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Rodríguez-Leal CM, González-Corralejo C, Candel FJ, Salavert M. Candent issues in pneumonia. Reflections from the Fifth Annual Meeting of Spanish Experts 2023. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2024; 37:221-251. [PMID: 38436606 PMCID: PMC11094633 DOI: 10.37201/req/018.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 03/05/2024]
Abstract
Pneumonia is a multifaceted illness with a wide range of clinical manifestations, degree of severity and multiple potential causing microorganisms. Despite the intensive research of recent decades, community-acquired pneumonia remains the third-highest cause of mortality in developed countries and the first due to infections; and hospital-acquired pneumonia is the main cause of death from nosocomial infection in critically ill patients. Guidelines for management of this disease are available world wide, but there are questions which generate controversy, and the latest advances make it difficult to stay them up to date. A multidisciplinary approach can overcome these limitations and can also aid to improve clinical results. Spanish medical societies involved in diagnosis and treatment of pneumonia have made a collaborative effort to actualize and integrate last expertise about this infection. The aim of this paper is to reflect this knowledge, communicated in Fifth Pneumonia Day in Spain. It reviews the most important questions about this disorder, such as microbiological diagnosis, advances in antibiotic and sequential therapy, management of beta-lactam allergic patient, preventive measures, management of unusual or multi-resistant microorganisms and adjuvant or advanced therapies in Intensive Care Unit.
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Affiliation(s)
| | | | - F J Candel
- Francisco Javier Candel, Clinical Microbiology Service. Hospital Clínico San Carlos. IdISSC and IML Health Research Institutes. 28040 Madrid. Spain.
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Lim EY, Lee SY, Shin HS, Kim GD. Reactive Oxygen Species and Strategies for Antioxidant Intervention in Acute Respiratory Distress Syndrome. Antioxidants (Basel) 2023; 12:2016. [PMID: 38001869 PMCID: PMC10669909 DOI: 10.3390/antiox12112016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/16/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening pulmonary condition characterized by the sudden onset of respiratory failure, pulmonary edema, dysfunction of endothelial and epithelial barriers, and the activation of inflammatory cascades. Despite the increasing number of deaths attributed to ARDS, a comprehensive therapeutic approach for managing patients with ARDS remains elusive. To elucidate the pathological mechanisms underlying ARDS, numerous studies have employed various preclinical models, often utilizing lipopolysaccharide as the ARDS inducer. Accumulating evidence emphasizes the pivotal role of reactive oxygen species (ROS) in the pathophysiology of ARDS. Both preclinical and clinical investigations have asserted the potential of antioxidants in ameliorating ARDS. This review focuses on various sources of ROS, including NADPH oxidase, uncoupled endothelial nitric oxide synthase, cytochrome P450, and xanthine oxidase, and provides a comprehensive overview of their roles in ARDS. Additionally, we discuss the potential of using antioxidants as a strategy for treating ARDS.
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Affiliation(s)
- Eun Yeong Lim
- Division of Food Functionality Research, Korea Food Research Institute (KFRI), Wanju 55365, Republic of Korea; (E.Y.L.); (S.-Y.L.); (H.S.S.)
| | - So-Young Lee
- Division of Food Functionality Research, Korea Food Research Institute (KFRI), Wanju 55365, Republic of Korea; (E.Y.L.); (S.-Y.L.); (H.S.S.)
- Department of Food Biotechnology, Korea University of Science and Technology (UST), Daejeon 34113, Republic of Korea
| | - Hee Soon Shin
- Division of Food Functionality Research, Korea Food Research Institute (KFRI), Wanju 55365, Republic of Korea; (E.Y.L.); (S.-Y.L.); (H.S.S.)
- Department of Food Biotechnology, Korea University of Science and Technology (UST), Daejeon 34113, Republic of Korea
| | - Gun-Dong Kim
- Division of Food Functionality Research, Korea Food Research Institute (KFRI), Wanju 55365, Republic of Korea; (E.Y.L.); (S.-Y.L.); (H.S.S.)
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Wallbank AM, Vaughn AE, Niemiec S, Bilodeaux J, Lehmann T, Knudsen L, Kolanthai E, Seal S, Zgheib C, Nozik E, Liechty KW, Smith BJ. CNP-miR146a improves outcomes in a two-hit acute- and ventilator-induced lung injury model. NANOMEDICINE : NANOTECHNOLOGY, BIOLOGY, AND MEDICINE 2023; 50:102679. [PMID: 37116556 PMCID: PMC10129905 DOI: 10.1016/j.nano.2023.102679] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 03/21/2023] [Accepted: 04/09/2023] [Indexed: 04/30/2023]
Abstract
Acute respiratory distress syndrome (ARDS) has high mortality (~40 %) and requires the lifesaving intervention of mechanical ventilation. A variety of systemic inflammatory insults can progress to ARDS, and the inflamed and injured lung is susceptible to ventilator-induced lung injury (VILI). Strategies to mitigate the inflammatory response while restoring pulmonary function are limited, thus we sought to determine if treatment with CNP-miR146a, a conjugate of novel free radical scavenging cerium oxide nanoparticles (CNP) to the anti-inflammatory microRNA (miR)-146a, would protect murine lungs from acute lung injury (ALI) induced with intratracheal endotoxin and subsequent VILI. Lung injury severity and treatment efficacy were evaluated via lung mechanical function, relative gene expression of inflammatory biomarkers, and lung morphometry (stereology). CNP-miR146a reduced the severity of ALI and slowed the progression of VILI, evidenced by improvements in inflammatory biomarkers, atelectasis, gas volumes in the parenchymal airspaces, and the stiffness of the pulmonary system.
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Affiliation(s)
- Alison M Wallbank
- Department of Bioengineering, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, USA
| | - Alyssa E Vaughn
- Laboratory for Fetal and Regenerative Biology, Department of Surgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Steve Niemiec
- Laboratory for Fetal and Regenerative Biology, Department of Surgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Jill Bilodeaux
- Department of Bioengineering, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, USA
| | - Tanner Lehmann
- Laboratory for Fetal and Regenerative Biology, Department of Surgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Lars Knudsen
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Centre for Lung Research (DZL), Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research, Germany
| | - Elayaraja Kolanthai
- Advanced Materials Processing and Analysis Center, Department of Materials Science and Engineering, University of Central Florida, Orlando, FL, USA
| | - Sudipta Seal
- Advanced Materials Processing and Analysis Center, Department of Materials Science and Engineering, University of Central Florida, Orlando, FL, USA
| | - Carlos Zgheib
- Laboratory for Fetal and Regenerative Biology, Department of Surgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Laboratory for Fetal and Regenerative Biology, Department of Surgery, University of Arizona Tucson College of Medicine and Banner Children's at Diamond Children's Medical Center, Tucson, AZ, USA
| | - Eva Nozik
- Developmental Lung Biology, Cardiovascular Pulmonary Research Laboratories, Division of Pulmonary Sciences and Critical Care Medicine, Division of Pediatric Critical Care, Departments of Medicine and Pediatrics, University of Colorado, Aurora, CO, USA
| | - Kenneth W Liechty
- Laboratory for Fetal and Regenerative Biology, Department of Surgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Laboratory for Fetal and Regenerative Biology, Department of Surgery, University of Arizona Tucson College of Medicine and Banner Children's at Diamond Children's Medical Center, Tucson, AZ, USA
| | - Bradford J Smith
- Department of Bioengineering, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, USA; Department of Pediatric Pulmonary and Sleep Medicine, School of Medicine, University of Colorado, Aurora, CO, USA.
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Predicting Persistent Acute Respiratory Failure in Acute Pancreatitis: The Accuracy of Two Lung Injury Indices. Dig Dis Sci 2023:10.1007/s10620-023-07855-y. [PMID: 36853545 DOI: 10.1007/s10620-023-07855-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 01/28/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND/AIMS Early and accurate identification of patients with acute pancreatitis (AP) at high risk of persistent acute respiratory failure (PARF) is crucial. We sought to determine the accuracy of simplified Lung Injury Prediction Score (sLIPS) and simplified Early Acute Lung Injury (sEALI) for predicting PARF in ward AP patients. METHODS Consecutive AP patients in a training cohort from West China Hospital of Sichuan University (n = 912) and a validation cohort from The First Affiliated Hospital of Nanchang University (n = 1033) were analyzed. PARF was defined as oxygen in arterial blood/fraction of inspired oxygen < 300 mmHg that lasts for > 48 h. The sLIPS was composed by shock (predisposing condition), alcohol abuse, obesity, high respiratory rate, low oxygen saturation, high oxygen requirement, hypoalbuminemia, and acidosis (risk modifiers). The sEALI was calculated from oxygen 2 to 6 L/min, oxygen > 6 L/min, and high respiratory rate. Both indices were calculated on admission. RESULTS PARF developed in 16% (145/912) and 22% (228/1033) (22%) of the training and validation cohorts, respectively. In these patients, sLIPS and sEALI were significantly increased. sLIPS ≥ 2 predicted PARF in the training (AUROC 0.87, 95% CI 0.84-0.89) and validation (AUROC 0.81, 95% CI 0.78-0.83) cohorts. sLIPS was significantly more accurate than sEALI and current clinical scoring systems in both cohorts (all P < 0.05). CONCLUSIONS Using routinely available clinical data, the sLIPS can accurately predict PARF in ward AP patients and outperforms the sEALI and current existing clinical scoring systems.
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Chiong OJ, Lu MM. Acute Respiratory Distress Syndrome: An Unexpected Outcome of Suspected Viral Gastroenteritis. Cureus 2021; 13:e18539. [PMID: 34754685 PMCID: PMC8570451 DOI: 10.7759/cureus.18539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 11/05/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening manifestation of diffuse inflammation damaging the lung pleura. Risk factors for development are numerous with most cases arising in those already hospitalized for critical illness. We describe a unique case of a healthy 20-year-old female developing myocarditis and severe ARDS while hospitalized for septic shock after initially presenting with gastroenteritis from a suspected Coxsackie B infection in the setting of an overseas military deployment. After two transfers via land and air, she reached a facility that delivered definitive care and survived. This case highlights how a common disease can develop into something far more deadly and how early recognition of ARDS risk factors can improve clinical decision-making at the time of admission.
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Affiliation(s)
- Oliver J Chiong
- General Practice, Naval Hospital Camp Pendleton, Oceanside, USA
| | - Michelle M Lu
- General Practice, Naval Hospital Camp Pendleton, Oceanside, USA
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6
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Abstract
Acute respiratory distress syndrome (ARDS) is one of the most common severe diseases seen in the clinical setting. With the continuous exploration of ARDS in recent decades, the understanding of ARDS has improved. ARDS is not a simple lung disease but a clinical syndrome with various etiologies and pathophysiological changes. However, in the intensive care unit, ARDS often occurs a few days after primary lung injury or after a few days of treatment for other severe extrapulmonary diseases. Under such conditions, ARDS often progresses rapidly to severe ARDS and is difficult to treat. The occurrence and development of ARDS in these circumstances are thus not related to primary lung injury; the real cause of ARDS may be the “second hit” caused by inappropriate treatment. In view of the limited effective treatments for ARDS, the strategic focus has shifted to identifying potential or high-risk ARDS patients during the early stages of the disease and implementing treatment strategies aimed at reducing ARDS and related organ failure. Future research should focus on the prevention of ARDS.
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Drescher GS, Al-Ahmad MM. Analysis of Noninvasive Ventilation in Subjects With Sepsis and Acute Respiratory Failure. Respir Care 2021; 66:1063-1073. [PMID: 33906956 DOI: 10.4187/respcare.08599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Acute respiratory failure is among the sequelae of complications that can develop in response to severe sepsis. Research into sepsis-related respiratory failure has focused on ARDS and invasive mechanical ventilation. We studied the factors associated with success and failure of noninvasive ventilation (NIV) in the treatment of sepsis-related acute respiratory failure. METHODS This retrospective study included 136 subjects with a diagnosis of acute respiratory failure and intrapulmonary or extrapulmonary sepsis who were placed on NIV. Subjects were divided into 2 groups based on the need for intubation from NIV: NIV failure (n = 70) and NIV success (n = 66). Demographic, clinical, and outcome data were collected and compared between groups, with the development of multivariate models to predict NIV failure and mortality. RESULTS The overall NIV failure rate in subjects with a diagnosis of sepsis was 51%. There were no between-group differences in demographic or baseline characteristics. However, there were significant differences in clinical variables, with higher SOFA scores (NIV failure: 6.4 [± 3.0] vs NIV success: 4.9 [± 2.1]; P = .002), 2nd lactate levels (NIV failure: 2.6 [1.7 - 4.3] vs NIV success: 1.9 [1.4 - 2.6] mmol/L; P = .007), and initial NIV [Formula: see text] settings (NIV failure: 0.50 [0.40 - 0.70] vs NIV failure: 0.40 [0.35 - 0.50]; P = .003) in subjects who failed NIV. There were also more subjects in the NIV failure group who had a lactate ≥ 4 mmol/L prior to NIV start compared to those who succeeded on NIV (33% vs 15%, P = .02). At NIV start, subjects in the NIV failure group had lower mean arterial pressure (85 mm Hg [IQR 74-96] vs 91.7 mm Hg [IQR 78-108], P = .042) and Glasgow coma scale scores (14 [IQR 13-15] vs 15 [IQR 14-15], P < .002), while fewer subjects in the NIV failure group received a fluid bolus in the 24 h prior to NIV start (33% vs 53%, P = .02) or had signs of volume overload (36% vs 64%, P < .001). Multivariate analysis indicated that age (odds ratio 1.05 [95% CI 1.01-1.09], P = .02), SOFA score (odds ratio 1.49 [95% CI 1.15-1.94], P = .002), first systolic blood pressure (odds ratio 0.97 [95% CI 0.95-0.99], P = .02), signs of volume overload (odds ratio 0.23 [95% CI 0.07-0.68], P = .008], fluids prior to NIV (odds ratio 0.08 [95% CI 0.02-0.31], P < .001), and initial [Formula: see text] on NIV (odds ratio 1.04 [95% CI 1.01-1.08, P = .002) independently predicted NIV failure with an area under the curve of 0.88. Only NIV failure independently predicted death in multivariate analysis (area under the curve = 0.70). CONCLUSIONS NIV failure in sepsis-related acute respiratory failure was independently predicted by patient acuity, first systolic blood pressure after sepsis alert, initial [Formula: see text] settings on NIV, fluid resuscitation, and signs of volume overload. However, only NIV failure independently predicted death in this cohort of subjects.
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Affiliation(s)
- Gail S Drescher
- Pulmonary Services Department, MedStar Washington Hospital Center, Washington, DC. Ms Drescher is Technical Editor of Respiratory Care.
| | - Ma'moon M Al-Ahmad
- Pulmonary Services Department, MedStar Washington Hospital Center, Washington, DC. Ms Drescher is Technical Editor of Respiratory Care
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Zhao C, Mo J, Zheng X, Wu Z, Li Q, Feng J, Luo J, Lu J, Zhang J. Identification of an Alveolar Macrophage-Related Core Gene Set in Acute Respiratory Distress Syndrome. J Inflamm Res 2021; 14:2353-2361. [PMID: 34103966 PMCID: PMC8179830 DOI: 10.2147/jir.s306136] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/13/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose Acute respiratory distress syndrome (ARDS) is a rapidly progressive diffuse lung injury that is characterized by high mortality and acute onset. The pathological mechanisms of ARDS are still unclear. But alveolar macrophages have been shown to play an important role in inflammatory responses during ARDS. We aimed to find the biomarkers for ARDS for early diagnosis, to give ARDS patients timely treatment. Methods Gene expression profiles were downloaded from Gene Expression Omnibus (GEO) and screened for differentially expressed genes (DEGs). The common upregulated genes in all the datasets were defined as circulating ARDS alveolar macrophage-related genes (cARDSAMGs). We performed a functional enrichment analysis to explore potential biological functions of cARDSAMGs, and we built protein–protein interaction networks. Gene set variation analysis (GSVA) was used to calculate the core gene set variation analysis (CGSVA) score for individual samples. Receiver operating characteristic (ROC) curve analysis was applied on the CGSVA score to evaluate its ability for diagnosis of ARDS. Results A total of 60 genes were upregulated in all ARDS datasets and were therefore denominated as cARDSAMGs. The cARDSAMGs were significantly involved in multiple inflammation-, immunity- and phagocytosis-related biological processes and pathways. In the protein–protein interaction network associated with host responses to ADRS, eight genes were identified as a core gene set: PTCRA, JAG1, C1QB, ADAM17, C1QA, MMP9, VSIG4 and TNFAIP3. ROC curve analysis showed that the CGSVA score may be considered as a biomarker for ARDS: it was significantly higher in patients with ARDS than those in healthy in both alveolar lavage fluid and whole blood. Conclusion The ARDS alveolar macrophage-related CGSVA score may be useful as a biomarker for ARDS.
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Affiliation(s)
- Chunling Zhao
- Department of Emergency Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, People's Republic of China
| | - Jingjia Mo
- Department of General Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, People's Republic of China
| | - Xiaowen Zheng
- Department of Emergency Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, People's Republic of China
| | - Zimeng Wu
- Department of Emergency Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, People's Republic of China
| | - Qian Li
- Department of Emergency Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, People's Republic of China
| | - Jihua Feng
- Department of Emergency Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, People's Republic of China
| | - Jiefeng Luo
- Department of Emergency Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, People's Republic of China
| | - Junyu Lu
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, People's Republic of China
| | - Jianfeng Zhang
- Department of Emergency Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, People's Republic of China
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Langley RJ, Migaud ME, Flores L, Thompson JW, Kean EA, Mostellar MM, Mowry M, Luckett P, Purcell LD, Lovato J, Gandotra S, Benton R, Files DC, Harrod KS, Gillespie MN, Morris PE. A metabolomic endotype of bioenergetic dysfunction predicts mortality in critically ill patients with acute respiratory failure. Sci Rep 2021; 11:10515. [PMID: 34006901 PMCID: PMC8131588 DOI: 10.1038/s41598-021-89716-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/05/2021] [Indexed: 12/25/2022] Open
Abstract
Acute respiratory failure (ARF) requiring mechanical ventilation, a complicating factor in sepsis and other disorders, is associated with high morbidity and mortality. Despite its severity and prevalence, treatment options are limited. In light of accumulating evidence that mitochondrial abnormalities are common in ARF, here we applied broad spectrum quantitative and semiquantitative metabolomic analyses of serum from ARF patients to detect bioenergetic dysfunction and determine its association with survival. Plasma samples from surviving and non-surviving patients (N = 15/group) were taken at day 1 and day 3 after admission to the medical intensive care unit and, in survivors, at hospital discharge. Significant differences between survivors and non-survivors (ANOVA, 5% FDR) include bioenergetically relevant intermediates of redox cofactors nicotinamide adenine dinucleotide (NAD) and NAD phosphate (NADP), increased acyl-carnitines, bile acids, and decreased acyl-glycerophosphocholines. Many metabolites associated with poor outcomes are substrates of NAD(P)-dependent enzymatic processes, while alterations in NAD cofactors rely on bioavailability of dietary B-vitamins thiamine, riboflavin and pyridoxine. Changes in the efficiency of the nicotinamide-derived cofactors' biosynthetic pathways also associate with alterations in glutathione-dependent drug metabolism characterized by substantial differences observed in the acetaminophen metabolome. Based on these findings, a four-feature model developed with semi-quantitative and quantitative metabolomic results predicted patient outcomes with high accuracy (AUROC = 0.91). Collectively, this metabolomic endotype points to a close association between mitochondrial and bioenergetic dysfunction and mortality in human ARF, thus pointing to new pharmacologic targets to reduce mortality in this condition.
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Affiliation(s)
| | - Marie E Migaud
- University of South Alabama College of Medicine, Mobile, AL, USA
| | - Lori Flores
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - J Will Thompson
- Duke University Center for Genomic and Computational Biology, Durham, NC, USA
| | - Elizabeth A Kean
- University of South Alabama College of Medicine, Mobile, AL, USA
| | | | - Matthew Mowry
- University of South Alabama College of Medicine, Mobile, AL, USA
| | - Patrick Luckett
- Washington University in Saint Louis, Saint Louis, MO, USA
- University of South Alabama School of Computing, Mobile, AL, USA
| | - Lina D Purcell
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - James Lovato
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Sheetal Gandotra
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- University of Alabama-Birmingham College of Medicine, Birmingham, AL, USA
| | - Ryan Benton
- University of South Alabama School of Computing, Mobile, AL, USA
| | - D Clark Files
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Kevin S Harrod
- University of Alabama-Birmingham College of Medicine, Birmingham, AL, USA
| | - Mark N Gillespie
- University of South Alabama College of Medicine, Mobile, AL, USA
| | - Peter E Morris
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky Health Care, 206E Mathews Building, Lexington, KY, 40506-0047, USA.
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Ross JT, Nesseler N, Leligdowicz A, Zemans RL, Mahida RY, Minus E, Langelier C, Gotts JE, Matthay MA. The ex vivo perfused human lung is resistant to injury by high-dose S. pneumoniae bacteremia. Am J Physiol Lung Cell Mol Physiol 2020; 319:L218-L227. [PMID: 32519893 DOI: 10.1152/ajplung.00053.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Few patients with bacteremia from a nonpulmonary source develop acute respiratory distress syndrome (ARDS). However, the mechanisms that protect the lung from injury in bacteremia have not been identified. We simulated bacteremia by adding Streptococcus pneumoniae to the perfusate of the ex vivo perfused human lung model. In contrast to a pneumonia model in which bacteria were instilled into the distal air spaces of one lobe, injection of high doses of S. pneumoniae into the perfusate was not associated with alveolar epithelial injury as demonstrated by low protein permeability of the alveolar epithelium, intact alveolar fluid clearance, and the absence of alveolar edema. Unexpectedly, the ex vivo human lung rapidly cleared large quantities of S. pneumoniae even though the perfusate had very few intravascular phagocytes and lacked immunoglobulins or complement. The bacteria were cleared in part by the small number of neutrophils in the perfusate, alveolar macrophages in the airspaces, and probably by interstitial pathways. Together, these findings identify one mechanism by which the lung and the alveolar epithelium are protected from injury in bacteremia.
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Affiliation(s)
- James T Ross
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Nicolas Nesseler
- Cardiovascular Research Institute, University of California San Francisco, San Francisco, California.,Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France.,University Rennes, CHU de Rennes, Inra, Inserm, Institut NUMECAN-UMR_A 1341, UMR_S 1241, Rennes, France.,University Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), Rennes, France
| | - Aleksandra Leligdowicz
- Cardiovascular Research Institute, University of California San Francisco, San Francisco, California.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rachel L Zemans
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Rahul Y Mahida
- Birmingham Acute Care Research Group, Institute of Inflammation and Aging, University of Birmingham, Birmingham, United Kingdom
| | | | - Chaz Langelier
- Division of Infectious Diseases, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Jeffrey E Gotts
- Department of Medicine, Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
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Puri G, Naura AS. Critical role of mitochondrial oxidative stress in acid aspiration induced ALI in mice. Toxicol Mech Methods 2020; 30:266-274. [DOI: 10.1080/15376516.2019.1710888] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Gayatri Puri
- Department of Biochemistry, Panjab University, Chandigarh, India
| | - Amarjit S. Naura
- Department of Biochemistry, Panjab University, Chandigarh, India
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12
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Iriyama H, Abe T, Kushimoto S, Fujishima S, Ogura H, Shiraishi A, Saitoh D, Mayumi T, Naito T, Komori A, Hifumi T, Shiino Y, Nakada TA, Tarui T, Otomo Y, Okamoto K, Umemura Y, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Takuma K, Tsuruta R, Hagiwara A, Yamakawa K, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Fujimi S, Gando S. Risk modifiers of acute respiratory distress syndrome in patients with non-pulmonary sepsis: a retrospective analysis of the FORECAST study. J Intensive Care 2020; 8:7. [PMID: 31938547 PMCID: PMC6954566 DOI: 10.1186/s40560-020-0426-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 01/01/2020] [Indexed: 11/10/2022] Open
Abstract
Background Predisposing conditions and risk modifiers instead of causes and risk factors have recently been used as alternatives to identify patients at a risk of acute respiratory distress syndrome (ARDS). However, data regarding risk modifiers among patients with non-pulmonary sepsis is rare. Methods We conducted a secondary analysis of the multicenter, prospective, Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis and Trauma (FORECAST) cohort study that was conducted in 59 intensive care units (ICUs) in Japan during January 2016–March 2017. Adult patients with severe sepsis caused by non-pulmonary infection were included, and the primary outcome was having ARDS, defined as meeting the Berlin definition on the first or fourth day of screening. Multivariate logistic regression modeling was used to identify risk modifiers associated with ARDS, and odds ratios (ORs) and their 95% confidence intervals were reported. The following explanatory variables were then assessed: age, sex, admission source, body mass index, smoking status, congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, steroid use, statin use, infection site, septic shock, and acute physiology and chronic health evaluation (APACHE) II score. Results After applying inclusion and exclusion criteria, 594 patients with non-pulmonary sepsis were enrolled, among whom 85 (14.3%) had ARDS. Septic shock was diagnosed in 80% of patients with ARDS and 66% of those without ARDS (p = 0.01). APACHE II scores were higher in patients with ARDS [26 (22–33)] than in those without ARDS [21 (16–28), p < 0.01]. In the multivariate logistic regression model, the following were independently associated with ARDS: ICU admission source [OR, 1.89 (1.06–3.40) for emergency department compared with hospital wards], smoking status [OR, 0.18 (0.06–0.59) for current smoking compared with never smoked], infection site [OR, 2.39 (1.04–5.40) for soft tissue infection compared with abdominal infection], and APACHE II score [OR, 1.08 (1.05–1.12) for higher compared with lower score]. Conclusions Soft tissue infection, ICU admission from an emergency department, and a higher APACHE II score appear to be the risk modifiers of ARDS in patients with non-pulmonary sepsis.
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Affiliation(s)
- Hiroki Iriyama
- 1Department of General Medicine, Juntendo University, 2-1-1 Hongo, 103 Bunkyo-ku, Tokyo, 113-0033 Japan
| | - Toshikazu Abe
- 1Department of General Medicine, Juntendo University, 2-1-1 Hongo, 103 Bunkyo-ku, Tokyo, 113-0033 Japan.,2Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan.,3Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shigeki Kushimoto
- 4Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Seitaro Fujishima
- 5Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Ogura
- 6Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Atsushi Shiraishi
- 7Emergency and Trauma Center, Kameda Medical Center, Kamogawa, Japan
| | - Daizoh Saitoh
- 8Division of Traumatology, Research Institute, National Defense Medical College, Tokyo, Japan
| | - Toshihiko Mayumi
- 9Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toshio Naito
- 1Department of General Medicine, Juntendo University, 2-1-1 Hongo, 103 Bunkyo-ku, Tokyo, 113-0033 Japan
| | - Akira Komori
- 1Department of General Medicine, Juntendo University, 2-1-1 Hongo, 103 Bunkyo-ku, Tokyo, 113-0033 Japan
| | - Toru Hifumi
- 10Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasukazu Shiino
- 11Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Taka-Aki Nakada
- 12Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takehiko Tarui
- 13Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Yasuhiro Otomo
- 14Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Yutaka Umemura
- 6Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Joji Kotani
- 16Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- 17Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- 18Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Kiyotsugu Takuma
- 20Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Ryosuke Tsuruta
- 21Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Akiyoshi Hagiwara
- Department of Emergency Medicine, Niizashiki Chuo General Hospital, Niiza, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Tomohiko Masuno
- 24Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Naoshi Takeyama
- 25Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Norio Yamashita
- 26Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Japan
| | - Hiroto Ikeda
- 27Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masashi Ueyama
- 28Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Satoshi Gando
- 29Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,30Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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13
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Jagrosse ML, Dean DA, Rahman A, Nilsson BL. RNAi therapeutic strategies for acute respiratory distress syndrome. Transl Res 2019; 214:30-49. [PMID: 31401266 PMCID: PMC7316156 DOI: 10.1016/j.trsl.2019.07.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
Acute respiratory distress syndrome (ARDS), replacing the clinical term acute lung injury, involves serious pathophysiological lung changes that arise from a variety of pulmonary and nonpulmonary injuries and currently has no pharmacological therapeutics. RNA interference (RNAi) has the potential to generate therapeutic effects that would increase patient survival rates from this condition. It is the purpose of this review to discuss potential targets in treating ARDS with RNAi strategies, as well as to outline the challenges of oligonucleotide delivery to the lung and tactics to circumvent these delivery barriers.
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Affiliation(s)
| | - David A Dean
- Department of Pediatrics and Neonatology, University of Rochester Medical Center, School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Arshad Rahman
- Department of Pediatrics and Neonatology, University of Rochester Medical Center, School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Bradley L Nilsson
- Department of Chemistry, University of Rochester, Rochester, New York.
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14
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Park KH, Chung EY, Choi YN, Jang HY, Kim JS, Kim GB. Oral administration of Ulmus davidiana extract suppresses interleukin-1β expression in LPS-induced immune responses and lung injury. Genes Genomics 2019; 42:87-95. [PMID: 31736005 DOI: 10.1007/s13258-019-00883-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/28/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Ulmus davidiana (UD) is a traditional Korean herb medicine that is used to treat inflammatory disorders. UD has been shown to modulate a number of inflammatory processes in vitro or in vivo studies. However, the molecular mechanisms of UD on lipopolysaccharide (LPS)-induced acute lung injury remain to be understood. OBJECTIVE The primary objective of this study is to determine the effect of UD bark water extract on LPS-induced immune responses and lung injury using both in vitro and in vivo models. METHODS RAW 264.7 cells and a rat model of acute lung injury (ALI) were used to study the effects of UD on several parameters. Nitrite level, lactate dehydrogenase (LDH) level, and superoxide dismutase (SOD) activities were measured. Tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and plasma transaminase activities in blood were also determined. Pathological investigations were also performed. RESULTS LPS infusion resulted in elevated IL-1β mRNA expression, nitrite levels, TNF-α expression, and IL-1β expression in RAW 264.7 cells. LPS infusion also increased levels of nitrite/nitrate, total protein, LDH, and TNF-α in bronchoalveolar lavage fluid, but reduced SOD levels in ex vivo and in vivo models. UD administration ameliorated all these inflammatory markers. In particular, treatment with UD reduced LPS-induced nitrite production in RAW 264.7 cells in a dose-dependent manner. UD treatment also counteracted the LPS-induced increase in alanine aminotransferase (ALT) and aspartate transaminase (AST) activity in rat plasma, leading to a significant reduction in ALT and AST activity. CONCLUSIONS The results revealed that UD treatment reduces LPS-induced nitrite production, IL-1β mRNA expression, and TNF-α expression. In addition, LPS-induced decrease in SOD level is significantly elevated by UD administration. These results indicate that UD extract merits consideration as a potential drug for treating and/or preventing ALI.
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Affiliation(s)
- Kwang-Hyun Park
- Department of Oriental Pharmaceutical Development, Nambu University, Gwangju, 62271, Republic of Korea.,Department of Emergency Medical Rescue, Nambu University, Gwangju, 62271, Republic of Korea
| | - Eun-Yong Chung
- Department of Anesthesiology and Pain Medicine, Bucheon St. Mary's Hospital, Catholic University of Korea, Bucheon, 14647, Republic of Korea
| | - Yu-Na Choi
- Department of Anesthesiology and Pain Medicine, Bucheon St. Mary's Hospital, Catholic University of Korea, Bucheon, 14647, Republic of Korea
| | - Hye-Yeon Jang
- Department of Biochemistry, Chonbuk National University Medical School, Jeonju, 54907, Republic of Korea
| | - Jong-Suk Kim
- Department of Biochemistry, Chonbuk National University Medical School, Jeonju, 54907, Republic of Korea.
| | - Gi-Beum Kim
- Eouidang Agricultural Company, Wanju, 55360, Republic of Korea.
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15
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Kaku S, Nguyen CD, Htet NN, Tutera D, Barr J, Paintal HS, Kuschner WG. Acute Respiratory Distress Syndrome: Etiology, Pathogenesis, and Summary on Management. J Intensive Care Med 2019; 35:723-737. [DOI: 10.1177/0885066619855021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The acute respiratory distress syndrome (ARDS) has multiple causes and is characterized by acute lung inflammation and increased pulmonary vascular permeability, leading to hypoxemic respiratory failure and bilateral pulmonary radiographic opacities. The acute respiratory distress syndrome is associated with substantial morbidity and mortality, and effective treatment strategies are limited. This review presents the current state of the literature regarding the etiology, pathogenesis, and management strategies for ARDS.
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Affiliation(s)
- Shawn Kaku
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Christopher D. Nguyen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Natalie N. Htet
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Dominic Tutera
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Juliana Barr
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Harman S. Paintal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Ware G. Kuschner
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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16
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Griffiths MJD, McAuley DF, Perkins GD, Barrett N, Blackwood B, Boyle A, Chee N, Connolly B, Dark P, Finney S, Salam A, Silversides J, Tarmey N, Wise MP, Baudouin SV. Guidelines on the management of acute respiratory distress syndrome. BMJ Open Respir Res 2019; 6:e000420. [PMID: 31258917 PMCID: PMC6561387 DOI: 10.1136/bmjresp-2019-000420] [Citation(s) in RCA: 257] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/01/2019] [Indexed: 12/16/2022] Open
Abstract
The Faculty of Intensive Care Medicine and Intensive Care Society Guideline Development Group have used GRADE methodology to make the following recommendations for the management of adult patients with acute respiratory distress syndrome (ARDS). The British Thoracic Society supports the recommendations in this guideline. Where mechanical ventilation is required, the use of low tidal volumes (<6 ml/kg ideal body weight) and airway pressures (plateau pressure <30 cmH2O) was recommended. For patients with moderate/severe ARDS (PF ratio<20 kPa), prone positioning was recommended for at least 12 hours per day. By contrast, high frequency oscillation was not recommended and it was suggested that inhaled nitric oxide is not used. The use of a conservative fluid management strategy was suggested for all patients, whereas mechanical ventilation with high positive end-expiratory pressure and the use of the neuromuscular blocking agent cisatracurium for 48 hours was suggested for patients with ARDS with ratio of arterial oxygen partial pressure to fractional inspired oxygen (PF) ratios less than or equal to 27 and 20 kPa, respectively. Extracorporeal membrane oxygenation was suggested as an adjunct to protective mechanical ventilation for patients with very severe ARDS. In the absence of adequate evidence, research recommendations were made for the use of corticosteroids and extracorporeal carbon dioxide removal.
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Affiliation(s)
| | - Danny Francis McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, West Midlands, UK
| | | | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Andrew Boyle
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Nigel Chee
- Academic Department of Critical Care, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, NIHR Biomedical Research Centre, University of Manchester, Manchester, Greater Manchester, UK
| | - Simon Finney
- Peri-Operative Medicine, Barts Health NHS Trust, London, UK
| | - Aemun Salam
- Peri-Operative Medicine, Barts Health NHS Trust, London, UK
| | - Jonathan Silversides
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Nick Tarmey
- Academic Department of Critical Care, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - Simon V Baudouin
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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17
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The authors reply. Crit Care Med 2019; 45:e625-e626. [PMID: 28509752 DOI: 10.1097/ccm.0000000000002445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Abstract
One of the defining features of acute respiratory distress syndrome (ARDS) is noncardiogenic pulmonary edema, resulting from increased permeability of the alveolar-capillary barrier and passage of protein-rich fluid into the interstitium and alveolar spaces. The loss of protein from the intravascular space disrupts the normal oncotic pressure differential and causes patients with ARDS to be particularly sensitive to the hydrostatic forces that correlate with intravascular volume. Conservative fluid management, in which diuretics are administered and intravenous fluid administration is minimized, may decrease hydrostatic pressure and increase serum oncotic pressure, potentially limiting the development of pulmonary edema. However, the cause of death in most patients with ARDS is multiorgan system failure, not hypoxemia, and the impact of conservative fluid management on the incidence of extrapulmonary organ failure during ARDS is unclear. These physiologic observations have led to a series of studies examining the impact of fluid management on the development of, resolution of, survival from, and long-term outcomes from ARDS. While questions remain, the current literature makes it clear that fluid management is an integral part of the care of patients with ARDS.
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Affiliation(s)
- Jonathan D. Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Todd W. Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
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19
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Nam H, Jang SH, Hwang YI, Kim JH, Park JY, Park S. Nonpulmonary risk factors of acute respiratory distress syndrome in patients with septic bacteraemia. Korean J Intern Med 2019; 34:116-124. [PMID: 29898577 PMCID: PMC6325442 DOI: 10.3904/kjim.2017.204] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 03/05/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND/AIMS The relationship between nonpulmonary organ failure and the development of acute respiratory distress syndrome (ARDS) in patients with sepsis has not been well studied. METHODS We retrospectively reviewed the medical records of patients with septic bacteremia admitted to the medical intensive care unit (ICU) of a tertiary academic hospital between January 2013 and December 2016. RESULTS The study enrolled 125 patients of median age 73.0 years. Urinary (n = 47), hepatobiliary (n = 30), and pulmonary infections (n = 28) were the most common causes of sepsis; the incidence of ARDS was 17.6%. The total number of nonpulmonary organ failures at the time of ICU admission was higher in patients with ARDS than in those without (p = 0.011), and the cardiovascular, central nervous system (CNS), and coagulation scores were significantly higher in ARDS patients. On multivariate analysis, apart from pneumonia sepsis, the CNS (odds ratio [OR], 1.917; 95% confidence interval [CI], 1.097 to 3.348) and coagulation scores (OR, 2.669; 95% CI, 1.438 to 4.954) were significantly associated with ARDS development. The 28-day and in-hospital mortality rates were higher in those with ARDS than in those without (63.6 vs. 8.7%, p < 0.001; 72.7% vs. 11.7%, p < 0.001), and ARDS development was found to be an independent risk factor for 28-day mortality. CONCLUSION Apart from pneumonia, CNS dysfunction and coagulopathy were significantly associated with ARDS development, which was an independent risk factor for 28-day mortality.
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Affiliation(s)
- Hyunseung Nam
- Department of Internal Medicine, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Seung Hun Jang
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Yong Il Hwang
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Joo-Hee Kim
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ji Young Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
- Correspondence to Sunghoon Park, M.D. Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang 14068, Korea Tel: +82-31-380-3715 Fax: +82-31-380-3973 E-mail:
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20
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Abstract
The acute respiratory distress syndrome (ARDS) is a common cause of respiratory failure in critically ill patients and is defined by the acute onset of noncardiogenic pulmonary oedema, hypoxaemia and the need for mechanical ventilation. ARDS occurs most often in the setting of pneumonia, sepsis, aspiration of gastric contents or severe trauma and is present in ~10% of all patients in intensive care units worldwide. Despite some improvements, mortality remains high at 30-40% in most studies. Pathological specimens from patients with ARDS frequently reveal diffuse alveolar damage, and laboratory studies have demonstrated both alveolar epithelial and lung endothelial injury, resulting in accumulation of protein-rich inflammatory oedematous fluid in the alveolar space. Diagnosis is based on consensus syndromic criteria, with modifications for under-resourced settings and in paediatric patients. Treatment focuses on lung-protective ventilation; no specific pharmacotherapies have been identified. Long-term outcomes of patients with ARDS are increasingly recognized as important research targets, as many patients survive ARDS only to have ongoing functional and/or psychological sequelae. Future directions include efforts to facilitate earlier recognition of ARDS, identifying responsive subsets of patients and ongoing efforts to understand fundamental mechanisms of lung injury to design specific treatments.
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21
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Iwashita Y, Yamashita K, Ikai H, Sanui M, Imai H, Imanaka Y. Epidemiology of mechanically ventilated patients treated in ICU and non-ICU settings in Japan: a retrospective database study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:329. [PMID: 30514327 PMCID: PMC6280379 DOI: 10.1186/s13054-018-2250-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 10/29/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND In most countries, patients receiving mechanical ventilation (MV) are treated in intensive care units (ICUs). However, in some countries, including Japan, many patients on MV are not treated in ICUs. There are insufficient epidemiological data on these patients. Here, we sought to describe the epidemiology of patients on MV in Japan by comparing and contrasting patients on MV treated in ICUs and in non-ICU settings. A preliminary comparison of patient outcomes between ICU and non-ICU patients was a secondary objective. METHODS Data on adult patients receiving MV for at least 3 days in ICUs or non-ICU settings from April 2010 through March 2012 were obtained from the Quality Indicator/Improvement Project, a voluntary data-administration project covering more than 400 acute-care hospitals in Japan. We excluded patients with cancer-related diagnoses. Patient demographic data and the critical care provided were compared between groups. RESULTS Over the study period, 17,775 patients on MV were treated only in non-ICU settings, whereas 20,516 patients were treated at least once in ICUs (46.4% vs. 53.6%). Average age was higher in non-ICU patients than in ICU patients (72.8 vs. 70.2, P < 0.001). Mean number of ventilation days was greater in non-ICU patients (11.7 vs. 9.5, P < 0.001). Hospital mortality was higher in non-ICU patients (41.4% vs. 38.8%, P < 0.001). Standard critical care (e.g., arterial line placement, enteral nutrition, and stress-ulcer prevention) was provided significantly less often in non-ICU patients. Multivariate analysis showed that ICU admission significantly decreased hospital mortality (adjusted odds ratio 0.713, 95% CI 0.676 to 0.753). CONCLUSIONS A large proportion of Japanese patients on MV were treated in non-ICU settings. Analysis of administrative data indicated preliminarily that hospital mortality rates in these patients were higher in non-ICU settings than in ICUs. Prospective analyses comparing non-ICU and ICU patients on MV by severity scoring are needed.
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Affiliation(s)
- Yoshiaki Iwashita
- Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, Japan.
| | - Kazuto Yamashita
- Department of Healthcare Economics and Quality Management, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Hiroshi Ikai
- Department of Healthcare Economics and Quality Management, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Masamitsu Sanui
- Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Saitama, Saitama, Japan
| | - Hiroshi Imai
- Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
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22
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Xie J, Liu L, Yang Y, Yu W, Li M, Yu K, Zheng R, Yan J, Wang X, Cai G, Li J, Gu Q, Zhao H, Mu X, Ma X, Qiu H. A modified acute respiratory distress syndrome prediction score: a multicenter cohort study in China. J Thorac Dis 2018; 10:5764-5773. [PMID: 30505484 DOI: 10.21037/jtd.2018.09.117] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background Early recognition of the risks of acute respiratory distress syndrome (ARDS) and prevention of the development of ARDS may be more effective in improving patient outcomes. We performed the present study to determine the ARDS risk factors in a Chinese population and validate a score to predict the development of ARDS. Methods This was an observational multicenter cohort study performed in 13 tertiary hospitals in China. Patients admitted into participating intensive care units (ICUs) from January 1 to January 31, 2012, and from January 1 to January 10, 2013, were enrolled in a retrospective derivation cohort and a prospective validation cohort, respectively. In the derivation cohort, the potential risk factors of ARDS were collected. The confirmed risk factors were determined with univariate and multivariate logistic regression analyses, and then the modified ARDS prediction score (MAPS) was established. We prospectively enrolled patients to verify the accuracy of MAPS. Results A total of 479 and 198 patients were enrolled into the retrospective derivation cohort and the prospective validation cohort, respectively. A total of 93 (19.4%) patients developed ARDS in the derivation cohort. Acute pancreatitis, pneumonia, hypoalbuminemia, acidosis, and high respiratory rate were the risk factors for ARDS. The MAPS discriminated patients who developed ARDS from those who did not, with an area under the curve (AUC) of 0.809 [95% confidence interval (CI), 0.758-0.859, P<0.001]. In the prospective validation cohort, performance of the MAPS was similar to the retrospective derivation cohort, with an AUC of 0.792 (95% CI, 0.717-0.867, P<0.001). The lung injury prediction score (LIPS) showed a predicted value of an AUC of 0.770 (95% CI, 0.728-0.812, P<0.001) in our patients, which was significantly lower than our score (P<0.046). Conclusions The MAPS based on risk factors could help the clinician to predict patients who will develop ARDS. Trial registration ClinicalTrials.gov NCT01666834.
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Affiliation(s)
- Jianfeng Xie
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
| | - Ling Liu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
| | - Wenkui Yu
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China
| | - Maoqin Li
- Department of Critical Care Medicine, Xuzhou Central Hospital, Xuzhou 221009, China
| | - Kaijiang Yu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin 150040, China.,Department of Critical Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Ruiqiang Zheng
- Department of Critical Care Medicine, Subei People's Hospital, School of Medicine, Yangzhou University, Yangzhou 225001, China
| | - Jie Yan
- Department of Critical Care Medicine, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi 214002, China
| | - Xue Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Guolong Cai
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou 310013, China
| | - Jianguo Li
- Department of Critical Care Medicine, Zhongnan Hospital, Wuhan University, 430071, Wuhan, China
| | - Qin Gu
- Department of Critical Care Medicine, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Hongsheng Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Nantong University, Nantong 226001, China
| | - Xinwei Mu
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang 110001, China
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
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Gaudet A, Parmentier E, Dubucquoi S, Poissy J, Duburcq T, Lassalle P, De Freitas Caires N, Mathieu D. Low endocan levels are predictive of Acute Respiratory Distress Syndrome in severe sepsis and septic shock. J Crit Care 2018; 47:121-126. [PMID: 29957509 DOI: 10.1016/j.jcrc.2018.06.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/07/2018] [Accepted: 06/18/2018] [Indexed: 01/30/2023]
Abstract
PURPOSE Endocan is a circulating proteoglycan measured at high blood levels during severe sepsis, with a likely lung anti-inflammatory function. The aim of this study was to assess whether paradoxically low endocan levels at Intensive Care Unit (ICU) admission could predict Acute Respiratory Distress Syndrome (ARDS) within 72 h in severe septic patients. MATERIALS AND METHODS Patients admitted for severe sepsis in the ICU of a French University Hospital were included in a prospective single-center observational study between October 2014 and March 2016. RESULTS 72 patients admitted in ICU for severe sepsis were included. Endocan blood values at inclusion were significantly lower in patients who developed an ARDS at 72 h (p < 0.001). For endocan blood values > 5.36 ng/mL, the adjusted OR for development of ARDS at 72 h was of 0.001 (95% CI 0-0.215; p = 0.011). In our cohort, an endocan value < 2.54 ng/mL predicted ARDS at 72 h with a positive predictive value of 1 (Sp = 1 (95% CI 0.94-1)). CONCLUSIONS In a cohort of severe septic patients, we observed that low blood levels of endocan at ICU admission were predictive of ARDS at 72 h.
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Affiliation(s)
- Alexandre Gaudet
- Univ. Lille, U1019 - UMR 8204 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France; CNRS, UMR 8204, F-59000 Lille, France; INSERM, U1019, F-59000 Lille, France; CHU Lille, Pôle de Réanimation, Hôpital Roger Salengro, F-59000 Lille, France.
| | - Erika Parmentier
- Univ. Lille, U1019 - UMR 8204 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France; CNRS, UMR 8204, F-59000 Lille, France; INSERM, U1019, F-59000 Lille, France; CHU Lille, Pôle de Réanimation, Hôpital Roger Salengro, F-59000 Lille, France
| | - Sylvain Dubucquoi
- CHU Lille, Institut d'Immunologie, Centre de Biologie Pathologie Génétique, F-59000 Lille, France
| | - Julien Poissy
- CHU Lille, Pôle de Réanimation, Hôpital Roger Salengro, F-59000 Lille, France
| | - Thibault Duburcq
- CHU Lille, Pôle de Réanimation, Hôpital Roger Salengro, F-59000 Lille, France
| | - Philippe Lassalle
- Univ. Lille, U1019 - UMR 8204 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France; CNRS, UMR 8204, F-59000 Lille, France; INSERM, U1019, F-59000 Lille, France; Institut Pasteur de Lille, F-59000 Lille, France
| | - Nathalie De Freitas Caires
- Univ. Lille, U1019 - UMR 8204 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France; CNRS, UMR 8204, F-59000 Lille, France; INSERM, U1019, F-59000 Lille, France; Lunginnov, 1 rue du Pr Calmette, F-59000 Lille, France
| | - Daniel Mathieu
- Univ. Lille, U1019 - UMR 8204 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France; CNRS, UMR 8204, F-59000 Lille, France; INSERM, U1019, F-59000 Lille, France; CHU Lille, Pôle de Réanimation, Hôpital Roger Salengro, F-59000 Lille, France
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24
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The preventive effect of antiplatelet therapy in acute respiratory distress syndrome: a meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018. [PMID: 29519254 PMCID: PMC5844104 DOI: 10.1186/s13054-018-1988-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Acute respiratory distress syndrome (ARDS) is a life-threatening condition with high mortality that imposes a serious medical burden. Antiplatelet therapy is a potential strategy for preventing ARDS in patients with a high risk of developing this condition. A meta-analysis was performed to investigate whether antiplatelet therapy could reduce the incidence of newly developed ARDS and its associated mortality in high-risk patients. Methods The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Medline, and the Web of Science were searched for published studies from inception to 26 October 2017. We included randomized clinical trials, cohort studies and case-control studies investigating antiplatelet therapy in adult patients presenting to the hospital or ICU with a high risk for ARDS. Baseline patient characteristics, interventions, controls and outcomes were extracted. Our primary outcome was the incidence of newly developed ARDS in high-risk patients. Secondary outcomes were hospital and ICU mortality. A random-effects or fixed-effects model was used for quantitative synthesis. Results We identified nine eligible studies including 7660 high-risk patients who received antiplatelet therapy. Based on seven observational studies, antiplatelet therapy was associated with a decreased incidence of ARDS (odds ratio (OR) 0.68, 95% confidence interval (CI) 0.52–0.88; I2 = 68.4%, p = 0.004). In two randomized studies, no significant difference was found in newly developed ARDS between the antiplatelet groups and placebo groups (OR 1.32, 95% CI 0.72–2.42; I2 = 0.0%, p = 0.329). Antiplatelet therapy did not reduce hospital mortality in randomized studies (OR 1.15, 95% CI 0.58–2.27; I2 = 0.0%; p = 0.440) or observational studies (OR 0.80, 95% CI 0.62–1.03; I2 = 31.9%, p = 0.221). Conclusions Antiplatelet therapy did not significantly decrease hospital mortality in high-risk patients. However, whether antiplatelet therapy is associated with a decreased incidence of ARDS in patients at a high risk of developing the condition remains unclear. Electronic supplementary material The online version of this article (10.1186/s13054-018-1988-y) contains supplementary material, which is available to authorized users.
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Abstract
Acute respiratory distress syndrome is a common cause of acute respiratory failure that is underdiagnosed both inside and outside of intensive care units. Progression to the most severe forms of the syndrome confers a mortality rate greater than 40% and is associated with often severe functional disability and psychological sequelae in survivors. While there are no disease-modifying pharmacotherapies for the syndrome, this progression may be prevented through the institution of quality improvement measures that minimise iatrogenic injury associated with acute severe illness.
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Affiliation(s)
| | - Nessa Dooley
- National Heart & Lung Institute, Imperial College, London, UK
| | - Mark Griffiths
- William Harvey Research Institute, Queen Mary University of London, London, UK
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26
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Lung Injury Prediction Score in Hospitalized Patients at Risk of Acute Respiratory Distress Syndrome. Crit Care Med 2017; 44:2182-2191. [PMID: 27513358 DOI: 10.1097/ccm.0000000000002001] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The Lung Injury Prediction Score identifies patients at risk for acute respiratory distress syndrome in the emergency department, but it has not been validated in non-emergency department hospitalized patients. We aimed to evaluate whether Lung Injury Prediction Score identifies non-emergency department hospitalized patients at risk of developing acute respiratory distress syndrome at the time of critical care contact. DESIGN Retrospective study. SETTING Five academic medical centers. PATIENTS Nine hundred consecutive patients (≥ 18 yr old) with at least one acute respiratory distress syndrome risk factor at the time of critical care contact. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Lung Injury Prediction Score was calculated using the worst values within the 12 hours before initial critical care contact. Patients with acute respiratory distress syndrome at the time of initial contact were excluded. Acute respiratory distress syndrome developed in 124 patients (13.7%) a median of 2 days (interquartile range, 2-3) after critical care contact. Hospital mortality was 22% and was significantly higher in acute respiratory distress syndrome than non-acute respiratory distress syndrome patients (48% vs 18%; p < 0.001). Increasing Lung Injury Prediction Score was significantly associated with development of acute respiratory distress syndrome (odds ratio, 1.31; 95% CI, 1.21-1.42) and the composite outcome of acute respiratory distress syndrome or death (odds ratio, 1.26; 95% CI, 1.18-1.34). A Lung Injury Prediction Score greater than or equal to 4 was associated with the development of acute respiratory distress syndrome (odds ratio, 4.17; 95% CI, 2.26-7.72), composite outcome of acute respiratory distress syndrome or death (odds ratio, 2.43; 95% CI, 1.68-3.49), and acute respiratory distress syndrome after accounting for the competing risk of death (hazard ratio, 3.71; 95% CI, 2.05-6.72). For acute respiratory distress syndrome development, the Lung Injury Prediction Score has an area under the receiver operating characteristic curve of 0.70 and a Lung Injury Prediction Score greater than or equal to 4 has 90% sensitivity (misses only 10% of acute respiratory distress syndrome cases), 31% specificity, 17% positive predictive value, and 95% negative predictive value. CONCLUSIONS In a cohort of non-emergency department hospitalized patients, the Lung Injury Prediction Score and Lung Injury Prediction Score greater than or equal to 4 can identify patients at increased risk of acute respiratory distress syndrome and/or death at the time of critical care contact but it does not perform as well as in the original emergency department cohort.
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Wei CY, Sun HL, Yang ML, Yang CP, Chen LY, Li YC, Lee CY, Kuan YH. Protective effect of wogonin on endotoxin-induced acute lung injury via reduction of p38 MAPK and JNK phosphorylation. ENVIRONMENTAL TOXICOLOGY 2017; 32:397-403. [PMID: 26892447 DOI: 10.1002/tox.22243] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 01/13/2016] [Accepted: 01/24/2016] [Indexed: 06/05/2023]
Abstract
Acute lung injury (ALI) is a serious inflammatory disorder which remains the primary cause of incidence and mortality in patients with acute pulmonary inflammation. However, there is still no effective medical strategy available clinically for the improvement of ALI. Wogonin, isolated from roots of Scutellaria baicalensis Georgi, is a common medicinal herb which presents biological and pharmacological effects, including antioxidation, anti-inflammation, and anticancer. Preadministration of wogonin inhibited not only lung edema but also protein leakage into the alveolar space in murine model of lipopolysaccharide (LPS)-induced ALI. Moreover, wogonin not only reduced the expression of inducible nitric oxide synthase (iNOS) and cyclooxygenase (COX)-2 but also inhibited the phosphorylation of mitogen-activated protein kinase (MAPK) induced by LPS. We further found wogonin inhibited the phosphorylation of p38 MAPK and JNK at a concentration lower than ERK. In addition, inhibition of lung edema, protein leakage, expression of iNOS and COX-2, and phosphorylation of p38 MAPK and JNK were all observed in a parallel concentration-dependent manner. These results suggest that wogonin possesses potential protective effect against LPS-induced ALI via downregulation of iNOS and COX-2 expression by blocking phosphorylation of p38 MAPK and JNK. © 2016 Wiley Periodicals, Inc. Environ Toxicol 32: 397-403, 2017.
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Affiliation(s)
- Cheng-Yu Wei
- Department of Neurology, Chang Bing Show Chwan Memorial Hospital, Changhua County, Taiwan, Republic of China
- Department of Neurology, Show Chwan Memorial Hospital, Changhua County, Taiwan, Republic of China
- Department of Exercise and Health Promotion, College of Education, Chinese Culture University, Taipei, Taiwan, Republic of China
| | - Hai-Lun Sun
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Ming-Ling Yang
- Department of Anatomy, School of Medicine, Chung Shan Medical University, Taichung Taiwan
| | - Ching-Ping Yang
- Department of Biotechology and Laboratory Science in Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Li-You Chen
- Department of Anatomy, School of Medicine, Chung Shan Medical University, Taichung Taiwan
| | - Yi-Ching Li
- Department of Pharmacology, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Pharmacy, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chien-Ying Lee
- Department of Pharmacology, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Pharmacy, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yu-Hsiang Kuan
- Department of Pharmacology, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Pharmacy, Chung Shan Medical University Hospital, Taichung, Taiwan
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Gil Cano A, Gracia Romero M, Monge García MI, Guijo González P, Ruiz Campos J. Preemptive hemodynamic intervention restricting the administration of fluids attenuates lung edema progression in oleic acid-induced lung injury. Med Intensiva 2016; 41:135-142. [PMID: 27986329 DOI: 10.1016/j.medin.2016.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/04/2016] [Accepted: 08/03/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE A study is made of the influence of preemptive hemodynamic intervention restricting fluid administration upon the development of oleic acid-induced lung injury. DESIGN A randomized in vivo study in rabbits was carried out. SETTING University research laboratory. SUBJECTS Sixteen anesthetized, mechanically ventilated rabbits. VARIABLES Hemodynamic measurements obtained by transesophageal Doppler signal. Respiratory mechanics computed by a least square fitting method. Lung edema assessed by the ratio of wet weight to dry weight of the right lung. Histological examination of the left lung. INTERVENTIONS Animals were randomly assigned to either the early protective lung strategy (EPLS) (n=8) or the early protective hemodynamic strategy (EPHS) (n=8). In both groups, lung injury was induced by the intravenous infusion of oleic acid (OA) (0.133mlkg-1h-1 for 2h). At the same time, the EPLS group received 15mlkg-1h-1 of Ringer lactate solution, while the EPHS group received 30mlkg-1h-1. Measurements were obtained at baseline and 1 and 2h after starting OA infusion. RESULTS After 2h, the cardiac index decreased in the EPLS group (p<0.05), whereas in the EPHS group it remained unchanged. Lung compliance decreased significantly only in the EPHS group (p<0.05). Lung edema was greater in the EPHS group (p<0.05). Histological damage proved similar in both groups (p=0.4). CONCLUSIONS In this experimental model of early lung injury, lung edema progression was attenuated by preemptively restricting the administration of fluids.
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Affiliation(s)
- A Gil Cano
- Laboratorio de Investigación Experimental, Unidad de Gestión Clínica de Medicina Intensiva, Hospital del SAS de Jerez, Jerez de la Frontera, Cádiz, Spain.
| | - M Gracia Romero
- Laboratorio de Investigación Experimental, Unidad de Gestión Clínica de Medicina Intensiva, Hospital del SAS de Jerez, Jerez de la Frontera, Cádiz, Spain
| | - M I Monge García
- Laboratorio de Investigación Experimental, Unidad de Gestión Clínica de Medicina Intensiva, Hospital del SAS de Jerez, Jerez de la Frontera, Cádiz, Spain
| | - P Guijo González
- Laboratorio de Investigación Experimental, Unidad de Gestión Clínica de Medicina Intensiva, Hospital del SAS de Jerez, Jerez de la Frontera, Cádiz, Spain
| | - J Ruiz Campos
- Servicio de Anatomía Patológica, Hospital del SAS de Jerez, Jerez de la Frontera, Cádiz, Spain
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Mason C, Dooley N, Griffiths M. Acute respiratory distress syndrome. Clin Med (Lond) 2016; 16. [PMID: 27956444 PMCID: PMC6329572 DOI: 10.7861/clinmedicine.16-6s-s66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Acute respiratory distress syndrome is a common cause of acute respiratory failure that is underdiagnosed both inside and outside of intensive care units. Progression to the most severe forms of the syndrome confers a mortality rate greater than 40% and is associated with often severe functional disability and psychological sequelae in survivors. While there are no disease-modifying pharmacotherapies for the syndrome, this progression may be prevented through the institution of quality improvement measures that minimise iatrogenic injury associated with acute severe illness.
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Affiliation(s)
| | - Nessa Dooley
- BNational Heart & Lung Institute, Imperial College, London, UK
| | - Mark Griffiths
- CWilliam Harvey Research Institute, Queen Mary University of London, London, UK,Address for correspondence: Dr M Griffiths, Office 10 (BNB_01_411), 1st Floor – KGV Building, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK.
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30
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Abstract
Acute respiratory distress syndrome is a common cause of acute respiratory failure that is underdiagnosed both inside and outside of intensive care units. Progression to the most severe forms of the syndrome confers a mortality rate greater than 40% and is associated with often severe functional disability and psychological sequelae in survivors. While there are no disease-modifying pharmacotherapies for the syndrome, this progression may be prevented through the institution of quality improvement measures that minimise iatrogenic injury associated with acute severe illness.
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Affiliation(s)
| | - Nessa Dooley
- National Heart & Lung Institute, Imperial College, London, UK
| | - Mark Griffiths
- William Harvey Research Institute, Queen Mary University of London, London, UK
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Ozolina A, Sarkele M, Sabelnikovs O, Skesters A, Jaunalksne I, Serova J, Ievins T, Bjertnaes LJ, Vanags I. Activation of Coagulation and Fibrinolysis in Acute Respiratory Distress Syndrome: A Prospective Pilot Study. Front Med (Lausanne) 2016; 3:64. [PMID: 27965960 PMCID: PMC5125303 DOI: 10.3389/fmed.2016.00064] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 11/15/2016] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Coagulation and fibrinolysis remain sparsely addressed with regards to acute respiratory distress syndrome (ARDS). We hypothesized that ARDS development might be associated with changes in plasma coagulation and fibrinolysis. Our aim was to investigate the relationships between ARDS diagnosis and plasma concentrations of tissue factor (TF), tissue plasminogen activator (t-PA), and plasminogen activator inhibitor-1 (PAI-1) in mechanically ventilated patients at increased risk of developing ARDS. MATERIALS AND METHODS We performed an ethically approved prospective observational pilot study. Inclusion criteria were patients with PaO2/FiO2 < 300 mmHg admitted to the intensive care unit (ICU) for mechanical ventilation for 24 h, or more, because of one or more disease conditions associated with increased risk of developing ARDS. Exclusion criteria were age below 18 years; cardiac disease. We sampled plasma prospectively and compared patients who developed ARDS with those who did not using descriptive statistics and chi-square analysis of baseline demographical and clinical data. We also analyzed plasma concentrations of TF, t-PA, and PAI-1 at inclusion (T0) and on third (T3) and seventh day (T7) of the ICU stay with non-parametric statistics inclusive their sensitivity and specificity associated with the development of ARDS using receiver operating characteristic curve analysis. Statistical significance: p < 0.05. RESULTS Of 24 patients at risk, 6 developed mild ARDS and 4 of each moderate or severe ARDS, respectively, 3 ± 2 (mean ± SD) days after inclusion. Median plasma concentrations of TF and PAI-1 were significantly higher at T7 in patients with ARDS, as compared to non-ARDS. Simultaneously, we found moderate correlations between plasma concentrations of TF and PAI-1, TF and PaO2/FiO2, and positive end-expiratory pressure and TF. TF plasma concentration was associated with ARDS with 71% sensitivity and 100% specificity, a cut off level of 145 pg/ml and AUC 0.78, p = 0.02. PAI-1 displayed 64% sensitivity and 100% specificity with a cut off concentration of 117.5 pg/ml and AUC 0.77, p = 0.02. t-PA did not change significantly during the observation time. CONCLUSION This pilot study showed that increased plasma concentrations of TF and PAI-1 might support ARDS diagnoses in mechanically ventilated patients after 7 days in ICU.
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Affiliation(s)
- Agnese Ozolina
- Department of Cardiac Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Riga Stradins University, Riga, Latvia
| | - Marina Sarkele
- Riga Stradins University, Riga, Latvia; Department of Anesthesiology and Intensive Care Unit, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Olegs Sabelnikovs
- Riga Stradins University, Riga, Latvia; Department of Anesthesiology and Intensive Care Unit, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Andrejs Skesters
- Laboratory of Biochemistry, Riga Stradins University , Riga , Latvia
| | - Inta Jaunalksne
- Clinical Immunology Centre, Pauls Stradins Clinical University Hospital , Riga , Latvia
| | - Jelena Serova
- Clinical Immunology Centre, Pauls Stradins Clinical University Hospital , Riga , Latvia
| | - Talis Ievins
- Department of Cardiac Surgery, Pauls Stradins Clinical University Hospital , Riga , Latvia
| | - Lars J Bjertnaes
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø , Tromsø , Norway
| | - Indulis Vanags
- Riga Stradins University, Riga, Latvia; Department of Anesthesiology and Intensive Care Unit, Pauls Stradins Clinical University Hospital, Riga, Latvia
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Abstract
Prevention of ventilator-induced lung injury (VILI) can attenuate multiorgan failure and improve survival in at-risk patients. Clinically significant VILI occurs from volutrauma, barotrauma, atelectrauma, biotrauma, and shear strain. Differences in regional mechanics are important in VILI pathogenesis. Several interventions are available to protect against VILI. However, most patients at risk of lung injury do not develop VILI. VILI occurs most readily in patients with concomitant physiologic insults. VILI prevention strategies must balance risk of lung injury with untoward side effects from the preventive effort, and may be most effective when targeted to subsets of patients at increased risk.
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Negrin LL, Prosch H, Kettner S, Halat G, Heinz T, Hajdu S. The clinical benefit of a follow-up thoracic computed tomography scan regarding parenchymal lung injury and acute respiratory distress syndrome in polytraumatized patients. J Crit Care 2016; 37:211-218. [PMID: 27969573 DOI: 10.1016/j.jcrc.2016.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 10/03/2016] [Accepted: 10/05/2016] [Indexed: 12/19/2022]
Abstract
PURPOSE To evaluate the increase of parenchymal lung injury (PLI) volume between the initial and a follow-up computed tomography (CT) scan and to ascertain which of the 2 scans was more appropriate to predict acute respiratory distress syndrome (ARDS). MATERIAL AND METHODS From 2011 to 2015, polytraumatized patients (≥18 years; ISS ≥ 16) directly admitted to our level I trauma center were included in our prospective study if a follow-up CT scan was possible 24 to 48 hours after the trauma. The PLI volume was measured using volumetric analysis. Statistical calculations were performed to identify patients at risk for ARDS. RESULTS One hundred thirty patients (mean age, 41.3 years; mean ISS, 31.9) met the inclusion criteria. Median relative PLI volume was higher in the follow-up than in the initial CTs (9.65% vs 4.84%; P = .001). The ARDS developed in 42 patients (32.3%). Their initial PLI volume was higher compared with those without ARDS (11.23% vs 2.14%; P < .0001). The ARDS incidence increased with increasing initial PLI volume. Receiver operating characteristic statistics identified initial (area under the curve = 0.753) and follow-up relative PLI volume as a predictor for ARDS (area under the curve = 0.725). CONCLUSIONS The CT scans performed directly after admission are sufficient to define patients at risk for ARDS. Therefore, solely the incidence of PLI does not justify a routine follow-up CT scan.
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Affiliation(s)
- Lukas L Negrin
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna 1090, Austria.
| | - Helmut Prosch
- Department of Radiology and Nuclear Medicine, Medical University of Vienna, Waehringer Guertel 18-20, Vienna 1090, Austria.
| | - Stephan Kettner
- Department of Anesthesiology, General Intensive Care and Pain Management, Medical University of Vienna, Waehringer Guertel 18-20, Vienna 1090, Austria.
| | - Gabriel Halat
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna 1090, Austria.
| | - Thomas Heinz
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna 1090, Austria.
| | - Stefan Hajdu
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna 1090, Austria.
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Kor DJ, Carter RE, Park PK, Festic E, Banner-Goodspeed VM, Hinds R, Talmor D, Gajic O, Ware LB, Gong MN. Effect of Aspirin on Development of ARDS in At-Risk Patients Presenting to the Emergency Department: The LIPS-A Randomized Clinical Trial. JAMA 2016; 315:2406-14. [PMID: 27179988 PMCID: PMC5450939 DOI: 10.1001/jama.2016.6330] [Citation(s) in RCA: 159] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
IMPORTANCE Management of acute respiratory distress syndrome (ARDS) remains largely supportive. Whether early intervention can prevent development of ARDS remains unclear. OBJECTIVE To evaluate the efficacy and safety of early aspirin administration for the prevention of ARDS. DESIGN, SETTING, AND PARTICIPANTS A multicenter, double-blind, placebo-controlled, randomized clinical trial conducted at 16 US academic hospitals. Between January 2, 2012, and November 17, 2014, 7673 patients at risk for ARDS (Lung Injury Prediction Score ≥4) in the emergency department were screened and 400 were randomized. Ten patients were excluded, leaving 390 in the final modified intention-to-treat analysis cohort. INTERVENTIONS Administration of aspirin, 325-mg loading dose followed by 81 mg/d (n = 195) or placebo (n = 195) within 24 hours of emergency department presentation and continued to hospital day 7, discharge, or death. MAIN OUTCOMES AND MEASURES The primary outcome was the development of ARDS by study day 7. Secondary measures included ventilator-free days, hospital and intensive care unit length of stay, 28-day and 1-year survival, and change in serum biomarkers associated with ARDS. A final α level of .0737 (α = .10 overall) was required for statistical significance of the primary outcome. RESULTS Among 390 analyzed patients (median age, 57 years; 187 [48%] women), the median (IQR) hospital length of stay was 6 3-10) days. Administration of aspirin, compared with placebo, did not significantly reduce the incidence of ARDS at 7 days (10.3% vs 8.7%, respectively; odds ratio, 1.24 [92.6% CI, 0.67 to 2.31], P = .53). No significant differences were seen in secondary outcomes: ventilator-free to day 28, mean (SD), 24.9 (7.4) days vs 25.2 (7.0) days (mean [90% CI] difference, -0.26 [-1.46 to 0.94] days; P = .72); ICU length of stay, mean (SD), 5.2 (7.0) days vs 5.4 (7.0) days (mean [90% CI] difference, -0.16 [-1.75 to 1.43] days; P = .87); hospital length of stay, mean (SD), 8.8 (10.3) days vs 9.0 (9.9) days (mean [90% CI] difference, -0.27 [-1.96 to 1.42] days; P = .79); or 28-day survival, 90% vs 90% (hazard ratio [90% CI], 1.03 [0.60 to 1.79]; P = .92) or 1-year survival, 73% vs 75% (hazard ratio [90% CI], 1.06 [0.75 to 1.50]; P = .79). Bleeding-related adverse events were infrequent in both groups (aspirin vs placebo, 5.6% vs 2.6%; odds ratio [90% CI], 2.27 [0.92 to 5.61]; P = .13). RESULTS Among 390 analyzed patients (median age, 57 years; 187 [48%] women), median (IQR) hospital length of stay was 6 (3-10) days. Administration of aspirin, compared with placebo, did not significantly reduce the incidence of ARDS at 7 days (OR, 1.24; 92.6%CI, 0.67-2.31). No significant differences were seen in secondary outcomes or adverse events. [table: see text] CONCLUSIONS AND RELEVANCE Among at-risk patients presenting to the ED, the use of aspirin compared with placebo did not reduce the risk of ARDS at 7 days. The findings of this phase 2b trial do not support continuation to a larger phase 3 trial. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01504867.
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Affiliation(s)
- Daryl J Kor
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Rickey E Carter
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Pauline K Park
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor
| | - Emir Festic
- Department of Medicine, Mayo Clinic College of Medicine, Jacksonville, Florida
| | | | - Richard Hinds
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Daniel Talmor
- Department of Anaesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ognjen Gajic
- Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Lorraine B Ware
- Department of Medicine and Pathology, Vanderbilt University School of Medicine, Nashville, Tennessee9Department of Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Michelle Ng Gong
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
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Timing of Intubation and Clinical Outcomes in Adults With Acute Respiratory Distress Syndrome. Crit Care Med 2016; 44:120-9. [PMID: 26474112 DOI: 10.1097/ccm.0000000000001359] [Citation(s) in RCA: 151] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The prevalence, clinical characteristics, and outcomes of critically ill, nonintubated patients with evidence of the acute respiratory distress syndrome remain inadequately characterized. DESIGN Secondary analysis of a prospective observational cohort study. SETTING Vanderbilt University Medical Center. PATIENTS Among adult patients enrolled in a large, multi-ICU prospective cohort study between the years of 2006 and 2011, we studied intubated and nonintubated patients with acute respiratory distress syndrome as defined by acute hypoxemia (PaO2/FIO2 ≤ 300 or SpO2/FIO2 ≤ 315) and bilateral radiographic opacities not explained by cardiac failure. We excluded patients not committed to full respiratory support. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 457 patients with acute respiratory distress syndrome, 106 (23%) were not intubated at the time of meeting all other acute respiratory distress syndrome criteria. Nonintubated patients had lower morbidity and severity of illness than intubated patients; however, mortality at 60 days was the same (36%) in both groups (p = 0.91). Of the 106 nonintubated patients, 36 (34%) required intubation within the subsequent 3 days of follow-up; this late-intubation subgroup had significantly higher 60-day mortality (56%) when compared with the both early intubation group (36%, P<0.03) and patients never requiring intubation (26%; p = 0.002). Increased mortality in the late intubation group persisted at 2-year follow-up. Adjustment for baseline clinical and demographic differences did not change the results. CONCLUSIONS A substantial proportion of critically ill adults with acute respiratory distress syndrome were not intubated in their initial days of intensive care, and many were never intubated. Late intubation was associated with increased mortality. Criteria defining the acute respiratory distress syndrome prior to need for positive pressure ventilation are required so that these patients can be enrolled in clinical studies and to facilitate early recognition and treatment of acute respiratory distress syndrome.
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Sadowitz B, Jain S, Kollisch-Singule M, Satalin J, Andrews P, Habashi N, Gatto LA, Nieman G. Preemptive mechanical ventilation can block progressive acute lung injury. World J Crit Care Med 2016; 5:74-82. [PMID: 26855896 PMCID: PMC4733459 DOI: 10.5492/wjccm.v5.i1.74] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 10/15/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023] Open
Abstract
Mortality from acute respiratory distress syndrome (ARDS) remains unacceptable, approaching 45% in certain high-risk patient populations. Treating fulminant ARDS is currently relegated to supportive care measures only. Thus, the best treatment for ARDS may lie with preventing this syndrome from ever occurring. Clinical studies were examined to determine why ARDS has remained resistant to treatment over the past several decades. In addition, both basic science and clinical studies were examined to determine the impact that early, protective mechanical ventilation may have on preventing the development of ARDS in at-risk patients. Fulminant ARDS is highly resistant to both pharmacologic treatment and methods of mechanical ventilation. However, ARDS is a progressive disease with an early treatment window that can be exploited. In particular, protective mechanical ventilation initiated before the onset of lung injury can prevent the progression to ARDS. Airway pressure release ventilation (APRV) is a novel mechanical ventilation strategy for delivering a protective breath that has been shown to block progressive acute lung injury (ALI) and prevent ALI from progressing to ARDS. ARDS mortality currently remains as high as 45% in some studies. As ARDS is a progressive disease, the key to treatment lies with preventing the disease from ever occurring while it remains subclinical. Early protective mechanical ventilation with APRV appears to offer substantial benefit in this regard and may be the prophylactic treatment of choice for preventing ARDS.
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Riviello ED, Kiviri W, Twagirumugabe T, Mueller A, Banner-Goodspeed VM, Officer L, Novack V, Mutumwinka M, Talmor DS, Fowler RA. Hospital Incidence and Outcomes of the Acute Respiratory Distress Syndrome Using the Kigali Modification of the Berlin Definition. Am J Respir Crit Care Med 2016; 193:52-9. [DOI: 10.1164/rccm.201503-0584oc] [Citation(s) in RCA: 206] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Dettmer MR, Mohr NM, Fuller BM. Sepsis-associated pulmonary complications in emergency department patients monitored with serial lactate: An observational cohort study. J Crit Care 2015; 30:1163-8. [PMID: 26362864 PMCID: PMC4648355 DOI: 10.1016/j.jcrc.2015.07.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 07/27/2015] [Accepted: 07/29/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE Patients with severe sepsis and septic shock are at high risk for development of pulmonary complications, including acute respiratory distress syndrome (ARDS). Serial lactate monitoring is a useful tool to gauge global tissue hypoxia in emergency department (ED) patients with sepsis. We hypothesized that patients undergoing serial lactate monitoring (SL) would demonstrate a decreased incidence of pulmonary complications. METHODS This is a retrospective observational cohort study of adult severe sepsis and septic shock patients with elevated lactate presenting to a large academic ED. A total of 243 patients were assigned to SL (n=132) or no serial lactate monitoring (NL; n=111). The primary outcome was a composite of pulmonary complications: (1) ARDS development and (2) respiratory failure. RESULTS Twenty-eight patients (21%) in the SL group and 37 patients (33%) in the NL group developed the primary outcome (P=.03). Multivariate analysis demonstrated an association between the NL group and development of pulmonary complications (adjusted odds ratio [aOR], 2.1; confidence interval [CI], 1.15-3.78). Emergency department mechanical ventilation was independently associated with development of ARDS (aOR, 3.5; 1.8-7.0). In the a priori subgroup of patients mechanically ventilated in the ED (n=97), those who developed ARDS received higher tidal volumes compared to patients who did not develop ARDS (8.7 mL/kg predicted body weight [interquartile range, 7.6-9.5] vs 7.6 [interquartile range, 6.8-9.0]; P<.01). CONCLUSIONS Serial lactate monitoring is associated with a decrease in major pulmonary complications in severe sepsis and septic shock. Acute respiratory distress syndrome incidence is also influenced by ED-based mechanical ventilation. These results provide 2 potentially modifiable variables to be targeted in future studies to prevent pulmonary complications in this patient subset.
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Affiliation(s)
- Matthew R Dettmer
- Division of Critical Care Medicine, Department of Medicine, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ 08103.
| | - Nicholas M Mohr
- Department of Emergency Medicine, Roy J. Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242; Division of Critical Care, Department of Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242.
| | - Brian M Fuller
- Division of Emergency Medicine, Washington University School of Medicine in St Louis, St Louis, MO 63110; Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, MO 63110.
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Nieman GF, Gatto LA, Habashi NM. Impact of mechanical ventilation on the pathophysiology of progressive acute lung injury. J Appl Physiol (1985) 2015; 119:1245-61. [PMID: 26472873 DOI: 10.1152/japplphysiol.00659.2015] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/01/2015] [Indexed: 02/08/2023] Open
Abstract
The earliest description of what is now known as the acute respiratory distress syndrome (ARDS) was a highly lethal double pneumonia. Ashbaugh and colleagues (Ashbaugh DG, Bigelow DB, Petty TL, Levine BE Lancet 2: 319-323, 1967) correctly identified the disease as ARDS in 1967. Their initial study showing the positive effect of mechanical ventilation with positive end-expiratory pressure (PEEP) on ARDS mortality was dampened when it was discovered that improperly used mechanical ventilation can cause a secondary ventilator-induced lung injury (VILI), thereby greatly exacerbating ARDS mortality. This Synthesis Report will review the pathophysiology of ARDS and VILI from a mechanical stress-strain perspective. Although inflammation is also an important component of VILI pathology, it is secondary to the mechanical damage caused by excessive strain. The mechanical breath will be deconstructed to show that multiple parameters that comprise the breath-airway pressure, flows, volumes, and the duration during which they are applied to each breath-are critical to lung injury and protection. Specifically, the mechanisms by which a properly set mechanical breath can reduce the development of excessive fluid flux and pulmonary edema, which are a hallmark of ARDS pathology, are reviewed. Using our knowledge of how multiple parameters in the mechanical breath affect lung physiology, the optimal combination of pressures, volumes, flows, and durations that should offer maximum lung protection are postulated.
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Affiliation(s)
- Gary F Nieman
- Department of Surgery, Upstate Medical University, Syracuse, New York;
| | - Louis A Gatto
- Biological Sciences Department, State University of New York, Cortland, New York; and
| | - Nader M Habashi
- R Adams Cowley Shock/Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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Pediatric acute respiratory distress syndrome: definition, incidence, and epidemiology: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16:S23-40. [PMID: 26035358 DOI: 10.1097/pcc.0000000000000432] [Citation(s) in RCA: 269] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Although there are similarities in the pathophysiology of acute respiratory distress syndrome in adults and children, pediatric-specific practice patterns, comorbidities, and differences in outcome necessitate a pediatric-specific definition. We sought to create such a definition. DESIGN A subgroup of pediatric acute respiratory distress syndrome investigators who drafted a pediatric-specific definition of acute respiratory distress syndrome based on consensus opinion and supported by detailed literature review tested elements of the definition with patient data from previously published investigations. SETTINGS International PICUs. SUBJECTS Children enrolled in published investigations of pediatric acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Several aspects of the proposed pediatric acute respiratory distress syndrome definition align with the Berlin Definition of acute respiratory distress syndrome in adults: timing of acute respiratory distress syndrome after a known risk factor, the potential for acute respiratory distress syndrome to coexist with left ventricular dysfunction, and the importance of identifying a group of patients at risk to develop acute respiratory distress syndrome. There are insufficient data to support any specific age for "adult" acute respiratory distress syndrome compared with "pediatric" acute respiratory distress syndrome. However, children with perinatal-related respiratory failure should be excluded from the definition of pediatric acute respiratory distress syndrome. Larger departures from the Berlin Definition surround 1) simplification of chest imaging criteria to eliminate bilateral infiltrates; 2) use of pulse oximetry-based criteria when PaO2 is unavailable; 3) inclusion of oxygenation index and oxygen saturation index instead of PaO2/FIO2 ratio with a minimum positive end-expiratory pressure level for invasively ventilated patients; 4) and specific inclusion of children with preexisting chronic lung disease or cyanotic congenital heart disease. CONCLUSIONS This pediatric-specific definition for acute respiratory distress syndrome builds on the adult-based Berlin Definition, but has been modified to account for differences between adults and children with acute respiratory distress syndrome. We propose using this definition for future investigations and clinical care of children with pediatric acute respiratory distress syndrome and encourage external validation with the hope for continued iterative refinement of the definition.
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41
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Prehospital aspirin use and acute respiratory distress syndrome--a case for aspirin in the drinking water? Crit Care Med 2015; 43:916-7. [PMID: 25768357 DOI: 10.1097/ccm.0000000000000835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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42
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Khemani RG, Smith L. Are we ready to accept the Berlin definition of acute respiratory distress syndrome for use in children? Crit Care Med 2015; 43:1132-4. [PMID: 25876111 PMCID: PMC4400856 DOI: 10.1097/ccm.0000000000000893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Affiliation(s)
- Robinder G. Khemani
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles; Department of Pediatrics, University of Southern California Keck School of Medicine
| | - Lincoln Smith
- Seattle Children’s Hospital, University of Washington School of Medicine
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43
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44
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Predictive value of C-reactive protein in critically ill patients who develop acute lung injury. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2015. [DOI: 10.1016/j.ejcdt.2014.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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45
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Beitler JR, Schoenfeld DA, Thompson BT. Preventing ARDS: progress, promise, and pitfalls. Chest 2014; 146:1102-1113. [PMID: 25288000 DOI: 10.1378/chest.14-0555] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Advances in critical care practice have led to a substantial decline in the incidence of ARDS over the past several years. Low tidal volume ventilation, timely resuscitation and antimicrobial administration, restrictive transfusion practices, and primary prevention of aspiration and nosocomial pneumonia have likely contributed to this reduction. Despite decades of research, there is no proven pharmacologic treatment of ARDS, and mortality from ARDS remains high. Consequently, recent initiatives have broadened the scope of lung injury research to include targeted prevention of ARDS. Prediction scores have been developed to identify patients at risk for ARDS, and clinical trials testing aspirin and inhaled budesonide/formoterol for ARDS prevention are ongoing. Future trials aimed at preventing ARDS face several key challenges. ARDS has not been validated as an end point for pivotal clinical trials, and caution is needed when testing toxic therapies that may prevent ARDS yet potentially increase mortality.
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Affiliation(s)
- Jeremy R Beitler
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital
| | - David A Schoenfeld
- Biostatistics Center, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital; Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA.
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Buregeya E, Fowler RA, Talmor DS, Twagirumugabe T, Kiviri W, Riviello ED. Acute respiratory distress syndrome in the global context. Glob Heart 2014; 9:289-95. [PMID: 25667180 DOI: 10.1016/j.gheart.2014.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 07/31/2014] [Accepted: 08/06/2014] [Indexed: 01/10/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a clinically defined syndrome of hypoxia and bilateral pulmonary infiltrates due to inflammatory pathways triggered by pulmonary and nonpulmonary insults, and ARDS is pathologically correlated with diffuse alveolar damage. Estimates of ARDS's impact in the developed world vary widely, with some of the discrepancies attributed to marked differences in the availability of intensive care beds and mechanical ventilation. Almost nothing is known about the epidemiology of ARDS in the developing world, in part due to a clinical definition requiring positive pressure ventilation, arterial blood gases, and chest radiography. Current frameworks for comparing the epidemiology of death and disability across the world including the GBD (Global Burden of Disease Study) 2010 are ill-suited to quantifying critical illness syndromes including ARDS. Modifications to the definition of ARDS to allow a provision for environments without the capacity for positive pressure ventilation, and to allow for alternate diagnostic techniques including pulse oximetry and ultrasound, may make it possible to quantify and describe the impact of ARDS in the global context.
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Affiliation(s)
- Egide Buregeya
- Department of Anesthesia, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda
| | - Robert A Fowler
- Department of Critical Care and Department of Medicine, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Daniel S Talmor
- Department of Anesthesia, Critical Care and Pain Management, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Theogene Twagirumugabe
- Department of Anesthesia, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda
| | - Willy Kiviri
- Department of Anesthesia, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda
| | - Elisabeth D Riviello
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Department of Medicine, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda.
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Sweatt AJ, Levitt JE. Evolving epidemiology and definitions of the acute respiratory distress syndrome and early acute lung injury. Clin Chest Med 2014; 35:609-24. [PMID: 25453413 DOI: 10.1016/j.ccm.2014.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This article reviews the evolving definitions and epidemiology of the acute respiratory distress syndrome (ARDS) and highlights current efforts to improve identification of high-risk patients, thus to target prevention and early treatment before progression to ARDS. This information will be important for general practitioners and intensivists interested in improving the care of patients at risk for ARDS, and clinical researchers interested in designing clinical trials targeting the prevention and early treatment of acute lung injury.
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Affiliation(s)
- Andrew J Sweatt
- Division of Pulmonary and Critical Care Medicine, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Joseph E Levitt
- Division of Pulmonary and Critical Care Medicine, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA.
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Predicting risk of postoperative lung injury in high-risk surgical patients: a multicenter cohort study. Anesthesiology 2014; 120:1168-81. [PMID: 24755786 DOI: 10.1097/aln.0000000000000216] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) remains a serious postoperative complication. Although ARDS prevention is a priority, the inability to identify patients at risk for ARDS remains a barrier to progress. The authors tested and refined the previously reported surgical lung injury prediction (SLIP) model in a multicenter cohort of at-risk surgical patients. METHODS This is a secondary analysis of a multicenter, prospective cohort investigation evaluating high-risk patients undergoing surgery. Preoperative ARDS risk factors and risk modifiers were evaluated for inclusion in a parsimonious risk-prediction model. Multiple imputation and domain analysis were used to facilitate development of a refined model, designated SLIP-2. Area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test were used to assess model performance. RESULTS Among 1,562 at-risk patients, ARDS developed in 117 (7.5%). Nine independent predictors of ARDS were identified: sepsis, high-risk aortic vascular surgery, high-risk cardiac surgery, emergency surgery, cirrhosis, admission location other than home, increased respiratory rate (20 to 29 and ≥30 breaths/min), FIO2 greater than 35%, and SpO2 less than 95%. The original SLIP score performed poorly in this heterogeneous cohort with baseline risk factors for ARDS (area under the receiver operating characteristic curve [95% CI], 0.56 [0.50 to 0.62]). In contrast, SLIP-2 score performed well (area under the receiver operating characteristic curve [95% CI], 0.84 [0.81 to 0.88]). Internal validation indicated similar discrimination, with an area under the receiver operating characteristic curve of 0.84. CONCLUSIONS In this multicenter cohort of patients at risk for ARDS, the SLIP-2 score outperformed the original SLIP score. If validated in an independent sample, this tool may help identify surgical patients at high risk for ARDS.
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The epidemiology of acute respiratory distress syndrome in patients presenting to the emergency department with severe sepsis. Shock 2014; 40:375-81. [PMID: 23903852 DOI: 10.1097/shk.0b013e3182a64682] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a serious complication of sepsis, and sepsis-associated ARDS is associated with significant morbidity and mortality. To date, no study has directly examined the epidemiology of ARDS in severe sepsis from the earliest presentation to the health care system, the emergency department (ED). METHODS This was a single-center retrospective, observational cohort study of 778 adults with severe sepsis presenting to the ED. The primary outcome was the development of ARDS requiring mechanical ventilation during the first 5 hospital days. Acute respiratory distress syndrome was defined using the Berlin definition. We used multivariable logistic regression to identify risk factors associated independently with ARDS development. RESULTS The incidence of ARDS was 6.2% (48/778 patients) in the entire cohort. Acute respiratory distress syndrome development varied across the continuum of care: 0.9% of patients fulfilled criteria for ARDS in the ED, 1.4% admitted to the ward developed ARDS, and 8.9% admitted to the intensive care unit developed ARDS. Acute respiratory distress syndrome developed a median of 1 day after admission and was associated with a 4-fold higher risk of in-hospital mortality (14% vs. 60%, P < 0.001). Independent risk factors associated with increased risk of ARDS development included intermediate (2-3.9 mmol/L) (P = 0.04) and high (≥4) serum lactate levels (P = 0.008), Lung Injury Prediction score (P < 0.001), and microbiologically proven infection (P = 0.01). CONCLUSIONS In patients presenting to the ED with severe sepsis, the rate of sepsis-associated ARDS development varied across the continuum of care. Acute respiratory distress syndrome developed rapidly and was associated with significant mortality. Elevated serum lactate levels in the ED and a recently validated clinical prediction score were independently associated with the development of ARDS in severe sepsis.
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50
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Impact of distinct definitions of acute lung injury on its incidence and outcomes in Brazilian ICUs: prospective evaluation of 7,133 patients*. Crit Care Med 2014; 42:574-82. [PMID: 24158166 DOI: 10.1097/01.ccm.0000435676.68435.56] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Evaluation of prevalence and outcomes of acute lung injury in a large cohort of critically ill patients in Brazil and comparison of predictive receiver operating characteristic curve mortality of American European Consensus conference definition with new Berlin definition of acute respiratory distress syndrome. DESIGN A 15-month prospective, multicenter, observational study. SETTING Fourteen medical ICUs in Espirito Santo, a state of Brazil. PATIENTS Mechanically ventilated patients who fulfilled American European Consensus conference criteria of acute lung injury or Berlin definition of acute respiratory distress syndrome. INTERVENTIONS Clinical and respiratory data were collected for 7 consecutive days and on the 14 and 28 days. Twenty-eight day mortality, hospital mortality, and predictive receiver operating characteristic curve mortality were calculated. MEASUREMENTS AND MAIN RESULTS Of 7,133 patients, 130 patients (1.8%) fulfilled criteria for acute lung injury (American European Consensus conference) or acute respiratory distress syndrome (Berlin definition). Median time for diagnosis was 2 days (interquartile range, 0-3 d). Main risk factors were pneumonia (35.3%) and nonpulmonary sepsis (31.5%). Mean age was 44.2 ± 15.9 years, and 61.5% were men. Mean Acute Physiology and Chronic Health Evaluation II score was 20.7 ± 7.9. Mean PaO2/FIO2 was 206 ± 61.5, significantly lower in nonsurvivors on day 7 (p = 0.003). Mean mechanical ventilation time was 21 ± 15 days. Length of ICU stay was 26.4 ± 18.7 days. Twenty-eight-day mortality was 38.5% (95% CI, 30.1-46.8); hospital mortality was 49.2% (95% CI, 40.6-57.8). Predictive 28-day mortality area under the receiver operating characteristic curve for American European Consensus conference definition was 0.5625 (95% CI, 0.4783-0.6467) and for the Berlin definition 0.5664 (95% CI, 0.4759-0.6568; p = 0.9510). CONCLUSIONS In our population, prevalence of acute lung injury was low, most cases were diagnosed 2 days after ICU admission, and Berlin definition was not different from American European Consensus conference definition in predicting mortality. There are still several problems with the global epidemiology, definition, and mortality predictive indices that should be added to the classification of this still lethal syndrome to improve its predictive mortality power in the future.
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