The beta agonist lung injury trial prevention. A randomized controlled trial

RATIONALE

Experimental studies suggest that pretreatment with β-agonists might prevent acute lung injury (ALI).

OBJECTIVES

To determine if in adult patients undergoing elective esophagectomy, perioperative treatment with inhaled β-agonists effects the development of early ALI.

METHODS

We conducted a randomized placebo-controlled trial in 12 UK centers (2008-2011). Adult patients undergoing elective esophagectomy were allocated to prerandomized, sequentially numbered treatment packs containing inhaled salmeterol (100 μg twice daily) or a matching placebo. Patients, clinicians, and researchers were masked to treatment allocation. The primary outcome was development of ALI within 72 hours of surgery. Secondary outcomes were ALI within 28 days, organ failure, adverse events, survival, and health-related quality of life. An exploratory substudy measured biomarkers of alveolar-capillary inflammation and injury.

MEASUREMENTS AND MAIN RESULTS

A total of 179 patients were randomized to salmeterol and 183 to placebo. Baseline characteristics were similar. Treatment with salmeterol did not prevent early lung injury (32 [19.2%] of 168 vs. 27 [16.0%] of 170; odds ratio [OR], 1.25; 95% confidence interval [CI], 0.71-2.22). There was no difference in organ failure, survival, or health-related quality of life. Adverse events were less frequent in the salmeterol group (55 vs. 70; OR, 0.63; 95% CI, 0.39-0.99), predominantly because of a lower number of pneumonia (7 vs. 17; OR, 0.39; 95% CI, 0.16-0.96). Salmeterol reduced some biomarkers of alveolar inflammation and epithelial injury.

CONCLUSION

Perioperative treatment with inhaled salmeterol was well tolerated but did not prevent ALI. Clinical trial registered with International Standard Randomized Controlled Trial Register (ISRCTN47481946) and European Union database of randomized Controlled Trials (EudraCT 2007-004096-19).

[Minimally invasive cardiopulmonary monitoring with the PiCCO Plus system]

Insertion of a central venous catheter and an arterial catheter would be indicated in hemodynamically unstable or severely hypoxic patients in critical care units. In this setting, cardiorespiratory monitoring by transpulmonary thermodilution (TPTD) can be considered minimally invasive given that only a single arterial thermodilution catheter and a single central venous catheter are required to be connected to a specific monitor (the PiCCO Plus, Pulsion Medical Systems, Munich, Germany). TDTP simultaneously measures cardiac output, preloading, and cardiac function in hemodynamically unstable patients and predicts the response to volume. The technique can be managed by any health care professional. In hypoxic patients, TDTP identifies cases of pulmonary edema that might benefit from a negative fluid balance, evaluates pulmonary vascular permeability, facilitates our understanding of pathophysiologic mechanisms of hypoxemia, and predicts the likelihood of deleterious hemodynamic effects of positive end-expiratory pressures.