshminrusimha S, Hedriana H, Albertson T. Pregnancy and Severe ARDS with COVID-19: Epidemiology, Diagnosis, Outcomes and Treatment. Semin Fetal Neonatal Med 2023; 28:101426. [PMID: 36964118 PMCID: PMC9990893 DOI: 10.1016/j.siny.2023.101426] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Pregnancy-related acute respiratory distress syndrome (ARDS) is fast becoming a growing and clinically relevant subgroup of ARDS amidst global outbreaks of various viral respiratory pathogens that include H1N1-influenza, severe acute respiratory syndrome (SARS), middle east respiratory syndrome (MERS), and the most recent COVID-19 pandemic. Pregnancy is a risk factor for severe viral-induced ARDS and commonly associated with poor maternal and fetal outcomes including fetal growth-restriction, preterm birth, and spontaneous abortion. Physiologic changes of pregnancy further compounded by mechanical and immunologic alterations are theorized to impact the development of ARDS from viral pneumonia. The COVID-19 sub-phenotype of ARDS share overlapping molecular features of maternal pathogenicity of pregnancy with respect to immune-dysregulation and endothelial/microvascular injury (i.e., preeclampsia) that may in part explain a trend toward poor maternal and fetal outcomes seen with severe COVID-19 maternal infections. To date, current ARDS diagnostic criteria and treatment management fail to include and consider physiologic adaptations that are unique to maternal physiology of pregnancy and consideration of maternal-fetal interactions. Treatment focused on lung-protective ventilation strategies have been shown to improve clinical outcomes in adults with ARDS but may have adverse maternal-fetal interactions when applied in pregnancy-related ARDS. No specific pharmacotherapy has been identified to improve outcomes in pregnancy with ARDS. Adjunctive therapies aimed at immune-modulation and anti-viral treatment with COVID-19 infection during pregnancy have been reported but data in regard to its efficacy and safety is currently lacking.
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Affiliation(s)
- Michelle J Lim
- UC Davis School of Medicine, UC Davis Children's Hospital, Department of Pediatrics, Division of Critical Care and Neonatology, Sacramento, CA, USA.
| | - Satyan Lakshminrusimha
- UC Davis School of Medicine, UC Davis Children's Hospital, Department of Pediatrics, Division of Critical Care and Neonatology, Sacramento, CA, USA
| | - Herman Hedriana
- UC Davis School of Medicine, UC Davis Medical Center, Department of Obstetrics and Gynecology, Sacramento, CA, USA
| | - Timothy Albertson
- UC Davis School of Medicine, UC Davis Medical Center, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Sacramento, CA, USA
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7
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Taenaka H, Matthay MA. Mechanisms of impaired alveolar fluid clearance. Anat Rec (Hoboken) 2023:10.1002/ar.25166. [PMID: 36688689 PMCID: PMC10564110 DOI: 10.1002/ar.25166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/09/2022] [Accepted: 01/04/2023] [Indexed: 01/24/2023]
Abstract
Impaired alveolar fluid clearance (AFC) is an important cause of alveolar edema fluid accumulation in patients with acute respiratory distress syndrome (ARDS). Alveolar edema leads to insufficient gas exchange and worse clinical outcomes. Thus, it is important to understand the pathophysiology of impaired AFC in order to develop new therapies for ARDS. Over the last few decades, multiple experimental studies have been done to understand the molecular, cellular, and physiological mechanisms that regulate AFC in the normal and the injured lung. This review provides a review of AFC in the normal lung, focuses on the mechanisms of impaired AFC, and then outlines the regulation of AFC. Finally, we summarize ongoing challenges and possible future research that may offer promising therapies for ARDS.
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Affiliation(s)
- Hiroki Taenaka
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California, USA
- Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, California, USA
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Michael A. Matthay
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California, USA
- Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, California, USA
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8
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Guervilly C, Fournier T, Chommeloux J, Arnaud L, Pinglis C, Baumstarck K, Boucekine M, Valera S, Sanz C, Adda M, Bobot M, Daviet F, Gragueb-Chatti I, Forel JM, Roch A, Hraiech S, Dignat-George F, Schmidt M, Lacroix R, Papazian L. Ultra-lung-protective ventilation and biotrauma in severe ARDS patients on veno-venous extracorporeal membrane oxygenation: a randomized controlled study. Crit Care 2022; 26:383. [PMID: 36510324 PMCID: PMC9744058 DOI: 10.1186/s13054-022-04272-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Ultra-lung-protective ventilation may be useful during veno-venous extracorporeal membrane oxygenation (vv-ECMO) for severe acute respiratory distress syndrome (ARDS) to minimize ventilator-induced lung injury and to facilitate lung recovery. The objective was to compare pulmonary and systemic biotrauma evaluated by numerous biomarkers of inflammation, epithelial, endothelial injuries, and lung repair according to two ventilator strategies on vv-ECMO. METHODS This is a prospective randomized controlled study. Patients were randomized to receive during 48 h either ultra-lung-protective ventilation combining very low tidal volume (1-2 mL/kg of predicted body weight), low respiratory rate (5-10 cycles per minute), positive expiratory transpulmonary pressure, and 16 h of prone position or lung-protective-ventilation which followed the ECMO arm of the EOLIA trial (control group). RESULTS The primary outcome was the alveolar concentrations of interleukin-1-beta, interleukin-6, interleukin-8, surfactant protein D, and blood concentrations of serum advanced glycation end products and angiopoietin-2 48 h after randomization. Enrollment was stopped for futility after the inclusion of 39 patients. Tidal volume, respiratory rate, minute ventilation, plateau pressure, and mechanical power were significantly lower in the ultra-lung-protective group. None of the concentrations of the pre-specified biomarkers differed between the two groups 48 h after randomization. However, a trend to higher 60-day mortality was observed in the ultra-lung-protective group compared to the control group (45 vs 17%, p = 0.06). CONCLUSIONS Despite a significant reduction in the mechanical power, ultra-lung-protective ventilation during 48 h did not reduce biotrauma in patients with vv-ECMO-supported ARDS. The impact of this ventilation strategy on clinical outcomes warrants further investigation. Trial registration Clinical trial registered with www. CLINICALTRIALS gov ( NCT03918603 ). Registered 17 April 2019.
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Affiliation(s)
- Christophe Guervilly
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Théotime Fournier
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France
| | - Juliette Chommeloux
- grid.411439.a0000 0001 2150 9058Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP, Sorbonne, Université Hôpital Pitié- Salpêtrière, Paris, France ,grid.462844.80000 0001 2308 1657INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Laurent Arnaud
- grid.414336.70000 0001 0407 1584Laboratoire d’Hématologie et de Biologie Vasculaire, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Camille Pinglis
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Karine Baumstarck
- grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Mohamed Boucekine
- grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Sabine Valera
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Celine Sanz
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Mélanie Adda
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Mickaël Bobot
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817INSERM 1263, Institut National de Recherche Pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Centre de Recherche en CardioVasculaire et Nutrition (C2VN), Université Aix-Marseille, Marseille, France ,grid.411535.70000 0004 0638 9491Centre de Néphrologie et Transplantation Rénale, AP-HM, Hôpital de la Conception, CHU de la Conception, 13005 Marseille, France
| | - Florence Daviet
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Ines Gragueb-Chatti
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Jean-Marie Forel
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Antoine Roch
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Sami Hraiech
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Françoise Dignat-George
- grid.414336.70000 0001 0407 1584Laboratoire d’Hématologie et de Biologie Vasculaire, Assistance Publique-Hôpitaux de Marseille, Marseille, France ,grid.5399.60000 0001 2176 4817INSERM 1263, Institut National de Recherche Pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Centre de Recherche en CardioVasculaire et Nutrition (C2VN), Université Aix-Marseille, Marseille, France
| | - Matthieu Schmidt
- grid.411439.a0000 0001 2150 9058Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP, Sorbonne, Université Hôpital Pitié- Salpêtrière, Paris, France ,grid.462844.80000 0001 2308 1657INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Romaric Lacroix
- grid.414336.70000 0001 0407 1584Laboratoire d’Hématologie et de Biologie Vasculaire, Assistance Publique-Hôpitaux de Marseille, Marseille, France ,grid.5399.60000 0001 2176 4817INSERM 1263, Institut National de Recherche Pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Centre de Recherche en CardioVasculaire et Nutrition (C2VN), Université Aix-Marseille, Marseille, France
| | - Laurent Papazian
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France ,Centre Hospitalier de Bastia, Service de Réanimation, 604 Chemin de Falconaja, 20600 Bastia, France
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Association of Ventilator Settings With Mortality in Pediatric Patients Treated With Extracorporeal Life Support for Respiratory Failure. ASAIO J 2022; 68:1536-1543. [PMID: 35671443 DOI: 10.1097/mat.0000000000001697] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Extracorporeal life support (ECLS) is a treatment for acute respiratory failure that can provide extracorporeal gas exchange, allowing lung rest. However, while most patients remain mechanically ventilated during ECLS, there is a paucity of evidence to guide the choice of ventilator settings. We studied the associations between ventilator settings 24 hours after ECLS initiation and mortality in pediatric patients using a retrospective analysis of data from the Extracorporeal Life Support Organization Registry. 3497 patients, 29 days to 18 years of age, treated with ECLS for respiratory failure between 2015 and 2021, were included for analysis. 93.3% of patients on ECLS were ventilated with conventional mechanical ventilation. Common settings included positive end-expiratory pressure (PEEP) of 10 cm H 2 O (45.7%), delta pressure (ΔP) of 10 cm H 2 O (28.3%), rate of 10-14 breaths per minute (55.9%), and fraction of inspired oxygen (FiO 2 ) of 0.31-0.4 (30.3%). In a multivariate model, PEEP >10 cm H 2 O ( versus PEEP < 8 cm H 2 O, odds ratio [OR]: 1.53, 95% CI: 1.20-1.96) and FiO 2 ≥0.45 ( versus FiO 2 < 0.4; 0.45 ≤ FiO 2 < 0.6, OR: 1.31, 95% CI: 1.03-1.67 and FiO 2 ≥ 0.6, OR: 2.30; 95% CI: 1.81-2.93) were associated with higher odds of mortality. In a secondary analysis of survivors, PEEP 8-10 cm H 2 O was associated with shorter ECLS run times ( versus PEEP < 8 cm H 2 O, coefficient: -1.64, 95% CI: -3.17 to -0.11), as was ΔP >16 cm H 2 O ( versus ΔP < 10 cm H 2 O, coefficient: -2.72, 95% CI: -4.30 to -1.15). Our results identified several categories of ventilator settings as associated with mortality or ECLS run-time. Further studies are necessary to understand whether these results represent a causal relationship.
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10
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Liao TY, Ruan SY, Lai CH, Tseng LJ, Keng LT, Chen YY, Wang CH, Chien JY, Wu HD, Chen YS, Yu CJ. Impact of ventilator settings during venovenous extracorporeal membrane oxygenation on clinical outcomes in influenza-associated acute respiratory distress syndrome: a multicenter retrospective cohort study. PeerJ 2022; 10:e14140. [PMID: 36248704 PMCID: PMC9558618 DOI: 10.7717/peerj.14140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 09/06/2022] [Indexed: 01/21/2023] Open
Abstract
Background Patients with influenza-associated acute respiratory distress syndrome (ARDS) requiring venovenous extracorporeal membrane oxygenation (vv-ECMO) support have a high mortality rate. Ventilator settings have been known to have a substantial impact on outcomes. However, the optimal settings of mechanical ventilation during vv-ECMO are still unknown. Methods This multicenter retrospective cohort study was conducted in the intensive care units (ICUs) of three tertiary referral hospitals in Taiwan between July 2009 and December 2019. It aims to describe the effect of ventilator settings during vv-ECMO on patient outcomes. Results A total of 93 patients with influenza receiving ECMO were screened. Patients were excluded if they: were receiving venoarterial ECMO, died within three days of vv-ECMO initiation, or were transferred to the tertiary referral hospital >24 hours after vv-ECMO initiation. A total of 62 patients were included in the study, and 24 (39%) died within six months. During the first three days of ECMO, there were no differences in tidal volume (5.1 vs. 5.2 mL/kg, p = 0.833), dynamic driving pressure (15 vs. 14 cmH2O, p = 0.146), and mechanical power (11.3 vs. 11.8 J/min, p = 0.352) between survivors and non-survivors. However, respiratory rates were significantly higher in non-survivors compared with survivors (15 vs. 12 breaths/min, p = 0.013). After adjustment for important confounders, a higher mean respiratory rate of >12 breaths/min was still associated with higher mortality (adjusted hazard ratio = 3.31, 95% confidence interval = 1.10-9.97, p = 0.034). Conclusions In patients with influenza-associated ARDS receiving vv-ECMO support, we found that a higher respiratory rate was associated with higher mortality. Respiratory rate might be a modifiable factor to improve outcomes in this patient population.
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Affiliation(s)
- Ting-Yu Liao
- Departments of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Sheng-Yuan Ruan
- Departments of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Heng Lai
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Jung Tseng
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Ta Keng
- Departments of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - You-Yi Chen
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu, Taiwan,Thoracic Medicine Center, Department of Medicine and Surgery, National Taiwan University Hospital Yunlin Branch, Dou-Liu, Taiwan
| | - Chih-Hsien Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Jung-Yien Chien
- Departments of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Dong Wu
- Departments of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chong-Jen Yu
- Departments of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan,Departments of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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11
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Bos LDJ, Ware LB. Acute respiratory distress syndrome: causes, pathophysiology, and phenotypes. Lancet 2022; 400:1145-1156. [PMID: 36070787 DOI: 10.1016/s0140-6736(22)01485-4] [Citation(s) in RCA: 158] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/14/2022] [Accepted: 07/27/2022] [Indexed: 12/15/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a common clinical syndrome of acute respiratory failure as a result of diffuse lung inflammation and oedema. ARDS can be precipitated by a variety of causes. The pathophysiology of ARDS is complex and involves the activation and dysregulation of multiple overlapping and interacting pathways of injury, inflammation, and coagulation, both in the lung and systemically. Mechanical ventilation can contribute to a cycle of lung injury and inflammation. Resolution of inflammation is a coordinated process that requires downregulation of proinflammatory pathways and upregulation of anti-inflammatory pathways. The heterogeneity of the clinical syndrome, along with its biology, physiology, and radiology, has increasingly been recognised and incorporated into identification of phenotypes. A precision-medicine approach that improves the identification of more homogeneous ARDS phenotypes should lead to an improved understanding of its pathophysiological mechanisms and how they differ from patient to patient.
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Affiliation(s)
- Lieuwe D J Bos
- Intensive Care, Amsterdam UMC-location AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Lorraine B Ware
- Vanderbilt University School of Medicine, Medical Center North, Vanderbilt University, Nashville, TN, USA.
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12
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Xin Y, Cereda M, Yehya N, Humayun S, Delvecchio P, Thompson JM, Martin K, Hamedani H, Martorano P, Duncan I, Kadlecek S, Makvandi M, Brenner JS, Rizi RR. Imatinib alleviates lung injury and prolongs survival in ventilated rats. Am J Physiol Lung Cell Mol Physiol 2022; 322:L866-L872. [PMID: 35438574 PMCID: PMC9142156 DOI: 10.1152/ajplung.00006.2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/28/2022] [Accepted: 04/13/2022] [Indexed: 11/22/2022] Open
Abstract
Imatinib, a tyrosine kinase inhibitor, attenuates pulmonary edema and inflammation in lung injury. However, the physiological effects of this drug and their impact on outcomes are poorly characterized. Using serial computed tomography (CT), we tested the hypothesis that imatinib reduces injury severity and improves survival in ventilated rats. Hydrochloric acid (HCl) was instilled in the trachea (pH 1.5, 2.5 mL/kg) of anesthetized, intubated supine rats. Animals were randomized (n = 17 each group) to receive intraperitoneal imatinib or vehicle immediately prior to HCl. All rats then received mechanical ventilation. CT was performed hourly for 4 h. Images were quantitatively analyzed to assess the progression of radiological abnormalities. Injury severity was confirmed via hourly blood gases, serum biomarkers, bronchoalveolar lavage (BAL), and histopathology. Serial blood drug levels were measured in a subset of rats. Imatinib reduced mortality while delaying functional and radiological injury progression: out of 17 rats per condition, 2 control vs. 8 imatinib-treated rats survived until the end of the experiment (P = 0.02). Imatinib attenuated edema after lung injury (P < 0.05), and survival time in both groups was negatively correlated with increased lung mass (R2 = 0.70) as well as other physiological and CT parameters. Capillary leak (BAL protein concentration) was significantly lower in the treated group (P = 0.04). Peak drug concentration was reached after 70 min, and the drug half-life was 150 min. Imatinib decreased both mortality and lung injury severity in mechanically ventilated rats. Pharmacological inhibition of edema could be used during mechanical ventilation to improve the severity and outcome of lung injury.
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Affiliation(s)
- Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nadir Yehya
- Pediatric Sepsis Program and Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Shiraz Humayun
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paolo Delvecchio
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jill M Thompson
- Pediatric Sepsis Program and Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kevin Martin
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul Martorano
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ian Duncan
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mehran Makvandi
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacob S Brenner
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rahim R Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Fior G, Colon ZFV, Peek GJ, Fraser JF. Mechanical Ventilation during ECMO: Lessons from Clinical Trials and Future Prospects. Semin Respir Crit Care Med 2022; 43:417-425. [PMID: 35760300 DOI: 10.1055/s-0042-1749450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Acute Respiratory Distress Syndrome (ARDS) accounts for 10% of ICU admissions and affects 3 million patients each year. Despite decades of research, it is still associated with one of the highest mortality rates in the critically ill. Advances in supportive care, innovations in technologies and insights from recent clinical trials have contributed to improved outcomes and a renewed interest in the scope and use of Extracorporeal life support (ECLS) as a treatment for severe ARDS, including high flow veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) and low flow Extracorporeal Carbon Dioxide Removal (ECCO2R). The rationale being that extracorporeal gas exchange allows the use of lung protective ventilator settings, thereby minimizing ventilator-induced lung injury (VILI). Ventilation strategies are adapted to the patient's condition during the different stages of ECMO support. Several areas in the management of mechanical ventilation in patients on ECMO, such as the best ventilator mode, extubation-decannulation sequence and tracheostomy timing, are tailored to the patients' recovery. Reduction in sedation allowing mobilization, nutrition and early rehabilitation are subsequent therapeutic goals after lung rest has been achieved.
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Affiliation(s)
- Gabriele Fior
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Zasha F Vazquez Colon
- Department of Pediatrics, Division of Pediatric Critical Care, University of Florida, Shands Children's Hospital, Gainesville, Florida
| | - Giles J Peek
- Department of Surgery, Congenital Heart Center, Shands Children's Hospital, Gainesville, University of Florida, Gainesville, Florida
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital and The Wesley Hospital, Uniting Care Hospitals, Brisbane, QLD, Australia
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14
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The Effect of Clusters of Double Triggering and Ineffective Efforts in Critically Ill Patients. Crit Care Med 2022; 50:e619-e629. [PMID: 35120043 DOI: 10.1097/ccm.0000000000005471] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To characterize clusters of double triggering and ineffective inspiratory efforts throughout mechanical ventilation and investigate their associations with mortality and duration of ICU stay and mechanical ventilation. DESIGN Registry-based, real-world study. BACKGROUND Asynchronies during invasive mechanical ventilation can occur as isolated events or in clusters and might be related to clinical outcomes. SUBJECTS Adults requiring mechanical ventilation greater than 24 hours for whom greater than or equal to 70% of ventilator waveforms were available. INTERVENTIONS We identified clusters of double triggering and ineffective inspiratory efforts and determined their power and duration. We used Fine-Gray's competing risk model to analyze their effects on mortality and generalized linear models to analyze their effects on duration of mechanical ventilation and ICU stay. MEASUREMENTS AND MAIN RESULTS We analyzed 58,625,796 breaths from 180 patients. All patients had clusters (mean/d, 8.2 [5.4-10.6]; mean power, 54.5 [29.6-111.4]; mean duration, 20.3 min [12.2-34.9 min]). Clusters were less frequent during the first 48 hours (5.5 [2.5-10] vs 7.6 [4.4-9.9] in the remaining period [p = 0.027]). Total number of clusters/d was positively associated with the probability of being discharged alive considering the total period of mechanical ventilation (p = 0.001). Power and duration were similar in the two periods. Power was associated with the probability of being discharged dead (p = 0.03), longer mechanical ventilation (p < 0.001), and longer ICU stay (p = 0.035); cluster duration was associated with longer ICU stay (p = 0.027). CONCLUSIONS Clusters of double triggering and ineffective inspiratory efforts are common. Although higher numbers of clusters might indicate better chances of survival, clusters with greater power and duration indicate a risk of worse clinical outcomes.
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15
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Abrams D, Agerstrand C, Beitler JR, Karagiannidis C, Madahar P, Yip NH, Pesenti A, Slutsky AS, Brochard L, Brodie D. Risks and Benefits of Ultra-Lung-Protective Invasive Mechanical Ventilation Strategies with a Focus on Extracorporeal Support. Am J Respir Crit Care Med 2022; 205:873-882. [PMID: 35044901 DOI: 10.1164/rccm.202110-2252cp] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Lung-protective ventilation strategies are the current standard of care for patients with acute respiratory distress syndrome (ARDS) in an effort to provide adequate ventilatory requirements while minimizing ventilator-induced lung injury. Some patients may benefit from ultra-lung-protective ventilation, a strategy that achieves lower airway pressures and tidal volumes than the current standard. Specific physiological parameters beyond severity of hypoxemia, such as driving pressure and respiratory system elastance, may be predictive of those most likely to benefit. Since application of ultra-lung-protective ventilation is often limited by respiratory acidosis, extracorporeal membrane oxygenation (ECMO) or extracorporeal carbon dioxide removal (ECCO2R), which remove carbon dioxide from blood, are attractive options. These strategies are associated with hematological complications, especially when applied at low blood flow rates with devices designed for higher blood flows, and a recent large randomized, controlled trial failed to show a benefit from an ECCO2R-facilitated ultra-lung-protective ventilation strategy. Only in patients with very severe forms of ARDS has the use of an ultra-lung-protective ventilation strategy - accomplished with ECMO - been suggested to have a favorable risk-to-benefit profile. In this Critical Care Perspective, we address key areas of controversy related to ultra-lung-protective ventilation, including the trade-offs between minimizing ventilator-induced lung injury and the risks from strategies to achieve this added protection. In addition, we suggest which patients might benefit most from an ultra-lung-protective strategy and propose areas of future research.
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Affiliation(s)
- Darryl Abrams
- Columbia University Medical Center, Medicine, Division of Pulmonary, Allergy, & Critical Care, New York, New York, United States
| | - Cara Agerstrand
- Columbia University Medical Center, Medicine, Division of Pulmonary, Allergy, & Critical Care, New York, New York, United States
| | - Jeremy R Beitler
- Columbia University College of Physicians and Surgeons, 12294, Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, New York, New York, United States.,NewYork-Presbyterian Hospital, 25065, New York, New York, United States
| | - Christian Karagiannidis
- Hospital Cologne-Merheim, 61060, Department of Pneumology and Critical Care Medicine, Koln, Germany.,Witten/Herdecke University, 12263, Cologne, Germany
| | - Purnema Madahar
- Columbia University Medical Center, Medicine, Division of Pulmonary, Allergy, & Critical Care, New York, New York, United States
| | - Natalie H Yip
- Columbia University Medical Center, Dept of Medicine Pulmonary, New York City, New York, United States
| | - Antonio Pesenti
- Universita degli Studi di Milano, 9304, Department of Pathophysiology and Transplantation, Milano, Italy
| | | | - Laurent Brochard
- St Michael's Hospital in Toronto, Li Ka Shing Knowledge Institute, Keenan Research Centre, Toronto, Ontario, Canada.,University of Toronto, 7938, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Daniel Brodie
- Columbia, Critical Care, New York, New York, United States;
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16
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Jin S, Ding X, Yang C, Li W, Deng M, Liao H, Lv X, Pitt BR, Billiar TR, Zhang LM, Li Q. Mechanical Ventilation Exacerbates Poly (I:C) Induced Acute Lung Injury: Central Role for Caspase-11 and Gut-Lung Axis. Front Immunol 2021; 12:693874. [PMID: 34349759 PMCID: PMC8327178 DOI: 10.3389/fimmu.2021.693874] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/02/2021] [Indexed: 11/22/2022] Open
Abstract
Background The mechanisms by which moderate tidal volume ventilation (MTV) exacerbates preexisting lung injury are unclear. We hypothesized that systemic endotoxemia via the gut-lung axis would lead to non-canonical and canonical inflammasome activation and pyroptosis in a two-hit model involving polyinosinic-polycytidylic acid (Poly(I:C)), a synthetic analog of dsRNA and MTV and that this would associate with acute lung injury (ALI). Methods Anesthetized mice were administered Poly(I:C) intratracheally and then 6 h later, they were mechanically ventilated for 4 h with otherwise non-injurious MTV (10ml/kg). Changes in intestinal and alveolar capillary permeability were measured. Further documentation of ALI was assessed by evans blue albumin permeability, protein and IL-1 family concentration in bronchoalveolar lavage fluid (BALF) or plasma, and histopathology in cohorts of wildtype (WT), whole body genetically ablated caspase-11 (caspase-11-/-), caspase-1/caspase-11 double knockout (caspase-1/11-/-), gasdermin D (GSDMD)-/-, nucleotide-binding domain leucine-rich repeat-containing protein 3 (NLRP3)-/- and advanced glycosylation end product-specific receptor (RAGE) -/- mice. Results Non-injurious MTV exacerbated the mild lung injury associated with Poly(I:C) administration. This included the disruption of alveolar-capillary barrier and increased levels of interleukin (IL)-6, high mobility group proteins 1 (HMGB-1), IL-1β in BALF and IL-18 in plasma. Combined (Poly(I:C)-MTV) injury was associated with increase in gastrointestinal permeability and endotoxin in plasma and BALF. Poly(I:C)-MTV injury was sensitive to caspase-11 deletion with no further contribution of caspase-1 except for maturation and release of IL-18 (that itself was sensitive to deletion of NLRP3). Combined injury led to large increases in caspase-1 and caspase-11. Genetic ablation of GSDMD attenuated alveolar-capillary disruption and release of cytokines in combined injury model. Conclusions The previously noted exacerbation of mild Poly(I:C)-induced ALI by otherwise non-injurious MTV is associated with an increase in gut permeability resulting in systemic endotoxemia. The gut-lung axis resulted in activation of pulmonary non-canonical (cytosolic mediated caspase-11 activation) and canonical (caspase-1) inflammasome (NLRP3) mediated ALI in this two-hit model resulting in GSDMD sensitive alveolar capillary barrier disruption, pyroptosis (alveolar macrophages) and cytokine maturation and release (IL-1β; IL-18). Pharmacologic strategies aimed at disrupting communication between gut and lung, inhibition of inflammasomes or GSDMD in pyroptosis may be useful in ALI.
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MESH Headings
- Acute Lung Injury/chemically induced
- Acute Lung Injury/enzymology
- Acute Lung Injury/microbiology
- Acute Lung Injury/pathology
- Animals
- Bacteria/metabolism
- Caspases, Initiator/genetics
- Caspases, Initiator/metabolism
- Disease Models, Animal
- Gastrointestinal Microbiome
- Intestines/microbiology
- Intracellular Signaling Peptides and Proteins/genetics
- Intracellular Signaling Peptides and Proteins/metabolism
- Lipopolysaccharides/metabolism
- Lung/enzymology
- Lung/pathology
- Macrophages, Alveolar/enzymology
- Macrophages, Alveolar/pathology
- Male
- Mice, Inbred C57BL
- Mice, Knockout
- NLR Family, Pyrin Domain-Containing 3 Protein/genetics
- NLR Family, Pyrin Domain-Containing 3 Protein/metabolism
- Phosphate-Binding Proteins/genetics
- Phosphate-Binding Proteins/metabolism
- Poly I-C
- Pyroptosis
- Receptor for Advanced Glycation End Products/genetics
- Receptor for Advanced Glycation End Products/metabolism
- Respiration, Artificial
- Signal Transduction
- Ventilator-Induced Lung Injury/enzymology
- Ventilator-Induced Lung Injury/etiology
- Ventilator-Induced Lung Injury/microbiology
- Ventilator-Induced Lung Injury/pathology
- Mice
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Affiliation(s)
- Shuqing Jin
- Department of Anesthesiology, Shanghai Pulmonary Hospital, TongJi University, Shanghai, China
- Department of Surgery, University of Pittsburgh Medical School, Pennsylvania, PA, United States
| | - Xibing Ding
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University Medical School, Shanghai, China
| | - Chenxuan Yang
- Department of Surgery, University of Pittsburgh Medical School, Pennsylvania, PA, United States
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenbo Li
- Department of Surgery, University of Pittsburgh Medical School, Pennsylvania, PA, United States
| | - Meihong Deng
- Department of Surgery, The Ohio State University, Ohio, OH, United States
| | - Hong Liao
- Department of Surgery, University of Pittsburgh Medical School, Pennsylvania, PA, United States
| | - Xin Lv
- Department of Anesthesiology, Shanghai Pulmonary Hospital, TongJi University, Shanghai, China
| | - Bruce R. Pitt
- Department of Environmental Occupational Health, University of Pittsburgh Graduate School Public Health, Pennsylvania, PA, United States
| | - Timothy R. Billiar
- Department of Surgery, University of Pittsburgh Medical School, Pennsylvania, PA, United States
| | - Li-Ming Zhang
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pennsylvania, PA, United States
| | - Quan Li
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
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17
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Stephens K, Mitchell N, Overton S, Tonna JE. On the Transition from Control Modes to Spontaneous Modes during ECMO. J Clin Med 2021; 10:jcm10051001. [PMID: 33801277 PMCID: PMC7958116 DOI: 10.3390/jcm10051001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 01/21/2023] Open
Abstract
The transition from control modes to spontaneous modes is ubiquitous for mechanically ventilated patients yet there is little data describing the changes and patterns that occur to breathing during this transition for patients on ECMO. We identified high fidelity data among a diverse cohort of 419 mechanically ventilated patients on ECMO. We examined every ventilator change, describing the differences in >30,000 sets of original ventilator observations, focused around the time of transition from control modes to spontaneous modes. We performed multivariate regression with mixed effects, clustered by patient, to examine changes in ventilator characteristics within patients, including a subset among patients with low compliance (<30 milliliters (mL)/centimeters water (cmH2O)). We found that during the transition to spontaneous modes among patients with low compliance, patients exhibited greater tidal volumes (471 mL (364,585) vs. 425 mL (320,527); p < 0.0001), higher respiratory rate (23 breaths per minute (bpm) (18,28) vs. 18 bpm (14,23); p = 0.003), greater mechanical power (elastic component) (0.08 mL/(cmH2O × minute) (0.05,0.12) vs. 0.05 mL/(cmH2O × minute) (0.02,0.09); p < 0.0001) (range 0 to 1.4), and lower positive end expiratory pressure (PEEP) (6 cmH2O (5,8) vs. 10 cmH2O (8,11); p < 0.0001). For patients on control modes, the combination of increased tidal volume and increased respiratory rate was temporally associated with significantly low partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio (p < 0.0001). These changes in ventilator parameters warrant prospective study, as they may be associated with worsened lung injury.
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Affiliation(s)
- Krista Stephens
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM 87131, USA;
| | - Nathan Mitchell
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT 84132, USA;
| | - Sean Overton
- Division of Critical Care, Department of Anesthesiology, University of Utah Health, Salt Lake City, UT 84132, USA;
| | - Joseph E. Tonna
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT 84132, USA;
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT 84132, USA
- Correspondence: ; Tel.: +1-801-587-9373
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18
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Jang WS, Kim J, Baek J, Jung H, Jang JS, Park JS, Oh TH, Jang SY, Kim YS, Kwon YS. Clinical course of COVID-19 patients treated with ECMO: A multicenter study in Daegu, South Korea. Heart Lung 2021; 50:21-27. [PMID: 34698019 PMCID: PMC7572066 DOI: 10.1016/j.hrtlng.2020.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/06/2020] [Accepted: 10/16/2020] [Indexed: 01/08/2023]
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19
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Low Spontaneous Breathing Effort during Extracorporeal Membrane Oxygenation in a Porcine Model of Severe Acute Respiratory Distress Syndrome. Anesthesiology 2020; 133:1106-1117. [PMID: 32898217 DOI: 10.1097/aln.0000000000003538] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND A lung rest strategy is recommended during extracorporeal membrane oxygenation in severe acute respiratory distress syndrome (ARDS). However, spontaneous breathing modes are frequently used in this context. The impact of this approach may depend on the intensity of breathing efforts. The authors aimed to determine whether a low spontaneous breathing effort strategy increases lung injury, compared to a controlled near-apneic ventilation, in a porcine severe ARDS model assisted by extracorporeal membrane oxygenation. METHODS Twelve female pigs were subjected to lung injury by repeated lavages, followed by 2-h injurious ventilation. Thereafter, animals were connected to venovenous extracorporeal membrane oxygenation and during the first 3 h, ventilated with near-apneic ventilation (positive end-expiratory pressure, 10 cm H2O; driving pressure, 10 cm H2O; respiratory rate, 5/min). Then, animals were allocated into (1) near-apneic ventilation, which continued with the previous ventilatory settings; and (2) spontaneous breathing: neuromuscular blockers were stopped, sweep gas flow was decreased until regaining spontaneous efforts, and ventilation was switched to pressure support mode (pressure support, 10 cm H2O; positive end-expiratory pressure, 10 cm H2O). In both groups, sweep gas flow was adjusted to keep Paco2 between 30 and 50 mmHg. Respiratory and hemodynamic as well as electric impedance tomography data were collected. After 24 h, animals were euthanized and lungs extracted for histologic tissue analysis. RESULTS Compared to near-apneic group, the spontaneous breathing group exhibited a higher respiratory rate (52 ± 17 vs. 5 ± 0 breaths/min; mean difference, 47; 95% CI, 34 to 59; P < 0.001), but similar tidal volume (2.3 ± 0.8 vs. 2.8 ± 0.4 ml/kg; mean difference, 0.6; 95% CI, -0.4 to 1.4; P = 0.983). Extracorporeal membrane oxygenation settings and gas exchange were similar between groups. Dorsal ventilation was higher in the spontaneous breathing group. No differences were observed regarding histologic lung injury. CONCLUSIONS In an animal model of severe ARDS supported with extracorporeal membrane oxygenation, spontaneous breathing characterized by low-intensity efforts, high respiratory rates, and very low tidal volumes did not result in increased lung injury compared to controlled near-apneic ventilation. EDITOR’S PERSPECTIVE
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20
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Goligher EC, Dres M, Patel BK, Sahetya SK, Beitler JR, Telias I, Yoshida T, Vaporidi K, Grieco DL, Schepens T, Grasselli G, Spadaro S, Dianti J, Amato M, Bellani G, Demoule A, Fan E, Ferguson ND, Georgopoulos D, Guérin C, Khemani RG, Laghi F, Mercat A, Mojoli F, Ottenheijm CAC, Jaber S, Heunks L, Mancebo J, Mauri T, Pesenti A, Brochard L. Lung- and Diaphragm-Protective Ventilation. Am J Respir Crit Care Med 2020; 202:950-961. [PMID: 32516052 DOI: 10.1164/rccm.202003-0655cp] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Mechanical ventilation can cause acute diaphragm atrophy and injury, and this is associated with poor clinical outcomes. Although the importance and impact of lung-protective ventilation is widely appreciated and well established, the concept of diaphragm-protective ventilation has recently emerged as a potential complementary therapeutic strategy. This Perspective, developed from discussions at a meeting of international experts convened by PLUG (the Pleural Pressure Working Group) of the European Society of Intensive Care Medicine, outlines a conceptual framework for an integrated lung- and diaphragm-protective approach to mechanical ventilation on the basis of growing evidence about mechanisms of injury. We propose targets for diaphragm protection based on respiratory effort and patient-ventilator synchrony. The potential for conflict between diaphragm protection and lung protection under certain conditions is discussed; we emphasize that when conflicts arise, lung protection must be prioritized over diaphragm protection. Monitoring respiratory effort is essential to concomitantly protect both the diaphragm and the lung during mechanical ventilation. To implement lung- and diaphragm-protective ventilation, new approaches to monitoring, to setting the ventilator, and to titrating sedation will be required. Adjunctive interventions, including extracorporeal life support techniques, phrenic nerve stimulation, and clinical decision-support systems, may also play an important role in selected patients in the future. Evaluating the clinical impact of this new paradigm will be challenging, owing to the complexity of the intervention. The concept of lung- and diaphragm-protective ventilation presents a new opportunity to potentially improve clinical outcomes for critically ill patients.
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Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Martin Dres
- Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Assistance Publique-Hopitaux de Paris, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,Unite Mixte de Recherche-Sorbonne 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Institut National de la Sante et de la Recherche Medicale, Sorbonne Université, Paris, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Sarina K Sahetya
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jeremy R Beitler
- Division of Pulmonary, Allergy, and Critical Care Medicine, Center for Acute Respiratory Failure, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy.,Dipartimento di Medicina d'Urgenza e di Terapia Intensiva e Anestesia, Fondazione Policlinico Universitario, A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Tom Schepens
- Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Giacomo Grasselli
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Savino Spadaro
- Department Morphology, Surgery and Experimental Medicine, ICU, St. Anne's Archbishop Hospital, University of Ferrara, Ferrara, Italy
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Intensive Care Unit, Department of Medicine, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Marcelo Amato
- Laboratório de Pneumologia, Laboratório de Investicação Médica 9, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Alexandre Demoule
- Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Assistance Publique-Hopitaux de Paris, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,Unite Mixte de Recherche-Sorbonne 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Institut National de la Sante et de la Recherche Medicale, Sorbonne Université, Paris, France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine.,Institute for Health Policy, Management, and Evaluation, and.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine.,Institute for Health Policy, Management, and Evaluation, and.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Dimitrios Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Claude Guérin
- Médecine Intensive-Réanimation, Hopital Edouard Herriot Lyon, Faculté de Médecine Lyon-Est, Université de Lyon, Institut National de la Santé et de la Recherche Médicale 955 Créteil, Lyon, France
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, University of Southern California, Los Angeles, California
| | - Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Stritch School of Medicine, Loyola University, Maywood, Illinois.,Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois
| | - Alain Mercat
- Département de Médecine Intensive-Réanimation et Médecine Hyperbare, Centre Hospitalier d'Angers, Angers, France
| | - Francesco Mojoli
- Department of Anesthesia and Intensive Care, Scientific Hospitalization and Care Institute, San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | | | - Samir Jaber
- Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, Montpellier University Hospital Center, University of Montpellier, Joint Research Unit 9214, National Institute of Health and Medical Research U1046, National Scientific Research Center, Montpellier, France; and
| | - Leo Heunks
- Department of Intensive Care, Vrije University Location, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jordi Mancebo
- Servei de Medicina Intensiva Hospital de Sant Pau, Barcelona, Spain
| | - Tommaso Mauri
- Dipartimento di Medicina d'Urgenza e di Terapia Intensiva e Anestesia, Fondazione Policlinico Universitario, A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Antonio Pesenti
- Dipartimento di Medicina d'Urgenza e di Terapia Intensiva e Anestesia, Fondazione Policlinico Universitario, A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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21
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Shaver CM, Landstreet SR, Pugazenthi S, Scott F, Putz N, Ware LB, Bastarache JA. The NLRP3 inflammasome in macrophages is stimulated by cell-free hemoglobin. Physiol Rep 2020; 8:e14589. [PMID: 33128438 PMCID: PMC7601531 DOI: 10.14814/phy2.14589] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 08/27/2020] [Accepted: 09/03/2020] [Indexed: 12/18/2022] Open
Abstract
Cell‐free hemoglobin (CFH) is associated with severe lung injury in human patients and is sufficient to induce airspace inflammation and alveolar–capillary barrier dysfunction in an experimental model of acute lung injury. The mechanisms through which this occurs are unknown. One key pathway which regulates inflammation during acute lung injury is the NLRP3 inflammasome. Because CFH can act as a damage‐associated molecular pattern, we hypothesized that CFH may activate the NLRP3 inflammasome during acute lung injury. Primary mouse alveolar macrophages and cultured murine macrophages exposed to CFH (0–1 mg/ml) for 24 hr demonstrated robust upregulation of the NLRP3 inflammasome components NLRP3, caspase‐1, and caspase‐11. Maximal induction of the NLRP3 inflammasome by CFH required TLR4. Compared to wild‐type controls, mice lacking NLRP3 developed less airspace inflammation (2.7 × 105 cells/ml in bronchoalveolar lavage fluid versus. 1.1 × 105/ml, p = .006) after exposure to intratracheal CFH. Together, these data demonstrate that CFH can stimulate the NLRP3 inflammasome in macrophages and that this pathway may be important in the pathogenesis of CFH‐induced acute lung injury.
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Affiliation(s)
- Ciara M Shaver
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stuart R Landstreet
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Fiona Scott
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nathan Putz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Julie A Bastarache
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN, USA
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22
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Ventilatory management of patients on ECMO. Indian J Thorac Cardiovasc Surg 2020; 37:248-253. [PMID: 33967448 PMCID: PMC8062618 DOI: 10.1007/s12055-020-01021-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 07/16/2020] [Accepted: 07/22/2020] [Indexed: 01/09/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is the final treatment offered to patients of acute respiratory distress syndrome (ARDS). The survival (to discharge) of patients on veno-venous ECMO is approximately 59% with an average duration of 8 days. The ventilatory management of lungs during the ECMO may have an impact on mortality. An ideal ventilation modality should promote recovery, prevent further damage to the alveoli, and enable weaning from mechanical ventilation. This article reviews the concept of “baby lung” in ARDS and the current evidence for the use of lung protective ventilation, prevention of ventilator-induced lung injury, recommended modes of mechanical ventilation, ideal ventilatory parameters (tidal volume, positive end expiratory pressure, plateau pressure, respiratory rate, fractional inspired oxygen concentration), and use of adjuncts (prone positioning, neuromuscular blocking agents) during the ECMO course.
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23
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Liang Z, Yin X, Sun W, Zhang S, Chen X, Pei L, Zhao N. Enhanced protection against lipopolysaccharide-induced acute lung injury by autologous transplantation of adipose-derived stromal cells combined with low tidal volume ventilation in rats. J Cell Physiol 2020; 236:1295-1308. [PMID: 32662079 DOI: 10.1002/jcp.29936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 07/02/2020] [Indexed: 12/30/2022]
Abstract
Adipose-derived stromal cells (ADSCs) showed excellent capacity in regeneration and tissue protection. Low tidal volume ventilation (LVT) strategy demonstrates a therapeutic benefit on the treatment of acute lung injury/acute respiratory distress syndrome (ALI/ARDS). This study, therefore, aimed to undertaken determine whether the combined LVT and ADSCs treatment exerts additional protection against lipopolysaccharide (LPS)-induced ALI in rats. The animals were randomized into seven groups: Group I (control), Group II (instillation of LPS at 10 mg/kg intratracheally), Group III (LPS+LVT 6 ml/kg), Group IV (LPS+intravenous autologous 5 × 106 ADSCs which were pretreated with a scrambled small interfering RNA [siRNA] of keratinocyte growth factor [KGF] negative control), Group V (LPS+ADSCs which were pretreated with a scrambled siRNA of KGF, Group VI (LPS+LVT and ADSCs as in the Group IV), and Group VII (LPS+LVT and ADSCs as in the Group V). We found that levels of tumor necrosis factor-α, transforming growth factor-β1, and interleukin (IL)-1β and IL-6, the proinflammatory cytokines, were remarkably increased in LPS rats. Moreover, the expressions of ENaC, activity of Na, K-ATPase, and alveolar fluid clearance (AFC) were obviously reduced by LPS-induced ALI. The rats treated by ADSCs showed improved effects in all these changes of ALI and further enhanced by ADSCs combined with LVT treatment. Importantly, the treatment of ADSCs with siRNA-mediated knockdown of KGF partially eliminated the therapeutic effects. In conclusion, combined treatment with ADSCs and LVT not only is superior to either ADSCs or LVT therapy alone in the prevention of ALI. Evidence of the beneficial effect may be partly due to improving AFC by paracrine or systemic production of KGF and anti-inflammatory properties.
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Affiliation(s)
- Zuodi Liang
- Department of Anesthesiology, The First Hospital Affiliated at China Medical University, Shenyang, China
| | - Xiuru Yin
- Department of Anesthesiology, The First Hospital Affiliated at China Medical University, Shenyang, China
| | - Wenchong Sun
- Department of Anesthesiology, The First Hospital Affiliated at China Medical University, Shenyang, China
| | - Shuo Zhang
- Department of Anesthesiology, The First Hospital Affiliated at China Medical University, Shenyang, China
| | - Xiaohuan Chen
- Department of Anesthesiology, The First Hospital Affiliated at China Medical University, Shenyang, China
| | - Ling Pei
- Department of Anesthesiology, The First Hospital Affiliated at China Medical University, Shenyang, China
| | - Ning Zhao
- Department of ENT, The First Hospital Affiliated at China Medical University, Shenyang, China
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24
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Should Patients With Acute Respiratory Distress Syndrome on Venovenous Extracorporeal Membrane Oxygenation Have Ventilatory Support Reduced to the Lowest Tolerable Settings? Yes. Crit Care Med 2020; 47:1143-1146. [PMID: 31149964 DOI: 10.1097/ccm.0000000000003835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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25
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Abrams D, Schmidt M, Pham T, Beitler JR, Fan E, Goligher EC, McNamee JJ, Patroniti N, Wilcox ME, Combes A, Ferguson ND, McAuley DF, Pesenti A, Quintel M, Fraser J, Hodgson CL, Hough CL, Mercat A, Mueller T, Pellegrino V, Ranieri VM, Rowan K, Shekar K, Brochard L, Brodie D. Mechanical Ventilation for Acute Respiratory Distress Syndrome during Extracorporeal Life Support. Research and Practice. Am J Respir Crit Care Med 2020; 201:514-525. [DOI: 10.1164/rccm.201907-1283ci] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Darryl Abrams
- Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, New York
- Center for Acute Respiratory Failure, Columbia University Medical Center, New York, New York
| | - Matthieu Schmidt
- INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique–Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Tài Pham
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France
| | - Jeremy R. Beitler
- Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, New York
- Center for Acute Respiratory Failure, Columbia University Medical Center, New York, New York
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - James J. McNamee
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Nicolò Patroniti
- Anaesthesia and Intensive Care, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) for Oncology, San Martino Policlinico Hospital, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - M. Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Alain Combes
- INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique–Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - Niall D. Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Danny F. McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Michael Quintel
- Department of Anesthesiology, University Medical Center, Georg August University, Goettingen, Germany
| | - John Fraser
- Critical Care Research Group, Prince Charles Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Carol L. Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Physiotherapy Department and
| | - Catherine L. Hough
- Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Alain Mercat
- Département de Médecine Intensive-Réanimation et Médecine Hyperbare, Centre Hospitalier Universitaire d’Angers, Université d’Angers, Angers, France
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital of Regensburg, Regensburg, Germany
| | - Vin Pellegrino
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
| | - V. Marco Ranieri
- Alma Mater Studiorum–Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant’Orsola, Università di Bologna, Bologna, Italy; and
| | - Kathy Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Kiran Shekar
- Critical Care Research Group, Prince Charles Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Daniel Brodie
- Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, New York
- Center for Acute Respiratory Failure, Columbia University Medical Center, New York, New York
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26
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The IL-33-ST2 Pathway Contributes to Ventilator-Induced Lung Injury in Septic Mice in a Tidal Volume-Dependent Manner. Shock 2019; 52:e1-e11. [DOI: 10.1097/shk.0000000000001260] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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27
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Brodie D, Slutsky AS, Combes A. Extracorporeal Life Support for Adults With Respiratory Failure and Related Indications: A Review. JAMA 2019; 322:557-568. [PMID: 31408142 DOI: 10.1001/jama.2019.9302] [Citation(s) in RCA: 230] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE The substantial growth over the last decade in the use of extracorporeal life support for adults with acute respiratory failure reveals an enthusiasm for the technology not always consistent with the evidence. However, recent high-quality data, primarily in patients with acute respiratory distress syndrome, have made extracorporeal life support more widely accepted in clinical practice. OBSERVATIONS Clinical trials of extracorporeal life support for acute respiratory failure in adults in the 1970s and 1990s failed to demonstrate benefit, reducing use of the intervention for decades and relegating it to a small number of centers. Nonetheless, technological improvements in extracorporeal support made it safer to use. Interest in extracorporeal life support increased with the confluence of 2 events in 2009: (1) the publication of a randomized clinical trial of extracorporeal life support for acute respiratory failure and (2) the use of extracorporeal life support in patients with severe acute respiratory distress syndrome during the influenza A(H1N1) pandemic. In 2018, a randomized clinical trial in patients with very severe acute respiratory distress syndrome demonstrated a seemingly large decrease in mortality from 46% to 35%, but this difference was not statistically significant. However, a Bayesian post hoc analysis of this trial and a subsequent meta-analysis together suggested that extracorporeal life support was beneficial for patients with very severe acute respiratory distress syndrome. As the evidence supporting the use of extracorporeal life support increases, its indications are expanding to being a bridge to lung transplantation and the management of patients with pulmonary vascular disease who have right-sided heart failure. Extracorporeal life support is now an acceptable form of organ support in clinical practice. CONCLUSIONS AND RELEVANCE The role of extracorporeal life support in the management of adults with acute respiratory failure is being redefined by advances in technology and increasing evidence of its effectiveness. Future developments in the field will result from technological advances, an increased understanding of the physiology and biology of extracorporeal support, and increased knowledge of how it might benefit the treatment of a variety of clinical conditions.
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Affiliation(s)
- Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York
- Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Alain Combes
- Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
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28
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Sklar MC, Patel BK, Beitler JR, Piraino T, Goligher EC. Optimal Ventilator Strategies in Acute Respiratory Distress Syndrome. Semin Respir Crit Care Med 2019; 40:81-93. [PMID: 31060090 PMCID: PMC7117088 DOI: 10.1055/s-0039-1683896] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Mechanical ventilation practices in patients with acute respiratory distress syndrome (ARDS) have progressed with a growing understanding of the disease pathophysiology. Paramount to the care of affected patients is the delivery of lung-protective mechanical ventilation which prioritizes tidal volume and plateau pressure limitation. Lung protection can probably be further enhanced by scaling target tidal volumes to the specific respiratory mechanics of individual patients. The best procedure for selecting optimal positive end-expiratory pressure (PEEP) in ARDS remains uncertain; several relevant issues must be considered when selecting PEEP, particularly lung recruitability. Noninvasive ventilation must be used with caution in ARDS as excessively high respiratory drive can further exacerbate lung injury; newer modes of delivery offer promising approaches in hypoxemic respiratory failure. Airway pressure release ventilation offers an alternative approach to maximize lung recruitment and oxygenation, but clinical trials have not demonstrated a survival benefit of this mode over conventional ventilation strategies. Rescue therapy with high-frequency oscillatory ventilation is an important option in refractory hypoxemia. Despite a disappointing lack of benefit (and possible harm) in patients with moderate or severe ARDS, possibly due to lung hyperdistention and right ventricular dysfunction, high-frequency oscillation may improve outcome in patients with very severe hypoxemia.
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Affiliation(s)
- Michael C Sklar
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, New York
| | - Thomas Piraino
- Keenan Centre for Biomedical Research, St. Michael's Hospital, Toronto, Ontario, Canada.,Division of Critical Care, Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada.,Department of Respiratory Therapy, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Ontario, Canada
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29
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Dougherty SC, Ghaus S, Debesa O. Extracorporeal Membrane Oxygenation in Severe Acute Eosinophilic Pneumonia. Front Med (Lausanne) 2019; 6:65. [PMID: 31024915 PMCID: PMC6467954 DOI: 10.3389/fmed.2019.00065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/15/2019] [Indexed: 01/09/2023] Open
Abstract
Acute Eosinophilic Pneumonia (AEP) is a potentially fatal cause of hypoxemic respiratory failure characterized by fever, diffuse bilateral pulmonary infiltrates, and pulmonary eosinophilia. Shown to be associated with a number of environmental exposures and lifestyle choices, AEP has a good prognosis when diagnosed early and treated with corticosteroids. In this clinical case report, we detail the presentation, evaluation, diagnosis, and management of a 40-year old male who presented to the emergency department with dyspnea, chills, and diaphoresis. He had a history of pulmonary embolism 8 years prior but was otherwise healthy, though he had re-started smoking cigarettes a week prior to presentation. Initial chest CT scan revealed widespread mixed groundglass and solid airspace opacities; over the next 12 hours, he rapidly decompensated and after not responding to other invasive mechanical ventilation, was emergently cannulated for veno-venous extracorporeal membrane oxygenation (V-V ECMO). Bronchoalveolar lavage later revealed pulmonary eosinophilia, and after an infectious workup was negative, a diagnosis of AEP was reached and the patient was started on corticosteroids. To our knowledge, this is one of few published cases of AEP requiring V-V ECMO for clinical stabilization, highlighting the utility of this treatment modality in severe disease.
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Affiliation(s)
- Sean C Dougherty
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Sophia Ghaus
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Orlando Debesa
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States
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30
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Abstract
Acute respiratory distress syndrome (ARDS) is a syndrome of acute respiratory failure caused by noncardiogenic pulmonary edema. Despite five decades of basic and clinical research, there is still no effective pharmacotherapy for this condition and the treatment remains primarily supportive. It is critical to study the molecular and physiologic mechanisms that cause ARDS to improve our understanding of this syndrome and reduce mortality. The goal of this review is to describe our current understanding of the pathogenesis and pathophysiology of ARDS. First, we will describe how pulmonary edema fluid accumulates in ARDS due to lung inflammation and increased alveolar endothelial and epithelial permeabilities. Next, we will review how pulmonary edema fluid is normally cleared in the uninjured lung, and describe how these pathways are disrupted in ARDS. Finally, we will explain how clinical trials and preclinical studies of novel therapeutic agents have further refined our understanding of this condition, highlighting, in particular, the study of mesenchymal stromal cells in the treatment of ARDS.
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Affiliation(s)
- Laura A. Huppert
- Department of Medicine, University of California San Francisco, San Francisco, CA USA
| | - Michael A. Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA USA
| | - Lorraine B. Ware
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN USA
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31
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Seo EH, Piao L, Park HJ, Lee JY, Sa M, Oh CS, Lee SH, Kim SH. Impact of general anaesthesia on endoplasmic reticulum stress: propofol vs. isoflurane. Int J Med Sci 2019; 16:1287-1294. [PMID: 31588195 PMCID: PMC6775274 DOI: 10.7150/ijms.36265] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/25/2019] [Indexed: 12/17/2022] Open
Abstract
Background: This study investigated the effects of propofol and isoflurane on endoplasmic reticulum (ER) stress in an animal model under general anaesthesia. Methods: Rats were randomly divided into Propofol and Isoflurane groups. Anaesthesia was maintained with propofol for Propofol group or isoflurane for Isoflurane group during 3 h. ER stress from lymphocytes in blood and tissues was evaluated between two groups after euthanasia. Reactive oxygen species (ROS) from lymphocytes in blood and tissues, and cytokines in blood were also checked. An immunohistochemical assay for ER stress marker from tissues was performed. Results: After anaesthesia, the levels of CCAAT-enhancer-binding protein homologous proteins (CHOP) in blood and liver were significantly higher in Isoflurane group, compared to Propofol group [blood, 31,499 ± 4,934 (30,733, 26,441-38,807) mean fluorescence intensity (MFI) in Isoflurane group vs. 20,595 ± 1,838 (20,780, 18,866-22,232) MFI in Propofol group, p = 0.002; liver, 28,342 ± 5,535 (29,421, 23,388-32,756) MFI in Isoflurane group vs. 20,004 ± 2,155 (19,244, 18,197-22,191) MFI in Propofol group, p = 0.020]. ROS in blood was significantly higher in Isoflurane group, compared to Propofol group. However, cytokines in blood and immunohistochemical assays in tissues were similar between groups. Conclusion: Significant higher of ER stress from blood and liver were observed in rats under anaesthesia with isoflurane, compared to those that received propofol. ROS from blood also showed significant higher under anaesthesia with isoflurane. However, these findings were not associated with any changes in cytokines in blood or immunohistochemical assay in tissues.
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Affiliation(s)
- Eun-Hye Seo
- BK21 Plus, Department of Cellular and Molecular Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Liyun Piao
- Department of Infection and Immunology, Konkuk University School of Medicine, Seoul, Korea
| | - Hyun-Jun Park
- Department of Infection and Immunology, Konkuk University School of Medicine, Seoul, Korea
| | - Ji Yeon Lee
- Department of Infection and Immunology, Konkuk University School of Medicine, Seoul, Korea
| | - Mijung Sa
- Department of Anesthesiology and Pain medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Chung-Sik Oh
- Department of Anesthesiology and Pain medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Seung-Hyun Lee
- Department of Microbiology, Konkuk University School of Medicine, Seoul, Korea.,Department of Medicine, Institute of Biomedical Science and Technology, Konkuk University School of Medicine, Seoul, Korea
| | - Seong-Hyop Kim
- Department of Infection and Immunology, Konkuk University School of Medicine, Seoul, Korea.,Department of Anesthesiology and Pain medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea.,Department of Medicine, Institute of Biomedical Science and Technology, Konkuk University School of Medicine, Seoul, Korea
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32
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Abstract
The acute respiratory distress syndrome (ARDS) is a common cause of respiratory failure in critically ill patients and is defined by the acute onset of noncardiogenic pulmonary oedema, hypoxaemia and the need for mechanical ventilation. ARDS occurs most often in the setting of pneumonia, sepsis, aspiration of gastric contents or severe trauma and is present in ~10% of all patients in intensive care units worldwide. Despite some improvements, mortality remains high at 30-40% in most studies. Pathological specimens from patients with ARDS frequently reveal diffuse alveolar damage, and laboratory studies have demonstrated both alveolar epithelial and lung endothelial injury, resulting in accumulation of protein-rich inflammatory oedematous fluid in the alveolar space. Diagnosis is based on consensus syndromic criteria, with modifications for under-resourced settings and in paediatric patients. Treatment focuses on lung-protective ventilation; no specific pharmacotherapies have been identified. Long-term outcomes of patients with ARDS are increasingly recognized as important research targets, as many patients survive ARDS only to have ongoing functional and/or psychological sequelae. Future directions include efforts to facilitate earlier recognition of ARDS, identifying responsive subsets of patients and ongoing efforts to understand fundamental mechanisms of lung injury to design specific treatments.
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33
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Ding X, Tong Y, Jin S, Chen Z, Li T, Billiar TR, Pitt BR, Li Q, Zhang LM. Mechanical ventilation enhances extrapulmonary sepsis-induced lung injury: role of WISP1-αvβ5 integrin pathway in TLR4-mediated inflammation and injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:302. [PMID: 30445996 PMCID: PMC6240278 DOI: 10.1186/s13054-018-2237-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 10/15/2018] [Indexed: 12/19/2022]
Abstract
Background High tidal volume ventilation of healthy lungs or exacerbation of existing acute lung injury (ALI) by more moderate mechanical ventilation (MTV) produces ventilator-induced lung injury. It is less clear whether extrapulmonary sepsis sensitizes the lung to MTV. Methods We used a two-hit model of cecal ligation and puncture (CLP) followed 12 h later by MTV (10 ml/kg; 6 h) to determine whether otherwise noninjurious MTV enhances CLP-induced ALI by contrasting wildtype and TLR4−/− mice with respect to: alveolar-capillary permeability, histopathology and intrapulmonary levels of WNT-inducible secreted protein 1 (WISP1) and integrin β5; plasma levels of cytokines and chemokines (TNF-α, IL-6, MIP-2, MCP-1) and intrapulmonary neutrophil infiltration; and other inflammatory signaling via intrapulmonary activation of JNK, p38 and ERK. A separate cohort of mice was pretreated with intratracheal neutralizing antibodies to WISP1, integrin β5 or IgG as control and the presented phenotyping repeated in a two-hit model; there were 10 mice per group in these first three experiments. Also, isolated peritoneal macrophages (PM) from wildtype and TLR4−/−, MyD88−/− and TRIF−/− mice were used to identify a WISP1–TLR4–integrin β5 pathway; and the requisite role of integrin β5 in WISP1-induced cytokine and chemokine production in LPS-primed PM was examined by siRNA treatment. Results MTV, that in itself did not cause ALI, exacerbated increases in alveolar-capillary permeability, histopathologic scoring and indices of pulmonary inflammation in mice that previously underwent CLP; the effects of this two-hit model were abrogated in TLR4−/− mice. Attendant with these findings was a significant increase in intrapulmonary WISP1 and integrin β5 in the two-hit model. Anti-WISP1 or anti-integrin β5 antibodies partially inhibited the two-hit phenotype. In PM, activation of TLR4 led to an increase in integrin β5 expression that was MyD88 and NF-κB dependent. Recombinant WISP1 increased LPS-induced cytokine release in PM that was inhibited by silencing either TLR4 or integrin β5. Conclusions These data show for the first time that otherwise noninjurious mechanical ventilation can exacerbate ALI due to extrapulmonary sepsis underscoring a potential interactive contribution of common events (sepsis and mechanical ventilation) in critical care, and that a WISP1–TLR4–integrin β5 pathway contributes to this phenomenon. Electronic supplementary material The online version of this article (10.1186/s13054-018-2237-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xibing Ding
- Department of Anesthesiology, East Hospital, Tongji University School of Medicine, 150 Jimo Road, Pudong, Shanghai, China.,Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Anesthesiology, University of Pittsburgh School of Medicine, 200 Lothrop St. UPMC MUH N467, Pittsburgh, 15213, PA, USA.,Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yao Tong
- Department of Anesthesiology, East Hospital, Tongji University School of Medicine, 150 Jimo Road, Pudong, Shanghai, China
| | - Shuqing Jin
- Department of Anesthesiology, East Hospital, Tongji University School of Medicine, 150 Jimo Road, Pudong, Shanghai, China.,Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Zhixia Chen
- Department of Anesthesiology, East Hospital, Tongji University School of Medicine, 150 Jimo Road, Pudong, Shanghai, China
| | - Tunliang Li
- Department of Anesthesiology, Xiangya 3rd Hospital, Central South University, Hunan, China.,Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Timothy R Billiar
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bruce R Pitt
- Department of Environmental and Occupational Health, University of Pittsburgh Graduate School Public Health, Pittsburgh, PA, USA
| | - Quan Li
- Department of Anesthesiology, East Hospital, Tongji University School of Medicine, 150 Jimo Road, Pudong, Shanghai, China. .,Department of Anesthesiology, Cancer Hospital Chinese Academy of Medical Sciences, Shenzhen, China.
| | - Li-Ming Zhang
- Department of Anesthesiology, University of Pittsburgh School of Medicine, 200 Lothrop St. UPMC MUH N467, Pittsburgh, 15213, PA, USA.
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34
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When the momentum has gone: what will be the role of extracorporeal lung support in the future? Curr Opin Crit Care 2018; 24:23-28. [PMID: 29140963 DOI: 10.1097/mcc.0000000000000475] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW There has been expanding interest in and use of extracorporeal support in respiratory failure concurrent with technological advances and predominantly observational data demonstrating improved outcomes. However, until there is more available data from rigorous, high-quality randomized studies, the future of extracorporeal support remains uncertain. RECENT FINDINGS Outcomes for patients supported with extracorporeal devices continue to show favorable trends. There are several large randomized controlled trials that are in various stages of planning or completion for extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R) in the acute respiratory distress syndrome (ARDS) and chronic obstructive pulmonary disease (COPD), which may help clarify the role of this technology for these disease processes, and which stand to have a significant impact on a large proportion of patients with acute respiratory failure. Novel applications of extracorporeal lung support include optimization of donor organ quality through ex-vivo perfusion and extracorporeal cross-circulation, allowing for multimodal therapeutic interventions. SUMMARY Despite the ongoing rise in ECMO use for acute respiratory failure, its true value will not be known until more information is gleaned from prospective randomized controlled trials. Additionally, there are modalities beyond the current considerations for extracorporeal support that have the potential to revolutionize respiratory failure, particularly in the realm of chronic lung disease and lung transplantation.
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35
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Richard C, Shabbir W, Ferraro P, Massé C, Berthiaume Y. Alveolar liquid clearance in lung injury: Evaluation of the impairment of the β 2-adrenergic agonist response in an ischemia-reperfusion lung injury model. Respir Physiol Neurobiol 2018; 259:104-110. [PMID: 30171906 DOI: 10.1016/j.resp.2018.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 07/27/2018] [Accepted: 08/27/2018] [Indexed: 01/05/2023]
Abstract
While alveolar liquid clearance (ALC) mediated by the β2-adrenergic receptor (β2-AR) plays an important role in lung edema resolution in certain models of lung injury, in more severe lung injury models, this response might disappear. Indeed, we have shown that in an ischemia-reperfusion-induced lung injury model, β2-agonists do not enhance ALC. The objective of this study was to determine if downregulation of the β2-AR could explain the lack of response to β2-agonists in this lung injury model. In an in vivo canine model of lung transplantation, we observed no change in β2-AR concentration or affinity in the injured transplanted lungs compared to the native lungs. Furthermore, we could not enhance ALC in transplanted lungs with dcAMP + aminophylline, a treatment that bypasses the β2-adrenergic receptor and is known to stimulate ALC in normal lungs. However, transplantation decreased αENaC expression in the lungs by 50%. We conclude that the lack of response to β2-agonists in ischemia-reperfusion-induced lung injury is not associated with significant downregulation of the β2-adrenergic receptors but is attributable to decreased expression of the ENaC channel, which is essential for sodium transport and alveolar liquid clearance in the lung.
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Affiliation(s)
- Chloé Richard
- Centre de recherche, Centre hospitalier de l'université de Montréal (CHUM), Canada
| | - Waheed Shabbir
- Institute of Pharmacology and Toxicology, University of Vienna, Vienna, Austria
| | - Pasquale Ferraro
- Centre de recherche, Centre hospitalier de l'université de Montréal (CHUM), Canada; Département de chirurgie, Université de Montréal, Montréal, Québec, Canada
| | - Chantal Massé
- Centre de recherche, Centre hospitalier de l'université de Montréal (CHUM), Canada; Institut de recherches cliniques de Montréal (IRCM), Montréal, Quebec, Canada
| | - Yves Berthiaume
- Centre de recherche, Centre hospitalier de l'université de Montréal (CHUM), Canada; Département de médecine, Université de Montréal, Montréal, Québec, Canada; Institut de recherches cliniques de Montréal (IRCM), Montréal, Quebec, Canada.
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36
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Setzer F, Schmidt B, Hueter L, Schwarzkopf K, Sänger J, Schreiber T. Characterization of the seven-day course of pulmonary response following unilateral lung acid injury in rats. PLoS One 2018; 13:e0198440. [PMID: 29864150 PMCID: PMC5986146 DOI: 10.1371/journal.pone.0198440] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/18/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Aspiration of gastric acid is an important cause of acute lung injury. The time course of the pulmonary response to such an insult beyond the initial 48 hours is incompletely characterized. The purpose of this study was to comprehensively describe the pulmonary effects of focal lung acid injury over a seven day period in both directly injured and not directly injured lung tissue. METHODS Male Wistar rats underwent left-endobronchial instillation with hydrochloric acid and were sacrificed at 4, 24, 48, 96 or 168 h after the insult. Healthy non-injured animals served as controls. We assessed inflammatory cell counts and cytokine levels in right and left lung lavage fluid and blood, arterial oxygen tension, alterations in lung histology, lung wet-to-dry weight ratio and differential lung perfusion. RESULTS Lung acid instillation induced an early strong inflammatory response in the directly affected lung, peaking at 4-24 hours, with only partial resolution after 7 days. A less severe response with complete resolution after 4 days was seen in the opposite lung. Alveolar cytokine levels, with exception of IL-6, only partially reflected the localization of lung injury and the time course of the functional and histologic alterations. Alveolar leucocyte subpopulations exhibited different time courses in the acid injured lung with persistent elevation of alveolar lymphocytes and macrophages. After acid instillation there was an early transient decrease in arterial oxygen tension and lung perfusion was preferentially distributed to the non-injured lung. CONCLUSION These findings provide a basis for further research in the field of lung acid injury and for studies exploring effects of mechanical ventilation on injured lungs. Incomplete recovery in the directly injured lung 7 days after acid instillation suggests that increased vulnerability and susceptibility to further noxious stimuli are still present at that time.
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Affiliation(s)
- Florian Setzer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- * E-mail:
| | - Barbara Schmidt
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Lars Hueter
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Department of Anesthesia and Intensive Care, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Konrad Schwarzkopf
- Department of Anesthesia and Intensive Care, Klinikum Saarbrücken, Winterberg, Saarbrücken, Germany
| | - Jörg Sänger
- Laboratory for Pathology and Cytology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Torsten Schreiber
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Department of Anesthesia and Intensive Care, Zentralklinik Bad Berka, Bad Berka, Germany
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37
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Cerebral Pathophysiology in Extracorporeal Membrane Oxygenation: Pitfalls in Daily Clinical Management. Crit Care Res Pract 2018; 2018:3237810. [PMID: 29744226 PMCID: PMC5878897 DOI: 10.1155/2018/3237810] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/24/2018] [Accepted: 02/12/2018] [Indexed: 12/12/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving technique that is widely being used in centers throughout the world. However, there is a paucity of literature surrounding the mechanisms affecting cerebral physiology while on ECMO. Studies have shown alterations in cerebral blood flow characteristics and subsequently autoregulation. Furthermore, the mechanical aspects of the ECMO circuit itself may affect cerebral circulation. The nature of these physiological/pathophysiological changes can lead to profound neurological complications. This review aims at describing the changes to normal cerebral autoregulation during ECMO, illustrating the various neuromonitoring tools available to assess markers of cerebral autoregulation, and finally discussing potential neurological complications that are associated with ECMO.
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38
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Pourfathi M, Cereda M, Chatterjee S, Xin Y, Kadlecek S, Duncan I, Hamedani H, Siddiqui S, Profka H, Ehrich J, Ruppert K, Rizi RR. Lung Metabolism and Inflammation during Mechanical Ventilation; An Imaging Approach. Sci Rep 2018; 8:3525. [PMID: 29476083 PMCID: PMC5824838 DOI: 10.1038/s41598-018-21901-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 02/13/2018] [Indexed: 12/20/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a major cause of mortality in critically ill patients. Patients are currently managed by protective ventilation and alveolar recruitment using positive-end expiratory pressure (PEEP). However, the PEEP's effect on both pulmonary metabolism and regional inflammation is poorly understood. Here, we demonstrate the effect of PEEP on pulmonary anaerobic metabolism in mechanically ventilated injured rats, using hyperpolarized carbon-13 imaging. Pulmonary lactate-to-pyruvate ratio was measured in 21 rats; 14 rats received intratracheal instillation of hydrochloric-acid, while 7 rats received sham saline. 1 hour after acid/saline instillation, PEEP was lowered to 0 cmH2O in 7 injured rats (ZEEP group) and in all sham rats; PEEP was continued in the remaining 7 injured rats (PEEP group). Pulmonary compliance, oxygen saturation, histological injury scores, ICAM-1 expression and myeloperoxidase expression were measured. Lactate-to-pyruvate ratio progressively increased in the dependent lung during mechanical ventilation at ZEEP (p < 0.001), but remained unchanged in PEEP and sham rats. Lactate-to-pyruvate ratio was correlated with hyaline membrane deposition (r = 0.612), edema severity (r = 0.663), ICAM-1 (r = 0.782) and myeloperoxidase expressions (r = 0.817). Anaerobic pulmonary metabolism increases during lung injury progression and is contained by PEEP. Pulmonary lactate-to-pyruvate ratio may indicate in-vivo neutrophil activity due to atelectasis.
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Affiliation(s)
- Mehrdad Pourfathi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department Electrical and Systems Engineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Shampa Chatterjee
- Department of Physiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ian Duncan
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarmad Siddiqui
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Harrilla Profka
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Ehrich
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Kai Ruppert
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Rahim R Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA.
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The Evolution of Extracorporeal Membrane Oxygenation for Adult Respiratory Failure. Ann Am Thorac Soc 2018; 15:S57-S60. [DOI: 10.1513/annalsats.201705-386kv] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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40
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Seo EH, Song GY, Namgung JH, Oh CS, Lee SH, Kim SH. Receptor for activated C kinase 1 in rats with ischemia-reperfusion injury: intravenous versus inhalation anaesthetic agents. Int J Med Sci 2018; 15:352-358. [PMID: 29511370 PMCID: PMC5835705 DOI: 10.7150/ijms.22591] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 01/12/2018] [Indexed: 01/04/2023] Open
Abstract
Background: The study examined the difference in the expression of the receptor for activated C kinase 1 (RACK1) between anaesthesia with propofol and isoflurane in rats with myocardial ischemia-reperfusion injury (IRI). Methods: Male Sprague-Dawley rats were studied. Anaesthesia was induced with xylazine 20 µg/g by intraperitoneal injection and maintained with propofol or isoflurane. Myocardial IRI was induced by ligating the left anterior descending artery for 1 hour. Reactive oxygen species (ROS), cardiomyocyte apoptosis, the expression of RACK1 and toll-like receptor 4 (TLR4), and the heart injury score were compared between the two groups. Results: Cardiomyocyte apoptosis with ROS was significantly lower in the propofol group than in the isoflurane group. The propofol group had significantly higher RACK1 expression and lower TLR4 expression, compared with the isoflurane group (RACK1, 1970.50 ± 120.50 vs. 1350.20 ± 250.30, p<0.05; TLR4, 980.50 ± 110.75 vs. 1275.50 ± 75.35, p<0.05). However, the heart injury scores in the two groups did not differ significantly (3.56 ± 0.29 vs. 4.33 ± 0.23 in the propofol and isoflurane groups, respectively, p=0.33). Conclusion: There were significant differences in inflammation and apoptosis, including the expression of RACK1 and TLR4, after myocardial IRI between the propofol and isoflurane groups. However, both groups had similar heart injury scores.
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Affiliation(s)
- Eun-Hye Seo
- BK21 Plus, Department of Cellular and Molecular Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Ga-Yun Song
- Department of Microbiology, Konkuk University School of Medicine, Seoul, Korea
| | - Ji Hyeon Namgung
- Department of Microbiology, Konkuk University School of Medicine, Seoul, Korea
| | - Chung-Sik Oh
- Department of Medicine, Institute of Biomedical Science and Technology, Konkuk University School of Medicine, Seoul, Korea
| | - Seung Hyun Lee
- Department of Microbiology, Konkuk University School of Medicine, Seoul, Korea.,Department of Medicine, Institute of Biomedical Science and Technology, Konkuk University School of Medicine, Seoul, Korea
| | - Seong-Hyop Kim
- Department of Medicine, Institute of Biomedical Science and Technology, Konkuk University School of Medicine, Seoul, Korea.,Department of Anesthesiology and Pain medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea.,Department of Infection and Immunology, Konkuk University School of Medicine, Seoul, Korea
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41
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López Sanchez M. Ventilación mecánica en pacientes tratados con membrana de oxigenación extracorpórea (ECMO). Med Intensiva 2017; 41:491-496. [DOI: 10.1016/j.medin.2016.12.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 12/13/2016] [Accepted: 12/14/2016] [Indexed: 01/19/2023]
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Marseu K, Slinger P. Perioperative lung protection. Korean J Anesthesiol 2017; 70:239-244. [PMID: 28580074 PMCID: PMC5453885 DOI: 10.4097/kjae.2017.70.3.239] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 05/04/2017] [Indexed: 12/15/2022] Open
Abstract
Perioperative pulmonary complications are known to be a major cause of morbidity and mortality, and as such, contribute a large burden to the health care system globally. Anesthesiologists have an important role during the perioperative period to identify patients at risk of these complications and intervene in order to reduce them. After describing perioperative pulmonary complications and risk factors for such, this article will address preoperative, intraoperative, and postoperative lung protective strategies to try and reduce the risk of these complications.
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Affiliation(s)
- Katherine Marseu
- Department of Anesthesia and Pain Management, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Peter Slinger
- Department of Anesthesia and Pain Management, Toronto General Hospital, University of Toronto, Toronto, Canada
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43
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Huppert LA, Matthay MA. Alveolar Fluid Clearance in Pathologically Relevant Conditions: In Vitro and In Vivo Models of Acute Respiratory Distress Syndrome. Front Immunol 2017; 8:371. [PMID: 28439268 PMCID: PMC5383664 DOI: 10.3389/fimmu.2017.00371] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 03/15/2017] [Indexed: 01/11/2023] Open
Abstract
Critically ill patients with respiratory failure from acute respiratory distress syndrome (ARDS) have reduced ability to clear alveolar edema fluid. This reduction in alveolar fluid clearance (AFC) contributes to the morbidity and mortality in ARDS. Thus, it is important to understand why AFC is reduced in ARDS in order to design targeted therapies. In this review, we highlight experiments that have advanced our understanding of ARDS pathogenesis, with particular reference to the alveolar epithelium. First, we review how vectorial ion transport drives the clearance of alveolar edema fluid in the uninjured lung. Next, we describe how alveolar edema fluid is less effectively cleared in lungs affected by ARDS and describe selected in vitro and in vivo experiments that have elucidated some of the molecular mechanisms responsible for the reduced AFC. Finally, we describe one potential therapy that targets this pathway: bone marrow-derived mesenchymal stem (stromal) cells (MSCs). Based on preclinical studies, MSCs enhance AFC and promote the resolution of pulmonary edema and thus may offer a promising cell-based therapy for ARDS.
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Affiliation(s)
- Laura A Huppert
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, UCSF School of Medicine, Cardiovascular Research Institute, San Francisco, CA, USA
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44
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Pourfathi M, Xin Y, Kadlecek SJ, Cereda MF, Profka H, Hamedani H, Siddiqui SM, Ruppert K, Drachman NA, Rajaei JN, Rizi RR. In vivo imaging of the progression of acute lung injury using hyperpolarized [1- 13 C] pyruvate. Magn Reson Med 2017; 78:2106-2115. [PMID: 28074497 DOI: 10.1002/mrm.26604] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/29/2016] [Accepted: 12/20/2016] [Indexed: 12/19/2022]
Abstract
PURPOSE To investigate pulmonary metabolic alterations during progression of acute lung injury. METHODS Using hyperpolarized [1-13 C] pyruvate imaging, we measured pulmonary lactate and pyruvate in 15 ventilated rats 1, 2, and 4 h after initiation of mechanical ventilation. Lung compliance was used as a marker for injury progression. 5 untreated rats were used as controls; 5 rats (injured-1) received 1 ml/kg and another 5 rats (injured-2) received 2 ml/kg hydrochloric acid (pH 1.25) in the trachea at 70 min. RESULTS The mean lactate-to-pyruvate ratio of the injured-1 cohort was 0.15 ± 0.02 and 0.15 ± 0.03 at baseline and 1 h after the injury, and significantly increased from the baseline value 3 h after the injury to 0.23 ± 0.02 (P = 0.002). The mean lactate-to-pyruvate ratio of the injured-2 cohort decreased from 0.14 ± 0.03 at baseline to 0.08 ± 0.02 1 h after the injury and further decreased to 0.07 ± 0.02 (P = 0.08) 3 h after injury. No significant change was observed in the control group. Compliance in both injured groups decreased significantly after the injury (P < 0.01). CONCLUSIONS Our findings suggest that in severe cases of lung injury, edema and hyperperfusion in the injured lung tissue may complicate interpretation of the pulmonary lactate-to-pyruvate ratio as a marker of inflammation. However, combining the lactate-to-pyruvate ratio with pulmonary compliance provides more insight into the progression of the injury and its severity. Magn Reson Med 78:2106-2115, 2017. © 2017 International Society for Magnetic Resonance in Medicine.
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Affiliation(s)
- Mehrdad Pourfathi
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Electrical and Systems Engineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephen J Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maurizio F Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Harrilla Profka
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarmad M Siddiqui
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kai Ruppert
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicholas A Drachman
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennia N Rajaei
- School of Medicine, Stanford University, Stanford, California, USA
| | - Rahim R Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Abstract
Prevention of ventilator-induced lung injury (VILI) can attenuate multiorgan failure and improve survival in at-risk patients. Clinically significant VILI occurs from volutrauma, barotrauma, atelectrauma, biotrauma, and shear strain. Differences in regional mechanics are important in VILI pathogenesis. Several interventions are available to protect against VILI. However, most patients at risk of lung injury do not develop VILI. VILI occurs most readily in patients with concomitant physiologic insults. VILI prevention strategies must balance risk of lung injury with untoward side effects from the preventive effort, and may be most effective when targeted to subsets of patients at increased risk.
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46
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Biotrauma and Ventilator-Induced Lung Injury: Clinical Implications. Chest 2016; 150:1109-1117. [PMID: 27477213 DOI: 10.1016/j.chest.2016.07.019] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 07/18/2016] [Accepted: 07/20/2016] [Indexed: 11/22/2022] Open
Abstract
The pathophysiological mechanisms by which mechanical ventilation can contribute to lung injury, termed "ventilator-induced lung injury" (VILI), is increasingly well understood. "Biotrauma" describes the release of mediators by injurious ventilatory strategies, which can lead to lung and distal organ injury. Insights from preclinical models demonstrating that traditional high tidal volumes drove the inflammatory response helped lead to clinical trials demonstrating lower mortality in patients who underwent ventilation with a lower-tidal-volume strategy. Other approaches that minimize VILI, such as higher positive end-expiratory pressure, prone positioning, and neuromuscular blockade have each been demonstrated to decrease indices of activation of the inflammatory response. This review examines the evolution of our understanding of the mechanisms underlying VILI, particularly regarding biotrauma. We will assess evidence that ventilatory and other "adjunctive" strategies that decrease biotrauma offer great potential to minimize the adverse consequences of VILI and to improve the outcomes of patients with respiratory failure.
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47
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Hamlington KL, Smith BJ, Allen GB, Bates JHT. Predicting ventilator-induced lung injury using a lung injury cost function. J Appl Physiol (1985) 2016; 121:106-14. [PMID: 27174922 DOI: 10.1152/japplphysiol.00096.2016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 05/11/2016] [Indexed: 01/25/2023] Open
Abstract
Managing patients with acute respiratory distress syndrome (ARDS) requires mechanical ventilation that balances the competing goals of sustaining life while avoiding ventilator-induced lung injury (VILI). In particular, it is reasonable to suppose that for any given ARDS patient, there must exist an optimum pair of values for tidal volume (VT) and positive end-expiratory pressure (PEEP) that together minimize the risk for VILI. To find these optimum values, and thus develop a personalized approach to mechanical ventilation in ARDS, we need to be able to predict how injurious a given ventilation regimen will be in any given patient so that the minimally injurious regimen for that patient can be determined. Our goal in the present study was therefore to develop a simple computational model of the mechanical behavior of the injured lung in order to calculate potential injury cost functions to serve as predictors of VILI. We set the model parameters to represent normal, mildly injured, and severely injured lungs and estimated the amount of volutrauma and atelectrauma caused by ventilating these lungs with a range of VT and PEEP. We estimated total VILI in two ways: 1) as the sum of the contributions from volutrauma and atelectrauma and 2) as the product of their contributions. We found the product provided estimates of VILI that are more in line with our previous experimental findings. This model may thus serve as the basis for the objective choice of mechanical ventilation parameters for the injured lung.
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Affiliation(s)
| | - Bradford J Smith
- Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont
| | - Gilman B Allen
- Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont
| | - Jason H T Bates
- Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont
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48
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Abstract
BACKGROUND Mechanical ventilation worsens acute respiratory distress syndrome, but this secondary "ventilator-associated" injury is variable and difficult to predict. The authors aimed to visualize the propagation of such ventilator-induced injury, in the presence (and absence) of a primary underlying lung injury, and to determine the predictors of propagation. METHODS Anesthetized rats (n = 20) received acid aspiration (hydrochloric acid) followed by ventilation with moderate tidal volume (V(T)). In animals surviving ventilation for at least 2 h, propagation of injury was quantified by using serial computed tomography. Baseline lung status was assessed by oxygenation, lung weight, and lung strain (V(T)/expiratory lung volume). Separate groups of rats without hydrochloric acid aspiration were ventilated with large (n = 10) or moderate (n = 6) V(T). RESULTS In 15 rats surviving longer than 2 h, computed tomography opacities spread outward from the initial site of injury. Propagation was associated with higher baseline strain (propagation vs. no propagation [mean ± SD]: 1.52 ± 0.13 vs. 1.16 ± 0.20, P < 0.01) but similar oxygenation and lung weight. Propagation did not occur where baseline strain was less than 1.29. In healthy animals, large V(T) caused injury that was propagated inward from the lung periphery; in the absence of preexisting injury, propagation did not occur where strain was less than 2.0. CONCLUSIONS Compared with healthy lungs, underlying injury causes propagation to occur at a lower strain threshold and it originates at the site of injury; this suggests that tissue around the primary lesion is more sensitive. Understanding how injury is propagated may ultimately facilitate a more individualized monitoring or management.
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49
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Marseu K, Slinger P. Peri-operative pulmonary dysfunction and protection. Anaesthesia 2016; 71 Suppl 1:46-50. [PMID: 26620146 DOI: 10.1111/anae.13311] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 11/27/2022]
Abstract
Pulmonary complications are a major cause of peri-operative morbidity and mortality, but have been researched less thoroughly than cardiac complications. It is important to try and predict which patients are at risk of peri-operative pulmonary complications and to intervene to reduce this risk. Anaesthetists are in a unique position to do this during the whole peri-operative period. Pre-operative training, smoking cessation and lung ventilation with tidal volumes of 6-8 ml.kg(-1) and low positive end-expiratory pressure probably reduce postoperative pulmonary complications.
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Affiliation(s)
- K Marseu
- Department of Anaesthesiology, Toronto General Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - P Slinger
- Department of Anaesthesiology, Toronto General Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
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50
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Shaver CM, Upchurch CP, Janz DR, Grove BS, Putz ND, Wickersham NE, Dikalov SI, Ware LB, Bastarache JA. Cell-free hemoglobin: a novel mediator of acute lung injury. Am J Physiol Lung Cell Mol Physiol 2016; 310:L532-41. [PMID: 26773065 PMCID: PMC4796260 DOI: 10.1152/ajplung.00155.2015] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 01/14/2016] [Indexed: 01/01/2023] Open
Abstract
Patients with the acute respiratory distress syndrome (ARDS) have elevated levels of cell-free hemoglobin (CFH) in the air space, but the contribution of CFH to the pathogenesis of acute lung injury is unknown. In the present study, we demonstrate that levels of CFH in the air space correlate with measures of alveolar-capillary barrier dysfunction in humans with ARDS (r = 0.89, P < 0.001) and in mice with ventilator-induced acute lung injury (r = 0.89, P < 0.001). To investigate the specific contribution of CFH to ARDS, we studied the impact of purified CFH in the mouse lung and on cultured mouse lung epithelial (MLE-12) cells. Intratracheal delivery of CFH in mice causes acute lung injury with air space inflammation and alveolar-capillary barrier disruption. Similarly, in MLE-12 cells, CFH increases proinflammatory cytokine expression and increases paracellular permeability as measured by electrical cell-substrate impedance sensing. Next, to determine whether these effects are mediated by the iron-containing heme moiety of CFH, we treated mice with intratracheal hemin, the chloride salt of heme, and found that hemin was sufficient to increase alveolar permeability but failed to induce proinflammatory cytokine expression or epithelial cell injury. Together, these data identify CFH in the air space as a previously unrecognized driver of lung epithelial injury in human and experimental ARDS and suggest that CFH and hemin may contribute to ARDS through different mechanisms. Interventions targeting CFH and heme in the air space could provide a new therapeutic approach for ARDS.
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Affiliation(s)
- Ciara M Shaver
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cameron P Upchurch
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - David R Janz
- Section of Pulmonary and Critical Care Medicine, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Brandon S Grove
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Nathan D Putz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Nancy E Wickersham
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Sergey I Dikalov
- Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee; and
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Julie A Bastarache
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee;
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