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Dushianthan A, Cumpstey AF, Ferrari M, Thomas W, Moonesinghe RS, Summers C, Montgomery H, Grocott MPW. Intensive care physicians' perceptions of the diagnosis & management of patients with acute hypoxic respiratory failure associated with COVID-19: A UK based survey. J Intensive Care Soc 2022; 23:285-292. [PMID: 36033252 PMCID: PMC9403530 DOI: 10.1177/17511437211002352] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Whilst the management of Coronavirus disease-2019 (COVID-19) has evolved in response to the emerging data, treating such patients remains a challenge, and many treatments lack robust clinical evidence. We conducted a survey to evaluate Intensive Care Unit (ICU) management of COVID-19 patients with acute hypoxic respiratory failure and compared the results with data from a similar survey focusing on Acute Respiratory Distress Syndrome (ARDS) that was conducted in 2013. METHODS The questionnaire was refined from a previous survey of ARDS-related clinical practice using an online electronic survey engine (Survey Monkey®) and all UK intensivists were encouraged to participate. The survey was conducted between 16/05/2020 and 17/06/2020. RESULTS There were 137 responses from 89 UK centres. Non-invasive ventilation was commonly used in the form of CPAP. The primary ventilation strategy was the ARDSnet protocol, with 63% deviating from its PEEP recommendations. Similar to our previous ARDS survey, most allowed permissive targets for hypoxia (94%), hypercapnia (55%) and pH (94%). The routine use of antibiotics was common, and corticosteroids were frequently used, usually in the context of a clinical trial (45%). Late tracheostomy (>7 days) was preferred (92%). Routine follow-up was offered by 66% with few centres providing routine dedicated rehabilitation programmes following discharge. Compared to the ARDS survey, there is an increased use of neuromuscular agents, APRV ventilation and improved provision of rehabilitation services. CONCLUSIONS Similar to our previous ARDS survey, this survey highlights variations in the management strategies used for patients with acute hypoxic respiratory failure due to COVID-19.
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Affiliation(s)
- Ahilanandan Dushianthan
- Critical Care Research Group, Southampton National Institute of Health Research Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Andrew F Cumpstey
- Critical Care Research Group, Southampton National Institute of Health Research Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Matteo Ferrari
- Critical Care Research Group, Southampton National Institute of Health Research Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - William Thomas
- Critical Care Research Group, Southampton National Institute of Health Research Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Ramani S Moonesinghe
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
| | - Charlotte Summers
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Hugh Montgomery
- Centre for Human Health and Performance, Department of Medicine, University College London, London, UK
| | - Michael PW Grocott
- Critical Care Research Group, Southampton National Institute of Health Research Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
- MPW Grocott, General Intensive care Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK.
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Xuan N, Zhang X, Hu W, Chen G, Wang Y, Zhang S, Cui W, Zhang G. Effects of the working experience, educational background, professional titles, and hospital grades of intensive care unit doctors on clinical glucocorticoid use in acute respiratory distress syndrome. Medicine (Baltimore) 2022; 101:e29021. [PMID: 35451401 PMCID: PMC8913106 DOI: 10.1097/md.0000000000029021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/28/2022] [Accepted: 02/13/2022] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT Although glucocorticoids are commonly used for patients with acute respiratory distress syndrome in the intensive care unit, the exact attitudes of different intensive care unit (ICU) doctors about glucocorticoid usage are largely unknown. Herein, we investigated the practice of glucocorticoid application for acute respiratory distress syndrome (ARDS) by ICU doctors in China. Questionnaires were developed and sent to ICU doctors at 45 hospitals to perform statistics and analysis. ICU doctors with more working experience and professional titles had more knowledge of ARDS. Glucocorticoids were more likely to be used for ARDS caused by chemical inhalation. Doctors with longer working experience, better educational background, and higher professional titles used fewer glucocorticoids. In addition, 97.2%of the doctors considered using methylprednisolone or hydrocortisone first, 50.9% used glucocorticoids within 24hours of onset, and 37.1% insisted that steroid therapy should last 3 to 5days. Although ICU doctors with more working experience and professional titles have a better understanding of glucocorticoid use in ARDS, the majority of clinical practices and attitudes are similar among different doctors regardless of working experience, educational background, professional titles, or hospital grades.
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Affiliation(s)
- Nanxia Xuan
- Department of Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xing Zhang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Medical Security Bureau of Yinzhou District, Ningbo, Zhejiang, China
| | - Wenqing Hu
- Department of Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Emergency Medicine, Haining People's Hospital (Haining Branch of the First Affiliated Hospital of Zhejiang University School of Medicine), Haining, Zhejiang, China
| | - Guodong Chen
- Department of Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Critical Care Medicine, The First Hospital of Ningbo Affiliated to Zhejiang University School of Medicine, Ningbo, Zhejiang, China
| | - Yesong Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shufang Zhang
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Wei Cui
- Department of Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Gensheng Zhang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhenjiang, China
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Ding H, Li Y, Li X, Liu X, Chen S, Liu M, Zeng H. Treatment with 7% and 10% CO 2 enhanced expression of IL-1β, TNF-α, and IL-6 in hypoxic cultures of human whole blood. J Int Med Res 2021; 48:300060520912105. [PMID: 32264730 PMCID: PMC7144675 DOI: 10.1177/0300060520912105] [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] [Indexed: 12/15/2022] Open
Abstract
Objective This study investigated whether hypercapnia influenced the inflammatory response of hypoxic blood. Methods Human whole blood was cultured with 0.2% oxygen (O2) and treated with 5%, 7%, or 10% carbon dioxide (CO2). Interleukin (IL)-1β, tumor necrosis factor (TNF)-α, and IL-6 were evaluated in whole blood cultures. Reactive oxygen species (ROS) production and expression levels of caspase-1 and IL-1β were evaluated in THP-1 monocytic cells. Results IL-1β, TNF-α, and IL-6 levels were higher in the hypoxia + 7% CO2 group than in the hypoxia + 5% CO2 group. The hypoxia + 10% CO2 group had the highest IL-1β, TNF-α, and IL-6 levels, compared with the hypoxia + 7% CO2 and hypoxia + 5% CO2 groups. Expression levels of IL-1β, TNF-α, and IL-6 were significantly negatively correlated with pH levels in the cell culture medium. Treatment with 7% and 10% CO2 increased the production of ROS and the expression of caspase-1 and IL-1β in hypoxia-activated THP-1 cells. Conclusions High levels of CO2 treatment increased expression levels of IL-1β, TNF-α, and IL-6 in hypoxic whole blood cultures. High levels of CO2-induced ROS overproduction and NLRP3 inflammasome activation in monocytes may comprise a target to mitigate the inflammatory response of hypoxic blood.
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Affiliation(s)
- Hongguang Ding
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ya Li
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Medicine, South China University of Technology, Guangzhou, China
| | - Xusheng Li
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xinqiang Liu
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shenglong Chen
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Mengting Liu
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hongke Zeng
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Ding HG, Li Y, Li XS, Liu XQ, Wang KR, Wen MY, Jiang WQ, Zeng HK. Hypercapnia promotes microglial pyroptosis via inhibiting mitophagy in hypoxemic adult rats. CNS Neurosci Ther 2020; 26:1134-1146. [PMID: 32666671 PMCID: PMC7564198 DOI: 10.1111/cns.13435] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 12/19/2022] Open
Abstract
Background Hypoxemia is a typical symptom of acute respiratory distress syndrome. To avoid pulmonary morbidity, low tidal volume ventilation is often applied. The ventilation strategy will certainly cause hypercapnia. This study aimed to explore whether hypercapnia would promote microglial pyroptosis via inhibiting mitophagy in adult rats with hypoxemia. Methods The cerebral oxygen extraction ratio (CERO2) and partial pressure of brain tissue oxygen (PbtO2) in a rat model of hypercapnia/hypoxemia were assessed. The reactive oxygen species (ROS) production and the expression of LC3‐II/I, p62, caspase‐1, gasdermin D‐N domains (GSDMD‐N), IL‐1β, and IL‐18 in microglial cells were detected. Results Hypercapnia decreased the PbtO2 levels of the hypoxic rats, which was further evidenced by the increased levels of CERO2. Expression levels of LC3‐II were reduced, while p62 expression was increased by hypercapnia in hypoxic microglia. Hypercapnia increased the production of ROS and the expression of caspase‐1, GSDMD‐N, IL‐1β, and IL‐18 in hypoxia‐activated microglia. Scavenging ROS inhibited microglial pyroptosis and expression of IL‐1β and IL‐18. Conclusions These results suggest that hypercapnia‐induced mitophagy inhibition may promote pyroptosis and enhance IL‐1β and IL‐18 release in hypoxia‐activated microglia.
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Affiliation(s)
- Hong-Guang Ding
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ya Li
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Medicine, South China University of Technology, Guangzhou, China
| | - Xu-Sheng Li
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xin-Qiang Liu
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Kang-Rong Wang
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Southern Medical University, Guangzhou, China
| | - Miao-Yun Wen
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wen-Qiang Jiang
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hong-Ke Zeng
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Ding H, Liu X, Li X, Wen M, Li Y, Han Y, Huang L, Liu M, Zeng H. Hypercapnia exacerbates the disruption of the blood‑brain barrier by inducing interleukin‑1β overproduction in the blood of hypoxemic adult rats. Int J Mol Med 2020; 46:762-772. [PMID: 32626911 PMCID: PMC7307827 DOI: 10.3892/ijmm.2020.4604] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 04/27/2020] [Indexed: 12/28/2022] Open
Abstract
Refractory hypoxemia is the main symptom of acute respiratory distress syndrome (ARDS). Low tidal volume ventilation is routinely applied in clinical practice to correct hypoxemia, which aims to prevent ventilator‑induced lung injury. However, this ventilation strategy inevitably leads to hypercapnia. Our previous study demonstrated that hypercapnia aggravated cognitive impairment in hypoxemic rats; however, the underlying mechanism remains unclear. The aim of the present study was to investigate whether hypercapnia exacerbates the blood‑brain barrier (BBB) disruption through inducing interleukin (IL)‑1β overproduction in the blood of hypoxemic rats. The BBB permeability in a rat model of hypercapnia/hypoxemia was evaluated. The levels of IL‑1β in the blood of rats and human whole‑blood cultures were assessed. The expression of IL‑1 receptor 1 (IL‑1R1), phosphorylated IL‑1R1‑associated kinase (p‑IRAK‑1) and tight junctional proteins in cerebral vascular endothelial cells was examined in vitro and in vivo. In addition, IL‑1Ra, an IL‑1 receptor antagonist, was used to determine whether hypercapnia affects tight junctional protein expression in hypoxic cerebral vascular endothelial cells through inducing IL‑1β overproduction. It was observed that hypercapnia alone did not disrupt the BBB, but aggravated the damage to the BBB integrity in hypoxemic rats. Hypercapnia increased IL‑1β expression in the blood of hypoxemic rats as well as in hypoxic human whole‑blood cultures. IL‑1R1 and p‑IRAK‑1 expression was increased, while that of tight junctional proteins was reduced by hypercapnia in hypoxemic cerebral vascular endothelial cells in vitro and in vivo. Additionally, the expression of tight junctional proteins was markedly increased following treatment with IL‑1Ra. These results suggest that hypercapnia‑induced IL‑1β overproduction in the hypoxemic blood may decrease tight junctional protein expression in cerebrovascular endothelial cells via the IL‑1R1/p‑IRAK‑1 pathway, further disrupting BBB integrity, and eventually resulting in increased BBB permeability.
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Affiliation(s)
- Hongguang Ding
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, P.R. China
| | - Xinqiang Liu
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, P.R. China
| | - Xusheng Li
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, P.R. China
| | - Miaoyun Wen
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, P.R. China
| | - Ya Li
- School of Medicine, South China University of Technology, Guangzhou, Guangdong 510006, P.R. China
| | - Yongli Han
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, P.R. China
| | - Linqiang Huang
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, P.R. China
| | - Mengting Liu
- School of Medicine, South China University of Technology, Guangzhou, Guangdong 510006, P.R. China
| | - Hongke Zeng
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, P.R. China
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6
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Blecha S, Brandstetter S, Dodoo-Schittko F, Brandl M, Graf BM, Bein T, Apfelbacher C. Acceptability of a German multicentre healthcare research study: a survey of research personnels' attitudes, experiences and work load. BMJ Open 2018; 8:e023166. [PMID: 30249633 PMCID: PMC6157522 DOI: 10.1136/bmjopen-2018-023166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The DACAPO study as a multicentre nationwide observational healthcare research study investigates the influence of quality of care on the quality of life in patients with acute respiratory distress syndrome. The aim of this study was to investigate the acceptability to the participating research personnels by assessing attitudes, experiences and workload associated with the conduct of the DACAPO study. DESIGN, SETTING AND PARTICIPANTS A prospective anonymous online survey was sent via email account to 169 participants in 65 study centres. The questionnaire included six different domains: (1) training for performing the study; (2) obtaining informed consent; (3) data collection; (4) data entry using the online documentation system; (5) opinion towards the study and (6) personal data. Descriptive data analysis was carried out. RESULTS A total of 78 participants took part (46%) in the survey, 75 questionnaires (44%) could be evaluated. 51% were senior medical specialists. 95% considered the time frame of the training as appropriate and the presentation was rated by 93% as good or very good. Time effort for obtaining consent, data collection and entry was considered by 41% as a burden. Support from the coordinating study centre was rated as good or very good by more than 90% of respondents. While the DACAPO study was seen as scientifically relevant by 81%, only 45% considered the study results valuable for improving patient care significantly. CONCLUSION Collecting feedback on the acceptability of a large multicentre healthcare research study provided important insights. Recruitment and data acquisition was mainly performed by physicians and often regarded as additional time burden in clinical practice. Reducing the amount of data collection and simplifying data entry could facilitate the conduct of healthcare research studies and could improve motivation of researchers in intensive care medicine. TRIAL REGISTRATION NUMBER NCT02637011; Pre-results.
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Affiliation(s)
- Sebastian Blecha
- Department of Anaesthesiology, University Medical Centre Regensburg, Regensburg, Germany
| | - Susanne Brandstetter
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Frank Dodoo-Schittko
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Magdalena Brandl
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Bernhard M Graf
- Department of Anaesthesiology, University Medical Centre Regensburg, Regensburg, Germany
| | - Thomas Bein
- Department of Anaesthesiology, University Medical Centre Regensburg, Regensburg, Germany
| | - Christian Apfelbacher
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
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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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Ding HG, Deng YY, Yang RQ, Wang QS, Jiang WQ, Han YL, Huang LQ, Wen MY, Zhong WH, Li XS, Yang F, Zeng HK. Hypercapnia induces IL-1β overproduction via activation of NLRP3 inflammasome: implication in cognitive impairment in hypoxemic adult rats. J Neuroinflammation 2018; 15:4. [PMID: 29304864 PMCID: PMC5755461 DOI: 10.1186/s12974-017-1051-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 12/27/2017] [Indexed: 12/29/2022] Open
Abstract
Background Cognitive impairment is one of common complications of acute respiratory distress syndrome (ARDS). Increasing evidence suggests that interleukin-1 beta (IL-1β) plays a role in inducing neuronal apoptosis in cognitive dysfunction. The lung protective ventilatory strategies, which serve to reduce pulmonary morbidity for ARDS patients, almost always lead to hypercapnia. Some studies have reported that hypercapnia contributes to the risk of cognitive impairment and IL-1β secretion outside the central nervous system (CNS). However, the underlying mechanism of hypercapnia aggravating cognitive impairment under hypoxia has remained uncertain. This study was aimed to explore whether hypercapnia would partake in increasing IL-1β secretion via activating the NLRP3 (NLR family, pyrin domain-containing 3) inflammasome in the hypoxic CNS and in aggravating cognitive impairment. Methods The Sprague-Dawley (SD) rats that underwent hypercapnia/hypoxemia were used for assessment of NLRP3, caspase-1, IL-1β, Bcl-2, Bax, and caspase-3 expression by Western blotting or double immunofluorescence, and the model was also used for Morris water maze test. In addition, Z-YVAD-FMK, a caspase-1 inhibitor, was used to treat BV-2 microglia to determine whether activation of NLRP3 inflammasome was required for the enhancing effect of hypercapnia on expressing IL-1β by Western blotting or double immunofluorescence. The interaction effects were analyzed by factorial ANOVA. Simple effects analyses were performed when an interaction was observed. Results There were interaction effects on cognitive impairment, apoptosis of hippocampal neurons, activation of NLRP3 inflammasome, and upregulation of IL-1β between hypercapnia treatment and hypoxia treatment. Hypercapnia + hypoxia treatment caused more serious damage to the learning and memory of rats than those subjected to hypoxia treatment alone. Expression levels of Bcl-2 were reduced, while that of Bax and caspase-3 were increased by hypercapnia in hypoxic hippocampus. Hypercapnia markedly increased the expression of NLRP3, caspase-1, and IL-1β in hypoxia-activated microglia both in vivo and in vitro. Pharmacological inhibition of NLRP3 inflammasome activation and release of IL-1β might ameliorate apoptosis of neurons. Conclusions The present results suggest that hypercapnia-induced IL-1β overproduction via activating the NLRP3 inflammasome by hypoxia-activated microglia may augment neuroinflammation, increase neuronal cell death, and contribute to the pathogenesis of cognitive impairments.
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Affiliation(s)
- Hong-Guang Ding
- Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China.,Department of Emergency and Critical Care Medicine, Guangdong General Hospital and Guangdong Academy of Medical Sciences, 106 ZhongshanEr Road, Guangzhou, 510080, China.,Department of Emergency, Dongguan Third People's Hospital, Dongguan, Guangdong, China
| | - Yi-Yu Deng
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital and Guangdong Academy of Medical Sciences, 106 ZhongshanEr Road, Guangzhou, 510080, China
| | - Ren-Qiang Yang
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital and Guangdong Academy of Medical Sciences, 106 ZhongshanEr Road, Guangzhou, 510080, China
| | - Qiao-Sheng Wang
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital and Guangdong Academy of Medical Sciences, 106 ZhongshanEr Road, Guangzhou, 510080, China
| | - Wen-Qiang Jiang
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital and Guangdong Academy of Medical Sciences, 106 ZhongshanEr Road, Guangzhou, 510080, China
| | - Yong-Li Han
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital and Guangdong Academy of Medical Sciences, 106 ZhongshanEr Road, Guangzhou, 510080, China
| | - Lin-Qiang Huang
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital and Guangdong Academy of Medical Sciences, 106 ZhongshanEr Road, Guangzhou, 510080, China
| | - Miao-Yun Wen
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital and Guangdong Academy of Medical Sciences, 106 ZhongshanEr Road, Guangzhou, 510080, China
| | - Wen-Hong Zhong
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital and Guangdong Academy of Medical Sciences, 106 ZhongshanEr Road, Guangzhou, 510080, China
| | - Xu-Sheng Li
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital and Guangdong Academy of Medical Sciences, 106 ZhongshanEr Road, Guangzhou, 510080, China
| | - Fan Yang
- Department of Emergency and Critical Care Medicine, Guangdong General Hospital and Guangdong Academy of Medical Sciences, 106 ZhongshanEr Road, Guangzhou, 510080, China
| | - Hong-Ke Zeng
- Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China. .,Department of Emergency and Critical Care Medicine, Guangdong General Hospital and Guangdong Academy of Medical Sciences, 106 ZhongshanEr Road, Guangzhou, 510080, China.
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Adjuvants to Mechanical Ventilation for Acute Respiratory Failure. Adoption, De-adoption, and Factors Associated with Selection. Ann Am Thorac Soc 2017; 14:94-102. [PMID: 27737558 DOI: 10.1513/annalsats.201606-438oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Adoption and de-adoption of adjuvant strategies to mechanical ventilation for acute respiratory failure (ARF), and factors associated with their selection, have not been extensively evaluated. OBJECTIVES To evaluate change in use of adjuvants to mechanical ventilation for ARF (2008-2013), the impact of landmark publications on adoption and de-adoption, and factors associated with use. METHODS Changes in use of four adjuvants for ARF from 2008 to 2013, the impact of landmark publications on use, and factors associated with use were evaluated with the Premier Database. Extracorporeal membrane oxygenation (ECMO), inhaled nitric oxide, inhaled epoprostenol, and continuous neuromuscular blockading agents (cNMBAs) in adult mechanically ventilated patients were identified on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification codes and billing data. MEASUREMENTS AND MAIN RESULTS Among 514,913 patients with ARF, 11,567 (2.3%) were treated with at least one adjuvant. cNMBAs were the most frequently used adjuvants (n = 10,073, 2.1% in capable hospitals), followed by inhaled pulmonary vasodilators (n = 1,878, 1.0% in capable hospitals; 58% nitric oxide), and ECMO (n = 195, 0.2% in capable hospitals). There was an increase in ECMO and inhaled epoprostenol over time but no change in nitric oxide or cNMBAs. Segmented regression analysis was used to evaluate whether clinical practice was in accordance with emerging evidence from landmark studies. Using the relevant landmark publication dates, these analyses did not reveal any change in use over time after publication with the exception of inhaled epoprostenol-for which rates of growth decreased over time, possibly in response to the evidence. There was a significant amount of variability in patient and hospital factors associated with use with between adjuvants. CONCLUSIONS Between 2008 and 2013, there was an increase in use of ECMO and inhaled epoprostenol, and no change in use of inhaled nitric oxide or continuous intravenous infusion of a neuromuscular blocking agent. There was considerable variability in patient and hospital factors associated with use across different adjuvants.
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Artigas A, Camprubí-Rimblas M, Tantinyà N, Bringué J, Guillamat-Prats R, Matthay MA. Inhalation therapies in acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:293. [PMID: 28828368 DOI: 10.21037/atm.2017.07.21] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The defining features of acute respiratory distress syndrome (ARDS) are an excessive inflammatory respiratory response associated with high morbidity and mortality. Treatment consists mainly of measures to avoid worsening lung injury and cannot reverse the underlying pathophysiological process. New pharmacological agents have shown promising results in preclinical studies; however, they have not been successfully translated to patients with ARDS. The lack of effective therapeutic interventions has resulted in a recent interest in strategies to prevent ARDS with treatments delivering medications directly to the lungs by inhalation and nebulization, hopefully minimizing systemic adverse events. We analyzed the effect of different aerosolized drugs such as bronchodilators, corticosteroids, pulmonary vasodilators, anticoagulants, mucolytics and surfactant. New therapeutic strategies and ongoing trials using carbon monoxide (CO) and AP301 peptide are also briefly reviewed.
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Affiliation(s)
- Antonio Artigas
- Institut d'Investigació i Innovació Parc Tauli (I3PT), Sabadell, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain.,Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Critical Care Center, Corporació Sanitària Universitaria Parc Taulí, Sabadell, Spain
| | - Marta Camprubí-Rimblas
- Institut d'Investigació i Innovació Parc Tauli (I3PT), Sabadell, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Neus Tantinyà
- Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Josep Bringué
- Institut d'Investigació i Innovació Parc Tauli (I3PT), Sabadell, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain.,Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Raquel Guillamat-Prats
- Institut d'Investigació i Innovació Parc Tauli (I3PT), Sabadell, Spain.,Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Michael A Matthay
- Departments of Medicine and Anesthesia and Cardiovascular Research Institute, University of California, San Francisco, USA
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11
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Adjuvants to mechanical ventilation for acute respiratory distress syndrome. Intensive Care Med 2016; 42:775-778. [PMID: 27022981 DOI: 10.1007/s00134-016-4327-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 03/11/2016] [Indexed: 01/21/2023]
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12
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Luedike P, Totzeck M, Rammos C, Kindgen-Milles D, Kelm M, Rassaf T. One-year experience with an acute respiratory distress syndrome standard operating procedure on intensive care unit. J Crit Care 2015. [PMID: 26216357 DOI: 10.1016/j.jcrc.2015.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Mortality in acute respiratory distress syndrome (ARDS) patients remains unacceptable high, and there is substantial variation in the diagnostic and management strategies used. We recently established a standardized algorithm for the early identification and guideline conform therapy of ARDS on intensive care units (ICUs). We here present the results of a first-year observatory period after implementation of the ARDS bundle on our ICU. METHODS AND RESULTS A retrospective, observative, single-center case control study over a period of 4 years was performed. We analyzed the effects after implementation of an ARDS standard operating procedure (SOP) on prevalence of the diagnosis ARDS, mortality from ARDS, and therapy strategies. Implementation of the SOP led to an increased frequency of ARDS diagnosis (P < .05), increased application of early prone positioning (P < .05), and use of neuromuscular blockers (P < .02) in ARDS patients. An influence on mortality in ARDS patients could not be detected after implementation of the SOP (P = not significant). CONCLUSION A standardized ARDS bundle fundamentally increases awareness of this clinical picture on ICU and facilitates application of evidence-based therapies like prone positioning and use of neuromuscular blockers. These data encourage evaluating our ARDS SOP in a prospective trial to identify potential effects on mortality.
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Affiliation(s)
- Peter Luedike
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Duesseldorf, Moorenstrasse 5, D-40225, Duesseldorf, Germany
| | - Matthias Totzeck
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Duesseldorf, Moorenstrasse 5, D-40225, Duesseldorf, Germany
| | - Christos Rammos
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Duesseldorf, Moorenstrasse 5, D-40225, Duesseldorf, Germany
| | - Detlef Kindgen-Milles
- Division of Anaesthesiology, Medical Faculty Heinrich-Heine-University, University Hospital Duesseldorf, Moorenstrasse 5, D-40225, Duesseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Duesseldorf, Moorenstrasse 5, D-40225, Duesseldorf, Germany
| | - Tienush Rassaf
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Duesseldorf, Moorenstrasse 5, D-40225, Duesseldorf, Germany.
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13
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Browne E, Hellyer TP, Baudouin SV, Conway Morris A, Linnett V, McAuley DF, Perkins GD, Simpson AJ. A national survey of the diagnosis and management of suspected ventilator-associated pneumonia. BMJ Open Respir Res 2014; 1:e000066. [PMID: 25553248 PMCID: PMC4275666 DOI: 10.1136/bmjresp-2014-000066] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 11/10/2014] [Accepted: 11/12/2014] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) affects up to 20% of patients admitted to intensive care units (ICU). It is associated with increased morbidity, mortality and healthcare costs. Despite published guidelines, variability in diagnosis and management exists, the extent of which remains unclear. We sought to characterise consultant opinions surrounding diagnostic and management practice for VAP in the UK. METHODS An online survey was sent to all consultant members of the UK Intensive Care Society (n=∼1500). Data were collected regarding respondents' individual practice in the investigation and management of suspected VAP including use of diagnostic criteria, microbiological sampling, chest X-ray (CXR), bronchoscopy and antibiotic treatments. RESULTS 339 (23%) responses were received from a broadly representative spectrum of ICU consultants. All respondents indicated that microbiological confirmation should be sought, the majority (57.8%) stating they would take an endotracheal aspirate prior to starting empirical antibiotics. Microbiology reporting services were described as qualitative only by 29.7%. Only 17% of respondents had access to routine reporting of CXRs by a radiologist. Little consensus exists regarding technique for bronchoalveolar lavage (BAL) with the reported volume of saline used ranging from 5 to 500 mL. 24.5% of consultants felt inadequately trained in bronchoscopy. CONCLUSIONS There is wide variability in the approach to diagnosis and management of VAP among UK consultants. Such variability challenges the reliability of the diagnosis of VAP and its reported incidence as a performance indicator in healthcare systems. The data presented suggest increased radiological and microbiological support, and standardisation of BAL technique, might improve this situation.
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Affiliation(s)
- Emma Browne
- Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
| | - Thomas P Hellyer
- Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
| | - Simon V Baudouin
- Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
| | - Andrew Conway Morris
- MRC Centre for Inflammation Research, University of Edinburgh, and Critical Care NHS Lothian , Edinburgh , UK
| | - Vanessa Linnett
- Queen Elizabeth Hospital, Gateshead Health NHS Trust , Gateshead , UK
| | - Danny F McAuley
- Centre for Infection and Immunity, Queen's University Belfast and Regional Intensive Care Unit, Royal Victoria Hospital Belfast , Belfast , Northern Ireland
| | - Gavin D Perkins
- Warwick Medical School and Heart of England NHS Foundation Trust , Birmingham , UK
| | - A John Simpson
- Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
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