1
|
Trieu M, Qadir N. Adjunctive Therapies in Acute Respiratory Distress Syndrome. Crit Care Clin 2024; 40:329-351. [PMID: 38432699 DOI: 10.1016/j.ccc.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Despite significant advances in understanding acute respiratory distress syndrome (ARDS), mortality rates remain high. The appropriate use of adjunctive therapies can improve outcomes, particularly for patients with moderate to severe hypoxia. In this review, the authors discuss the evidence basis behind prone positioning, recruitment maneuvers, neuromuscular blocking agents, corticosteroids, pulmonary vasodilators, and extracorporeal membrane oxygenation and considerations for their use in individual patients and specific clinical scenarios. Because the heterogeneity of ARDS poses challenges in finding universally effective treatments, an individualized approach and continued research efforts are crucial for optimizing the utilization of adjunctive therapies and improving patient outcomes.
Collapse
Affiliation(s)
- Megan Trieu
- Division of Pulmonary Critical Care Sleep Medicine and Physiology, Department of Medicine, University of California San Diego, 9300 Campus Point Drive, #7381, La Jolla, CA 92037-1300, USA
| | - Nida Qadir
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Avenue, Room 43-229 CHS, Los Angeles, CA 90095, USA.
| |
Collapse
|
2
|
Aribindi K, Lim M, Lakshminrusimha S, Albertson T. Investigational pharmacological agents for the treatment of ARDS. Expert Opin Investig Drugs 2024; 33:243-277. [PMID: 38316432 DOI: 10.1080/13543784.2024.2315128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/25/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Acute Respiratory Distress Syndrome (ARDS) is a heterogeneous form of lung injury with severe hypoxemia and bilateral infiltrates after an inciting event that results in diffuse lung inflammation with a high mortality rate. While research in COVID-related ARDS has resulted in several pharmacotherapeutic agents that have undergone successful investigation, non-COVID ARDS studies have not resulted in many widely accepted pharmacotherapeutic agents despite exhaustive research. AREAS COVERED The aim of this review is to discuss adjuvant pharmacotherapies targeting non-COVID Acute Lung Injury (ALI)/ARDS and novel therapeutics in COVID associated ALI/ARDS. In ARDS, variable data may support selective use of neuromuscular blocking agents, corticosteroids and neutrophil elastase inhibitors, but are not yet universally used. COVID-ALI/ARDS has data supporting the use of IL-6 monoclonal antibodies, corticosteroids, and JAK inhibitor therapy. EXPERT OPINION Although ALI/ARDS modifying pharmacological agents have been identified in COVID-related disease, the data in non-COVID ALI/ARDS has been less compelling. The increased use of more specific molecular phenotyping based on physiologic parameters and biomarkers, will ensure equipoise between groups, and will likely allow more precision in confirming pharmacological agent efficacy in future studies.
Collapse
Affiliation(s)
- Katyayini Aribindi
- Department of Internal Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, U.C. Davis School of Medicine, Sacramento, CA, USA
- Department of Medicine, Veterans Affairs North California Health Care System, Mather, CA, USA
| | - Michelle Lim
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, U.C. Davis School of Medicine, Sacramento, CA, USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, U.C. Davis School of Medicine, Sacramento, CA, USA
| | - Timothy Albertson
- Department of Internal Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, U.C. Davis School of Medicine, Sacramento, CA, USA
| |
Collapse
|
3
|
Huang Q, Le Y, Li S, Bian Y. Signaling pathways and potential therapeutic targets in acute respiratory distress syndrome (ARDS). Respir Res 2024; 25:30. [PMID: 38218783 PMCID: PMC10788036 DOI: 10.1186/s12931-024-02678-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 01/03/2024] [Indexed: 01/15/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a common condition associated with critically ill patients, characterized by bilateral chest radiographical opacities with refractory hypoxemia due to noncardiogenic pulmonary edema. Despite significant advances, the mortality of ARDS remains unacceptably high, and there are still no effective targeted pharmacotherapeutic agents. With the outbreak of coronavirus disease 19 worldwide, the mortality of ARDS has increased correspondingly. Comprehending the pathophysiology and the underlying molecular mechanisms of ARDS may thus be essential to developing effective therapeutic strategies and reducing mortality. To facilitate further understanding of its pathogenesis and exploring novel therapeutics, this review provides comprehensive information of ARDS from pathophysiology to molecular mechanisms and presents targeted therapeutics. We first describe the pathogenesis and pathophysiology of ARDS that involve dysregulated inflammation, alveolar-capillary barrier dysfunction, impaired alveolar fluid clearance and oxidative stress. Next, we summarize the molecular mechanisms and signaling pathways related to the above four aspects of ARDS pathophysiology, along with the latest research progress. Finally, we discuss the emerging therapeutic strategies that show exciting promise in ARDS, including several pharmacologic therapies, microRNA-based therapies and mesenchymal stromal cell therapies, highlighting the pathophysiological basis and the influences on signal transduction pathways for their use.
Collapse
Affiliation(s)
- Qianrui Huang
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095, Jie Fang Avenue, Wuhan, 430030, China
- Department of Emergency Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jie Fang Avenue, Wuhan, 430030, China
| | - Yue Le
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjia Bridge, Hunan Road, Gu Lou District, Nanjing, 210009, China
| | - Shusheng Li
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095, Jie Fang Avenue, Wuhan, 430030, China.
- Department of Emergency Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jie Fang Avenue, Wuhan, 430030, China.
| | - Yi Bian
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095, Jie Fang Avenue, Wuhan, 430030, China.
- Department of Emergency Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jie Fang Avenue, Wuhan, 430030, China.
| |
Collapse
|
4
|
Goldman M, Lucke-Wold B, Katz J, Dawoud B, Dagra A. Respiratory Patterns in Neurological Injury, Pathophysiology, Ventilation Management, and Future Innovations: A Systematic Review. EXPLORATORY RESEARCH AND HYPOTHESIS IN MEDICINE 2023; 8:338-349. [PMID: 38130817 PMCID: PMC10735242 DOI: 10.14218/erhm.2022.00081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Traumatic brain injuries (TBI), ischemic stroke, hemorrhagic stroke, brain tumors, and seizures have diverse and sometimes overlapping associated breathing patterns. Homeostatic mechanisms for respiratory control are intertwined with complex neurocircuitry, both centrally and peripherally. This paper summarizes the neurorespiratory control and pathophysiology of its disruption. It also reviews the clinical presentation, ventilatory management, and emerging therapeutics. This review additionally serves to update all recent preclinical and clinical research regarding the spectrum of respiratory dysfunction. Having a solid pathophysiological foundation of disruptive mechanisms would permit further therapeutic development. This novel review bridges experimental/physiological data with bedside management, thus allowing neurosurgeons and intensivists alike to rapidly diagnose and treat respiratory sequelae of acute brain injury.
Collapse
Affiliation(s)
| | | | | | - Bavly Dawoud
- Neurosurgical Resident, University of Illinois, Peoria Illinois, United States
| | - Abeer Dagra
- Research Assistant, University of Florida, Gainesville, United States
| |
Collapse
|
5
|
Romero MJ, Yue Q, Singla B, Hamacher J, Sridhar S, Moseley AS, Song C, Mraheil MA, Fischer B, Zeitlinger M, Chakraborty T, Fulton D, Gan L, Annex BH, Csanyi G, Eaton DC, Lucas R. Direct endothelial ENaC activation mitigates vasculopathy induced by SARS-CoV2 spike protein. Front Immunol 2023; 14:1241448. [PMID: 37638055 PMCID: PMC10449264 DOI: 10.3389/fimmu.2023.1241448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction Although both COVID-19 and non-COVID-19 ARDS can be accompanied by significantly increased levels of circulating cytokines, the former significantly differs from the latter by its higher vasculopathy, characterized by increased oxidative stress and coagulopathy in lung capillaries. This points towards the existence of SARS-CoV2-specific factors and mechanisms that can sensitize the endothelium towards becoming dysfunctional. Although the virus is rarely detected within endothelial cells or in the circulation, the S1 subunit of its spike protein, which contains the receptor binding domain (RBD) for human ACE2 (hACE2), can be detected in plasma from COVID-19 patients and its levels correlate with disease severity. It remains obscure how the SARS-CoV2 RBD exerts its deleterious actions in lung endothelium and whether there are mechanisms to mitigate this. Methods In this study, we use a combination of in vitro studies in RBD-treated human lung microvascular endothelial cells (HL-MVEC), including electrophysiology, barrier function, oxidative stress and human ACE2 (hACE2) surface protein expression measurements with in vivo studies in transgenic mice globally expressing human ACE2 and injected with RBD. Results We show that SARS-CoV2 RBD impairs endothelial ENaC activity, reduces surface hACE2 expression and increases reactive oxygen species (ROS) and tissue factor (TF) generation in monolayers of HL-MVEC, as such promoting barrier dysfunction and coagulopathy. The TNF-derived TIP peptide (a.k.a. solnatide, AP301) -which directly activates ENaC upon binding to its a subunit- can override RBD-induced impairment of ENaC function and hACE2 expression, mitigates ROS and TF generation and restores barrier function in HL-MVEC monolayers. In correlation with the increased mortality observed in COVID-19 patients co-infected with S. pneumoniae, compared to subjects solely infected with SARS-CoV2, we observe that prior intraperitoneal RBD treatment in transgenic mice globally expressing hACE2 significantly increases fibrin deposition and capillary leak upon intratracheal instillation of S. pneumoniae and that this is mitigated by TIP peptide treatment.
Collapse
Affiliation(s)
- Maritza J. Romero
- Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA, United States
- Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Qian Yue
- Department of Medicine, School of Medicine, Emory University, Atlanta, GA, United States
| | - Bhupesh Singla
- Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Jürg Hamacher
- Pneumology, Clinic for General Internal Medicine, Lindenhofspital, Bern, Switzerland
- Lungen-und Atmungsstiftung, Bern, Switzerland
- Medical Clinic V—Pneumology, Allergology, Intensive Care Medicine, and Environmental Medicine, Faculty of Medicine, Saarland University, University Medical Centre of the Saarland, Homburg, Germany
| | - Supriya Sridhar
- Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Auriel S. Moseley
- Department of Medicine, School of Medicine, Emory University, Atlanta, GA, United States
| | - Chang Song
- Department of Medicine, School of Medicine, Emory University, Atlanta, GA, United States
| | - Mobarak A. Mraheil
- Institute for Medical Microbiology, German Centre for Infection Giessen-Marburg-Langen Site, Faculty of Medicine, Justus-Liebig University, Giessen, Germany
| | | | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Trinad Chakraborty
- Institute for Medical Microbiology, German Centre for Infection Giessen-Marburg-Langen Site, Faculty of Medicine, Justus-Liebig University, Giessen, Germany
| | - David Fulton
- Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA, United States
- Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Lin Gan
- Department of Neuroscience and Regenerative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Brian H. Annex
- Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Gabor Csanyi
- Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA, United States
- Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Douglas C. Eaton
- Department of Medicine, School of Medicine, Emory University, Atlanta, GA, United States
| | - Rudolf Lucas
- Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA, United States
- Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Augusta, GA, United States
- Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA, United States
- Division of Pulmonary and Critical Care Medicine, Medical College of Georgia at Augusta University, Augusta, GA, United States
| |
Collapse
|
6
|
Costa L, Sousa E, Fernandes C. Cyclic Peptides in Pipeline: What Future for These Great Molecules? Pharmaceuticals (Basel) 2023; 16:996. [PMID: 37513908 PMCID: PMC10386233 DOI: 10.3390/ph16070996] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023] Open
Abstract
Cyclic peptides are molecules that are already used as drugs in therapies approved for various pharmacological activities, for example, as antibiotics, antifungals, anticancer, and immunosuppressants. Interest in these molecules has been growing due to the improved pharmacokinetic and pharmacodynamic properties of the cyclic structure over linear peptides and by the evolution of chemical synthesis, computational, and in vitro methods. To date, 53 cyclic peptides have been approved by different regulatory authorities, and many others are in clinical trials for a wide diversity of conditions. In this review, the potential of cyclic peptides is presented, and general aspects of their synthesis and development are discussed. Furthermore, an overview of already approved cyclic peptides is also given, and the cyclic peptides in clinical trials are summarized.
Collapse
Affiliation(s)
- Lia Costa
- Laboratório de Química Orgânica e Farmacêutica, Departamento de Ciências Químicas, Faculdade de Farmácia, Universidade do Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal;
- Interdisciplinary Centre of Marine and Environmental Research (CIIMAR), Edifício do Terminal de Cruzeiros do Porto de Leixões, Av. General Norton de Matos s/n, 4050-208 Matosinhos, Portugal
| | - Emília Sousa
- Laboratório de Química Orgânica e Farmacêutica, Departamento de Ciências Químicas, Faculdade de Farmácia, Universidade do Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal;
- Interdisciplinary Centre of Marine and Environmental Research (CIIMAR), Edifício do Terminal de Cruzeiros do Porto de Leixões, Av. General Norton de Matos s/n, 4050-208 Matosinhos, Portugal
| | - Carla Fernandes
- Laboratório de Química Orgânica e Farmacêutica, Departamento de Ciências Químicas, Faculdade de Farmácia, Universidade do Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal;
- Interdisciplinary Centre of Marine and Environmental Research (CIIMAR), Edifício do Terminal de Cruzeiros do Porto de Leixões, Av. General Norton de Matos s/n, 4050-208 Matosinhos, Portugal
| |
Collapse
|
7
|
Lemmens-Gruber R, Tzotzos S. The Epithelial Sodium Channel-An Underestimated Drug Target. Int J Mol Sci 2023; 24:ijms24097775. [PMID: 37175488 PMCID: PMC10178586 DOI: 10.3390/ijms24097775] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 05/15/2023] Open
Abstract
Epithelial sodium channels (ENaC) are part of a complex network of interacting biochemical pathways and as such are involved in several disease states. Dependent on site and type of mutation, gain- or loss-of-function generated symptoms occur which span from asymptomatic to life-threatening disorders such as Liddle syndrome, cystic fibrosis or generalized pseudohypoaldosteronism type 1. Variants of ENaC which are implicated in disease assist further understanding of their molecular mechanisms in order to create models for specific pharmacological targeting. Identification and characterization of ENaC modifiers not only furthers our basic understanding of how these regulatory processes interact, but also enables discovery of new therapeutic targets for the disease conditions caused by ENaC dysfunction. Numerous test compounds have revealed encouraging results in vitro and in animal models but less in clinical settings. The EMA- and FDA-designated orphan drug solnatide is currently being tested in phase 2 clinical trials in the setting of acute respiratory distress syndrome, and the NOX1/ NOX4 inhibitor setanaxib is undergoing clinical phase 2 and 3 trials for therapy of primary biliary cholangitis, liver stiffness, and carcinoma. The established ENaC blocker amiloride is mainly used as an add-on drug in the therapy of resistant hypertension and is being studied in ongoing clinical phase 3 and 4 trials for special applications. This review focuses on discussing some recent developments in the search for novel therapeutic agents.
Collapse
Affiliation(s)
- Rosa Lemmens-Gruber
- Department of Pharmaceutical Sciences, Division of Pharmacology and Toxicology, University of Vienna, A-1090 Vienna, Austria
| | | |
Collapse
|
8
|
Pinto ACMD, Nunes RDM, Nogueira IA, Fischer B, Lucas R, Girão-Carmona VCC, de Oliveira VLS, Amaral FA, Schett G, Rocha FAC. Potent anti-inflammatory activity of the lectin-like domain of TNF in joints. Front Immunol 2022; 13:1049368. [PMID: 36389831 PMCID: PMC9659759 DOI: 10.3389/fimmu.2022.1049368] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/17/2022] [Indexed: 10/22/2023] Open
Abstract
In view of the crucial role of tumor necrosis factor (TNF) in joint destruction, TNF inhibitors, including neutralizing anti-TNF antibodies and soluble TNF receptor constructs, are commonly used therapeutics for the treatment of arthropathies like rheumatoid arthritis (RA). However, not all patients achieve remission; moreover, there is a risk of increased susceptibility to infection with these agents. Spatially distinct from its receptor binding sites, TNF harbors a lectin-like domain, which exerts unique functions that can be mimicked by the 17 residue solnatide peptide. This domain binds to specific oligosaccharides such as N'N'-diacetylchitobiose and directly target the α subunit of the epithelial sodium channel. Solnatide was shown to have anti-inflammatory actions in acute lung injury and glomerulonephritis models. In this study, we evaluated whether the lectin-like domain of TNF can mitigate the development of immune-mediated arthritis in mice. In an antigen-induced arthritis model, solnatide reduced cell influx and release of pro-inflammatory mediators into the joints, associated with reduction in edema and tissue damage, as compared to controls indicating that TNF has anti-inflammatory effects in an acute model of joint inflammation via its lectin-like domain.
Collapse
Affiliation(s)
| | - Rodolfo de Melo Nunes
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, Brazil
| | - Igor Albuquerque Nogueira
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, Brazil
| | | | - Rudolf Lucas
- Vascular Biology Center, Department of Pharmacology and Toxicology, Division of Pulmonary and Critical Care Medicine, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | | | | | - Flavio Almeida Amaral
- Departamento de Bioquímica e Imunologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Georg Schett
- Department of Internal Medicine 3, Rheumatology and Immunolgy, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | | |
Collapse
|
9
|
Keskinidou C, Vassiliou AG, Dimopoulou I, Kotanidou A, Orfanos SE. Mechanistic Understanding of Lung Inflammation: Recent Advances and Emerging Techniques. J Inflamm Res 2022; 15:3501-3546. [PMID: 35734098 PMCID: PMC9207257 DOI: 10.2147/jir.s282695] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/04/2022] [Indexed: 12/12/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening lung injury characterized by an acute inflammatory response in the lung parenchyma. Hence, it is considered as the most appropriate clinical syndrome to study pathogenic mechanisms of lung inflammation. ARDS is associated with increased morbidity and mortality in the intensive care unit (ICU), while no effective pharmacological treatment exists. It is very important therefore to fully characterize the underlying pathobiology and the related mechanisms, in order to develop novel therapeutic approaches. In vivo and in vitro models are important pre-clinical tools in biological and medical research in the mechanistic and pathological understanding of the majority of diseases. In this review, we will present data from selected experimental models of lung injury/acute lung inflammation, which have been based on clinical disorders that can lead to the development of ARDS and related inflammatory lung processes in humans, including ventilation-induced lung injury (VILI), sepsis, ischemia/reperfusion, smoke, acid aspiration, radiation, transfusion-related acute lung injury (TRALI), influenza, Streptococcus (S.) pneumoniae and coronaviruses infection. Data from the corresponding clinical conditions will also be presented. The mechanisms related to lung inflammation that will be covered are oxidative stress, neutrophil extracellular traps, mitogen-activated protein kinase (MAPK) pathways, surfactant, and water and ion channels. Finally, we will present a brief overview of emerging techniques in the field of omics research that have been applied to ARDS research, encompassing genomics, transcriptomics, proteomics, and metabolomics, which may recognize factors to help stratify ICU patients at risk, predict their prognosis, and possibly, serve as more specific therapeutic targets.
Collapse
Affiliation(s)
- Chrysi Keskinidou
- First Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, "Evangelismos" Hospital, Athens, Greece
| | - Alice G Vassiliou
- First Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, "Evangelismos" Hospital, Athens, Greece
| | - Ioanna Dimopoulou
- First Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, "Evangelismos" Hospital, Athens, Greece
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, "Evangelismos" Hospital, Athens, Greece
| | - Stylianos E Orfanos
- First Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, "Evangelismos" Hospital, Athens, Greece
| |
Collapse
|
10
|
Saha R, Assouline B, Mason G, Douiri A, Summers C, Shankar-Har M. The Impact of Sample Size Misestimations on the Interpretation of ARDS Trials: Systematic Review and Meta-analysis. Chest 2022; 162:1048-1062. [PMID: 35643115 DOI: 10.1016/j.chest.2022.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/06/2022] [Accepted: 05/04/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Indeterminate randomized controlled trials (RCTs) in ARDS may arise from sample size misspecification, leading to abandonment of efficacious therapies. RESEARCH QUESTIONS If evidence exists for sample size misspecification in ARDS RCTs, has this led to rejection of potentially beneficial therapies? Does evidence exist for prognostic enrichment in RCTs using mortality as a primary outcome? STUDY DESIGN AND METHODS We identified 150 ARDS RCTs commencing recruitment after the 1994 American European Consensus Conference ARDS definition and published before October 31, 2020. We examined predicted-observed sample size, predicted-observed control event rate (CER), predicted-observed average treatment effect (ATE), and the relationship between observed CER and observed ATE for RCTs with mortality and nonmortality primary outcome measures. To quantify the strength of evidence, we used Bayesian-averaged meta-analysis, trial sequential analysis, and Bayes factors. RESULTS Only 84 of 150 RCTs (56.0%) reported sample size estimations. In RCTs with mortality as the primary outcome, CER was overestimated in 16 of 28 RCTs (57.1%). To achieve predicted ATE, interventions needed to prevent 40.8% of all deaths, compared with the original prediction of 29.3%. Absolute reduction in mortality ≥ 10% was observed in 5 of 28 RCTs (17.9%), but predicted in 21 of 28 RCTs (75%). For RCTs with mortality as the primary outcome, no association was found between observed CER and observed ATE (pooled OR: β = -0.04; 95% credible interval, -0.18 to 0.09). We identified three interventions that are not currently standard of care with a Bayesian-averaged effect size of > 0.20 and moderate strength of existing evidence: corticosteroids, airway pressure release ventilation, and noninvasive ventilation. INTERPRETATION Reporting of sample size estimations was inconsistent in ARDS RCTs, and misspecification of CER and ATE was common. Prognostic enrichment strategies in ARDS RCTs based on all-cause mortality are unlikely to be successful. Bayesian methods can be used to prioritize interventions for future effectiveness RCTs.
Collapse
Affiliation(s)
- Rohit Saha
- Critical Care Centre, King's College London, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Benjamin Assouline
- Service de Médecine Intensive Réanimation, Faculté de Médecine Sorbonne Université, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Georgina Mason
- Critical Care Centre, King's College London, London, United Kingdom
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, King's College London, London, United Kingdom; National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Charlotte Summers
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Manu Shankar-Har
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom.
| |
Collapse
|
11
|
Martin-Malpartida P, Arrastia-Casado S, Farrera-Sinfreu J, Lucas R, Fischer H, Fischer B, Eaton DC, Tzotzos S, Macias MJ. Conformational ensemble of the TNF-derived peptide solnatide in solution. Comput Struct Biotechnol J 2022; 20:2082-2090. [PMID: 35601958 PMCID: PMC9079168 DOI: 10.1016/j.csbj.2022.04.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 12/12/2022] Open
Abstract
Tumor necrosis factor (TNF) is a homotrimer that has two spatially distinct binding regions, three lectin-like domains (LLD) at the TIP of the protein and three basolaterally located receptor-binding sites, the latter of which are responsible for the inflammatory and cell death-inducing properties of the cytokine. Solnatide (a.k.a. TIP peptide, AP301) is a 17-mer cyclic peptide that mimics the LLD of human TNF which activates the amiloride-sensitive epithelial sodium channel (ENaC) and, as such, recapitulates the capacity of TNF to enhance alveolar fluid clearance, as demonstrated in numerous preclinical studies. TNF and solnatide interact with glycoproteins and these interactions are necessary for their trypanolytic and ENaC-activating activities. In view of the crucial role of ENaC in lung liquid clearance, solnatide is currently being evaluated as a novel therapeutic agent to treat pulmonary edema in patients with moderate-to-severe acute respiratory distress syndrome (ARDS), as well as severe COVID-19 patients with ARDS. To facilitate the description of the functional properties of solnatide in detail, as well as to further target-docking studies, we have analyzed its folding properties by NMR. In solution, solnatide populates a set of conformations characterized by a small hydrophobic core and two electrostatically charged poles. Using the structural information determined here and also that available for the ENaC protein, we propose a model to describe solnatide interaction with the C-terminal domain of the ENaCα subunit. This model may serve to guide future experiments to validate specific interactions with ENaCα and the design of new solnatide analogs with unexplored functionalities.
Collapse
Key Words
- AP301 peptide
- ARDS, Acute Respiratory Distress Syndrome
- AlphaFold applications
- Alveolar fluid clearance
- Amiloride-sensitive epithelial sodium channel
- Amphipathic helix
- ENaC
- ENaC, Amiloride-sensitive Epithelial Sodium/Channel
- HPLC, High Performance Liquid Chromatography
- HSQC, Heteronuclear Single Quantum Coherence
- LLD, Lectin-Like Domains
- MARCKS, Myristoylated Alanine-Rich C Kinase Substrate
- NMR, Nuclear Magnetic Resonance
- NOESY, Nuclear Overhauser Effect Spectroscopy
- PIP2, Phosphatidylinositol Bisphosphate
- Peptide NMR
- Pulmonary edema
- Solnatide structure
- TIP peptide
- TM, Transmembrane Regions
- TNF, Tumor Necrosis Factor
- TOCSY, Total Correlation Spectroscopy
- Tumor necrosis factor
Collapse
Affiliation(s)
- Pau Martin-Malpartida
- Institute for Research in Biomedicine, The Barcelona Institute of Science and Technology, Baldiri Reixac, 10, Barcelona 08028, Spain
| | | | | | - Rudolf Lucas
- Vascular Biology Center, Dept of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Hendrik Fischer
- APEPTICO Forschung und Entwicklung GmbH, Mariahilferstraße 136, 1150 Vienna, Austria
| | - Bernhard Fischer
- APEPTICO Forschung und Entwicklung GmbH, Mariahilferstraße 136, 1150 Vienna, Austria
| | - Douglas C. Eaton
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Susan Tzotzos
- APEPTICO Forschung und Entwicklung GmbH, Mariahilferstraße 136, 1150 Vienna, Austria
| | - Maria J. Macias
- Institute for Research in Biomedicine, The Barcelona Institute of Science and Technology, Baldiri Reixac, 10, Barcelona 08028, Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Passeig Lluís Companys 23, Barcelona 08010, Spain
| |
Collapse
|
12
|
Schmid B, Kranke P, Lucas R, Meybohm P, Zwissler B, Frank S. Safety and preliminary efficacy of sequential multiple ascending doses of solnatide to treat pulmonary permeability edema in patients with moderate to severe ARDS in a randomized, placebo-controlled, double-blind trial: preliminary evaluation of safety and feasibility in light of the COVID-19 pandemic. Trials 2022; 23:252. [PMID: 35379296 PMCID: PMC8978157 DOI: 10.1186/s13063-022-06182-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 03/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background In May 2018, the first patient was enrolled in the phase-IIb clinical trial “Safety and Preliminary Efficacy of Sequential Multiple Ascending Doses of Solnatide to Treat Pulmonary Permeability Edema in Patients with Moderate to Severe ARDS.” With the onset of the COVID-19 pandemic in early 2020, the continuation and successful execution of this clinical study was in danger. Therefore, before the Data Safety Monitoring Board (DSMB) allowed proceeding with the study and enrollment of further COVID-19 ARDS patients into it, additional assessment on possible study bias was considered mandatory. Methods We conducted an ad hoc interim analysis of 16 patients (5 COVID-19- ARDS patients and 11 with ARDS from different causes) from the phase-IIB clinical trial. We assessed possible differences in clinical characteristics of the ARDS patients and the impact of the pandemic on study execution. Results COVID-19 patients seemed to be less sick at baseline, which also showed in higher survival rates over the 28-day observation period. Trial specific outcomes regarding pulmonary edema and ventilation parameters did not differ between the groups, nor did more general indicators of (pulmonary) sepsis like oxygenation ratio and required noradrenaline doses. Conclusion The DSMB and the investigators did not find any evidence that patients suffering from ARDS due to SARS-CoV-2 may be at higher (or generally altered) risk when included in the trial, nor were there indications that those patients might influence the integrity of the study data altogether. For this reason, a continuation of the phase IIB clinical study activities can be justified. Researchers continuing clinical trials during the pandemic should always be aware that the exceptional circumstances may alter study results and therefore adaptations of the study design might be necessary.
Collapse
|
13
|
Lucas R, Hadizamani Y, Enkhbaatar P, Csanyi G, Caldwell RW, Hundsberger H, Sridhar S, Lever AA, Hudel M, Ash D, Ushio-Fukai M, Fukai T, Chakraborty T, Verin A, Eaton DC, Romero M, Hamacher J. Dichotomous Role of Tumor Necrosis Factor in Pulmonary Barrier Function and Alveolar Fluid Clearance. Front Physiol 2022; 12:793251. [PMID: 35264975 PMCID: PMC8899333 DOI: 10.3389/fphys.2021.793251] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/30/2021] [Indexed: 02/04/2023] Open
Abstract
Alveolar-capillary leak is a hallmark of the acute respiratory distress syndrome (ARDS), a potentially lethal complication of severe sepsis, trauma and pneumonia, including COVID-19. Apart from barrier dysfunction, ARDS is characterized by hyper-inflammation and impaired alveolar fluid clearance (AFC), which foster the development of pulmonary permeability edema and hamper gas exchange. Tumor Necrosis Factor (TNF) is an evolutionarily conserved pleiotropic cytokine, involved in host immune defense against pathogens and cancer. TNF exists in both membrane-bound and soluble form and its mainly -but not exclusively- pro-inflammatory and cytolytic actions are mediated by partially overlapping TNFR1 and TNFR2 binding sites situated at the interface between neighboring subunits in the homo-trimer. Whereas TNFR1 signaling can mediate hyper-inflammation and impaired barrier function and AFC in the lungs, ligand stimulation of TNFR2 can protect from ventilation-induced lung injury. Spatially distinct from the TNFR binding sites, TNF harbors within its structure a lectin-like domain that rather protects lung function in ARDS. The lectin-like domain of TNF -mimicked by the 17 residue TIP peptide- represents a physiological mediator of alveolar-capillary barrier protection. and increases AFC in both hydrostatic and permeability pulmonary edema animal models. The TIP peptide directly activates the epithelial sodium channel (ENaC) -a key mediator of fluid and blood pressure control- upon binding to its α subunit, which is also a part of the non-selective cation channel (NSC). Activity of the lectin-like domain of TNF is preserved in complexes between TNF and its soluble TNFRs and can be physiologically relevant in pneumonia. Antibody- and soluble TNFR-based therapeutic strategies show considerable success in diseases such as rheumatoid arthritis, psoriasis and inflammatory bowel disease, but their chronic use can increase susceptibility to infection. Since the lectin-like domain of TNF does not interfere with TNF's anti-bacterial actions, while exerting protective actions in the alveolar-capillary compartments, it is currently evaluated in clinical trials in ARDS and COVID-19. A more comprehensive knowledge of the precise role of the TNFR binding sites versus the lectin-like domain of TNF in lung injury, tissue hypoxia, repair and remodeling may foster the development of novel therapeutics for ARDS.
Collapse
Affiliation(s)
- Rudolf Lucas
- Vascular Biology Center, Augusta University, Augusta, GA, United States,Department of Pharmacology and Toxicology, Augusta University, Augusta, GA, United States,Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, United States,*Correspondence: Rudolf Lucas,
| | - Yalda Hadizamani
- Lungen-und Atmungsstiftung Bern, Bern, Switzerland,Pneumology, Clinic for General Internal Medicine, Lindenhofspital Bern, Bern, Switzerland
| | - Perenlei Enkhbaatar
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, United States
| | - Gabor Csanyi
- Vascular Biology Center, Augusta University, Augusta, GA, United States,Department of Pharmacology and Toxicology, Augusta University, Augusta, GA, United States
| | - Robert W. Caldwell
- Department of Pharmacology and Toxicology, Augusta University, Augusta, GA, United States
| | - Harald Hundsberger
- Department of Medical Biotechnology, University of Applied Sciences, Krems, Austria,Department of Dermatology, University Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Supriya Sridhar
- Vascular Biology Center, Augusta University, Augusta, GA, United States
| | - Alice Ann Lever
- Vascular Biology Center, Augusta University, Augusta, GA, United States,Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, United States
| | - Martina Hudel
- Institute for Medical Microbiology, Justus-Liebig University, Giessen, Germany
| | - Dipankar Ash
- Vascular Biology Center, Augusta University, Augusta, GA, United States
| | - Masuko Ushio-Fukai
- Vascular Biology Center, Augusta University, Augusta, GA, United States,Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, United States
| | - Tohru Fukai
- Vascular Biology Center, Augusta University, Augusta, GA, United States,Department of Pharmacology and Toxicology, Augusta University, Augusta, GA, United States,Charlie Norwood Veterans Affairs Medical Center, Augusta, GA, United States
| | - Trinad Chakraborty
- Institute for Medical Microbiology, Justus-Liebig University, Giessen, Germany
| | - Alexander Verin
- Vascular Biology Center, Augusta University, Augusta, GA, United States,Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, United States
| | - Douglas C. Eaton
- Department of Medicine, School of Medicine, Emory University, Atlanta, GA, United States
| | - Maritza Romero
- Vascular Biology Center, Augusta University, Augusta, GA, United States,Department of Pharmacology and Toxicology, Augusta University, Augusta, GA, United States,Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA, United States
| | - Jürg Hamacher
- Lungen-und Atmungsstiftung Bern, Bern, Switzerland,Pneumology, Clinic for General Internal Medicine, Lindenhofspital Bern, Bern, Switzerland,Medical Clinic V-Pneumology, Allergology, Intensive Care Medicine, and Environmental Medicine, Faculty of Medicine, University Medical Centre of the Saarland, Saarland University, Homburg, Germany,Institute for Clinical & Experimental Surgery, Faculty of Medicine, Saarland University, Homburg, Germany,Jürg Hamacher,
| |
Collapse
|
14
|
Kulkarni HS, Lee JS, Bastarache JA, Kuebler WM, Downey GP, Albaiceta GM, Altemeier WA, Artigas A, Bates JHT, Calfee CS, Dela Cruz CS, Dickson RP, Englert JA, Everitt JI, Fessler MB, Gelman AE, Gowdy KM, Groshong SD, Herold S, Homer RJ, Horowitz JC, Hsia CCW, Kurahashi K, Laubach VE, Looney MR, Lucas R, Mangalmurti NS, Manicone AM, Martin TR, Matalon S, Matthay MA, McAuley DF, McGrath-Morrow SA, Mizgerd JP, Montgomery SA, Moore BB, Noël A, Perlman CE, Reilly JP, Schmidt EP, Skerrett SJ, Suber TL, Summers C, Suratt BT, Takata M, Tuder R, Uhlig S, Witzenrath M, Zemans RL, Matute-Bello G. Update on the Features and Measurements of Experimental Acute Lung Injury in Animals: An Official American Thoracic Society Workshop Report. Am J Respir Cell Mol Biol 2022; 66:e1-e14. [PMID: 35103557 PMCID: PMC8845128 DOI: 10.1165/rcmb.2021-0531st] [Citation(s) in RCA: 83] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Advancements in methods, technology, and our understanding of the pathobiology of lung injury have created the need to update the definition of experimental acute lung injury (ALI). We queried 50 participants with expertise in ALI and acute respiratory distress syndrome using a Delphi method composed of a series of electronic surveys and a virtual workshop. We propose that ALI presents as a "multidimensional entity" characterized by four "domains" that reflect the key pathophysiologic features and underlying biology of human acute respiratory distress syndrome. These domains are 1) histological evidence of tissue injury, 2) alteration of the alveolar-capillary barrier, 3) presence of an inflammatory response, and 4) physiologic dysfunction. For each domain, we present "relevant measurements," defined as those proposed by at least 30% of respondents. We propose that experimental ALI encompasses a continuum of models ranging from those focusing on gaining specific mechanistic insights to those primarily concerned with preclinical testing of novel therapeutics or interventions. We suggest that mechanistic studies may justifiably focus on a single domain of lung injury, but models must document alterations of at least three of the four domains to qualify as "experimental ALI." Finally, we propose that a time criterion defining "acute" in ALI remains relevant, but the actual time may vary based on the specific model and the aspect of injury being modeled. The continuum concept of ALI increases the flexibility and applicability of the definition to multiple models while increasing the likelihood of translating preclinical findings to critically ill patients.
Collapse
|
15
|
Nagaraju YH, Sapare A. A comprehensive review on the management of ARDS among pediatric patients. INDIAN JOURNAL OF RESPIRATORY CARE 2022. [DOI: 10.4103/ijrc.ijrc_158_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
16
|
Jia Q, Yang Y, Chen X, Yao S, Hu Z. Emerging roles of mechanosensitive ion channels in acute lung injury/acute respiratory distress syndrome. Respir Res 2022; 23:366. [PMID: 36539808 PMCID: PMC9764320 DOI: 10.1186/s12931-022-02303-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) is a devastating respiratory disorder with high rates of mortality and morbidity, but the detailed underlying mechanisms of ALI/ARDS remain largely unknown. Mechanosensitive ion channels (MSCs), including epithelial sodium channel (ENaC), Piezo channels, transient receptor potential channels (TRPs), and two-pore domain potassium ion (K2P) channels, are highly expressed in lung tissues, and the activity of these MSCs can be modulated by mechanical forces (e.g., mechanical ventilation) and other stimuli (e.g., LPS, hyperoxia). Dysfunction of MSCs has been found in various types of ALI/ARDS, and MSCs play a key role in regulating alveolar fluid clearance, alveolar epithelial/endothelial barrier function, the inflammatory response and surfactant secretion in ALI/ARDS lungs. Targeting MSCs exerts therapeutic effects in the treatment of ALI/ARDS. In this review, we summarize the structure and functions of several well-recognized MSCs, the role of MSCs in the pathogenesis of ALI/ARDS and recent advances in the pharmacological and molecular modulation of MSCs in the treatment of ALI/ARDS. According to the current literature, targeting MSCs might be a very promising therapeutic approach against ALI/ARDS.
Collapse
Affiliation(s)
- Qi Jia
- grid.33199.310000 0004 0368 7223Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yiyi Yang
- grid.33199.310000 0004 0368 7223Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiangdong Chen
- grid.33199.310000 0004 0368 7223Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shanglong Yao
- grid.33199.310000 0004 0368 7223Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiqiang Hu
- grid.33199.310000 0004 0368 7223Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
17
|
Wick KD, McAuley DF, Levitt JE, Beitler JR, Annane D, Riviello ED, Calfee CS, Matthay MA. Promises and challenges of personalized medicine to guide ARDS therapy. Crit Care 2021; 25:404. [PMID: 34814925 PMCID: PMC8609268 DOI: 10.1186/s13054-021-03822-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/09/2021] [Indexed: 02/08/2023] Open
Abstract
Identifying new effective treatments for the acute respiratory distress syndrome (ARDS), including COVID-19 ARDS, remains a challenge. The field of ARDS investigation is moving increasingly toward innovative approaches such as the personalization of therapy to biological and clinical sub-phenotypes. Additionally, there is growing recognition of the importance of the global context to identify effective ARDS treatments. This review highlights emerging opportunities and continued challenges for personalizing therapy for ARDS, from identifying treatable traits to innovative clinical trial design and recognition of patient-level factors as the field of critical care investigation moves forward into the twenty-first century.
Collapse
Affiliation(s)
- Katherine D Wick
- Cardiovascular Research Institute, University of California San Francisco, 513 Parnassus Avenue, HSE 760, San Francisco, CA, 94143, USA.
| | - Daniel F McAuley
- Belfast Health and Social Care Trust, Royal Victoria Hospital and Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Joseph E Levitt
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Djillali Annane
- Department of Intensive Care, FHU SEPSIS, and RHU RECORDS, Hôpital Raymond Poincaré (APHP), Garches, France
- Laboratory of Infection & Inflammation, School of Medicine Simone Veil, INSERM, University Versailles Saint Quentin, University Paris Saclay, Garches, France
| | - Elisabeth D Riviello
- Harvard Medical School and Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Carolyn S Calfee
- Cardiovascular Research Institute, University of California San Francisco, 513 Parnassus Avenue, HSE 760, San Francisco, CA, 94143, USA
- Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California San Francisco, 513 Parnassus Avenue, HSE 760, San Francisco, CA, 94143, USA
- Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| |
Collapse
|
18
|
Schmid B, Kredel M, Ullrich R, Krenn K, Lucas R, Markstaller K, Fischer B, Kranke P, Meybohm P, Zwißler B, Frank S. Safety and preliminary efficacy of sequential multiple ascending doses of solnatide to treat pulmonary permeability edema in patients with moderate-to-severe ARDS-a randomized, placebo-controlled, double-blind trial. Trials 2021; 22:643. [PMID: 34544463 PMCID: PMC8450703 DOI: 10.1186/s13063-021-05588-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is a complex clinical diagnosis with various possible etiologies. One common feature, however, is pulmonary permeability edema, which leads to an increased alveolar diffusion pathway and, subsequently, impaired oxygenation and decarboxylation. A novel inhaled peptide agent (AP301, solnatide) was shown to markedly reduce pulmonary edema in animal models of ARDS and to be safe to administer to healthy humans in a Phase I clinical trial. Here, we present the protocol for a Phase IIB clinical trial investigating the safety and possible future efficacy endpoints in ARDS patients. Methods This is a randomized, placebo-controlled, double-blind intervention study. Patients with moderate to severe ARDS in need of mechanical ventilation will be randomized to parallel groups receiving escalating doses of solnatide or placebo, respectively. Before advancing to a higher dose, a data safety monitoring board will investigate the data from previous patients for any indication of patient safety violations. The intervention (application of the investigational drug) takes places twice daily over the course of 7 days, ensued by a follow-up period of another 21 days. Discussion The patients to be included in this trial will be severely sick and in need of mechanical ventilation. The amount of data to be collected upon screening and during the course of the intervention phase is substantial and the potential timeframe for inclusion of any given patient is short. However, when prepared properly, adherence to this protocol will make for the acquisition of reliable data. Particular diligence needs to be exercised with respect to informed consent, because eligible patients will most likely be comatose and/or deeply sedated at the time of inclusion. Trial registration This trial was prospectively registered with the EU Clinical trials register (clinicaltrialsregister.eu). EudraCT Number: 2017-003855-47.
Collapse
Affiliation(s)
- Benedikt Schmid
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Markus Kredel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Roman Ullrich
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Katharina Krenn
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Rudolf Lucas
- Vascular Biology Center, Division of Pulmonary Medicine, Medical College of Georgia, Augusta University, Augusta, USA
| | - Klaus Markstaller
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Bernhard Zwißler
- Department of Anesthesiology, University Hospital of Ludwig-Maximilians-University (LMU), Munich, Germany.,Comprehensive Pulmonary Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Sandra Frank
- Department of Anesthesiology, University Hospital of Ludwig-Maximilians-University (LMU), Munich, Germany
| | | |
Collapse
|
19
|
Prasanna P, Rathee S, Upadhyay A, Sulakshana S. Nanotherapeutics in the treatment of acute respiratory distress syndrome. Life Sci 2021; 276:119428. [PMID: 33785346 PMCID: PMC7999693 DOI: 10.1016/j.lfs.2021.119428] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/12/2021] [Accepted: 03/20/2021] [Indexed: 01/08/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is a form of oxygenation failure primarily characterized by rapid inflammation resulting from a direct pulmonary or indirect systemic insult. ARDS has been a major cause of death in the recent COVID-19 outbreak wherein asymptomatic respiratory tract infection progresses to ARDS from pneumonia have emphasized the need for a reliable therapy for the disease. The disease has a high mortality rate of approximately 30-50%. Despite the high mortality rate, a dearth of effective pharmacotherapy exists that demands extensive research in this area. The complex ARDS pathophysiology which remains to be understood completely and the multifactorial etiology of the disease has led to the poor diagnosis, impeded drug-delivery to the deeper pulmonary tissues, and delayed treatment of the ARDS patients. Besides, critically ill patients are unable to tolerate the off-target side effects. The vast domain of nanobiotechnology presents several drug delivery systems offering numerous benefits such as targeted delivery, prolonged drug release, and uniform drug-distribution. The present review presents a brief insight into the ARDS pathophysiology and summarizes conventional pharmacotherapies available to date. Furthermore, the review provides an updated report of major developments in the nanomedicinal approaches for the treatment of ARDS. We also discuss different nano-formulations studied extensively in the ARDS preclinical models along with underlining the advantages as well as challenges that need to be addressed in the future.
Collapse
Affiliation(s)
- Pragya Prasanna
- Department of Biotechnology, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, Bihar 844102, India
| | - Shweta Rathee
- Department of Food Science and Technology, National Institute of Food Technology Entrepreneurship and Management, Sonipat, Haryana 131028, India
| | - Arun Upadhyay
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Sulakshana Sulakshana
- Department of Anesthesiology and Critical Care, Sri Ram Murti Smarak Institute of Medical Sciences (SRMS-IMS), Bareilly, Uttar Pradesh 243202, India.
| |
Collapse
|
20
|
Saha R, Assouline B, Mason G, Douiri A, Summers C, Shankar-Hari M. Impact of differences in acute respiratory distress syndrome randomised controlled trial inclusion and exclusion criteria: systematic review and meta-analysis. Br J Anaesth 2021; 127:85-101. [PMID: 33812666 PMCID: PMC9768208 DOI: 10.1016/j.bja.2021.02.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/31/2021] [Accepted: 02/21/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Control-arm mortality varies between acute respiratory distress syndrome (ARDS) RCTs. METHODS We systematically reviewed ARDS RCTs that commenced recruitment after publication of the American-European Consensus (AECC) definition (MEDLINE, Embase, and Cochrane central register of controlled trials; January 1994 to October 2020). We assessed concordance of RCT inclusion criteria to ARDS consensus definitions and whether exclusion criteria are strongly or poorly justified. We estimated the proportion of between-trial difference in control-arm 28-day mortality explained by the inclusion criteria and RCT design characteristics using meta-regression. RESULTS A literature search identified 43 709 records. One hundred and fifty ARDS RCTs were included; 146/150 (97.3%) RCTs defined ARDS inclusion criteria using AECC/Berlin definitions. Deviations from consensus definitions, primarily aimed at improving ARDS diagnostic certainty, frequently related to duration of hypoxaemia (117/146; 80.1%). Exclusion criteria could be grouped by rationale for selection into strongly or poorly justified criteria. Common poorly justified exclusions included pregnancy related, age, and comorbidities (infectious/immunosuppression, hepatic, renal, and human immunodeficiency virus/acquired immunodeficiency syndrome). Control-arm 28-day mortality varied between ARDS RCTs (mean: 29.8% [95% confidence interval: 27.0-32.7%; I2=88.8%; τ2=0.02; P<0.01]), and differed significantly between RCTs with different Pao2:FiO2 ratio inclusion thresholds (26.6-39.9 kPa vs <26.6 kPa; P<0.01). In a meta-regression model, inclusion criteria and RCT design characteristics accounted for 30.6% of between-trial difference (P<0.01). CONCLUSIONS In most ARDS RCTs, consensus definitions are modified to use as inclusion criteria. Between-RCT mortality differences are mostly explained by the Pao2:FiO2 ratio threshold within the consensus definitions. An exclusion criteria framework can be applied when designing and reporting exclusion criteria in future ARDS RCTs.
Collapse
Affiliation(s)
- Rohit Saha
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Georgina Mason
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, King's College London, London, UK,National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Manu Shankar-Hari
- Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK,School of Immunology & Microbial Sciences, King's College London, London, UK,Corresponding author
| |
Collapse
|
21
|
Mraheil MA, Toque HA, La Pietra L, Hamacher J, Phanthok T, Verin A, Gonzales J, Su Y, Fulton D, Eaton DC, Chakraborty T, Lucas R. Dual Role of Hydrogen Peroxide as an Oxidant in Pneumococcal Pneumonia. Antioxid Redox Signal 2021; 34:962-978. [PMID: 32283950 PMCID: PMC8035917 DOI: 10.1089/ars.2019.7964] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Significance:Streptococcus pneumoniae (Spn), a facultative anaerobic Gram-positive human pathogen with increasing rates of penicillin and macrolide resistance, is a major cause of lower respiratory tract infections worldwide. Pneumococci are a primary agent of severe pneumonia in children younger than 5 years and of community-acquired pneumonia in adults. A major defense mechanism toward Spn is the generation of reactive oxygen species, including hydrogen peroxide (H2O2), during the oxidative burst of neutrophils and macrophages. Paradoxically, Spn produces high endogenous levels of H2O2 as a strategy to promote colonization. Recent Advances: Pneumococci, which express neither catalase nor common regulators of peroxide stress resistance, have developed unique mechanisms to protect themselves from H2O2. Spn generates high levels of H2O2 as a strategy to promote colonization. Production of H2O2 moreover constitutes an important virulence phenotype and its cellular activities overlap and complement those of other virulence factors, such as pneumolysin, in modulating host immune responses and promoting organ injury. Critical Issues: This review examines the dual role of H2O2 in pneumococcal pneumonia, from the viewpoint of both the pathogen (defense mechanisms, lytic activity toward competing pathogens, and virulence) and the resulting host-response (inflammasome activation, endoplasmic reticulum stress, and damage to the alveolar-capillary barrier in the lungs). Future Directions: An understanding of the complexity of H2O2-mediated host-pathogen interactions is necessary to develop novel strategies that target these processes to enhance lung function during severe pneumonia.
Collapse
Affiliation(s)
- Mobarak Abu Mraheil
- Institute for Medical Microbiology, Justus-Liebig University, Giessen, Germany
| | - Haroldo A Toque
- Vascular Biology Center and Medical College of Georgia at Augusta University, Augusta, Georgia, USA.,Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Luigi La Pietra
- Institute for Medical Microbiology, Justus-Liebig University, Giessen, Germany
| | - Juerg Hamacher
- Internal Medicine and Pneumology, Lindenhofspital, Bern, Switzerland.,Lungen- und Atmungsstiftung Bern, Bern, Switzerland.,Internal Medicine V-Pneumology, Allergology, Respiratory and Environmental Medicine, Faculty of Medicine, Saarland University, Saarbrücken, Germany
| | - Tenzing Phanthok
- Department of Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Alexander Verin
- Vascular Biology Center and Medical College of Georgia at Augusta University, Augusta, Georgia, USA.,Department of Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Joyce Gonzales
- Department of Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Yunchao Su
- Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - David Fulton
- Vascular Biology Center and Medical College of Georgia at Augusta University, Augusta, Georgia, USA.,Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Douglas C Eaton
- Department of Medicine, Emory School of Medicine, Atlanta, Georgia, USA
| | - Trinad Chakraborty
- Institute for Medical Microbiology, Justus-Liebig University, Giessen, Germany
| | - Rudolf Lucas
- Vascular Biology Center and Medical College of Georgia at Augusta University, Augusta, Georgia, USA.,Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA.,Department of Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| |
Collapse
|
22
|
Jiang Y, Xia M, Xu J, Huang Q, Dai Z, Zhang X. Dexmedetomidine alleviates pulmonary edema through the epithelial sodium channel (ENaC) via the PI3K/Akt/Nedd4-2 pathway in LPS-induced acute lung injury. Immunol Res 2021; 69:162-175. [PMID: 33641076 PMCID: PMC8106593 DOI: 10.1007/s12026-021-09176-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 01/10/2021] [Indexed: 01/11/2023]
Abstract
Dexmedetomidine (Dex), a highly selective α2-adrenergic receptor (α2AR) agonist, has an anti-inflammatory property and can alleviate pulmonary edema in lipopolysaccharide (LPS)-induced acute lung injury (ALI), but the mechanism is still unclear. In this study, we attempted to investigate the effect of Dex on alveolar epithelial sodium channel (ENaC) in the modulation of alveolar fluid clearance (AFC) and the underlying mechanism. Lipopolysaccharide (LPS) was used to induce acute lung injury (ALI) in rats and alveolar epithelial cell injury in A549 cells. In vivo, Dex markedly reduced pulmonary edema induced by LPS through promoting AFC, prevented LPS-induced downregulation of α-, β-, and γ-ENaC expression, attenuated inflammatory cell infiltration in lung tissue, reduced the concentrations of TNF-α, IL-1β, and IL-6, and increased concentrations of IL-10 in bronchoalveolar lavage fluid (BALF). In A549 cells stimulated with LPS, Dex attenuated LPS-mediated cell injury and the downregulation of α-, β-, and γ-ENaC expression. However, all of these effects were blocked by the PI3K inhibitor LY294002, suggesting that the protective role of Dex is PI3K-dependent. Additionally, Dex increased the expression of phosphorylated Akt and reduced the expression of Nedd4-2, while LY294002 reversed the effect of Dex in vivo and in vitro. Furthermore, insulin-like growth factor (IGF)-1, a PI3K agonists, promoted the expression of phosphorylated Akt and reduced the expression of Nedd4-2 in LPS-stimulated A549 cells, indicating that Dex worked through PI3K, and Akt and Nedd4-2 are downstream of PI3K. In conclusion, Dex alleviates pulmonary edema by suppressing inflammatory response in LPS-induced ALI, and the mechanism is partly related to the upregulation of ENaC expression via the PI3K/Akt/Nedd4-2 signaling pathway.
Collapse
Affiliation(s)
- Yuanxu Jiang
- Department of Anesthesiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The Fist Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, China
- Shenzhen Anesthesiology Engineering Center, Shenzhen, 518020, China
| | - Mingzhu Xia
- Hubei Community Health Service Center, Luohu Hospital Group, Luohu People's Hospital, Shenzhen, 518020, China
| | - Jing Xu
- Department of Pathology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The Fist Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, China
| | - Qiang Huang
- Department of Anesthesiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The Fist Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, China
- Shenzhen Anesthesiology Engineering Center, Shenzhen, 518020, China
| | - Zhongliang Dai
- Department of Anesthesiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The Fist Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, China.
- Shenzhen Anesthesiology Engineering Center, Shenzhen, 518020, China.
| | - Xueping Zhang
- Department of Anesthesiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The Fist Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, China.
- Shenzhen Anesthesiology Engineering Center, Shenzhen, 518020, China.
| |
Collapse
|
23
|
Juschten J, Tuinman PR, Guo T, Juffermans NP, Schultz MJ, Loer SA, Girbes ARJ, de Grooth HJ. Between-trial heterogeneity in ARDS research. Intensive Care Med 2021; 47:422-434. [PMID: 33713156 PMCID: PMC7955690 DOI: 10.1007/s00134-021-06370-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/15/2021] [Indexed: 02/07/2023]
Abstract
Purpose Most randomized controlled trials (RCTs) in patients with acute respiratory distress syndrome (ARDS) revealed indeterminate or conflicting study results. We aimed to systematically evaluate between-trial heterogeneity in reporting standards and trial outcome. Methods A systematic review of RCTs published between 2000 and 2019 was performed including adult ARDS patients receiving lung-protective ventilation. A random-effects meta-regression model was applied to quantify heterogeneity (non-random variability) and to evaluate trial and patient characteristics as sources of heterogeneity. Results In total, 67 RCTs were included. The 28-day control-group mortality rate ranged from 10 to 67% with large non-random heterogeneity (I2 = 88%, p < 0.0001). Reported baseline patient characteristics explained some of the outcome heterogeneity, but only six trials (9%) reported all four independently predictive variables (mean age, mean lung injury score, mean plateau pressure and mean arterial pH). The 28-day control group mortality adjusted for patient characteristics (i.e. the residual heterogeneity) ranged from 18 to 45%. Trials with significant benefit in the primary outcome reported a higher control group mortality than trials with an indeterminate outcome or harm (mean 28-day control group mortality: 44% vs. 28%; p = 0.001). Conclusion Among ARDS RCTs in the lung-protective ventilation era, there was large variability in the description of baseline characteristics and significant unexplainable heterogeneity in 28-day control group mortality. These findings signify problems with the generalizability of ARDS research and underline the urgent need for standardized reporting of trial and baseline characteristics. Supplementary Information The online version of this article (10.1007/s00134-021-06370-w) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- J Juschten
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands. .,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands. .,Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - P R Tuinman
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - T Guo
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Division of System Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - N P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, Universiteit Van Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
| | - M J Schultz
- Department of Intensive Care, Amsterdam UMC, Universiteit Van Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - S A Loer
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - A R J Girbes
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - H J de Grooth
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
24
|
Mehta PP, Dhapte-Pawar VS. Novel and Evolving Therapies for COVID-19 Related Pulmonary Complications . Am J Med Sci 2021; 361:557-566. [PMID: 33640363 PMCID: PMC7906517 DOI: 10.1016/j.amjms.2021.02.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 11/07/2020] [Accepted: 02/23/2021] [Indexed: 12/23/2022]
Abstract
Coronaviruses disease 2019 (COVID-19) is the most crucial threat, the world has ever witnessed. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of this disease pandemic. The World Health Organization has confirmed the continuing epidemic as a worldwide public health crisis. Presently, the research on COVID-19 is even in the primitive stage. Studies on unveiling the natural route of COVID-19 infection and related pathophysiology, the biology of pulmonary airways pose a more rational restorative approach in the management of COVID-19. Thus, based on the existing facts, we methodically reviewed the efforts put forth by various research institutes, pharmaceutical companies and biotechnology firms in pulmonary delivery to prevent and control the COVID-19. This article would be valuable for the healthcare community, which is efficiently dealing with the SARS-CoV-2 crisis.
Collapse
Affiliation(s)
- Piyush P Mehta
- Department of Quality Assurance Technique, Poona College of Pharmacy, Bharati Vidyapeeth University, Pune - 38, Maharashtra, India
| | - Vividha S Dhapte-Pawar
- Department of Pharmaceutics, Poona College of Pharmacy, Bharati Vidyapeeth University, Pune - 38, Maharashtra, India.
| |
Collapse
|
25
|
Wang X, Guan Y. COVID-19 drug repurposing: A review of computational screening methods, clinical trials, and protein interaction assays. Med Res Rev 2021; 41:5-28. [PMID: 32864815 PMCID: PMC8049524 DOI: 10.1002/med.21728] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/21/2020] [Accepted: 08/12/2020] [Indexed: 12/12/2022]
Abstract
The situation of coronavirus disease 2019 (COVID-19) pandemic is rapidly evolving, and medical researchers around the globe are dedicated to finding cures for the disease. Drug repurposing, as an efficient way for drug development, has received a lot of attention. However, the huge amount of studies makes it challenging to keep up to date with the literature on COVID-19 therapeutic development. This review addresses this challenge by grouping the COVID-19 drug repurposing research into three large groups, including clinical trials, computational research, and in vitro protein-binding experiments. Particularly, to facilitate future drug discovery and the creation of effective drug combinations, drugs are organized by their mechanisms of action and reviewed by their efficacy measured by clinical trials. Providing this subtyping information, we hope this review would serve the scientists, clinicians, and the pharmaceutical industry who are looking at the new therapeutics for COVID-19 treatment.
Collapse
Affiliation(s)
- Xueqing Wang
- Department of Computational Medicine and Bioinformatics, Michigan Medicine, University of Michigan, Ann Arbor, USA
| | - Yuanfang Guan
- Department of Computational Medicine and Bioinformatics, Michigan Medicine, University of Michigan, Ann Arbor, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, USA
| |
Collapse
|
26
|
Wang X, Liu F, Xu M, Wu L. Penehyclidine hydrochloride alleviates lipopolysaccharide‑induced acute respiratory distress syndrome in cells via regulating autophagy‑related pathway. Mol Med Rep 2020; 23:100. [PMID: 33300058 PMCID: PMC7723159 DOI: 10.3892/mmr.2020.11739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 04/30/2020] [Indexed: 12/13/2022] Open
Abstract
Acute progressive hypoxic respiratory failure caused by various predisposing factors is known as acute respiratory distress syndrome (ARDS). Although penehyclidine hydrochloride (PHC), an anticholinergic drug, is widely applied in clinical practice, the specific mechanisms underlying PHC in the treatment of ARDS are not completely understood. In the present study, BEAS-2B cells were treated with 10 ng/ml lipopolysaccharide (LPS) to establish an ARDS cell model and a rat model of acute lung injury (ALI). The influences of PHC and/or autophagy inhibitor (3-methyladenine (3-MA)) on the morphology, autophagy, proliferation and apoptosis of cells and tissues were evaluated using hematoxylin and eosin staining, Cell Counting Kit-8 assays, Hoechst staining, TUNEL staining, flow cytometry, immunofluorescence assays, ELISAs and scanning electron microscopy. The expression levels of apoptosis- and autophagy-related proteins were measured via western blotting. The results indicated that PHC enhanced proliferation and autophagy, and decreased apoptosis and the inflammatory response in LPS-induced BEAS-2B cells and ALI model rats. In addition, 3-MA reversed the effects of PHC on proliferation, inflammation, apoptosis and autophagy in LPS-induced BEAS-2B cells. Therefore, the present study suggested that PHC demonstrated a protective effect in LPS-induced ARDS by regulating an autophagy-related pathway.
Collapse
Affiliation(s)
- Xiaopeng Wang
- Department of Pediatrics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, P.R. China
| | - Fen Liu
- Department of Pediatrics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, P.R. China
| | - Min Xu
- Department of Pediatrics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, P.R. China
| | - Liangxia Wu
- Department of Pediatrics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, P.R. China
| |
Collapse
|
27
|
Laupland KB, Coyer F. Physician and Nurse Research in Multidisciplinary Intensive Care Units. Am J Crit Care 2020; 29:450-457. [PMID: 33130861 DOI: 10.4037/ajcc2020136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Although clinical care is multidisciplinary, intensive care unit research commonly focuses on single-discipline themes. We sought to characterize intensive care unit research conducted by physicians and nurses. METHODS One hundred randomly selected reports of clinical studies published in critical care medical and nursing journals were reviewed. RESULTS Of the 100 articles reviewed, 50 were published in medical journals and 50 were published in nursing journals. Only 1 medical study (2%) used qualitative methods, compared with 9 nursing studies (18%) (P = .02). The distribution of quantitative study designs differed between medical and nursing journals (P < .001), with medical journals having a predominance of cohort studies (29 articles [58%]). Compared with medical journal articles, nursing journal articles had significantly fewer authors (median [interquartile range], 5 [3-6] vs 8 [6-10]; P < .001) and study participants (94 [51-237] vs 375 [86-4183]; P < .001) and a significantly lower proportion of male study participants (55% [26%-65%] vs 60% [51%-65%]; P = .02). Studies published in medical journals were much more likely than those published in nursing journals to exclusively involve patients as participants (47 [94%] vs 25 [50%]; P < .001). Coauthorship between physicians and nurses was evident in 14 articles (14%), with infrequent inclusion of authors from other health care disciplines. CONCLUSIONS Physician research and nurse research differ in several important aspects and tend to occur within silos. Increased interprofessional collaboration is possible and worthwhile.
Collapse
Affiliation(s)
- Kevin B. Laupland
- Kevin B. Laupland is an intensivist, Intensive Care Services, at Royal Brisbane and Women’s Hospital, and a professor at the School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Fiona Coyer
- Fiona Coyer is a professor of nursing with a joint appointment in Intensive Care Services at Royal Brisbane and Women’s Hospital and the School of Nursing, Queensland University of Technology (QUT)
| |
Collapse
|
28
|
Khulood D, Adil MS, Sultana R, Nimra. Convalescent plasma appears efficacious and safe in COVID-19. Ther Adv Infect Dis 2020; 7:2049936120957931. [PMID: 33062267 PMCID: PMC7534072 DOI: 10.1177/2049936120957931] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 08/19/2020] [Indexed: 12/13/2022] Open
Abstract
A cluster of pneumonia cases of unknown etiology associated with pyrexia and acute respiratory distress was identified in Southern China. Links between the previous severe acute respiratory syndrome (SARS) cases and the region’s seafood market were noted with the possibility of a new zoonosis and SARS-CoV-2 was identified as the responsible agent. Currently, there are no effective prophylactic or therapeutic options to deal with coronavirus disease-19 (COVID-19) or any other human coronavirus (HCoV) infections. Convalescent plasma (CP) therapy is a classic adaptive immunotherapy which has been in use for more a century to prevent and treat infections including SARS, Middle East respiratory syndrome (MERS), and H1N1 pandemic. Moreover, the World Health Organization regarded CP transfusion as the most promising therapy to treat MERS-CoV. This review was undertaken to demonstrate the potential of CP in the treatment of the pandemic COVID-19 disease. A total of eight studies conducted on CP therapy in patients with COVID-19 were reviewed wherein 25,028 patients above 18 years of age were involved. The vast majority of patients reported favorable outcomes when treated with CP with <1% serious adverse events. Despite its promising beneficial effects in patients severely ill with COVID-19, CP therapy requires further evaluation in randomized clinical trials (RCTs) as a lack of satisfactory efficacy data from this area certainly enhances the hesitancy with regard to employing this treatment. In the present circumstances of unsatisfactory pharmacological therapy and the urgent need for a successful curative remedy, considering the use of CP therapy is reasonable provided RCTs confirm its safety, efficacy, and tolerability.
Collapse
Affiliation(s)
- Daulat Khulood
- Dr. NTR University of Health Sciences, Vijayawada, India
| | - Mir Shoebulla Adil
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, Augusta University Campus 1120 15th Street, HM BLDG, Augusta, GA 30912, USA
| | | | - Nimra
- Sri Venkateshwara College of Pharmacy, Hyderabad, India
| |
Collapse
|
29
|
Eisenhut M, Shin JI. Pathways in the Pathophysiology of Coronavirus 19 Lung Disease Accessible to Prevention and Treatment. Front Physiol 2020; 11:872. [PMID: 32922301 PMCID: PMC7457053 DOI: 10.3389/fphys.2020.00872] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/29/2020] [Indexed: 12/12/2022] Open
Abstract
Background: In COVID 19 related lung disease, which is a leading cause of death from this disease, cytokines like tumor necrosis factor-alpha (TNF alpha) may be pivotal in the pathogenesis. TNF alpha reduces fluid absorption due to impairment of sodium and chloride transport required for building an osmotic gradient across epithelial cells, which in the airways maintains airway surface liquid helping to keep airways open and enabling bacterial clearance and aids water absorption from the alveolar spaces. TNF alpha can, through Rho-kinase, disintegrate the endothelial and epithelial cytoskeleton, and thus break up intercellular tight junctional proteins, breaching the intercellular barrier, which prevents flooding of the interstitial and alveolar spaces with fluid. Hypotheses: (1) Preservation and restoration of airway and alveolar epithelial sodium and chloride transport and the cytoskeleton dependent integrity of the cell barriers within the lung can prevent and treat COVID 19 lung disease. (2) TNF alpha is the key mediator of pulmonary edema in COVID 19 lung disease. Confirmation of hypothesis and implications: The role of a reduction in the function of epithelial sodium and chloride transport could with regards to chloride transport be tested by analysis of chloride levels in exhaled breath condensate and levels correlated with TNF alpha concentrations. Reduced levels would indicate a reduction of the function of the cystic fibrosis transmembrane conductance regulator (CFTR) chloride channel and a correlation with TNF alpha levels indicative of its involvement. Anti-TNF alpha treatment with antibodies is already available and needs to be tested in randomized controlled trials of COVID 19 lung disease. TNF alpha levels could also be reduced by statins, aspirin, and curcumin. Chloride transport could be facilitated by CFTR activators, including curcumin and phosphodiesterase-5 inhibitors. Sodium and chloride transport could be further regulated to prevent accumulation of alveolar fluid by use of Na(+)/K(+)/2Cl(-) cotransporter type 1 inhibitors, which have been associated with improved outcome in adults ventilated for acute respiratory distress syndrome (ARDS) in randomized controlled trials. Primary prevention of coronavirus infection and TNF alpha release in response to it could be improved by induction of antimicrobial peptides LL-37 and human beta defensin-2 and reduction of TNF alpha production by vitamin D prophylaxis for the population as a whole.
Collapse
Affiliation(s)
- Michael Eisenhut
- Children's & Adolescent Services, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, United Kingdom
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea
| |
Collapse
|
30
|
Horie S, McNicholas B, Rezoagli E, Pham T, Curley G, McAuley D, O'Kane C, Nichol A, Dos Santos C, Rocco PRM, Bellani G, Laffey JG. Emerging pharmacological therapies for ARDS: COVID-19 and beyond. Intensive Care Med 2020; 46:2265-2283. [PMID: 32654006 PMCID: PMC7352097 DOI: 10.1007/s00134-020-06141-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023]
Abstract
ARDS, first described in 1967, is the commonest form of acute severe hypoxemic respiratory failure. Despite considerable advances in our knowledge regarding the pathophysiology of ARDS, insights into the biologic mechanisms of lung injury and repair, and advances in supportive care, particularly ventilatory management, there remains no effective pharmacological therapy for this syndrome. Hospital mortality at 40% remains unacceptably high underlining the need to continue to develop and test therapies for this devastating clinical condition. The purpose of the review is to critically appraise the current status of promising emerging pharmacological therapies for patients with ARDS and potential impact of these and other emerging therapies for COVID-19-induced ARDS. We focus on drugs that: (1) modulate the immune response, both via pleiotropic mechanisms and via specific pathway blockade effects, (2) modify epithelial and channel function, (3) target endothelial and vascular dysfunction, (4) have anticoagulant effects, and (5) enhance ARDS resolution. We also critically assess drugs that demonstrate potential in emerging reports from clinical studies in patients with COVID-19-induced ARDS. Several therapies show promise in earlier and later phase clinical testing, while a growing pipeline of therapies is in preclinical testing. The history of unsuccessful clinical trials of promising therapies underlines the challenges to successful translation. Given this, attention has been focused on the potential to identify biologically homogenous subtypes within ARDS, to enable us to target more specific therapies ‘precision medicines.’ It is hoped that the substantial number of studies globally investigating potential therapies for COVID-19 will lead to the rapid identification of effective therapies to reduce the mortality and morbidity of this devastating form of ARDS.
Collapse
Affiliation(s)
- Shahd Horie
- Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland, Galway, Ireland
| | - Bairbre McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland
| | - Emanuele Rezoagli
- Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland, Galway, Ireland.,Department of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Tài Pham
- Service de médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Ger Curley
- Department of Anaesthesiology, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Danny McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland, UK.,Department of Intensive Care Medicine, Royal Victoria Hospital, Belfast, Northern Ireland, UK
| | - Cecilia O'Kane
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Alistair Nichol
- Clinical Research Centre at St Vincent's University Hospital, University College Dublin, Dublin, Ireland.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.,Intensive Care Unit, Alfred Hospital, Melbourne, Australia
| | - Claudia Dos Santos
- Keenan Research Centre and Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - John G Laffey
- Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland, Galway, Ireland. .,Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland.
| |
Collapse
|
31
|
In Brief. Curr Probl Surg 2020. [DOI: 10.1016/j.cpsurg.2020.100778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
32
|
Mowery NT, Terzian WTH, Nelson AC. Acute lung injury. Curr Probl Surg 2020; 57:100777. [PMID: 32505224 DOI: 10.1016/j.cpsurg.2020.100777] [Citation(s) in RCA: 137] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 02/24/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Nathan T Mowery
- Associate Professor of Surgery, Wake Forest Medical Center, Winston-Salem, NC.
| | | | - Adam C Nelson
- Acute Care Surgery Fellow, Wake Forest Medical Center, Winston-Salem, NC
| |
Collapse
|
33
|
Lewis SR, Pritchard MW, Thomas CM, Smith AF. Pharmacological agents for adults with acute respiratory distress syndrome. Cochrane Database Syst Rev 2019; 7:CD004477. [PMID: 31334568 PMCID: PMC6646953 DOI: 10.1002/14651858.cd004477.pub3] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a life-threatening condition caused by direct or indirect injury to the lungs. Despite improvements in clinical management (for example, lung protection strategies), mortality in this patient group is at approximately 40%. This is an update of a previous version of this review, last published in 2004. OBJECTIVES To evaluate the effectiveness of pharmacological agents in adults with ARDS on mortality, mechanical ventilation, and fitness to return to work at 12 months. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and CINAHL on 10 December 2018. We searched clinical trials registers and grey literature, and handsearched reference lists of included studies and related reviews. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing pharmacological agents with control (placebo or standard therapy) to treat adults with established ARDS. We excluded trials of nitric oxide, inhaled prostacyclins, partial liquid ventilation, neuromuscular blocking agents, fluid and nutritional interventions and medical oxygen. We excluded studies published earlier than 2000, because of changes to lung protection strategies for people with ARDS since this date. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We assessed the certainty of evidence with GRADE. MAIN RESULTS We included 48 RCTs with 6299 participants who had ARDS; two included only participants with mild ARDS (also called acute lung injury). Most studies included causes of ARDS that were both direct and indirect injuries. We noted differences between studies, for example the time of administration or the size of dose, and because of unclear reporting we were uncertain whether all studies had used equivalent lung protection strategies.We included five types of agents as the primary comparisons in the review: corticosteroids, surfactants, N-acetylcysteine, statins, and beta-agonists. We included 15 additional agents (sivelestat, mesenchymal stem cells, ulinastatin, anisodimine, angiotensin-converting enzyme (ACE) inhibitor, recombinant human ACE2 (palifermin), AP301, granulocyte-macrophage colony stimulating factor (GM-CSF), levosimendan, prostacyclins, lisofylline, ketaconazole, nitroglycerins, L-2-oxothiazolidine-4-carboxylic acid (OTZ), and penehyclidine hydrochloride).We used GRADE to downgrade outcomes for imprecision (because of few studies and few participants), for study limitations (e.g. high risks of bias) and for inconsistency (e.g. differences between study data).Corticosteroids versus placebo or standard therapyCorticosteroids may reduce all-cause mortality within three months by 86 per 1000 patients (with as many as 161 fewer to 19 more deaths); however, the 95% confidence interval (CI) includes the possibility of both increased and reduced deaths (risk ratio (RR) 0.77, 95% CI 0.57 to 1.05; 6 studies, 574 participants; low-certainty evidence). Due to the very low-certainty evidence, we are uncertain whether corticosteroids make little or no difference to late all-cause mortality (later than three months) (RR 0.99, 95% CI 0.64 to 1.52; 1 study, 180 participants), or to the duration of mechanical ventilation (mean difference (MD) -4.30, 95% CI -9.72 to 1.12; 3 studies, 277 participants). We found that ventilator-free days up to day 28 (VFD) may be improved with corticosteroids (MD 4.09, 95% CI 1.74 to 6.44; 4 studies, 494 participants; low-certainty evidence). No studies reported adverse events leading to discontinuation of study medication, or fitness to return to work at 12 months (FTR).Surfactants versus placebo or standard therapyWe are uncertain whether surfactants make little or no difference to early mortality (RR 1.08, 95% CI 0.91 to 1.29; 9 studies, 1338 participants), or whether they reduce late all-cause mortality (RR 1.28, 95% CI 1.01 to 1.61; 1 study, 418 participants). Similarly, we are uncertain whether surfactants reduce the duration of mechanical ventilation (MD -2.50, 95% CI -4.95 to -0.05; 1 study, 16 participants), make little or no difference to VFD (MD -0.39, 95% CI -2.49 to 1.72; 2 studies, 344 participants), or to adverse events leading to discontinuation of study medication (RR 0.50, 95% CI 0.17 to 1.44; 2 studies, 88 participants). We are uncertain of these effects because we assessed them as very low-certainty. No studies reported FTR.N-aceytylcysteine versus placeboWe are uncertain whether N-acetylcysteine makes little or no difference to early mortality, because we assessed this as very low-certainty evidence (RR 0.64, 95% CI 0.32 to 1.30; 1 study, 36 participants). No studies reported late all-cause mortality, duration of mechanical ventilation, VFD, adverse events leading to study drug discontinuation, or FTR.Statins versus placeboStatins probably make little or no difference to early mortality (RR 0.99, 95% CI 0.78 to 1.26; 3 studies, 1344 participants; moderate-certainty evidence) or to VFD (MD 0.40, 95% CI -0.71 to 1.52; 3 studies, 1342 participants; moderate-certainty evidence). Statins may make little or no difference to duration of mechanical ventilation (MD 2.70, 95% CI -3.55 to 8.95; 1 study, 60 participants; low-certainty evidence). We could not include data for adverse events leading to study drug discontinuation in one study because it was unclearly reported. No studies reported late all-cause mortality or FTR.Beta-agonists versus placebo controlBeta-blockers probably slightly increase early mortality by 40 per 1000 patients (with as many as 119 more or 25 fewer deaths); however, the 95% CI includes the possibility of an increase as well as a reduction in mortality (RR 1.14, 95% CI 0.91 to 1.42; 3 studies, 646 participants; moderate-certainty evidence). Due to the very low-certainty evidence, we are uncertain whether beta-agonists increase VFD (MD -2.20, 95% CI -3.68 to -0.71; 3 studies, 646 participants), or make little or no difference to adverse events leading to study drug discontinuation (one study reported little or no difference between groups, and one study reported more events in the beta-agonist group). No studies reported late all-cause mortality, duration of mechanical ventilation, or FTR. AUTHORS' CONCLUSIONS We found insufficient evidence to determine with certainty whether corticosteroids, surfactants, N-acetylcysteine, statins, or beta-agonists were effective at reducing mortality in people with ARDS, or duration of mechanical ventilation, or increasing ventilator-free days. Three studies awaiting classification may alter the conclusions of this review. As the potential long-term consequences of ARDS are important to survivors, future research should incorporate a longer follow-up to measure the impacts on quality of life.
Collapse
Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Michael W Pritchard
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Carmel M Thomas
- Greater Manchester Mental Health NHS Foundation TrustDepartment of Research and InnovationHarrop HousePrestwichManchesterUKM25 3BL
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
| | | |
Collapse
|
34
|
Madaio MP, Czikora I, Kvirkvelia N, McMenamin M, Yue Q, Liu T, Toque HA, Sridhar S, Covington K, Alaisami R, O'Connor PM, Caldwell RW, Chen JK, Clauss M, Brands MW, Eaton DC, Romero MJ, Lucas R. The TNF-derived TIP peptide activates the epithelial sodium channel and ameliorates experimental nephrotoxic serum nephritis. Kidney Int 2019; 95:1359-1372. [PMID: 30905471 DOI: 10.1016/j.kint.2018.12.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 12/19/2018] [Accepted: 12/20/2018] [Indexed: 02/07/2023]
Abstract
In mice, the initial stage of nephrotoxic serum-induced nephritis (NTN) mimics antibody-mediated human glomerulonephritis. Local immune deposits generate tumor necrosis factor (TNF), which activates pro-inflammatory pathways in glomerular endothelial cells (GECs) and podocytes. Because TNF receptors mediate antibacterial defense, existing anti-TNF therapies can promote infection; however, we have previously demonstrated that different functional domains of TNF may have opposing effects. The TIP peptide mimics the lectin-like domain of TNF, and has been shown to blunt inflammation in acute lung injury without impairing TNF receptor-mediated antibacterial activity. We evaluated the impact of TIP peptide in NTN. Intraperitoneal administration of TIP peptide reduced inflammation, proteinuria, and blood urea nitrogen. The protective effect was blocked by the cyclooxygenase inhibitor indomethacin, indicating involvement of prostaglandins. Targeted glomerular delivery of TIP peptide improved pathology in moderate NTN and reduced mortality in severe NTN, indicating a local protective effect. We show that TIP peptide activates the epithelial sodium channel(ENaC), which is expressed by GEC, upon binding to the channel's α subunit. In vitro, TNF treatment of GEC activated pro-inflammatory pathways and decreased the generation of prostaglandin E2 and nitric oxide, which promote recovery from NTN. TIP peptide counteracted these effects. Despite the capacity of TIP peptide to activate ENaC, it did not increase mean arterial blood pressure in mice. In the later autologous phase of NTN, TIP peptide blunted the infiltration of Th17 cells. By countering the deleterious effects of TNF through direct actions in GEC, TIP peptide could provide a novel strategy to treat glomerular inflammation.
Collapse
Affiliation(s)
- Michael P Madaio
- Department of Medicine, Augusta University, Augusta, Georgia, USA.
| | - Istvan Czikora
- Vascular Biology Center, Augusta University, Augusta, Georgia, USA; Department of Physiology, Augusta University, Augusta, Georgia, USA
| | - Nino Kvirkvelia
- Department of Medicine, Augusta University, Augusta, Georgia, USA
| | | | - Qiang Yue
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ting Liu
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, Georgia, USA
| | - Haroldo A Toque
- Vascular Biology Center, Augusta University, Augusta, Georgia, USA
| | - Supriya Sridhar
- Vascular Biology Center, Augusta University, Augusta, Georgia, USA
| | | | - Rabei Alaisami
- Department of Physiology, Augusta University, Augusta, Georgia, USA
| | - Paul M O'Connor
- Department of Physiology, Augusta University, Augusta, Georgia, USA
| | - Robert W Caldwell
- Department of Pharmacology and Toxicology, Augusta University, Augusta, Georgia, USA
| | - Jian-Kang Chen
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, Georgia, USA
| | - Matthias Clauss
- Indiana Center for Vascular Biology and Medicine, RLR-VA Medical Center, Indianapolis, Indiana, USA
| | - Michael W Brands
- Department of Physiology, Augusta University, Augusta, Georgia, USA
| | - Douglas C Eaton
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maritza J Romero
- Vascular Biology Center, Augusta University, Augusta, Georgia, USA; Department of Pharmacology and Toxicology, Augusta University, Augusta, Georgia, USA; Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Rudolf Lucas
- Department of Medicine, Augusta University, Augusta, Georgia, USA; Vascular Biology Center, Augusta University, Augusta, Georgia, USA; Department of Pharmacology and Toxicology, Augusta University, Augusta, Georgia, USA.
| |
Collapse
|
35
|
Shaw TD, McAuley DF, O’Kane CM. Emerging drugs for treating the acute respiratory distress syndrome. Expert Opin Emerg Drugs 2019; 24:29-41. [DOI: 10.1080/14728214.2019.1591369] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Timothy D. Shaw
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, UK
| | - Daniel F. McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | - Cecilia M. O’Kane
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, UK
| |
Collapse
|
36
|
Vadász I, Lucas R. Editorial: Cytokine-Ion Channel Interactions in Pulmonary Inflammation. Front Immunol 2018; 9:2598. [PMID: 30459774 PMCID: PMC6232534 DOI: 10.3389/fimmu.2018.02598] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/22/2018] [Indexed: 01/11/2023] Open
Affiliation(s)
- István Vadász
- Department of Internal Medicine, Justus Liebig University, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Giessen, Germany
| | - Rudolf Lucas
- Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, United States.,Department of Pharmacology and Toxicology, Medical College of Georgia, Augusta University, Augusta, GA, United States.,Division of Pulmonary and Critical Care Medicine, Medical College of Georgia, Augusta University, Augusta, GA, United States
| |
Collapse
|
37
|
Pappalardo F, Montisci A. Adjunctive therapies during veno-venous extracorporeal membrane oxygenation. J Thorac Dis 2018; 10:S683-S691. [PMID: 29732187 DOI: 10.21037/jtd.2017.10.08] [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] [Indexed: 01/11/2023]
Abstract
Veno-venous extracorporeal membrane oxygenation (VV ECMO) restores gas exchanges in severely hypoxemic patients. The need for adjunctive therapies usually originates either from refractory hypoxemia during ECMO (defined as the persistence of low blood oxygen levels despite extracorporeal support) or from the attempt to give a specific therapy for acute respiratory distress syndrome (ARDS). In this review, therapeutic strategies to treat refractory and persistent hypoxemia during ECMO are evaluated. In the second part, therapies that can be added on top of VV ECMO to address inflammation and altered vascular permeability in ARDS are examined. The therapies currently available often allow for an effective treatment of hypoxemia during ECMO. ARDS is still lacking a specific therapy, with low-grade evidence sustaining the majority of currently used drugs.
Collapse
Affiliation(s)
- Federico Pappalardo
- Department of Anesthesia and Intensive Care and Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Montisci
- Department of Anesthesia and Intensive Care, Cardiothoracic Center, Istituto Clinico Sant'Ambrogio, Gruppo Ospedaliero San Donato, University and Research Hospitals, Milan, Italy
| |
Collapse
|
38
|
Anderson R, Nel JG, Feldman C. Multifaceted Role of Pneumolysin in the Pathogenesis of Myocardial Injury in Community-Acquired Pneumonia. Int J Mol Sci 2018; 19:E1147. [PMID: 29641429 PMCID: PMC5979279 DOI: 10.3390/ijms19041147] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 03/14/2018] [Accepted: 03/21/2018] [Indexed: 12/14/2022] Open
Abstract
Pneumolysin (PLY), a member of the family of Gram-positive bacterial, cholesterol-dependent, β-barrel pore-forming cytolysins, is the major protein virulence factor of the dangerous respiratory pathogen, Streptococcus pneumoniae (pneumococcus). PLY plays a major role in the pathogenesis of community-acquired pneumonia (CAP), promoting colonization and invasion of the upper and lower respiratory tracts respectively, as well as extra-pulmonary dissemination of the pneumococcus. Notwithstanding its role in causing acute lung injury in severe CAP, PLY has also been implicated in the development of potentially fatal acute and delayed-onset cardiovascular events, which are now recognized as being fairly common complications of this condition. This review is focused firstly on updating mechanisms involved in the immunopathogenesis of PLY-mediated myocardial damage, specifically the direct cardiotoxic and immunosuppressive activities, as well as the indirect pro-inflammatory/pro-thrombotic activities of the toxin. Secondly, on PLY-targeted therapeutic strategies including, among others, macrolide antibiotics, natural product antagonists, cholesterol-containing liposomes, and fully humanized monoclonal antibodies, as well as on vaccine-based preventive strategies. These sections are preceded by overviews of CAP in general, the role of the pneumococcus as the causative pathogen, the occurrence and types of CAP-associated cardiac complication, and the structure and biological activities of PLY.
Collapse
Affiliation(s)
- Ronald Anderson
- Department of Immunology and Institute for Cellular and Molecular Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa.
| | - Jan G Nel
- Department of Haematology, Faculty of Health Sciences, University of Pretoria and Tshwane Academic Division of the National Health Laboratory Service, Pretoria 0001, South Africa.
| | - Charles Feldman
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 0002, South Africa.
| |
Collapse
|
39
|
Wohlrab P, Kraft F, Tretter V, Ullrich R, Markstaller K, Klein KU. Recent advances in understanding acute respiratory distress syndrome. F1000Res 2018; 7. [PMID: 29568488 PMCID: PMC5840611 DOI: 10.12688/f1000research.11148.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2018] [Indexed: 12/17/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by acute diffuse lung injury, which results in increased pulmonary vascular permeability and loss of aerated lung tissue. This causes bilateral opacity consistent with pulmonary edema, hypoxemia, increased venous admixture, and decreased lung compliance such that patients with ARDS need supportive care in the intensive care unit to maintain oxygenation and prevent adverse outcomes. Recently, advances in understanding the underlying pathophysiology of ARDS led to new approaches in managing these patients. In this review, we want to focus on recent scientific evidence in the field of ARDS research and discuss promising new developments in the treatment of this disease.
Collapse
Affiliation(s)
- Peter Wohlrab
- Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Felix Kraft
- Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Verena Tretter
- Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Roman Ullrich
- Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Klaus Markstaller
- Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Klaus Ulrich Klein
- Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| |
Collapse
|
40
|
Yang G, Pillich H, White R, Czikora I, Pochic I, Yue Q, Hudel M, Gorshkov B, Verin A, Sridhar S, Isales CM, Eaton DC, Hamacher J, Chakraborty T, Lucas R. Listeriolysin O Causes ENaC Dysfunction in Human Airway Epithelial Cells. Toxins (Basel) 2018; 10:toxins10020079. [PMID: 29439494 PMCID: PMC5848180 DOI: 10.3390/toxins10020079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/01/2018] [Accepted: 02/07/2018] [Indexed: 01/22/2023] Open
Abstract
Pulmonary permeability edema is characterized by reduced alveolar Na⁺ uptake capacity and capillary barrier dysfunction and is a potentially lethal complication of listeriosis. Apical Na⁺ uptake is mainly mediated by the epithelial sodium channel (ENaC) and initiates alveolar liquid clearance. Here we examine how listeriolysin O (LLO), the pore-forming toxin of Listeria monocytogenes, impairs the expression and activity of ENaC. To that purpose, we studied how sub-lytic concentrations of LLO affect negative and positive regulators of ENaC expression in the H441 airway epithelial cell line. LLO reduced expression of the crucial ENaC-α subunit in H441 cells within 2 h and this was preceded by activation of PKC-α, a negative regulator of the channel's expression. At later time points, LLO caused a significant reduction in the phosphorylation of Sgk-1 at residue T256 and of Akt-1 at residue S473, both of which are required for full activation of ENaC. The TNF-derived TIP peptide prevented LLO-mediated PKC-α activation and restored phospho-Sgk-1-T256. The TIP peptide also counteracted the observed LLO-induced decrease in amiloride-sensitive Na⁺ current and ENaC-α expression in H441 cells. Intratracheally instilled LLO caused profound pulmonary edema formation in mice, an effect that was prevented by the TIP peptide; thus indicating the therapeutic potential of the peptide for the treatment of pore-forming toxin-associated permeability edema.
Collapse
Affiliation(s)
- Guang Yang
- Vascular Biology Center, Medical College of Georgia at Augusta University, Room CB-3213B, Augusta, GA 30912-2500, USA.
| | - Helena Pillich
- Institute of Medical Microbiology, Justus-Liebig University Giessen, 35392 Gießen, Germany.
| | - Richard White
- Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Room CB-3213B, Augusta, GA 30912-2500, USA.
- Department of Biomedical Sciences, Georgia Campus-Philadelphia College of Osteopathic Medicine, Atlanta, GA 30224, USA.
| | - Istvan Czikora
- Vascular Biology Center, Medical College of Georgia at Augusta University, Room CB-3213B, Augusta, GA 30912-2500, USA.
| | - Isabelle Pochic
- Biochemical Pharmacology, University of Konstanz, 78464 Konstanz, Germany.
- Sandoz Inc., 83607 Holzkirchen, Germany.
| | - Qiang Yue
- Department of Physiology, Emory School of Medicine, Atlanta, GA 30307, USA.
| | - Martina Hudel
- Institute of Medical Microbiology, Justus-Liebig University Giessen, 35392 Gießen, Germany.
| | - Boris Gorshkov
- Vascular Biology Center, Medical College of Georgia at Augusta University, Room CB-3213B, Augusta, GA 30912-2500, USA.
| | - Alexander Verin
- Vascular Biology Center, Medical College of Georgia at Augusta University, Room CB-3213B, Augusta, GA 30912-2500, USA.
| | - Supriya Sridhar
- Vascular Biology Center, Medical College of Georgia at Augusta University, Room CB-3213B, Augusta, GA 30912-2500, USA.
| | - Carlos M Isales
- Department of Medicine, Medical College of Georgia, Augusta, GA 30901, USA.
| | - Douglas C Eaton
- Department of Physiology, Emory School of Medicine, Atlanta, GA 30307, USA.
| | - Jürg Hamacher
- Biochemical Pharmacology, University of Konstanz, 78464 Konstanz, Germany.
- Department of Pneumology, Lindenhofspital, 3001 Bern, Switzerland.
- Internal, Pulmonary and Critical Care Medicine, Saarland University, 66424 Homburg/Saar, Germany.
- Lungen-und Atmungsstifung, 3001 Bern, Switzerland.
| | - Trinad Chakraborty
- Institute of Medical Microbiology, Justus-Liebig University Giessen, 35392 Gießen, Germany.
| | - Rudolf Lucas
- Vascular Biology Center, Medical College of Georgia at Augusta University, Room CB-3213B, Augusta, GA 30912-2500, USA.
- Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Room CB-3213B, Augusta, GA 30912-2500, USA.
- Department of Medicine, Medical College of Georgia, Augusta, GA 30901, USA.
| |
Collapse
|
41
|
Hamacher J, Hadizamani Y, Borgmann M, Mohaupt M, Männel DN, Moehrlen U, Lucas R, Stammberger U. Cytokine-Ion Channel Interactions in Pulmonary Inflammation. Front Immunol 2018; 8:1644. [PMID: 29354115 PMCID: PMC5758508 DOI: 10.3389/fimmu.2017.01644] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 11/10/2017] [Indexed: 12/12/2022] Open
Abstract
The lungs conceptually represent a sponge that is interposed in series in the bodies’ systemic circulation to take up oxygen and eliminate carbon dioxide. As such, it matches the huge surface areas of the alveolar epithelium to the pulmonary blood capillaries. The lung’s constant exposure to the exterior necessitates a competent immune system, as evidenced by the association of clinical immunodeficiencies with pulmonary infections. From the in utero to the postnatal and adult situation, there is an inherent vital need to manage alveolar fluid reabsorption, be it postnatally, or in case of hydrostatic or permeability edema. Whereas a wealth of literature exists on the physiological basis of fluid and solute reabsorption by ion channels and water pores, only sparse knowledge is available so far on pathological situations, such as in microbial infection, acute lung injury or acute respiratory distress syndrome, and in the pulmonary reimplantation response in transplanted lungs. The aim of this review is to discuss alveolar liquid clearance in a selection of lung injury models, thereby especially focusing on cytokines and mediators that modulate ion channels. Inflammation is characterized by complex and probably time-dependent co-signaling, interactions between the involved cell types, as well as by cell demise and barrier dysfunction, which may not uniquely determine a clinical picture. This review, therefore, aims to give integrative thoughts and wants to foster the unraveling of unmet needs in future research.
Collapse
Affiliation(s)
- Jürg Hamacher
- Internal Medicine and Pneumology, Lindenhofspital, Bern, Switzerland.,Internal Medicine V - Pneumology, Allergology, Respiratory and Environmental Medicine, Faculty of Medicine, Saarland University, Saarbrücken, Germany.,Lungen- und Atmungsstiftung Bern, Bern, Switzerland
| | - Yalda Hadizamani
- Internal Medicine and Pneumology, Lindenhofspital, Bern, Switzerland.,Lungen- und Atmungsstiftung Bern, Bern, Switzerland
| | - Michèle Borgmann
- Internal Medicine and Pneumology, Lindenhofspital, Bern, Switzerland.,Lungen- und Atmungsstiftung Bern, Bern, Switzerland
| | - Markus Mohaupt
- Internal Medicine, Sonnenhofspital Bern, Bern, Switzerland
| | | | - Ueli Moehrlen
- Paediatric Visceral Surgery, Universitäts-Kinderspital Zürich, Zürich, Switzerland
| | - Rudolf Lucas
- Department of Pharmacology and Toxicology, Vascular Biology Center, Medical College of Georgia, Augusta, GA, United States
| | - Uz Stammberger
- Lungen- und Atmungsstiftung Bern, Bern, Switzerland.,Novartis Institutes for Biomedical Research, Translational Clinical Oncology, Novartis Pharma AG, Basel, Switzerland
| |
Collapse
|
42
|
Ware LB. Targeting resolution of pulmonary edema in primary graft dysfunction after lung transplantation: Is inhaled AP301 the answer? J Heart Lung Transplant 2017; 37:S1053-2498(17)32114-9. [PMID: 29198870 DOI: 10.1016/j.healun.2017.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 11/13/2017] [Indexed: 01/11/2023] Open
Affiliation(s)
- Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee.
| |
Collapse
|