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Montini L, Antonelli M. Precision Medicine Approach in ARDS: A New Challenge. Chest 2024:S0012-3692(24)00680-9. [PMID: 38838954 DOI: 10.1016/j.chest.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/20/2024] [Indexed: 06/07/2024] Open
Affiliation(s)
- Luca Montini
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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2
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Goligher EC, McNamee JJ, Dianti J, Fan E, Ferguson ND, Slutsky AS, McAuley DF. Heterogeneous Treatment Effects of Extracorporeal CO 2 Removal in Acute Hypoxemic Respiratory Failure. Am J Respir Crit Care Med 2023; 208:739-742. [PMID: 37433221 DOI: 10.1164/rccm.202304-0689le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/11/2023] [Indexed: 07/13/2023] Open
Affiliation(s)
- Ewan C Goligher
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, Department of Medicine
- Department of Physiology, and
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - James J McNamee
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Science, Queen's University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom; and
| | - Jose Dianti
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, Department of Medicine
| | - Eddy Fan
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, Department of Medicine
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, Department of Medicine
- Department of Physiology, and
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, Department of Medicine
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Science, Queen's University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom; and
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3
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Worku E, Schmidt M, Shekar K. Is It Time to Put Low-Flow Extracorporeal Carbon Dioxide Removal to REST? Crit Care Med 2023; 51:973-976. [PMID: 37318293 DOI: 10.1097/ccm.0000000000005889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Elliott Worku
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, QLD, Australia
| | - Matthieu Schmidt
- Médecine Intensive Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
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4
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Dianti J, Morris IS, Urner M, Schmidt M, Tomlinson G, Amato MBP, Blanch L, Rubenfeld G, Goligher EC. Linking Acute Physiology to Outcomes in the ICU: Challenges and Solutions for Research. Am J Respir Crit Care Med 2023; 207:1441-1450. [PMID: 36705985 DOI: 10.1164/rccm.202206-1216ci] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 01/27/2023] [Indexed: 01/28/2023] Open
Abstract
ICU clinicians rely on bedside physiological measurements to inform many routine clinical decisions. Because deranged physiology is usually associated with poor clinical outcomes, it is tempting to hypothesize that manipulating and intervening on physiological parameters might improve outcomes for patients. However, testing these hypotheses through mathematical models of the relationship between physiology and outcomes presents a number of important methodological challenges. These models reflect the theories of the researcher and can therefore be heavily influenced by one's assumptions and background beliefs. Model building must therefore be approached with great care and forethought, because failure to consider relevant sources of measurement error, confounding, coupling, and time dependency or failure to assess the direction of causality for associations of interest before modeling may give rise to spurious results. This paper outlines the main challenges in analyzing and interpreting these models and offers potential solutions to address these challenges.
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Affiliation(s)
- Jose Dianti
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health System
| | - Idunn S Morris
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health System
- Department of Intensive Care Medicine, Nepean Hospital, Sydney, Australia
| | - Martin Urner
- Interdepartmental Division of Critical Care Medicine
- Department of Anesthesiology and Pain Medicine
| | | | - George Tomlinson
- Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil
| | - Lluis Blanch
- Critical Care Center, Institut d'Investigacio i Innovacio Parc Taulí I3PT-CERCA, Parc Taulí Hospital Universitari, Universitat Autonoma de Barcelona, Sabadell, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Universitat Autonoma de Barcelona, Parc Taulí 1, Sabadell, Spain
| | - Gordon Rubenfeld
- Interdepartmental Division of Critical Care Medicine
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; and
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health System
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
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5
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Hochberg CH, Sahetya SK. Laying the Groundwork for Physiology-Guided Precision Medicine in the Critically Ill. NEJM EVIDENCE 2023; 2:EVIDe2300051. [PMID: 38320026 DOI: 10.1056/evide2300051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Canonical critical care syndromes such as sepsis and acute respiratory distress syndrome (ARDS) include patients with markedly heterogeneous biology.1 This, paired with decades of randomized controlled trials (RCTs) that were traditionally viewed as "negative," has stalled progress in improving patient outcomes.2 However, emerging awareness of sub-phenotypes based on differences in biomarker profiles and resulting heterogeneous treatment effects have led to calls for precision medicine in which therapies are targeted to those most likely to benefit.3.
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Affiliation(s)
- Chad H Hochberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore
| | - Sarina K Sahetya
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore
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6
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Dianti J, McNamee JJ, Slutsky AS, Fan E, Ferguson ND, McAuley DF, Goligher EC. Determinants of Effect of Extracorporeal CO 2 Removal in Hypoxemic Respiratory Failure. NEJM EVIDENCE 2023; 2:EVIDoa2200295. [PMID: 38320056 DOI: 10.1056/evidoa2200295] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Dead space and respiratory system elastance (Ers) may influence the clinical benefit of a ventilation strategy combining very low tidal volume (VT) with extracorporeal carbon dioxide removal (ECCO2R) in patients with acute hypoxemic respiratory failure. We sought to evaluate whether the effect of ECCO2R on mortality varies according to ventilatory ratio (VR; a composite variable reflective of dead space and shunt) and Ers. METHODS: Secondary analysis of a trial of a strategy combining very low VT and low-flow ECCO2R planned before the availability of trial results. Bayesian logistic regression was used to estimate the posterior probability of effect moderation by VR, Ers, and severity of hypoxemia (ratio of arterial partial pressure of oxygen to fraction of inspired oxygen [PaO2:FiO2]) on 90-day mortality. Credibility of effect moderation was appraised according to the Instrument for Assessing the Credibility of Effect Modification Analyses criteria. RESULTS: A total of 405 patients were available for analysis. The effect of the intervention on mortality varied substantially with VR (posterior probability of interaction, 94%; high credibility). Benefit was more probable than harm in patients with VR 3 or higher. In patients with VR less than 3, the probability of increased mortality with intervention was high (>90%). The effect of the intervention also varied with PaO2:FiO2 (posterior probability of interaction, >99%; low credibility). Benefit was more probable than harm in patients with PaO2:FiO2 110 mm Hg or higher. The effect of the intervention did not vary substantially with Ers (posterior probability of interaction, 68%; low credibility). CONCLUSIONS: VR has a highly credible influence on the effect of a strategy combining very low VT and low-flow ECCO2R on mortality. This intervention may reduce mortality in patients with high VR. (Funded by an Early Career Investigator Award from the Canadian Institutes of Health Research to Dr. Goligher.)
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Affiliation(s)
- Jose Dianti
- Department of Medicine, Division of Respirology, University Health Network, University of Toronto, Toronto, ON
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
| | - James J McNamee
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - Eddy Fan
- Department of Medicine, Division of Respirology, University Health Network, University of Toronto, Toronto, ON
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
- Toronto General Hospital Research Institute, Toronto, ON
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology, University Health Network, University of Toronto, Toronto, ON
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
- Toronto General Hospital Research Institute, Toronto, ON
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
- Department of Physiology, University of Toronto, Toronto, ON
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Ewan C Goligher
- Department of Medicine, Division of Respirology, University Health Network, University of Toronto, Toronto, ON
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
- Toronto General Hospital Research Institute, Toronto, ON
- Department of Physiology, University of Toronto, Toronto, ON
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7
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Rizzo AN, Aggarwal NR, Thompson BT, Schmidt EP. Advancing Precision Medicine for the Diagnosis and Treatment of Acute Respiratory Distress Syndrome. J Clin Med 2023; 12:1563. [PMID: 36836098 PMCID: PMC9966442 DOI: 10.3390/jcm12041563] [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: 01/20/2023] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a common and life-threatening cause of respiratory failure. Despite decades of research, there are no effective pharmacologic therapies to treat this disease process and mortality remains high. The shortcomings of prior translational research efforts have been increasingly attributed to the heterogeneity of this complex syndrome, which has led to an increased focus on elucidating the mechanisms underlying the interpersonal heterogeneity of ARDS. This shift in focus aims to move the field towards personalized medicine by defining subgroups of ARDS patients with distinct biology, termed endotypes, to quickly identify patients that are most likely to benefit from mechanism targeted treatments. In this review, we first provide a historical perspective and review the key clinical trials that have advanced ARDS treatment. We then review the key challenges that exist with regards to the identification of treatable traits and the implementation of personalized medicine approaches in ARDS. Lastly, we discuss potential strategies and recommendations for future research that we believe will aid in both understanding the molecular pathogenesis of ARDS and the development of personalized treatment approaches.
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Affiliation(s)
- Alicia N. Rizzo
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02144, USA
| | - Neil R. Aggarwal
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02144, USA
| | - Eric P. Schmidt
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02144, USA
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8
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Zheng M. Dead space ventilation-related indices: bedside tools to evaluate the ventilation and perfusion relationship in patients with acute respiratory distress syndrome. Crit Care 2023; 27:46. [PMID: 36732812 PMCID: PMC9894747 DOI: 10.1186/s13054-023-04338-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
Cumulative evidence has demonstrated that the ventilatory ratio closely correlates with mortality in acute respiratory distress syndrome (ARDS), and a primary feature in coronavirus disease 2019 (COVID-19)-ARDS is increased dead space that has been reported recently. Thus, new attention has been given to this group of dead space ventilation-related indices, such as physiological dead space fraction, ventilatory ratio, and end-tidal-to-arterial PCO2 ratio, which, albeit distinctive, are all global indices with which to assess the relationship between ventilation and perfusion. These parameters have already been applied to positive end expiratory pressure titration, prediction of responses to the prone position and the field of extracorporeal life support for patients suffering from ARDS. Dead space ventilation-related indices remain hampered by several deflects; notwithstanding, for this catastrophic syndrome, they may facilitate better stratifications and identifications of subphenotypes, thereby providing therapy tailored to individual needs.
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Affiliation(s)
- Mingjia Zheng
- Department of Respiratory and Critical Care Medicine, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, No. 1558, Sanhuan North Road, Wuxing, Huzhou, Zhejiang, People's Republic of China.
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9
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Worku ET, Yeung F, Anstey C, Shekar K. The impact of reduction in intensity of mechanical ventilation upon venovenous ECMO initiation on radiographically assessed lung edema scores: A retrospective observational study. Front Med (Lausanne) 2022; 9:1005192. [PMID: 36203770 PMCID: PMC9531725 DOI: 10.3389/fmed.2022.1005192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/26/2022] [Indexed: 11/26/2022] Open
Abstract
Background Patients with severe acute respiratory distress syndrome (ARDS) typically receive ultra-protective ventilation after extracorporeal membrane oxygenation (ECMO) is initiated. While the benefit of ECMO appears to derive from supporting “lung rest”, reductions in the intensity of mechanical ventilation, principally tidal volume limitation, may manifest radiologically. This study evaluated the relative changes in radiographic assessment of lung edema (RALE) score upon venovenous ECMO initiation in patients with severe ARDS. Methods Digital chest x-rays (CXR) performed at baseline immediately before initiation of ECMO, and at intervals post (median 1.1, 2.1, and 9.6 days) were reviewed in 39 Adult ARDS patients. One hundred fifty-six digital images were scored by two independent, blinded radiologists according to the RALE (Radiographic Assessment of Lung Edema) scoring criteria. Ventilatory data, ECMO parameters and fluid balance were recorded at corresponding time points. Multivariable analysis was performed analyzing the change in RALE score over time relative to baseline. Results The RALE score demonstrated excellent inter-rater agreement in this novel application in an ECMO cohort. Mean RALE scores increased from 28 (22–37) at baseline to 35 (26–42) (p < 0.001) on D1 of ECMO; increasing RALE was associated with higher baseline APACHE III scores [ß value +0.19 (0.08, 0.30) p = 0.001], and greater reductions in tidal volume [ß value −2.08 (−3.07, −1.10) p < 0.001] after ECMO initiation. Duration of mechanical ventilation, and ECMO support did not differ between survivors and non-survivors. Conclusions The magnitude of reductions in delivered tidal volumes correlated with increasing RALE scores (radiographic worsening) in ARDS patients receiving ECMO. Implications for patient centered outcomes remain unclear. There is a need to define appropriate ventilator settings on venovenous ECMO, counterbalancing the risks vs. benefits of optimal “lung rest” against potential atelectrauma.
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Affiliation(s)
- Elliott T. Worku
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- *Correspondence: Elliott T. Worku
| | - Francis Yeung
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Chris Anstey
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- School of Medicine, Griffith University, Sunshine Coast Campus, Birtinya, QLD, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
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10
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11
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Martin TR, Zemans RL, Ware LB, Schmidt EP, Riches DWH, Bastarache L, Calfee CS, Desai TJ, Herold S, Hough CL, Looney MR, Matthay MA, Meyer N, Parikh SM, Stevens T, Thompson BT. New Insights into Clinical and Mechanistic Heterogeneity of the Acute Respiratory Distress Syndrome: Summary of the Aspen Lung Conference 2021. Am J Respir Cell Mol Biol 2022; 67:284-308. [PMID: 35679511 PMCID: PMC9447141 DOI: 10.1165/rcmb.2022-0089ws] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/09/2022] [Indexed: 12/15/2022] Open
Abstract
Clinical and molecular heterogeneity are common features of human disease. Understanding the basis for heterogeneity has led to major advances in therapy for many cancers and pulmonary diseases such as cystic fibrosis and asthma. Although heterogeneity of risk factors, disease severity, and outcomes in survivors are common features of the acute respiratory distress syndrome (ARDS), many challenges exist in understanding the clinical and molecular basis for disease heterogeneity and using heterogeneity to tailor therapy for individual patients. This report summarizes the proceedings of the 2021 Aspen Lung Conference, which was organized to review key issues related to understanding clinical and molecular heterogeneity in ARDS. The goals were to review new information about ARDS phenotypes, to explore multicellular and multisystem mechanisms responsible for heterogeneity, and to review how best to account for clinical and molecular heterogeneity in clinical trial design and assessment of outcomes. The report concludes with recommendations for future research to understand the clinical and basic mechanisms underlying heterogeneity in ARDS to advance the development of new treatments for this life-threatening critical illness.
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Affiliation(s)
- Thomas R. Martin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Rachel L. Zemans
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Program in Cellular and Molecular Biology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine and
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eric P. Schmidt
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - David W. H. Riches
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Program in Cell Biology, Department of Pediatrics, National Jewish Health, Denver, Colorado
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carolyn S. Calfee
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Anesthesia
| | - Tushar J. Desai
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Stem Cell Institute, Stanford University School of Medicine, Stanford, California
| | - Susanne Herold
- Department of Internal Medicine VI and Cardio-Pulmonary Institute (CPI), Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Catherine L. Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Michael A. Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | - Nuala Meyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samir M. Parikh
- Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Division of Nephrology, University of Texas Southwestern, Dallas, Texas
| | - Troy Stevens
- Department of Physiology and Cell Biology, College of Medicine, Center for Lung Biology, University of South Alabama, Mobile, Alabama; and
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
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12
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Goligher EC, Telias I, Sahetya SK, Baedorf-Kassis E, Patel BK, Yehya N, Silversides JA, Ferguson ND, Brochard LJ, Lawler PR, Zarychanski R, Slutsky AS. Physiology Is Vital to Precision Medicine in Acute Respiratory Distress Syndrome and Sepsis. Am J Respir Crit Care Med 2022; 206:14-16. [PMID: 35442864 PMCID: PMC9954327 DOI: 10.1164/rccm.202202-0230ed] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ewan C. Goligher
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada,Department of Medicine University Health NetworkToronto, Ontario, Canada,Toronto General Hospital Research InstituteToronto, Ontario, Canada
| | - Irene Telias
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada,Department of Medicine University Health NetworkToronto, Ontario, Canada,Li Ka Shing Knowledge Institute Unity HealthToronto, Ontario, Canada
| | | | - Elias Baedorf-Kassis
- Division of Pulmonary and Critical CareHarvard Medical SchoolBoston, Massachusetts
| | - Bhakti K. Patel
- Department of MedicineUniversity of ChicagoChicago, Illinois
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care MedicineChildren’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania
| | - Jonathan A Silversides
- Wellcome-Wolfson Institute for Experimental MedicineQueen’s University BelfastBelfast, United Kingdom,Department of Critical CareBelfast Health and Social Care TrustBelfast, United Kingdom
| | - Niall D. Ferguson
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada,Department of Medicine University Health NetworkToronto, Ontario, Canada,Toronto General Hospital Research InstituteToronto, Ontario, Canada
| | - Laurent J. Brochard
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada,Li Ka Shing Knowledge Institute Unity HealthToronto, Ontario, Canada
| | - Patrick R. Lawler
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada,Toronto General Hospital Research InstituteToronto, Ontario, Canada,Peter Munk Cardiac CentreUniversity Health NetworkToronto, Ontario, Canada
| | - Ryan Zarychanski
- Department of Medical Oncology and HematologyCancerCare ManitobaWinnipeg, Manitoba, Canada
| | - Arthur S. Slutsky
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada,Li Ka Shing Knowledge Institute Unity HealthToronto, Ontario, Canada
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13
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Worku E, Brodie D, Ling RR, Ramanathan K, Combes A, Shekar K. Venovenous extracorporeal CO 2 removal to support ultraprotective ventilation in moderate-severe acute respiratory distress syndrome: A systematic review and meta-analysis of the literature. Perfusion 2022:2676591221096225. [PMID: 35656595 DOI: 10.1177/02676591221096225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A strategy that limits tidal volumes and inspiratory pressures, improves outcomes in patients with the acute respiratory distress syndrome (ARDS). Extracorporeal carbon dioxide removal (ECCO2R) may facilitate ultra-protective ventilation. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of venovenous ECCO2R in supporting ultra-protective ventilation in moderate-to-severe ARDS. METHODS MEDLINE and EMBASE were interrogated for studies (2000-2021) reporting venovenous ECCO2R use in patients with moderate-to-severe ARDS. Studies reporting ≥10 adult patients in English language journals were included. Ventilatory parameters after 24 h of initiating ECCO2R, device characteristics, and safety outcomes were collected. The primary outcome measure was the change in driving pressure at 24 h of ECCO2R therapy in relation to baseline. Secondary outcomes included change in tidal volume, gas exchange, and safety data. RESULTS Ten studies reporting 421 patients (PaO2:FiO2 141.03 mmHg) were included. Extracorporeal blood flow rates ranged from 0.35-1.5 L/min. Random effects modelling indicated a 3.56 cmH2O reduction (95%-CI: 3.22-3.91) in driving pressure from baseline (p < .001) and a 1.89 mL/kg (95%-CI: 1.75-2.02, p < .001) reduction in tidal volume. Oxygenation, respiratory rate and PEEP remained unchanged. No significant interactions between driving pressure reduction and baseline driving pressure, partial pressure of arterial carbon dioxide or PaO2:FiO2 ratio were identified in metaregression analysis. Bleeding and haemolysis were the commonest complications of therapy. CONCLUSIONS Venovenous ECCO2R permitted significant reductions in ∆P in patients with moderate-to-severe ARDS. Heterogeneity amongst studies and devices, a paucity of randomised controlled trials, and variable safety reporting calls for standardisation of outcome reporting. Prospective evaluation of optimal device operation and anticoagulation in high quality studies is required before further recommendations can be made.
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Affiliation(s)
- Elliott Worku
- Adult Intensive Care Services, 67567The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Daniel Brodie
- Department of Medicine, 12294Columbia University College of Physicians and Surgeons, NY, USA
- Center for Acute Respiratory Failure, 25065New York-Presbyterian Hospital, NY, USA
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Cardiothoracic Intensive Care Unit, 375583National University Heart Centre, National University Hospital, Singapore
| | - Alain Combes
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Paris, France
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, 26933Pitié-Salpêtrière Hospital, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, 67567The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane and Bond University, Gold Coast, QLD, Australia
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14
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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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15
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Ruberto F, Alessandri F, Piazzolla M, Zullino V, Bruno K, Celli P, Diso D, Venuta F, Bilotta F, Pugliese F. Intraoperative use of extracorporeal CO 2 removal (ECCO 2R) and emergency ECMO requirement in patients undergoing lung transplant: a case-matched cohort retrospective study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:22. [PMID: 37386563 DOI: 10.1186/s44158-022-00050-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/10/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND The use of extracorporeal carbon dioxide removal (ECCO2R) is less invasive than extracorporeal membrane oxygenation (ECMO), and intraoperative control of gas exchange could be feasible. The aim of this study in intermediate intraoperative severity patients undergoing LT was to assess the role of intraoperative ECCO2R on emergency ECMO requirement in patients. METHODS Thirty-eight consecutive patients undergoing lung transplantation (LT) with "intermediate" intraoperative severity in the intervals 2007 to 2010 or 2011 to 2014 were analyzed as historical comparison of case-matched cohort retrospective study. The "intermediate" intraoperative severity was defined as the development of intraoperative severe respiratory acidosis with maintained oxygenation function (i.e., pH <7.25, PaCO2 >60 mmHg, and PaO2/FiO2 >150), not associated with hemodynamic instability. Of these 38 patients, twenty-three patients were treated in the 2007-2010 interval by receiving "standard intraoperative treatment," while 15 patients were treated in the 2011-2014 interval by receiving "standard intraoperative treatment + ECCO2R." RESULTS ECMO requirement was more frequent among patients that received "standard intraoperative treatment" alone than in those treated with "standard intraoperative treatment + ECCO2R" (17/23 vs. 3/15; p = 0.004). The use of ECCO2R improved pH and PaCO2 while mean pulmonary artery pressure (mPAP) decreased. CONCLUSION In intermediate intraoperative severity patients, the use of ECCO2R reduces the ECMO requirement.
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Affiliation(s)
- Franco Ruberto
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Alessandri
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Mario Piazzolla
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Veronica Zullino
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Katia Bruno
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Paola Celli
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Daniele Diso
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Federico Venuta
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Federico Bilotta
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Pugliese
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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16
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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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17
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Leypoldt JK, Kurz J, Echeverri J, Storr M, Harenski K. Targeting arterial partial pressure of carbon dioxide in acute respiratory distress syndrome patients using extracorporeal carbon dioxide removal. Artif Organs 2021; 46:677-687. [PMID: 34817074 DOI: 10.1111/aor.14127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/06/2021] [Accepted: 11/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND A retrospective analysis of SUPERNOVA trial data showed that reductions in tidal volume to ultraprotective levels without significant increases in arterial partial pressure of carbon dioxide (PaCO2 ) for critically ill, mechanically ventilated patients with acute respiratory distress syndrome (ARDS) depends on the rate of extracorporeal carbon dioxide removal (ECCO2 R). METHODS We used a whole-body mathematical model of acid-base balance to quantify the effect of altering carbon dioxide (CO2 ) removal rates using different ECCO2 R devices to achieve target PaCO2 levels in ARDS patients. Specifically, we predicted the effect of using a new, larger surface area PrismaLung+ device instead of the original PrismaLung device on the results from two multicenter clinical studies in critically ill, mechanically ventilated ARDS patients. RESULTS After calibrating model parameters to the clinical study data using the PrismaLung device, model predictions determined optimal extracorporeal blood flow rates for the PrismaLung+ and mechanical ventilation frequencies to obtain target PaCO2 levels of 45 and 50 mm Hg in mild and moderate ARDS patients treated at a tidal volume of 3.98 ml/kg predicted body weight (PW). Comparable model predictions showed that reductions in tidal volumes below 6 ml/kg PBW may be difficult for acidotic highly severe ARDS patients with acute kidney injury and high CO2 production rates using a PrismaLung+ device in-series with a continuous venovenous hemofiltration device. CONCLUSIONS The described model provides guidance on achieving target PaCO2 levels in mechanically ventilated ARDS patients using protective and ultraprotective tidal volumes when increasing CO2 removal rates from ECCO2 R devices.
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Affiliation(s)
- John K Leypoldt
- Department IV-Modeling and Supporting of Internal Functions, Nalecz Institute of Biocybernetics and Biomedical Engineering Polish Academy of Sciences, Warsaw, Poland
| | - Jörg Kurz
- Medical Affairs, Baxter Deutschland GmbH, Unterschleissheim, Germany
| | - Jorge Echeverri
- Medical Affairs, Baxter Healthcare Corporation, Deerfield, Illinois, USA
| | - Markus Storr
- Research and Development, Baxter International, Hechingen, Germany
| | - Kai Harenski
- Medical Affairs, Baxter Deutschland GmbH, Unterschleissheim, Germany
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18
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McNamee JJ, Gillies MA, Barrett NA, Perkins GD, Tunnicliffe W, Young D, Bentley A, Harrison DA, Brodie D, Boyle AJ, Millar JE, Szakmany T, Bannard-Smith J, Tully RP, Agus A, McDowell C, Jackson C, McAuley DF. Effect of Lower Tidal Volume Ventilation Facilitated by Extracorporeal Carbon Dioxide Removal vs Standard Care Ventilation on 90-Day Mortality in Patients With Acute Hypoxemic Respiratory Failure: The REST Randomized Clinical Trial. JAMA 2021; 326:1013-1023. [PMID: 34463700 PMCID: PMC8408762 DOI: 10.1001/jama.2021.13374] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE In patients who require mechanical ventilation for acute hypoxemic respiratory failure, further reduction in tidal volumes, compared with conventional low tidal volume ventilation, may improve outcomes. OBJECTIVE To determine whether lower tidal volume mechanical ventilation using extracorporeal carbon dioxide removal improves outcomes in patients with acute hypoxemic respiratory failure. DESIGN, SETTING, AND PARTICIPANTS This multicenter, randomized, allocation-concealed, open-label, pragmatic clinical trial enrolled 412 adult patients receiving mechanical ventilation for acute hypoxemic respiratory failure, of a planned sample size of 1120, between May 2016 and December 2019 from 51 intensive care units in the UK. Follow-up ended on March 11, 2020. INTERVENTIONS Participants were randomized to receive lower tidal volume ventilation facilitated by extracorporeal carbon dioxide removal for at least 48 hours (n = 202) or standard care with conventional low tidal volume ventilation (n = 210). MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality 90 days after randomization. Prespecified secondary outcomes included ventilator-free days at day 28 and adverse event rates. RESULTS Among 412 patients who were randomized (mean age, 59 years; 143 [35%] women), 405 (98%) completed the trial. The trial was stopped early because of futility and feasibility following recommendations from the data monitoring and ethics committee. The 90-day mortality rate was 41.5% in the lower tidal volume ventilation with extracorporeal carbon dioxide removal group vs 39.5% in the standard care group (risk ratio, 1.05 [95% CI, 0.83-1.33]; difference, 2.0% [95% CI, -7.6% to 11.5%]; P = .68). There were significantly fewer mean ventilator-free days in the extracorporeal carbon dioxide removal group compared with the standard care group (7.1 [95% CI, 5.9-8.3] vs 9.2 [95% CI, 7.9-10.4] days; mean difference, -2.1 [95% CI, -3.8 to -0.3]; P = .02). Serious adverse events were reported for 62 patients (31%) in the extracorporeal carbon dioxide removal group and 18 (9%) in the standard care group, including intracranial hemorrhage in 9 patients (4.5%) vs 0 (0%) and bleeding at other sites in 6 (3.0%) vs 1 (0.5%) in the extracorporeal carbon dioxide removal group vs the control group. Overall, 21 patients experienced 22 serious adverse events related to the study device. CONCLUSIONS AND RELEVANCE Among patients with acute hypoxemic respiratory failure, the use of extracorporeal carbon dioxide removal to facilitate lower tidal volume mechanical ventilation, compared with conventional low tidal volume mechanical ventilation, did not significantly reduce 90-day mortality. However, due to early termination, the study may have been underpowered to detect a clinically important difference. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02654327.
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Affiliation(s)
- James J. McNamee
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Michael A. Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Nicholas A. Barrett
- Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, United Kingdom
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - William Tunnicliffe
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Duncan Young
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, United Kingdom
| | - Andrew Bentley
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - David A. Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
| | - Andrew J. Boyle
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | | | - Tamas Szakmany
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
- Critical Care Directorate, Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, Gwent, United Kingdom
| | - Jonathan Bannard-Smith
- Department of Critical Care, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, United Kingdom
| | - Redmond P. Tully
- Department of Anaesthetics and Intensive Care, Royal Oldham Hospital, Northern Care Alliance, Oldham, United Kingdom
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast, United Kingdom
| | - Clíona McDowell
- Northern Ireland Clinical Trials Unit, Belfast, United Kingdom
| | - Colette Jackson
- Northern Ireland Clinical Trials Unit, Belfast, United Kingdom
| | - Daniel F. McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
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19
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Amado-Rodríguez L, Del Busto C, López-Alonso I, Parra D, Mayordomo-Colunga J, Arias-Guillén M, Albillos-Almaraz R, Martín-Vicente P, López-Martínez C, Huidobro C, Camporota L, Slutsky AS, Albaiceta GM. Biotrauma during ultra-low tidal volume ventilation and venoarterial extracorporeal membrane oxygenation in cardiogenic shock: a randomized crossover clinical trial. Ann Intensive Care 2021; 11:132. [PMID: 34453620 PMCID: PMC8397875 DOI: 10.1186/s13613-021-00919-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/05/2021] [Indexed: 01/19/2023] Open
Abstract
Background Cardiogenic pulmonary oedema (CPE) may contribute to ventilator-associated lung injury (VALI) in patients with cardiogenic shock. The appropriate ventilatory strategy remains unclear. We aimed to evaluate the impact of ultra-low tidal volume ventilation with tidal volume of 3 ml/kg predicted body weight (PBW) in patients with CPE and veno–arterial extracorporeal membrane oxygenation (V–A ECMO) on lung inflammation compared to conventional ventilation. Methods A single-centre randomized crossover trial was performed in the Cardiac Intensive Care Unit (ICU) at a tertiary university hospital. Seventeen adults requiring V–A ECMO and mechanical ventilation due to cardiogenic shock were included from February 2017 to December 2018. Patients were ventilated for two consecutive periods of 24 h with tidal volumes of 6 and 3 ml/kg of PBW, respectively, applied in random order. Primary outcome was the change in proinflammatory mediators in bronchoalveolar lavage fluid (BALF) between both ventilatory strategies. Results Ventilation with 3 ml/kg PBW yielded lower driving pressures and end-expiratory lung volumes. Overall, there were no differences in BALF cytokines. Post hoc analyses revealed that patients with high baseline levels of IL-6 showed statistically significant lower levels of IL-6 and IL-8 during ultra-low tidal volume ventilation. This reduction was significantly proportional to the decrease in driving pressure. In contrast, those with lower IL-6 baseline levels showed a significant increase in these biomarkers. Conclusions Ultra-low tidal volume ventilation in patients with CPE and V–A ECMO may attenuate inflammation in selected cases. VALI may be driven by an interaction between the individual proinflammatory profile and the mechanical load overimposed by the ventilator. Trial registration The trial was registered in ClinicalTrials.gov (identifier NCT03041428, Registration date: 2nd February 2017). Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00919-0.
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Affiliation(s)
- Laura Amado-Rodríguez
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avda de Roma s/n, 33011, Oviedo, Spain. .,Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain. .,Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - Cecilia Del Busto
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avda de Roma s/n, 33011, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Inés López-Alonso
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain.,Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Diego Parra
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avda de Roma s/n, 33011, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Juan Mayordomo-Colunga
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain.,Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Miguel Arias-Guillén
- Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Servicio de Neumología, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Rodrigo Albillos-Almaraz
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avda de Roma s/n, 33011, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Paula Martín-Vicente
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain.,Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias (IUOPA), Universidad de Oviedo, Oviedo, Spain
| | - Cecilia López-Martínez
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain.,Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Covadonga Huidobro
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain.,Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, King's College, London, UK
| | - Arthur S Slutsky
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Guillermo M Albaiceta
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avda de Roma s/n, 33011, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain.,Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias (IUOPA), Universidad de Oviedo, Oviedo, Spain
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20
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Goligher EC, Costa ELV, Yarnell CJ, Brochard LJ, Stewart TE, Tomlinson G, Brower RG, Slutsky AS, Amato MPB. Effect of Lowering Vt on Mortality in Acute Respiratory Distress Syndrome Varies with Respiratory System Elastance. Am J Respir Crit Care Med 2021; 203:1378-1385. [PMID: 33439781 DOI: 10.1164/rccm.202009-3536oc] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Rationale: If the risk of ventilator-induced lung injury in acute respiratory distress syndrome (ARDS) is causally determined by driving pressure rather than by Vt, then the effect of ventilation with lower Vt on mortality would be predicted to vary according to respiratory system elastance (Ers). Objectives: To determine whether the mortality benefit of ventilation with lower Vt varies according to Ers. Methods: In a secondary analysis of patients from five randomized trials of lower- versus higher-Vt ventilation strategies in ARDS and acute hypoxemic respiratory failure, the posterior probability of an interaction between the randomized Vt strategy and Ers on 60-day mortality was computed using Bayesian multivariable logistic regression. Measurements and Main Results: Of 1,096 patients available for analysis, 416 (38%) died by Day 60. The posterior probability that the mortality benefit from lower-Vt ventilation strategies varied with Ers was 93% (posterior median interaction odds ratio, 0.80 per cm H2O/[ml/kg]; 90% credible interval, 0.63-1.02). Ers was classified as low (<2 cm H2O/[ml/kg], n = 321, 32%), intermediate (2-3 cm H2O/[ml/kg], n = 475, 46%), and high (>3 cm H2O/[ml/kg], n = 224, 22%). In these groups, the posterior probabilities of an absolute risk reduction in mortality ≥ 1% were 55%, 82%, and 92%, respectively. The posterior probabilities of an absolute risk reduction ≥ 5% were 29%, 58%, and 82%, respectively. Conclusions: The mortality benefit of ventilation with lower Vt in ARDS varies according to elastance, suggesting that lung-protective ventilation strategies should primarily target driving pressure rather than Vt.
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Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto General Hospital, Toronto, Ontario, Canada
| | - Eduardo L V Costa
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Brazil.,Research and Education Institute, Hospital Sírio-Libanes, São Paulo, Brazil
| | - Christopher J Yarnell
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - George Tomlinson
- Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Roy G Brower
- Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Marcelo P B Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Brazil
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21
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Ethgen O, Goldstein J, Harenski K, Mekontso Dessap A, Morimont P, Quintel M, Combes A. A preliminary cost-effectiveness analysis of lung protective ventilation with extra corporeal carbon dioxide removal (ECCO 2R) in the management of acute respiratory distress syndrome (ARDS). J Crit Care 2021; 63:45-53. [PMID: 33618281 PMCID: PMC7972812 DOI: 10.1016/j.jcrc.2021.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 12/29/2022]
Abstract
Background Mechanical ventilation (MV) is the cornerstone in the management of the acute respiratory distress syndrome (ARDS). Recent research suggests that decreasing the intensity of MV using lung protective ventilation (LPV) with lower tidal volume (Vt) and driving pressure (∆P) could improve survival. Extra-corporal CO2 removal (ECCO2R) precisely enables LPV by allowing lower Vt, ∆P and mechanical power while maintaining PaCO2 within a physiologic range. This study evaluates the potential cost-effectiveness of ECCO2R-enabled LPV in France. Methods We modelled the distribution over time of ventilated ARDS patients across 3 health-states (alive & ventilated, alive & weaned from ventilation, dead). We compared the outcomes of 3 strategies: MV (no ECCO2R), LPV (ECCO2R when PaCO2 > 55 mmHg) and Ultra-LPV (ECCO2R for all). Patients characteristics, ventilation settings, survival and lengths of stay were derived from a large ARDS epidemiology study. Survival benefits associated with lower ∆P were taken from the analysis of more than 3000 patients enrolled in 9 randomized trials. Health outcomes were expressed in quality-adjusted life years (QALYs). Incremental cost-effectiveness ratios (ICERs) were computed with both Day 60 cost and Lifetime cost. Results Both LPV and ULPV as enabled by ECCO2R provided favorable results at Day 60 as compared to MV. Survival rates were increased with the protective strategies, notably with ULPV that provided even more manifest benefits as compared to MV. LPV and ULPV produced +0.162 and + 0.627 incremental QALYs as compared to MV, respectively. LPV and ULPV costs were augmented because of their survival benefits. Nonetheless, ICERs of LPV and ULPV vs. MV were all well below the €50,000 threshold. ULPV also presented with favorable ICERs as compared to LPV (i.e. less than €25,000/QALY). Conclusions ECCO2R-enabled LPV strategies might provide cost-effective survival benefit. Additional data from interventional and observational studies are needed to support this preliminary model-based analysis.
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Affiliation(s)
- Oliver Ethgen
- SERFAN Innovation, Namur, Belgium; Department of Public Health, Epidemiology & Health Economics, University of Liège, Liège, Belgium.
| | | | - Kai Harenski
- Baxter Healthcare Corporation, Deerfield, IL, USA
| | - Armand Mekontso Dessap
- UPEC, Institut Mondor de Recherche Biomédicale, Groupe de Recherche Clinique CARMAS, Créteil F-94010, France; APHP, Hôpitaux Universitaires Henri Mondor, Service de Médecine Intensive Réanimation, Créteil F-94010, France
| | - Philippe Morimont
- GIGA-Laboratory of Critical Care Basic Sciences, University of Liège, Liège, Belgium
| | - Michael Quintel
- Department of Anaesthesia and Intensive Care Medicine, University of Göttingen Medical Center Von-Siebold-Straße 3, 37075 Göttingen, Germany
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardio Metabolism and Nutrition, F-75013 Paris, France; Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Hôpital Pitié-Salpêtrière, F-75013 Paris, France
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22
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Goligher EC, Zampieri F, Calfee CS, Seymour CW. A manifesto for the future of ICU trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:686. [PMID: 33298134 PMCID: PMC7724445 DOI: 10.1186/s13054-020-03393-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. .,Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada. .,Toronto General Hospital Research Institute, 585 University Ave., 11-PMB Room 192, Toronto, ON, M5G 2N2, Canada.
| | | | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Christopher W Seymour
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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23
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Matthay MA, Arabi YM, Siegel ER, Ware LB, Bos LDJ, Sinha P, Beitler JR, Wick KD, Curley MAQ, Constantin JM, Levitt JE, Calfee CS. Phenotypes and personalized medicine in the acute respiratory distress syndrome. Intensive Care Med 2020; 46:2136-2152. [PMID: 33206201 PMCID: PMC7673253 DOI: 10.1007/s00134-020-06296-9] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/13/2020] [Indexed: 12/15/2022]
Abstract
Although the acute respiratory distress syndrome (ARDS) is well defined by the development of acute hypoxemia, bilateral infiltrates and non-cardiogenic pulmonary edema, ARDS is heterogeneous in terms of clinical risk factors, physiology of lung injury, microbiology, and biology, potentially explaining why pharmacologic therapies have been mostly unsuccessful in treating ARDS. Identifying phenotypes of ARDS and integrating this information into patient selection for clinical trials may increase the chance for efficacy with new treatments. In this review, we focus on classifying ARDS by the associated clinical disorders, physiological data, and radiographic imaging. We consider biologic phenotypes, including plasma protein biomarkers, gene expression, and common causative microbiologic pathogens. We will also discuss the issue of focusing clinical trials on the patient's phase of lung injury, including prevention, administration of therapy during early acute lung injury, and treatment of established ARDS. A more in depth understanding of the interplay of these variables in ARDS should provide more success in designing and conducting clinical trials and achieving the goal of personalized medicine.
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Affiliation(s)
- Michael A Matthay
- Department of Anesthesia, University of California San Francisco, San Francisco, CA, USA.
- Cardiovascular Research Institute, University of California, San Francisco, USA.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, USA.
| | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Emily R Siegel
- Cardiovascular Research Institute, University of California, San Francisco, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lieuwe D J Bos
- Department of Respiratory Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Infection and Immunity, Amsterdam, The Netherlands
| | - Pratik Sinha
- Department of Anesthesiology, Washington University, Saint Louis, MO, USA
| | - Jeremy R Beitler
- Division of Pulmonary, Allergy, and Critical Care Medicine, Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Katherine D Wick
- Cardiovascular Research Institute, University of California, San Francisco, USA
| | - Martha A Q Curley
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Jean-Michel Constantin
- Department of Anesthesia and Critical Care, La Pitié Salpetriere Hospital, University Paris-Sorbonne, Paris, France
| | - Joseph E Levitt
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Carolyn S Calfee
- Department of Anesthesia, University of California San Francisco, San Francisco, CA, USA
- Cardiovascular Research Institute, University of California, San Francisco, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, USA
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24
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Combes A, Schmidt M, Hodgson CL, Fan E, Ferguson ND, Fraser JF, Jaber S, Pesenti A, Ranieri M, Rowan K, Shekar K, Slutsky AS, Brodie D. Extracorporeal life support for adults with acute respiratory distress syndrome. Intensive Care Med 2020; 46:2464-2476. [PMID: 33140180 PMCID: PMC7605473 DOI: 10.1007/s00134-020-06290-1] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/10/2020] [Indexed: 12/28/2022]
Abstract
Extracorporeal life support (ECLS) can support gas exchange in patients with the acute respiratory distress syndrome (ARDS). During ECLS, venous blood is drained from a central vein via a cannula, pumped through a semipermeable membrane that permits diffusion of oxygen and carbon dioxide, and returned via a cannula to a central vein. Two related forms of ECLS are used. Venovenous extracorporeal membrane oxygenation (ECMO), which uses high blood flow rates to both oxygenate the blood and remove carbon dioxide, may be considered in patients with severe ARDS whose oxygenation or ventilation cannot be maintained adequately with best practice conventional mechanical ventilation and adjunctive therapies, including prone positioning. Extracorporeal carbon dioxide removal (ECCO2R) uses lower blood flow rates through smaller cannulae and provides substantial CO2 elimination (~ 20–70% of total CO2 production), albeit with marginal improvement in oxygenation. The rationale for using ECCO2R in ARDS is to facilitate lung-protective ventilation by allowing a reduction of tidal volume, respiratory rate, plateau pressure, driving pressure and mechanical power delivered by the mechanical ventilator. This narrative review summarizes physiological concepts related to ECLS, as well as the rationale and evidence supporting ECMO and ECCO2R for the treatment of ARDS. It also reviews complications, limitations, and the ethical dilemmas that can arise in treating patients with ECLS. Finally, it discusses future key research questions and challenges for this technology.
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Affiliation(s)
- Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 75013, Paris, France. .,Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, 75013, Paris, France.
| | - Matthieu Schmidt
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 75013, Paris, France.,Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care-Research Centre, Monash University, Melbourne, Australia
| | - Eddy Fan
- Interdepartmenal Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - John F Fraser
- Critical Care Research Group, Adult Intensive Care Services, Northside Medical School, The Prince Charles Hospital, University of Queensland, Brisbane, Australia
| | - Samir Jaber
- Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), From the PhyMedExp, University of Montpellier, Centre Hospitalier Universitaire (CHU) Montpellier, Montpellier, France.,Département d'Anesthésie-Réanimation, Hôpital Saint-Eloi, Montpellier Cedex, France
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Marco Ranieri
- Intensive Care Unit, Policlinico di Sant'Orsola, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Kiran Shekar
- Adult Intensive Care Services, Critical Care Research Group, the Prince Charles Hospital, Brisbane, QLD, Australia.,Queensland University of Technology, University of Queensland, Brisbane, QLD, Australia
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, USA.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York, USA
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25
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Ware LB, Matthay MA, Mebazaa A. Designing an ARDS trial for 2020 and beyond: focus on enrichment strategies. Intensive Care Med 2020; 46:2153-2156. [PMID: 33136196 PMCID: PMC7605340 DOI: 10.1007/s00134-020-06232-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/26/2020] [Indexed: 02/07/2023]
Abstract
With the exception of a few successes in trials of supportive care, the majority of interventional clinical trials for acute respiratory distress syndrome (ARDS) have not led to new therapies. To improve the likelihood of benefit from clinical trial interventions in ARDS, clinical trial design must be improved. To optimize trial design, many factors need to be considered including the type of therapy to be tested, the type of trial (phase 2 or 3), how patients will be selected, primary and secondary end-points, and strategy for conduct of the trial, including potential newer trial designs such as platform or adaptive trials. Of these, optimization of patient selection is central to the likelihood of success and is particularly relevant in ARDS, which is a heterogeneous clinical syndrome, not a homogeneous disease. Recent advances including improved understanding of pathophysiologic mechanisms and better tools for outcome prediction in ARDS should facilitate both predictive and prognostic enrichment. This commentary focuses on new information and novel methods for prognostic and predictive enrichment that may be useful to optimize patient selection and increase the likelihood of positive clinical trials in ARDS.
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Affiliation(s)
- Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - Michael A Matthay
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Alexandre Mebazaa
- Department of Anaesthesia and Critical Care, Lariboisière Hospital, APHP; Inserm UMR-S942 Mascot, FHU PROMICE and Université de Paris, Paris, France
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26
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Xia J, Feng Y, Li M, Yu X, Zhang Y, Duan J, Zhan Q. Increased physiological dead space in mechanically ventilated COVID-19 patients recovering from severe acute respiratory distress syndrome: a case report. BMC Infect Dis 2020; 20:637. [PMID: 32854630 PMCID: PMC7450943 DOI: 10.1186/s12879-020-05360-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An ongoing outbreak of coronavirus disease 2019 (COVID-19) is spreading globally. Recently, several articles have mentioned that the early acute respiratory distress syndrome (ARDS) caused by COVID-19 significantly differ from those of ARDS due to other causes. Actually, we newly observed that some mechanically ventilated COVID-19 patients recovering from severe ARDS (more than 14 days after invasive ventilation) often experienced evidently gradual increases in CO2 retention and minute ventilation. However, the underlying mechanics remain unclear. CASE PRESENTATION To explain these pathophysiological features and discuss the ventilatory strategy during the late phase of severe ARDS in COVID-19 patients, we first used a metabolic module on a General Electric R860 ventilator (Engstrom Carestation; GE Healthcare, USA) to monitor parameters related to gas metabolism, lung mechanics and physiological dead space in two COVID-19 patients. We found that remarkably decreased ventilatory efficiency (e.g., the ratio of dead space to tidal volume 70-80%, arterial to end-tidal CO2 difference 18-23 mmHg and ventilatory ratio 3-4) and hypermetabolism (oxygen consumption 300-400 ml/min, CO2 elimination 200-300 ml/min) may explain why these patients experienced more severe respiratory distress and CO2 retention in the late phase of ARDS caused by COVID-19. CONCLUSION During the recovery period of ARDS among mechanically-ventilated COVID-19 patients, attention should be paid to the monitoring of physiological dead space and metabolism. Tidal volume (8-9 ml/kg) could be increased appropriately under the limited plateau pressure; however, barotrauma should still be kept in mind.
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Affiliation(s)
- Jingen Xia
- Department of Pulmonary and Critical Care Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No 2, East Yinghua Road, Chaoyang District, Beijing, 100029, China.,School of Biological Science and Medical Engineering, Beihang University, Beijing, 100191, China
| | - Yingying Feng
- Department of Pulmonary and Critical Care Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No 2, East Yinghua Road, Chaoyang District, Beijing, 100029, China
| | - Min Li
- Department of Pulmonary and Critical Care Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No 2, East Yinghua Road, Chaoyang District, Beijing, 100029, China
| | - Xin Yu
- Department of Pulmonary and Critical Care Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No 2, East Yinghua Road, Chaoyang District, Beijing, 100029, China
| | - Yi Zhang
- Department of Pulmonary and Critical Care Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No 2, East Yinghua Road, Chaoyang District, Beijing, 100029, China
| | - Jun Duan
- Department of Surgical Intensive Care Unit, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Qingyuan Zhan
- Department of Pulmonary and Critical Care Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No 2, East Yinghua Road, Chaoyang District, Beijing, 100029, China.
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27
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28
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Combes A, Price S, Slutsky AS, Brodie D. Temporary circulatory support for cardiogenic shock. Lancet 2020; 396:199-212. [PMID: 32682486 DOI: 10.1016/s0140-6736(20)31047-3] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/24/2020] [Accepted: 04/29/2020] [Indexed: 12/15/2022]
Abstract
Cardiogenic shock can occur due to acute ischaemic or non-ischaemic cardiac events, or from progression of long-standing underlying heart disease. When addressing the cause of underlying disease, the management of cardiogenic shock consists of vasopressors and inotropes; however, these agents can increase myocardial oxygen consumption, impair tissue perfusion, and are frequently ineffective. An alternative approach is to temporarily augment cardiac output using mechanical devices. The use of these devices-known as temporary circulatory support systems-has increased substantially in recent years, despite being expensive, resource intensive, associated with major complications, and lacking high-quality evidence to support their use. This Review summarises the physiological basis underlying the use of temporary circulatory support for cardiogenic shock, reviews the evidence informing indications and contraindications, addresses ethical considerations, and highlights the need for further research.
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Affiliation(s)
- Alain Combes
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Paris, France; Service de Médecine Intensive-Réanimation, Höpitaux Universitaires Pitié Salpêtrière, Assistance Publique-Höpitaux de Paris, Institut de Cardiologie, Paris, France.
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College, London, UK
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY, USA; Centre for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
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29
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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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30
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Goligher EC, Combes A, Brodie D, Ferguson ND, Pesenti AM, Ranieri VM, Slutsky AS. Determinants of the effect of extracorporeal carbon dioxide removal in the SUPERNOVA trial: implications for trial design. Intensive Care Med 2019; 45:1219-1230. [PMID: 31432216 DOI: 10.1007/s00134-019-05708-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/18/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE To describe the variability and determinants of the effect of extracorporeal CO2 removal (ECCO2R) on tidal volume (Vt), driving pressure (ΔP), and mechanical power (PowerRS) and to determine whether highly responsive patients can be identified for the purpose of predictive enrichment in ECCO2R trial design. METHODS Using data from the SUPERNOVA trial (95 patients with early moderate acute respiratory distress syndrome), the independent effects of alveolar dead space fraction (ADF), respiratory system compliance (Crs), hypoxemia (PaO2/FiO2), and device performance (higher vs lower CO2 extraction) on the magnitude of reduction in Vt, ΔP, and PowerRS permitted by ECCO2R were assessed by linear regression. Predicted and observed changes in ΔP were compared by Bland-Altman analysis. Hypothetical trials of ECCO2R, incorporating predictive enrichment and different target CO2 removal rates, were simulated in the SUPERNOVA study population. RESULTS Changes in Vt permitted by ECCO2R were independently associated with ADF and device performance but not PaO2/FiO2. Changes in ΔP and PowerRS were independently associated with ADF, Crs, and device performance but not PaO2/FiO2. The change in ΔP predicted from ADF and Crs was moderately correlated with observed change in ΔP (R2 0.32, p < 0.001); limits of agreement between observed and predicted changes in ΔP were ± 3.9 cmH2O. In simulated trials, restricting enrollment to patients with a larger predicted decrease in ΔP enhanced the average reduction in ΔP, increased predicted mortality benefit, and reduced sample size and screening size requirements. The increase in statistical power obtained by restricting enrollment based on predicted ΔP response varied according to device performance as specified by the target CO2 removal rate. CONCLUSIONS The lung-protective benefits of ECCO2R increase with higher alveolar dead space fraction, lower respiratory system compliance, and higher device performance. ADF and Crs, rather than severity of hypoxemia, should be the primary factors determining whether to enroll patients in clinical trials of ECCO2R.
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Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. .,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada. .,Toronto General Hospital Research Institute, 585 University Ave., 11-PMB Room 192, Toronto, ON, M5G 2N2, Canada.
| | - Alain Combes
- APHP Hôpital Pitié-Salpêtrière, Institut de Cardiologie, Institute of Cardio-metabolism and Nutrition, and Service de Médecine Intensive-réanimation, UMRS_1166-ICAN, INSERM, Sorbonne Université, Paris, France
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada.,Toronto General Hospital Research Institute, 585 University Ave., 11-PMB Room 192, Toronto, ON, M5G 2N2, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.,Department of Physiology, University of Toronto, Toronto, Canada
| | - Antonio M Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.,Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - V Marco Ranieri
- Policlinico di Sant'Orsola, Anesthesia and Intensive Care Medicine, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum-Università di Bologna, Bologna, Italy
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
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31
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Augy JL, Aissaoui N, Richard C, Maury E, Fartoukh M, Mekontso-Dessap A, Paulet R, Anguel N, Blayau C, Cohen Y, Chiche JD, Gaudry S, Voicu S, Demoule A, Combes A, Megarbane B, Charpentier E, Haghighat S, Panczer M, Diehl JL. A 2-year multicenter, observational, prospective, cohort study on extracorporeal CO 2 removal in a large metropolis area. J Intensive Care 2019; 7:45. [PMID: 31452899 PMCID: PMC6701003 DOI: 10.1186/s40560-019-0399-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 08/12/2019] [Indexed: 11/17/2022] Open
Abstract
Background Extracorporeal carbon dioxide removal (ECCO2R) is a promising technique for the management of acute respiratory failure, but with a limited level of evidence to support its use outside clinical trials and/or data collection initiatives. We report a collaborative initiative in a large metropolis. Methods To assess on a structural basis the rate of utilization as well as efficacy and safety parameters of 2 ECCO2R devices in 10 intensive care units (ICU) during a 2-year period. Results Seventy patients were recruited in 10 voluntary and specifically trained centers. The median utilization rate was 0.19 patient/month/center (min 0.04; max 1.20). ECCO2R was started under invasive mechanical ventilation (IMV) in 59 patients and non-invasive ventilation in 11 patients. The Hemolung Respiratory Assist System (Alung) was used in 53 patients and the iLA Activve iLA kit (Xenios Novalung) in 17 patients. Main indications were ultraprotective ventilation for ARDS patients (n = 24), shortening the duration of IMV in COPD patients (n = 21), preventing intubation in COPD patients (n = 9), and controlling hypercapnia and dynamic hyperinflation in mechanically ventilated patients with severe acute asthma (n = 6). A reduction in median VT was observed in ARDS patients from 5.9 to 4.1 ml/kg (p <0.001). A reduction in PaCO2 values was observed in AE-COPD patients from 67.5 to 51 mmHg (p< 0.001). Median duration of ECCO2R was 5 days (IQR 3–8). Reasons for ECCO2R discontinuation were improvement (n = 33), ECCO2R-related complications (n = 18), limitation of life-sustaining therapies or measures decision (n = 10), and death (n = 9). Main adverse events were hemolysis (n = 21), bleeding (n = 17), and lung membrane clotting (n = 11), with different profiles between the devices. Thirty-five deaths occurred during the ICU stay, 3 of which being ECCO2R-related. Conclusions Based on a registry, we report a low rate of ECCO2R device utilization, mainly in severe COPD and ARDS patients. Physiological efficacy was confirmed in these two populations. We confirmed safety concerns such as hemolysis, bleeding, and thrombosis, with different profiles between the devices. Such results could help to design future studies aiming to enhance safety, to demonstrate a still-lacking strong clinical benefit of ECCO2R, and to guide the choice between different devices. Trial registration ClinicalTrials.gov: Identifier: NCT02965079 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT02965079
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Affiliation(s)
- J L Augy
- 1Service de Médecine Intensive Réanimation, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - N Aissaoui
- 1Service de Médecine Intensive Réanimation, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - C Richard
- 2Service de Médecine Intensive Réanimation, AP-HP, Hôpital de Bicètre, Le Kremlin Bicètre, France
| | - E Maury
- 3Service de Médecine Intensive Réanimation, AP-HP, Hôpital Saint-Antoine, Paris, France
| | - M Fartoukh
- Service de Réanimation Polyvalente, AP-HP, Hôpital Tenon, Paris, France
| | - A Mekontso-Dessap
- 5Service de Médecine Intensive Réanimation, AP-HP, Hôpital Henri Mondor, Créteil, France
| | - R Paulet
- Service de Réanimation Polyvalente, Centre Hospitalier de Longjumeau, Longjumeau, France
| | - N Anguel
- 2Service de Médecine Intensive Réanimation, AP-HP, Hôpital de Bicètre, Le Kremlin Bicètre, France
| | - C Blayau
- Service de Réanimation Polyvalente, AP-HP, Hôpital Tenon, Paris, France
| | - Y Cohen
- 7Service de Réanimation Polyvalente, AP-HP, Hôpital Avicenne, Bobigny, France
| | - J D Chiche
- 8Service de Médecine Intensive Réanimation, AP-HP, Hôpital Cochin, Paris, France
| | - S Gaudry
- 9Service de Réanimation Polyvalente, AP-HP, Hôpital Louis Mourier, Colombes, France
| | - S Voicu
- 10Service de Médecine Intensive Réanimation, AP-HP, Hôpital Lariboisière, Paris, France
| | - A Demoule
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - A Combes
- 12Service de Médecine Intensive Réanimation, AP-HP, Hôpital Pitié-Salpétrière, Institut de Cardiologie, Paris, France
| | - B Megarbane
- 10Service de Médecine Intensive Réanimation, AP-HP, Hôpital Lariboisière, Paris, France
| | - E Charpentier
- 13AP-HP, Office du Transfert de Technologie et des Partenariats Industriels, Paris, France
| | - S Haghighat
- 14AP-HP, Agence Générale des Equipements et des Produits de Santé, Paris, France
| | - M Panczer
- 14AP-HP, Agence Générale des Equipements et des Produits de Santé, Paris, France
| | - J L Diehl
- 1Service de Médecine Intensive Réanimation, AP-HP, Hôpital Européen Georges Pompidou, Paris, France.,15Faculty of Pharmacy, INSERM UMR-S1140, Paris Descartes University, Paris, France
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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: 220] [Impact Index Per Article: 44.0] [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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Guervilly C, Parzy G, Papazian L. Acute respiratory distress syndrome phenotyping and latent class analysis, first steps toward precision medicine in critical care illness? J Thorac Dis 2019; 11:S303-S306. [PMID: 30997204 DOI: 10.21037/jtd.2019.01.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Christophe Guervilly
- Medical Intensive Care Unit, North Hospital, APHM, Marseille, France.,CEReSS, Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Gabriel Parzy
- Medical Intensive Care Unit, North Hospital, APHM, Marseille, France
| | - Laurent Papazian
- Medical Intensive Care Unit, North Hospital, APHM, Marseille, France.,CEReSS, Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
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Feasibility and safety of extracorporeal CO2 removal to enhance protective ventilation in acute respiratory distress syndrome: the SUPERNOVA study. Intensive Care Med 2019; 45:592-600. [DOI: 10.1007/s00134-019-05567-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/09/2019] [Indexed: 10/27/2022]
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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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Bourenne J, Hraiech S, Rambaud R, Forel JM, Persico N, Guervilly C, Papazian L. Non-ventilatory therapies for acute respiratory distress syndrome. Minerva Anestesiol 2018; 84:1093-1101. [DOI: 10.23736/s0375-9393.18.12328-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Giants in Chest Medicine: Arthur S. Slutsky, MD, MASc, BASc. Chest 2018; 154:8-9. [PMID: 30044747 DOI: 10.1016/j.chest.2018.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 03/07/2018] [Indexed: 11/22/2022] Open
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Extracorporeal organ support (ECOS) in critical illness and acute kidney injury: from native to artificial organ crosstalk. Intensive Care Med 2018; 44:1447-1459. [DOI: 10.1007/s00134-018-5329-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 07/18/2018] [Indexed: 12/11/2022]
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Acute life-threatening hypoxemia during mechanical ventilation. Curr Opin Crit Care 2018; 23:541-548. [PMID: 29016366 DOI: 10.1097/mcc.0000000000000459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE OF REVIEW To describe current evidence-based practice in the management of acute life-threatening hypoxemia in mechanically ventilated patients and some of the methods used to individualize the care of the patient. RECENT FINDINGS Patients with acute life-threatening hypoxemia will often meet criteria for severe ARDS, for which there are only a few treatment strategies that have been shown to improve survival outcomes. Recent findings have increased our knowledge of the physiological effects of spontaneous breathing and the application of PEEP. Additionally, the use of advanced bedside monitoring has a promising future in the management of hypoxemic patients to fine-tune the ventilator and to evaluate the individual patient response to therapy. SUMMARY Treating the patient with acute life-threatening hypoxemia during mechanical ventilation should begin with an evidence-based approach, with the goal of improving oxygenation and minimizing the harmful effects of mechanical ventilation. The use of advanced monitoring and the application of simple maneuvers at the bedside may assist clinicians to better individualize treatment and improve clinical outcomes.
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Azoulay E, Lemiale V, Mourvillier B, Garrouste-Orgeas M, Schwebel C, Ruckly S, Argaud L, Cohen Y, Souweine B, Papazian L, Reignier J, Marcotte G, Siami S, Kallel H, Darmon M, Timsit JF. Management and outcomes of acute respiratory distress syndrome patients with and without comorbid conditions. Intensive Care Med 2018; 44:1050-1060. [PMID: 29881987 PMCID: PMC7095161 DOI: 10.1007/s00134-018-5209-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/05/2018] [Indexed: 12/14/2022]
Abstract
Rationale The standard of care for patients with acute respiratory distress syndrome (ARDS) has been developed based on studies that usually excluded patients with major comorbidities. Objectives To describe treatments and outcomes according to comorbidities in patients with ARDS admitted to 19 ICUs (1997–2014). Methods Patients were grouped based on comorbidities. Determinants of day-28 mortality were identified by multivariable Cox analysis stratified on center. Measurements and main results Among 4953 ARDS patients, 2545 (51.4%) had major comorbidities; the proportion with major comorbidities increased after 2008. Hematological malignancy was associated with severe ARDS and rescue therapies for refractory hypoxemia. COPD, HIV infection, and hematological malignancy were associated with a lower likelihood of invasive mechanical ventilation on the admission day. Admission-day SOFA score was higher in patients with major comorbidities, who more often received vasopressors, dialysis, or treatment-limitation decisions. Day-28 mortality was 33.7% overall, 27.2% in patients without major comorbidities, and 31.1% (COPD) to 56% (hematological malignancy) in patients with major comorbidities. By multivariable analysis, mortality was lower in patients with COPD and higher in those with chronic heart failure, solid tumors, or hematological malignancies. Mortality was independently associated with PaO2/FiO2 and PaCO2 on day 1, ARDS of pulmonary origin, worse SOFA score, and ICU-acquired events. Conclusions Half the patients with ARDS had major comorbidities, which were associated with severe ARDS, multiple organ dysfunction, and day-28 mortality. These findings do not support the exclusion of ARDS patients with severe comorbidities from randomized clinical trials. Trials in ARDS patients with whatever comorbidities are warranted. Electronic supplementary material The online version of this article (10.1007/s00134-018-5209-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elie Azoulay
- Medical Intensive Care Unit, AP-HP, Saint-Louis hospital, ECSTRA Team, Biostatistics and CLINICAL EPIDEMIOLOGY, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France.
| | - Virginie Lemiale
- Medical Intensive Care Unit, AP-HP, Saint-Louis hospital, ECSTRA Team, Biostatistics and CLINICAL EPIDEMIOLOGY, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France
| | - Bruno Mourvillier
- Réanimation Médicale et Infectieuse, Hôpital Bichat Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Carole Schwebel
- Service de Réanimation Médicale, Centre Hospitalier Universitaire Grenoble-Alpes, CS10217, Grenoble Cedex 09, France
| | | | - Laurent Argaud
- Medical ICU, Edouard Hériot University Hospital, Lyon, France
| | - Yves Cohen
- Medical-Surgical ICU, Bobigny University hospital, Paris, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Laurent Papazian
- Réanimation des Détresses Respiratoires et Infections Sévères, Hôpital Nord, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, Unité de Recherche sur les Maladies Infectieuses et Tropicales Émergentes (URMITE), UMR CNRS 7278, Marseille, France
| | - Jean Reignier
- Medical Intensive Care Unit, Nantes University Hospital Center, Nantes, France
| | | | - Shidasp Siami
- Réanimation polyvalente-Surveillance Continue-Site d'Etampes, Centre hospitalier Sud Essonne (Etampes), Paris, France
| | - Hatem Kallel
- Medical Surgical ICU, Centre hospitalier de Cayenne, Guyane, France
| | - Michael Darmon
- Medical Intensive Care Unit, AP-HP, Saint-Louis hospital, ECSTRA Team, Biostatistics and CLINICAL EPIDEMIOLOGY, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France
| | - Jean-François Timsit
- UMR 1137, Infection Antimicrobials Modelling Evolution (IAME) Team 5, Decision Sciences in Infectious Diseases (DeSCID), Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, Paris, France
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Mauri T, Galazzi A, Binda F, Masciopinto L, Corcione N, Carlesso E, Lazzeri M, Spinelli E, Tubiolo D, Volta CA, Adamini I, Pesenti A, Grasselli G. Impact of flow and temperature on patient comfort during respiratory support by high-flow nasal cannula. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:120. [PMID: 29743098 PMCID: PMC5941611 DOI: 10.1186/s13054-018-2039-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/13/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The high-flow nasal cannula (HFNC) delivers up to 60 l/min of humidified air/oxygen blend at a temperature close to that of the human body. In this study, we tested whether higher temperature and flow decrease patient comfort. In more severe patients, instead, we hypothesized that higher flow might be associated with improved comfort. METHODS A prospective, randomized, cross-over study was performed on 40 acute hypoxemic respiratory failure (AHRF) patients (PaO2/FiO2 ≤ 300 + pulmonary infiltrates + exclusion of cardiogenic edema) supported by HFNC. The primary outcome was the assessment of patient comfort during HFNC delivery at increasing flow and temperature. Two flows (30 and 60 l/min), each combined with two temperatures (31 and 37 °C), were randomly applied for 20 min (four steps per patient), leaving clinical FiO2 unchanged. Toward the end of each step, the following were recorded: comfort by Visual Numerical Scale ranging between 1 (extreme discomfort) and 5 (very comfortable), together with respiratory parameters. A subgroup of more severe patients was defined by clinical FiO2 ≥ 45%. RESULTS Patient comfort was reported as significantly higher during steps at the lower temperature (31 °C) in comparison to 37 °C, with the HFNC set at both 30 and 60 l/min (p < 0.0001). Higher flow, however, was not associated with poorer comfort. In the subgroup of patients with clinical FiO2 ≥ 45%, both lower temperature (31 °C) and higher HFNC flow (60 l/min) led to higher comfort (p < 0.01). CONCLUSIONS HFNC temperature seems to significantly impact the comfort of AHRF patients: for equal flow, lower temperature could be more comfortable. Higher flow does not decrease patient comfort; at variance, it improves comfort in the more severely hypoxemic patient.
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Affiliation(s)
- Tommaso Mauri
- Anesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Via F. Sforza 35, 20122, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Alessandro Galazzi
- Anesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Via F. Sforza 35, 20122, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Filippo Binda
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Laura Masciopinto
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Nadia Corcione
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Eleonora Carlesso
- Anesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Via F. Sforza 35, 20122, Milan, Italy
| | - Marta Lazzeri
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Daniela Tubiolo
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Carlo Alberto Volta
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Ileana Adamini
- Anesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Via F. Sforza 35, 20122, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Antonio Pesenti
- Anesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Via F. Sforza 35, 20122, Milan, Italy. .,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
| | - Giacomo Grasselli
- Anesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Via F. Sforza 35, 20122, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
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Mauri T, Galazzi A, Binda F, Masciopinto L, Corcione N, Carlesso E, Lazzeri M, Spinelli E, Tubiolo D, Volta CA, Adamini I, Pesenti A, Grasselli G. Impact of flow and temperature on patient comfort during respiratory support by high-flow nasal cannula. CRITICAL CARE (LONDON, ENGLAND) 2018. [PMID: 29743098 DOI: 10.1186/s13054‐018‐2039‐4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The high-flow nasal cannula (HFNC) delivers up to 60 l/min of humidified air/oxygen blend at a temperature close to that of the human body. In this study, we tested whether higher temperature and flow decrease patient comfort. In more severe patients, instead, we hypothesized that higher flow might be associated with improved comfort. METHODS A prospective, randomized, cross-over study was performed on 40 acute hypoxemic respiratory failure (AHRF) patients (PaO2/FiO2 ≤ 300 + pulmonary infiltrates + exclusion of cardiogenic edema) supported by HFNC. The primary outcome was the assessment of patient comfort during HFNC delivery at increasing flow and temperature. Two flows (30 and 60 l/min), each combined with two temperatures (31 and 37 °C), were randomly applied for 20 min (four steps per patient), leaving clinical FiO2 unchanged. Toward the end of each step, the following were recorded: comfort by Visual Numerical Scale ranging between 1 (extreme discomfort) and 5 (very comfortable), together with respiratory parameters. A subgroup of more severe patients was defined by clinical FiO2 ≥ 45%. RESULTS Patient comfort was reported as significantly higher during steps at the lower temperature (31 °C) in comparison to 37 °C, with the HFNC set at both 30 and 60 l/min (p < 0.0001). Higher flow, however, was not associated with poorer comfort. In the subgroup of patients with clinical FiO2 ≥ 45%, both lower temperature (31 °C) and higher HFNC flow (60 l/min) led to higher comfort (p < 0.01). CONCLUSIONS HFNC temperature seems to significantly impact the comfort of AHRF patients: for equal flow, lower temperature could be more comfortable. Higher flow does not decrease patient comfort; at variance, it improves comfort in the more severely hypoxemic patient.
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Affiliation(s)
- Tommaso Mauri
- Anesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Via F. Sforza 35, 20122, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Alessandro Galazzi
- Anesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Via F. Sforza 35, 20122, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Filippo Binda
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Laura Masciopinto
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Nadia Corcione
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Eleonora Carlesso
- Anesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Via F. Sforza 35, 20122, Milan, Italy
| | - Marta Lazzeri
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Daniela Tubiolo
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Carlo Alberto Volta
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Ileana Adamini
- Anesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Via F. Sforza 35, 20122, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Antonio Pesenti
- Anesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Via F. Sforza 35, 20122, Milan, Italy. .,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
| | - Giacomo Grasselli
- Anesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Via F. Sforza 35, 20122, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
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Goligher EC, Amato MBP, Slutsky AS. Reply to Morales-Quinteros et al.: Precision Medicine for Extracorporeal CO 2 Removal for Acute Respiratory Distress Syndrome: CO 2 Physiological Considerations. Am J Respir Crit Care Med 2018; 197:1091-1092. [PMID: 29211496 DOI: 10.1164/rccm.201711-2226le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ewan C Goligher
- 1 University of Toronto Toronto, Canada.,2 University Health Network and Mount Sinai Hospital Toronto, Canada
| | - Marcelo B P Amato
- 3 Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo São Paulo, Brazil and
| | - Arthur S Slutsky
- 1 University of Toronto Toronto, Canada.,4 St. Michael's Hospital Toronto, Canada
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Morales-Quinteros L, Artigas A, Kaufman DA. Precision Medicine for Extracorporeal CO 2 Removal for Acute Respiratory Distress Syndrome: CO 2 Physiological Considerations. Am J Respir Crit Care Med 2018; 197:1090-1091. [PMID: 29211495 DOI: 10.1164/rccm.201710-2124le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Antonio Artigas
- 2 Corporació Sanitaria I Universitària Parc Taulí Sabadell, Spain and
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Abstract
IMPORTANCE Acute respiratory distress syndrome (ARDS) is a life-threatening form of respiratory failure that affects approximately 200 000 patients each year in the United States, resulting in nearly 75 000 deaths annually. Globally, ARDS accounts for 10% of intensive care unit admissions, representing more than 3 million patients with ARDS annually. OBJECTIVE To review advances in diagnosis and treatment of ARDS over the last 5 years. EVIDENCE REVIEW We searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews from 2012 to 2017 focusing on randomized clinical trials, meta-analyses, systematic reviews, and clinical practice guidelines. Articles were identified for full text review with manual review of bibliographies generating additional references. FINDINGS After screening 1662 citations, 31 articles detailing major advances in the diagnosis or treatment of ARDS were selected. The Berlin definition proposed 3 categories of ARDS based on the severity of hypoxemia: mild (200 mm Hg<Pao2/Fio2≤300 mm Hg), moderate (100 mm Hg<Pao2/Fio2≤200 mm Hg), and severe (Pao2/Fio2 ≤100 mm Hg), along with explicit criteria related to timing of the syndrome's onset, origin of edema, and the chest radiograph findings. The Berlin definition has significantly greater predictive validity for mortality than the prior American-European Consensus Conference definition. Clinician interpretation of the origin of edema and chest radiograph criteria may be less reliable in making a diagnosis of ARDS. The cornerstone of management remains mechanical ventilation, with a goal to minimize ventilator-induced lung injury (VILI). Aspirin was not effective in preventing ARDS in patients at high-risk for the syndrome. Adjunctive interventions to further minimize VILI, such as prone positioning in patients with a Pao2/Fio2 ratio less than 150 mm Hg, were associated with a significant mortality benefit whereas others (eg, extracorporeal carbon dioxide removal) remain experimental. Pharmacologic therapies such as β2 agonists, statins, and keratinocyte growth factor, which targeted pathophysiologic alterations in ARDS, were not beneficial and demonstrated possible harm. Recent guidelines on mechanical ventilation in ARDS provide evidence-based recommendations related to 6 interventions, including low tidal volume and inspiratory pressure ventilation, prone positioning, high-frequency oscillatory ventilation, higher vs lower positive end-expiratory pressure, lung recruitment maneuvers, and extracorporeal membrane oxygenation. CONCLUSIONS AND RELEVANCE The Berlin definition of acute respiratory distress syndrome addressed limitations of the American-European Consensus Conference definition, but poor reliability of some criteria may contribute to underrecognition by clinicians. No pharmacologic treatments aimed at the underlying pathology have been shown to be effective, and management remains supportive with lung-protective mechanical ventilation. Guidelines on mechanical ventilation in patients with acute respiratory distress syndrome can assist clinicians in delivering evidence-based interventions that may lead to improved outcomes.
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Affiliation(s)
- Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, University Health Network and Sinai Health System, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Keenan Research Center, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
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46
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Brodie D, Vincent JL, Brochard LJ, Combes A, Ferguson ND, Hodgson CL, Laffey JG, Mercat A, Pesenti A, Quintel M, Slutsky AS, Ranieri VM. Research in Extracorporeal Life Support: A Call to Action. Chest 2018; 153:788-791. [PMID: 29355550 DOI: 10.1016/j.chest.2017.12.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 12/19/2017] [Accepted: 12/22/2017] [Indexed: 01/19/2023] Open
Affiliation(s)
- Daniel Brodie
- Department of Medicine, Columbia University College of Physicians & Surgeons, and New York-Presbyterian Hospital, New York, NY.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Brussels, Belgium
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Alain Combes
- Medical Intensive Care Unit, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, and Sorbonne Pierre-Marie Curie University Paris, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, and Department of Medicine, Division of Respirology & Critical Care, Toronto General Research Institute, University Health Network and Sinai Health System, Toronto, ON, Canada
| | - Carol L Hodgson
- Australian & New Zealand Intensive Care Research Centre, Monash University, Melbourne, and the Alfred Hospital, Prahran, Australia
| | - John G Laffey
- Departments of Anesthesia and Critical Care Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, and Departments of Anesthesia, Physiology, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Alain Mercat
- Département de Réanimation Médicale et Médecine Hyperbare, CHU d' Angers, Université d'Angers, Angers, France
| | | | - Michael Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, and Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - V Marco Ranieri
- Anesthesia and Intensive Care Medicine, Sapienza Università di Rome, Rome, Italy
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47
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Alessandri F, Pugliese F, Ranieri VM. Mechanical ventilation: we have come a long way but still have a long road ahead. THE LANCET RESPIRATORY MEDICINE 2017; 5:922-924. [PMID: 29128520 DOI: 10.1016/s2213-2600(17)30431-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 10/06/2017] [Accepted: 10/06/2017] [Indexed: 01/21/2023]
Affiliation(s)
- Francesco Alessandri
- Department of Anaesthesia and Intensive Care Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Francesco Pugliese
- Department of Anaesthesia and Intensive Care Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - V Marco Ranieri
- Department of Anaesthesia and Intensive Care Medicine, Sapienza University of Rome, 00161 Rome, Italy.
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Combes A, Pesenti A, Brodie D. Do we need randomized clinical trials in extracorporeal respiratory support? Yes. Intensive Care Med 2017; 43:1862-1865. [PMID: 28914339 DOI: 10.1007/s00134-017-4933-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/06/2017] [Indexed: 12/20/2022]
Abstract
Extracorporeal respiratory support, also known as extracorporeal gas exchange, may be used to rescue the most severe forms of acute hypoxemic respiratory failure with high blood flow venovenous extracorporeal membrane oxygenation. Alternatively, lower flow extracorporeal carbon dioxide removal might be applied to reduce the intensity of mechanical ventilation in patients with less severe forms of the disease. However, critical reading of the results of the randomized trials and case series published to date reveals major methodological biases. Older trials are not relevant anymore since the ECMO circuitry was not heparin-coated leading to severe hemorrhagic complications due to high levels of anticoagulation, and because extracorporeal membrane oxygenation (ECMO) and control group patients did not receive lung-protective ventilation. Alternatively, in the more recent CESAR trial, many patients randomized to the ECMO arm did not receive ECMO and no standardized protocol for lung-protective mechanical ventilation existed in the control group. Since these techniques are costly and associated with potentially serious adverse events, there is an urgent need for high-quality data, for which the cornerstone remains randomized controlled trials.
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Affiliation(s)
- Alain Combes
- Medical-Surgical Intensive Care Unit, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 75013, Paris, France. .,Sorbonne University Paris, INSERM, Institute of Cardiometabolism and Nutrition UMRS_1166-ICAN, 75013, Paris, France.
| | - Antonio Pesenti
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, AND Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center/New York-Presbyterian Hospital, Columbia University, New York, NY, USA
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49
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Chiumello D, Brochard L, Marini JJ, Slutsky AS, Mancebo J, Ranieri VM, Thompson BT, Papazian L, Schultz MJ, Amato M, Gattinoni L, Mercat A, Pesenti A, Talmor D, Vincent JL. Respiratory support in patients with acute respiratory distress syndrome: an expert opinion. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:240. [PMID: 28899408 PMCID: PMC5596474 DOI: 10.1186/s13054-017-1820-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a common condition in intensive care unit patients and remains a major concern, with mortality rates of around 30–45% and considerable long-term morbidity. Respiratory support in these patients must be optimized to ensure adequate gas exchange while minimizing the risks of ventilator-induced lung injury. The aim of this expert opinion document is to review the available clinical evidence related to ventilator support and adjuvant therapies in order to provide evidence-based and experience-based clinical recommendations for the management of patients with ARDS.
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Affiliation(s)
- Davide Chiumello
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - John J Marini
- University of Minnesota, Minneapolis, Saint Paul, MN, USA
| | - Arthur S Slutsky
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jordi Mancebo
- University of Montreal and Department of Intensive Care, Centre Hospitalier Université de Montréal, Montréal, QC, Canada
| | - V Marco Ranieri
- Department of Anesthesia and Critical Care Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161, Rome, Italy
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Laurent Papazian
- Réanimation des Détresses Respiratoires et Infections Sévères, Hôpital Nord-Assistance Publique-Hôpitaux de Marseille Aix-Marseille Université, Marseille, France
| | - Marcus J Schultz
- Mahidol Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Marcelo Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luciano Gattinoni
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Alain Mercat
- CHU d'Angers, Réanimation Médicale et Médecine Hyperbare, Angers, France
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Daniel Talmor
- Department of Anesthesia and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
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Predicting Major Adverse Kidney Events among Critically Ill Adults Using the Electronic Health Record. J Med Syst 2017; 41:156. [PMID: 28861688 DOI: 10.1007/s10916-017-0806-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 08/24/2017] [Indexed: 10/19/2022]
Abstract
Prediction of major adverse kidney events in critically ill patients may help target therapy, allow risk adjustment, and facilitate the conduct of clinical trials. In a cohort comprised of all critically ill adults admitted to five intensive care units at a single tertiary care center over one year, we developed a logistic regression model for the outcome of Major Adverse Kidney Events within 30 days (MAKE30), the composite of persistent renal dysfunction, new renal replacement therapy (RRT), and in-hospital mortality. Proposed risk factors for the MAKE30 outcome were selected a priori and included age, race, gender, University Health System Consortium (UHC) expected mortality, baseline creatinine, volume of isotonic crystalloid fluid received in the prior 24 h, admission service, intensive care unit (ICU), source of admission, mechanical ventilation or receipt of vasopressors within 24 h of ICU admission, renal replacement therapy prior to ICU admission, acute kidney injury, chronic kidney disease as defined by baseline creatinine value, and renal failure as defined by the Elixhauser index. Among 10,983 patients in the study population, 1489 patients (13.6%) met the MAKE30 endpoint. The strongest independent predictors of MAKE30 were UHC expected mortality (OR 2.32 [95%CI 2.06-2.61]) and presence of acute kidney injury at ICU admission (OR 4.98 [95%CI 4.12-6.03]). The model had strong predictive properties including excellent discrimination with a bootstrap-corrected area-under-the-curve (AUC) of 0.903, and high precision of calibration with a mean absolute error prediction of 1.7%. The MAKE30 composite outcome can be reliably predicted from factors present within 24 h of ICU admission using data derived from the electronic health record.
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