1
|
Gertz SJ, Bhalla A, Chima RS, Emeriaud G, Fitzgerald JC, Hsing DD, Jeyapalan AS, Pike F, Sallee CJ, Thomas NJ, Yehya N, Rowan CM. Immunocompromised-Associated Pediatric Acute Respiratory Distress Syndrome: Experience From the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Prospective Cohort Study. Pediatr Crit Care Med 2024; 25:288-300. [PMID: 38236083 PMCID: PMC10994753 DOI: 10.1097/pcc.0000000000003421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVES To characterize immunocompromised-associated pediatric acute respiratory distress syndrome (I-PARDS) and contrast it to PARDS. DESIGN This is a secondary analysis of the 2016-2017 PARDS incidence and epidemiology (PARDIE) study, a prospective observational, cross-sectional study of children with PARDS. SETTING Dataset of 145 PICUs across 27 countries. PATIENTS During 10 nonconsecutive weeks (from May 2016 to June 2017), data about immunocompromising conditions (ICCs, defined as malignancy, congenital/acquired immunodeficiency, posttransplantation, or diseases requiring immunosuppression) were collected. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 708 subjects, 105 (14.8%) had ICC. Before the development of I-PARDS, those with ICC were more likely to be hospitalized (70% vs. 35%, p < 0.001), have more at-risk for PARDS ( p = 0.046), and spent more hours at-risk (20 [interquartile range, IQR: 8-46] vs. 11 [IQR: 4-33], [ p = 0.002]). Noninvasive ventilation (NIV) use was more common in those with ICC ( p < 0.001). Of those diagnosed with PARDS on NIV ( n = 161), children with ICC were more likely to be subsequently intubated ( n = 28/40 [70%] vs n = 53/121 [44%], p = 0.004). Severe PARDS was more common (32% vs 23%, p < 0.001) in I-PARDS. Oxygenation indices were higher at diagnosis and had less improvement over the first 3 days of PARDS ( p < 0.001). Children with I-PARDS had greater nonpulmonary organ dysfunction. Adjusting for Pediatric Risk of Mortality IV and oxygenation index, children with I-PARDS had a higher severity of illness-adjusted PICU mortality (adjusted hazard ratio: 3.0 [95% CI, 1.9-4.7] p < 0.001) and were less likely to be extubated alive within 28 days (subdistribution hazard ratio: 0.47 [95% CI, 0.31-0.71] p < 0.001). CONCLUSIONS I-PARDS is a unique subtype of PARDS associated with hospitalization before diagnosis and increased: time at-risk for PARDS, NIV use, hypoxia, nonpulmonary organ dysfunction, and mortality. The opportunity for early detection and intervention seems to exist. Dedicated study in these patients is imperative to determine if targeted interventions will benefit these unique patients with the ultimate goal of improving outcomes.
Collapse
Affiliation(s)
- Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, NJ
| | - Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles and University of Southern California, Los Angeles, CA
| | - Ranjit S Chima
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH
| | - Guillaume Emeriaud
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine and Université de Montréal, Montreal, QC, Canada
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Deyin D Hsing
- Department of Pediatrics, New York Presbyterian Hospital and Weill Cornell Medical College, New York, NY
| | - Asumthia S Jeyapalan
- Division of Critical Care Medicine, Department of Pediatrics, University of Miami, Miami, FL
| | - Francis Pike
- Department of Biostatistics, Indiana University, Indianapolis, IN
| | - Colin J Sallee
- Division of Pediatric Critical Care, Department of Pediatrics, UCLA Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, PA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Courtney M Rowan
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at IU Health, Indianapolis, IN
| |
Collapse
|
2
|
Hu Y, Shen J, An Y, Jiang Y, Zhao H. Phenotypes and Lung Microbiota Signatures of Immunocompromised Patients with Pneumonia-Related Acute Respiratory Distress Syndrome. J Inflamm Res 2024; 17:1429-1441. [PMID: 38444638 PMCID: PMC10913798 DOI: 10.2147/jir.s453123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/27/2024] [Indexed: 03/07/2024] Open
Abstract
Objective We aim to identify the clinical phenotypes of immunocompromised patients with pneumonia-related ARDS, to investigate the lung microbiota signatures and the outcomes of different phenotypes, and finally, to develop a machine learning classifier for a specified phenotype. Methods This prospective study included immunocompromised patients with pneumonia-related ARDS. We identified phenotypes using hierarchical clustering to analyze clinical variables and serum cytokine levels. We then compared outcomes and lung microbiota signatures between phenotypes. Based on lung microbiota markers, we developed a random forest classifier for a specified phenotype with worse outcomes. Results This study included 92 patients, who were divided into three phenotypes, namely "type α" (N = 33), "type β" (N = 12), and "type γ" (N = 47). Compared to type α or type β, patients with type γ had no obvious inflammatory presentation and had significantly lower IL-6 levels and more severe oxygenation failure. Type γ was also related to higher 30-day mortality and lower ventilator free days. The microbiota signatures of type γ were characterized by lower alpha diversity and distinct compositions than those of other patients. We developed a lung microbiota-derived random forest model to differentiate patients with type γ from other phenotypes. Conclusion Immunocompromised patients with pneumonia-related ARDS can be clustered into three clinical phenotypes, namely type α, type β, and type γ. Phenotypes were distinguished from each other with different outcomes and lung microbiota signatures. Type γ, which was characterized by insufficient inflammation response and worse outcomes, can be detected with a random forest model based on lung microbiota markers.
Collapse
Affiliation(s)
- Yan Hu
- Department of Respiratory and Critical Care Medicine, Peking University International Hospital, Beijing, People’s Republic of China
| | - Jiawei Shen
- Department of Critical Care Medicine, Peking University People’s Hospital, Beijing, People’s Republic of China
| | - Youzhong An
- Department of Critical Care Medicine, Peking University People’s Hospital, Beijing, People’s Republic of China
| | - Yanwen Jiang
- Department of Respiratory and Critical Care Medicine, Peking University International Hospital, Beijing, People’s Republic of China
| | - Huiying Zhao
- Department of Critical Care Medicine, Peking University People’s Hospital, Beijing, People’s Republic of China
| |
Collapse
|
3
|
Ferreyro BL, Azoulay E. Can We Predict Acute Respiratory Distress Syndrome in Hematopoietic Stem Cell Recipients? Am J Respir Crit Care Med 2024; 209:473-476. [PMID: 38285548 PMCID: PMC10919118 DOI: 10.1164/rccm.202312-2318ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/26/2024] [Indexed: 01/31/2024] Open
Affiliation(s)
- Bruno L Ferreyro
- Interdepartmental Division of Critical Care Medicine University of Toronto Toronto, Ontario, Canada and Department of Medicine Sinai Health System and University Health Network Toronto, Ontario, Canada
| | - Elie Azoulay
- Assistance Publique des Hôpitaux de Paris St-Louis Teaching Hospital and Paris 7 University Paris, France and Groupe de Recherche Respiratoire en Reanimation Onco-Hématologique Paris, France
| |
Collapse
|
4
|
Heidari A, Kaur S, Pearson SJ, Munoz A, Sandhu H, Mann G, Schivo M, Zeki AA, Bays DJ, Wilson M, Albertson TE, Johnson R, Thompson GR. Hypoxemic Respiratory Failure and Coccidioidomycosis-Associated Acute Respiratory Distress Syndrome. Open Forum Infect Dis 2024; 11:ofad679. [PMID: 38370292 PMCID: PMC10873137 DOI: 10.1093/ofid/ofad679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/27/2023] [Indexed: 02/20/2024] Open
Abstract
Background Severe coccidioidomycosis presenting with respiratory failure is an uncommon manifestation of disease. Current knowledge of this condition is limited to case reports and small case series. Methods A retrospective multicenter review of patients with coccidioidomycosis-associated acute respiratory distress syndrome (CA-ARDS) was conducted. It assessed clinical and laboratory variables at the time of presentation, reviewed the treatment course, and compared this cohort with a national database of patients with noncoccidioidomycosis ARDS. Survivors and nonsurvivors of coccidioidomycosis were also compared to determine prognostic factors. Results In this study, CA-ARDS (n = 54) was most common in males, those of Hispanic ethnicity, and those with concurrent diabetes mellitus. As compared with the PETAL network database (Prevention and Early Treatment of Acute Lung Injury; n = 1006), patients with coccidioidomycosis were younger, had fewer comorbid conditions, and were less acidemic. The 90-day mortality was 15.4% for patients with coccidioidomycosis, as opposed to 42.6% (P < .0001) for patients with noncoccidioidomycosis ARDS. Patients with coccidioidomycosis who died, as compared with those who survived, were older, had higher APACHE II scores (Acute Physiology and Chronic Health Evaluation), and did not receive corticosteroid therapy. Conclusions CA-ARDS is an uncommon but morbid manifestation of infection. When compared with a national database, the overall mortality appears favorable vs other causes of ARDS. Patients with CA-ARDS had a low overall mortality but required prolonged antifungal therapy. The utility of corticosteroids in this condition remains unconfirmed.
Collapse
Affiliation(s)
- Arash Heidari
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Bakersfield, California, USA
- Dignity Health, Bakersfield Memorial Hospital, Bakersfield, California, USA
- Valley Fever Institute, Bakersfield, California, USA
| | - Simmer Kaur
- Valley Fever Institute, Bakersfield, California, USA
- Division of Infectious Diseases, Department of Internal Medicine, Kern Medical, Bakersfield, California, USA
| | - Skyler J Pearson
- University of California–Davis Medical Center, Sacramento, CA, USA
| | - Augustine Munoz
- Valley Fever Institute, Bakersfield, California, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kern Medical, Bakersfield, California, USA
| | - Harleen Sandhu
- Division of Infectious Diseases, Department of Internal Medicine, Kern Medical, Bakersfield, California, USA
| | - Gursimran Mann
- University of California–Davis Medical Center, Sacramento, CA, USA
| | - Michael Schivo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, UC Davis Lung Center, University of California Davis Medical Center, Sacramento, CA, USA
| | - Amir A Zeki
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, UC Davis Lung Center, University of California Davis Medical Center, Sacramento, CA, USA
| | - Derek J Bays
- Division of Infectious Diseases, Department of Internal Medicine, University of California Davis Medical Center, Sacramento, CA, USA
| | - Machelle Wilson
- Department of Public Health Sciences, University of California–Davis, Davis, California, USA
| | - Timothy E Albertson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, UC Davis Lung Center, University of California Davis Medical Center, Sacramento, CA, USA
| | - Royce Johnson
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Bakersfield, California, USA
- Valley Fever Institute, Bakersfield, California, USA
- Division of Infectious Diseases, Department of Internal Medicine, Kern Medical, Bakersfield, California, USA
| | - George R Thompson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, UC Davis Lung Center, University of California Davis Medical Center, Sacramento, CA, USA
- Department of Medical Microbiology and Immunology, University of California–Davis Medical Center, Davis, California, USA
| |
Collapse
|
5
|
Wang J, Duan J, Zhou L. Incidence of noninvasive ventilation failure and mortality in patients with acute respiratory distress syndrome: a systematic review and proportion meta-analysis. BMC Pulm Med 2024; 24:48. [PMID: 38254064 PMCID: PMC10802073 DOI: 10.1186/s12890-024-02839-8] [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: 09/02/2023] [Accepted: 01/01/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Noninvasive ventilation (NIV) is commonly used in patients with acute respiratory distress syndrome (ARDS). However, the incidence and distribution of treatment failure are unclear. METHODS A comprehensive online search was conducted to select potentially eligible studies with reports of the rate of NIV failure in patients with ARDS. A manual search was also performed to identify additional studies. Data were extracted to calculate the pooled incidences of NIV failure and mortality. Based on oxygenation, the severity of the disease was classified as mild, moderate, or severe ARDS. Based on etiologies, ARDS was defined as being of pulmonary origin or extrapulmonary origin. RESULTS We enrolled 90 studies in this meta-analysis, involving 98 study arms. The pooled incidence of NIV failure was 48% (n = 5847, 95% confidence interval [CI]: 43-52%). The pooled incidence of ICU mortality was 29% (n = 2363, 95%CI: 22-36%), and that of hospital mortality was 33% (n = 2927, 95%CI: 27-40%). In patients with mild, moderate, and severe ARDS, the pooled incidence of NIV failure was 30% (n = 819, 95%CI: 21-39%), 51% (n = 1332, 95%CI: 43-60%), and 71% (n = 525, 95%CI: 62-79%), respectively. In patients with pulmonary ARDS, it was 45% (n = 2687, 95%CI: 39-51%). However, it was 30% (n = 802, 95%CI: 21-38%) in those with extrapulmonary ARDS. In patients with immunosuppression, the incidence of NIV failure was 62% (n = 806, 95%CI: 50-74%). However, it was 46% (n = 5041, 95%CI: 41-50%) in those without immunosuppression. CONCLUSIONS Nearly half of patients with ARDS experience NIV failure. The incidence of NIV failure increases with increasing ARDS severity. Pulmonary ARDS seems to have a higher rate of NIV failure than extrapulmonary ARDS. ARDS patients with immunosuppression have the highest rate of NIV failure.
Collapse
Affiliation(s)
- Jie Wang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, 400016, Chongqing, China
| | - Jun Duan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, 400016, Chongqing, China.
| | - Ling Zhou
- Department of Medical Laboratory, Song Shan Hospital of Chongqing, 69 Renhe Xingguang Avenue, Yubei District, 401121, Chongqing, China.
| |
Collapse
|
6
|
Rajsic S, Breitkopf R, Kojic D, Bukumiric Z, Treml B. Extracorporeal Life Support for Patients With Newly Diagnosed HIV and Acute Respiratory Distress Syndrome: A Systematic Review and Analysis of Individual Patient Data. ASAIO J 2023; 69:e513-e519. [PMID: 37738393 DOI: 10.1097/mat.0000000000002047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) may improve survival in patients with severe acute respiratory distress syndrome (ARDS). However, presence of immunosuppression is a relative contraindication for ECMO, which is withheld in HIV patients. We performed a systematic review to investigate the outcome of newly diagnosed HIV patients with ARDS receiving ECMO support. Our search yielded 288 publications, with 22 studies finally included. Initial presentation included fever, respiratory distress, and cough. Severe immunodeficiency was confirmed in most patients. Deceased patients had a higher viral load, a lower Horovitz index, and antiretroviral therapy utilized before ECMO. Moreover, ECMO duration was longer ( p = 0.0134), and all deceased suffered from sepsis ( p = 0.0191). Finally, despite the development of therapeutic options for HIV patients, ECMO remains a relative contraindication. We found that ECMO may successfully bridge the time for pulmonary recovery in 93% of patients, with a very good outcome. Using ECMO, the time for antimicrobial therapy, lung-protective ventilation, and immune system restitution may be gained. Further studies clarifying the role of ECMO in HIV are crucial and until these data are available, ECMO might be appropriate in immunocompromised patients. This holds especially true in newly diagnosed HIV patients, who are usually young, without comorbidities, with a good rehabilitation potential.
Collapse
Affiliation(s)
- Sasa Rajsic
- From the Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Robert Breitkopf
- From the Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Dejan Kojic
- Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Benedikt Treml
- From the Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| |
Collapse
|
7
|
Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2023. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.
Collapse
Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
| |
Collapse
|
8
|
Giannakoulis VG, Papoutsi E, Kaldis V, Tsirogianni A, Kotanidou A, Siempos II. Postoperative acute respiratory distress syndrome in randomized controlled trials. Surgery 2023; 174:1050-1055. [PMID: 37481422 DOI: 10.1016/j.surg.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/05/2023] [Accepted: 06/18/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Acute respiratory distress syndrome is a potentially fatal postoperative complication. We aimed to estimate temporal trends of the representation of patients with postoperative acute respiratory distress syndrome in clinical trials, determine their distinct clinical features, and identify predictors of mortality. METHODS This is a secondary analysis of 7 randomized controlled clinical trials conducted by the Acute Respiratory Distress Syndrome Network and the Clinical Trials Network for the Prevention and Early Treatment of Acute Lung Injury. Patients with acute respiratory distress syndrome were classified into a postoperative acute respiratory distress syndrome group (ie, patients who had undergone elective surgery in the immediate period before trial enrollment) and a non-postoperative acute respiratory distress syndrome group. RESULTS Out of 5,316 patients with acute respiratory distress syndrome, 256 (4.8%) had postoperative acute respiratory distress syndrome. Representation of postoperative acute respiratory distress syndrome in trials gradually declined from 2000 to 2011, but it remained stable afterward at 2.7%. Postoperative acute respiratory distress syndrome was associated with lower 90-day mortality (24.6% vs 30.9%, P = .032) than non-postoperative acute respiratory distress syndrome, even after adjusting for age, acute respiratory distress syndrome severity, usage of vasopressors at baseline, and the study publication year (hazard ratio 0.63, 95% confidence interval 0.49-0.82). Age (odds ratio 1.07, 95% confidence interval 1.04-1.09), immunosuppression (odds ratio 4.12, 95% confidence interval 1.43-11.86), and positive fluid balance (odds ratio 1.09, 95% confidence interval 1.04-1.14) were associated with 90-day mortality among patients with postoperative acute respiratory distress syndrome. CONCLUSION Representation of postoperative acute respiratory distress syndrome in trials of the Acute Respiratory Distress Syndrome Network and the Clinical Trials Network for the Prevention and Early Treatment of Acute Lung Injury gradually declined from 2000 to 2011 but remained stable afterward. Postoperative acute respiratory distress syndrome was associated with lower mortality than non-postoperative acute respiratory distress syndrome. These findings may put both temporal trends and the prognosis of postoperative acute respiratory distress syndrome in perspective. Also, positive fluid balance was associated with the mortality of patients with postoperative acute respiratory distress syndrome.
Collapse
Affiliation(s)
- Vassilis G Giannakoulis
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Greece
| | - Eleni Papoutsi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Greece
| | - Vassileios Kaldis
- Department of Emergency Medicine, KAT General Hospital, Athens, Greece
| | | | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Greece
| | - Ilias I Siempos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Greece; Department of Medicine, Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY.
| |
Collapse
|
9
|
Lyons PG, McEvoy CA, Hayes-Lattin B. Sepsis and acute respiratory failure in patients with cancer: how can we improve care and outcomes even further? Curr Opin Crit Care 2023; 29:472-483. [PMID: 37641516 PMCID: PMC11142388 DOI: 10.1097/mcc.0000000000001078] [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] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Care and outcomes of critically ill patients with cancer have improved over the past decade. This selective review will discuss recent updates in sepsis and acute respiratory failure among patients with cancer, with particular focus on important opportunities to improve outcomes further through attention to phenotyping, predictive analytics, and improved outcome measures. RECENT FINDINGS The prevalence of cancer diagnoses in intensive care units (ICUs) is nontrivial and increasing. Sepsis and acute respiratory failure remain the most common critical illness syndromes affecting these patients, although other complications are also frequent. Recent research in oncologic sepsis has described outcome variation - including ICU, hospital, and 28-day mortality - across different types of cancer (e.g., solid vs. hematologic malignancies) and different sepsis definitions (e.g., Sepsis-3 vs. prior definitions). Research in acute respiratory failure in oncology patients has highlighted continued uncertainty in the value of diagnostic bronchoscopy for some patients and in the optimal respiratory support strategy. For both of these syndromes, specific challenges include multifactorial heterogeneity (e.g. in etiology and/or underlying cancer), delayed recognition of clinical deterioration, and complex outcomes measurement. SUMMARY Improving outcomes in oncologic critical care requires attention to the heterogeneity of cancer diagnoses, timely recognition and management of critical illness, and defining appropriate ICU outcomes.
Collapse
Affiliation(s)
- Patrick G Lyons
- Department of Medicine, Oregon Health & Science University
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University
- Knight Cancer Institute, Oregon Health & Science University
| | - Colleen A McEvoy
- Department of Medicine, Washington University School of Medicine
- Siteman Cancer Center, Washington University School of Medicine
| | - Brandon Hayes-Lattin
- Department of Medicine, Oregon Health & Science University
- Knight Cancer Institute, Oregon Health & Science University
| |
Collapse
|
10
|
Guastella V, Lambert C, Lafforgue A, Metretin P, Verstreate A, Watelet S, Perceau-Chambard É, Lautrette A. Withholding or withdrawing life-sustaining treatments in the COVID-19 pandemic: adherence to legal standards. BMJ Support Palliat Care 2023:spcare-2023-004504. [PMID: 37536752 DOI: 10.1136/spcare-2023-004504] [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: 07/19/2023] [Accepted: 07/22/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVES In France, when the patient is unable to express his wishes, the decision to withhold or withdraw life-sustaining treatment (WWLST) is made following a collegial procedure described by a law. The aim of our study was to assess how closely this WWLST decision-making procedure in end of life patients was maintained during the COVID-19 pandemic. METHODS This retrospective observational multicentre study compared the rate of non-compliance with WWLST decision-making procedures during the pandemic period from March to June 2020 with control period in 2019, in Clermont-Ferrand and Lyon Hospitals. Secondary objectives were to determine the factors associated with non-compliance. RESULTS In 430 deceased patients included (176 in 2019 and 254 in 2020), the rate of non-compliance was 61.4% in 2019 and 59.1% in 2020 (p=0.63). In multivariable analysis, non-compliance was associated with immunosuppression status (OR 1.69, 95% CI (1.12 to 2.54), p=0.01) but was lower in intensive care unit (OR 0.54, 95% CI (0.36 to 0.82), p=0.003) and when the patient had visits from relatives (OR 0.41, 95% CI (0.22 to 0.75), p=0.004). CONCLUSION In France, more than half of WWLST decisions do not comply with the law. The COVID-19 pandemic did not increase this non-compliance rate. Further studies are needed for a better understanding of the mechanisms underlying non-compliance with WWLST decision-making procedure. TRIAL REGISTRATION NUMBER NCT04452487.
Collapse
Affiliation(s)
- Virginie Guastella
- Palliative Care Departement, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Aurore Lafforgue
- Palliative Care Departement, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Pauline Metretin
- Palliative Care Departement, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | | | | | | | | |
Collapse
|
11
|
Benguerfi S, Dumas G, Soares M, Meert AP, Martin-Loeches I, Pene F, Bauer P, Mehta S, Metaxa V, Burghi G, Kouatchet A, Montini L, Mokart D, Van de Louw A, Azoulay E, Lemiale V. Etiologies and Outcome of Patients with Solid Tumors Admitted to ICU with Acute Respiratory Failure: A Secondary Analysis of the EFRAIM Study. Respir Care 2023; 68:740-748. [PMID: 37072164 PMCID: PMC10209001 DOI: 10.4187/respcare.10604] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
BACKGROUND Acute respiratory failure (ARF) remains the most frequent reason for ICU admission in patients who are immunocompromised. This study reports etiologies and outcomes of ARF in subjects with solid tumors. METHODS This study was a post hoc analysis of the EFRAIM study, a prospective multinational cohort study that included 1611 subjects who were immunocompromised and with ARF admitted to the ICU. Subjects with solid tumors admitted to the ICU with ARF were included in the analysis. RESULTS Among the subjects from the EFRAIM cohort, 529 subjects with solid tumors (32.8%) were included in the analysis. At ICU admission, the median (interquartile range) Sequential Organ Failure Assessment score was 5 (3-9). The types of solid tumor were mostly lung cancer (n = 111, 21%), breast cancer (n = 52, 9.8%), and digestive cancer (n = 47, 8.9%). A majority, 379 subjects (71.6%) were full code at ICU admission. The ARF was caused by bacterial or viral infection (n = 220, 41.6%), extrapulmonary sepsis (n = 62, 11.7%), or related to cancer or treatment toxicity (n = 83, 15.7%), or fungal infection (n = 23, 4.3%). For 63 subjects (11.9%), the ARF etiology remained unknown after an extensive diagnostic workup. The hospital mortality rate was 45.7% (n = 232/508). Hospital mortality was independently associated with chronic cardiac failure (odds ratio 1.78, 95% CI 1.09-2.92; P = .02), lung cancer (odds ratio 2.50, 95% CI 1.51-4.19; P < .001), day 1 Sequential Organ Failure Assessment score (odds ratio 1.97, 95% CI 1.32-2.96; P < .001). ARF etiologies other than infectious, related to cancer, or treatment toxicity were associated with better outcomes (odds ratio 0.32, 95% CI 0.16-0.61; P < .001). CONCLUSIONS Infectious diseases remained the most frequent cause of ARF in subjects with solid tumors admitted to the ICU. Hospital mortality was related to severity at ICU admission, previous comorbidities, and ARF etiologies related to non-malignant causes or pulmonary embolism. Lung tumor was also independently associated with higher mortality.
Collapse
Affiliation(s)
- Soraya Benguerfi
- Department of Intensive-Resuscitation Medicine, APHP, Hôpital Saint-Louis, Paris Diderot Sorbonne Université, Paris, France.
| | - Guillaume Dumas
- Department of Intensive-Resuscitation Medicine, APHP, Hôpital Saint-Louis, Paris Diderot Sorbonne Université, Paris, France
| | - Marcio Soares
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Programa de Pós-Graduaçãoem Clínica Médica, Rio De Janeiro, Brazil
| | - Anne-Pascale Meert
- Internal Medicine Service, Soins Intensifs & Urgences Oncologique, Institut Jules Bordet, Brussels, Belgium
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization, St James's Hospital, Dublin, Ireland
| | - Frederic Pene
- Medical ICU, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and Paris Descartes University, Paris, France
| | - Philippe Bauer
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Gaston Burghi
- Terapia Intensiva, Hospital Maciel, Montevideo, Uruguay
| | - Achille Kouatchet
- Department of Medical Intensive Care Medicine, University Hospital of Angers, Angers, France
| | - Luca Montini
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Djamel Mokart
- Multipurpose Resuscitation Service and Department of Anesthesia and Resuscitation, Institut Paoli-Calmettes, Marseille, France
| | - Andry Van de Louw
- Division of Pulmonary and Critical Care Medicine, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Elie Azoulay
- Department of Intensive-Resuscitation Medicine, APHP, Hôpital Saint-Louis, Paris Diderot Sorbonne Université, Paris, France
| | - Virginie Lemiale
- Department of Intensive-Resuscitation Medicine, APHP, Hôpital Saint-Louis, Paris Diderot Sorbonne Université, Paris, France
| |
Collapse
|
12
|
Blazoski C, Kirupaharan P, Hilton R, Leong R, Baram M. Outcomes of extracorporeal membrane oxygenation in immunosuppressed vs. Immunocompetent patients. Heart Lung 2023; 58:179-184. [PMID: 36535131 DOI: 10.1016/j.hrtlng.2022.12.003] [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: 07/07/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Immunosuppressed hosts represent a growing group of patients who suffer acute respiratory failure and may be considered for therapies such as extracorporeal membrane oxygenation (ECMO). OBJECTIVES We conducted this retrospective study to determine whether acutely or chronically immunosuppressed patients placed on ECMO for cardiac and/or respiratory failure in our institution have different outcomes than immunocompetent patients placed on ECMO in our institution. METHODS Adult patients placed on ECMO between June 31, 2010 and July 7, 2021 were identified within an IRB-approved database. Data was retrospectively extracted from the database and patients' medical records. Patients who survived ECMO decannulation were sub-grouped by the presence of acute or chronic immunosuppression, defined by the use of high-dose steroids or immunosuppressive agents for greater than four weeks prior to ECMO initiation. We analyzed and compared baseline characteristics and clinical outcomes using chi-squared tests for categorical variables and a one-way analysis of variance (ANOVA) for continuous variables. RESULTS 385 patients were included in this study, with 39 identified as chronically immunosuppressed, 49 as acutely immunosuppressed, and 297 as immunocompetent. There was no statistical difference in ECMO survival (respectively 54%, 59%, 65% p = 0.359) or 30-day survival (33%, 51%, 48% p = 0.149) for chronically immunosuppressed, acutely immunosuppressed, and immunocompetent, respectively. There were significant differences in rates of pre-ECMO COVID infection (p<0.001), coronary artery disease (p<0.001), smoking (p = 0.003), and acute kidney injury (p = 0.032). Acutely immunosuppressed patients had the highest rates of new infections during ECMO (p = 0.006). CONCLUSION When compared to immunocompetent patients, both acutely and chronically immunosuppressed patients had no significant difference in ECMO survival or 30-day survival. Acutely immunosuppressed patients had less comorbidities than chronically immunosuppressed patients, but they were more commonly infected during ECMO. ECMO may still be a valuable tool in appropriately selected patients with refractory respiratory or cardiac failure.
Collapse
Affiliation(s)
- Cameron Blazoski
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Palestine, United States
| | - Pradhab Kirupaharan
- Department of Medicine, Thomas Jefferson University, Philadelphia, Palestine, United States
| | - Robert Hilton
- Department of Medicine, Thomas Jefferson University, Philadelphia, Palestine, United States
| | - Ron Leong
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA
| | - Michael Baram
- Department of Medicine, Thomas Jefferson University, Philadelphia, Palestine, United States.
| |
Collapse
|
13
|
Five new realities in critical care for patients with cancer. Intensive Care Med 2023; 49:345-348. [PMID: 36757470 DOI: 10.1007/s00134-023-06988-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/16/2023] [Indexed: 02/10/2023]
|
14
|
Lazarus HM, Pitts K, Wang T, Lee E, Buchbinder E, Dougan M, Armstrong DG, Paine R, Ragsdale CE, Boyd T, Rock EP, Gale RP. Recombinant GM-CSF for diseases of GM-CSF insufficiency: Correcting dysfunctional mononuclear phagocyte disorders. Front Immunol 2023; 13:1069444. [PMID: 36685591 PMCID: PMC9850113 DOI: 10.3389/fimmu.2022.1069444] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/05/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction Endogenous granulocyte-macrophage colony-stimulating factor (GM-CSF), identified by its ability to support differentiation of hematopoietic cells into several types of myeloid cells, is now known to support maturation and maintain the metabolic capacity of mononuclear phagocytes including monocytes, macrophages, and dendritic cells. These cells sense and attack potential pathogens, present antigens to adaptive immune cells, and recruit other immune cells. Recombinant human (rhu) GM-CSF (e.g., sargramostim [glycosylated, yeast-derived rhu GM-CSF]) has immune modulating properties and can restore the normal function of mononuclear phagocytes rendered dysfunctional by deficient or insufficient endogenous GM-CSF. Methods We reviewed the emerging biologic and cellular effects of GM-CSF. Experts in clinical disease areas caused by deficient or insufficient endogenous GM-CSF examined the role of GM-CSF in mononuclear phagocyte disorders including autoimmune pulmonary alveolar proteinosis (aPAP), diverse infections (including COVID-19), wound healing, and anti-cancer immune checkpoint inhibitor therapy. Results We discuss emerging data for GM-CSF biology including the positive effects on mitochondrial function and cell metabolism, augmentation of phagocytosis and efferocytosis, and immune cell modulation. We further address how giving exogenous rhu GM-CSF may control or treat mononuclear phagocyte dysfunction disorders caused or exacerbated by GM-CSF deficiency or insufficiency. We discuss how rhu GM-CSF may augment the anti-cancer effects of immune checkpoint inhibitor immunotherapy as well as ameliorate immune-related adverse events. Discussion We identify research gaps, opportunities, and the concept that rhu GM-CSF, by supporting and restoring the metabolic capacity and function of mononuclear phagocytes, can have significant therapeutic effects. rhu GM-CSF (e.g., sargramostim) might ameliorate multiple diseases of GM-CSF deficiency or insufficiency and address a high unmet medical need.
Collapse
Affiliation(s)
- Hillard M. Lazarus
- Department of Medicine, Division of Hematology and Oncology, Case Western Reserve University, Cleveland, OH, United States
| | - Katherine Pitts
- Medical Affairs, Partner Therapeutics, Inc., Lexington, MA, United States
| | - Tisha Wang
- Division of Pulmonary, Critical Care, and Sleep Medicine, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Elinor Lee
- Division of Pulmonary, Critical Care, and Sleep Medicine, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Elizabeth Buchbinder
- Department of Medicine, Harvard Medical School, Boston, MA, United States
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Michael Dougan
- Department of Medicine, Harvard Medical School, Boston, MA, United States
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - David G. Armstrong
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Robert Paine
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, United States
| | | | - Timothy Boyd
- Clinical Development, Partner Therapeutics, Inc., Lexington, MA, United States
| | - Edwin P. Rock
- Clinical Development, Partner Therapeutics, Inc., Lexington, MA, United States
| | - Robert Peter Gale
- Hematology Centre, Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| |
Collapse
|
15
|
Herasevich S, Frank RD, Hogan WJ, Alkhateeb H, Limper AH, Gajic O, Yadav H. Post-Transplant and In-Hospital Risk Factors for ARDS After Hematopoietic Stem Cell Transplantation. Respir Care 2023; 68:77-86. [PMID: 36127128 PMCID: PMC9993520 DOI: 10.4187/respcare.10224] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND ARDS is a serious complication of hematopoietic stem cell transplant (HSCT). Pre-transplant risk factors for developing ARDS after HSCT have been recently identified. The objective of this study was to better understand post-transplant risk factors for developing ARDS after HSCT. METHODS This was a nested case-control study. ARDS cases were matched to hospitalized non-ARDS controls by age, type of transplantation (allogeneic vs autologous), and time from transplantation. In a conditional logistic regression model, any potential risk factors were adjusted a priori for risk factors known to be associated with ARDS development. RESULTS One hundred and seventy ARDS cases were matched 1:1 to non-ARDS hospitalized controls. Pre-admission, cases were more likely to be on steroids (odds ratio [OR] 1.90 [1.13-3.19], P = .02). At time of admission, cases had lower platelet count (OR 0.95 [0.91-0.99], P = .02), lower bicarbonate (OR 0.94 [0.88-0.99], P = .035), and higher creatinine (OR 1.91 [1.23-2.94], P = .004). During the first 24 h after admission, cases were more likely to have received transfusion (OR 2.41 [1.48-3.94], P < .001), opioids (OR 2.94 [1.67-5.18], P < .001), and have greater fluid administration (OR 1.52 [1.30-1.78], P < .001). During the hospitalization, ARDS cases had higher temperature (OR 1.77 [1.34-2.33], P < .001) and higher breathing frequency (OR 1.52 [1.33-1.74], P < .001). ARDS cases were more likely to have had sepsis (OR 68.0 [15.2-301.7], P < .001), bloodstream infection (OR 4.59 [2.46-8.57], P < .001), and pneumonia (OR 9.76 [5.01-19.00], P < .001). CONCLUSIONS Several post-transplant predictors of ARDS development specific to the HSCT population were identified in the pre-hospital and early in-hospital domains. These findings can provide insights into causal mechanisms of ARDS development and be used to develop HSCT-specific risk prediction models.
Collapse
Affiliation(s)
- Svetlana Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ryan D Frank
- Division of Health Sciences Research, Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | | | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hemang Yadav
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
16
|
Cheng Z, Zhu Q, Chen J, Sun Y, Liang Z. Analysis of clinical characteristics and prognostic factors of ARDS caused by community-acquired pneumonia in people with different immune status. Expert Rev Anti Infect Ther 2022; 20:1643-1650. [PMID: 36306191 DOI: 10.1080/14787210.2022.2142116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The purpose of this study is to describe the clinical characteristics and prognostic risk factors of acute respiratory distress syndrome (ARDS) caused by community-acquired pneumonia under different immune states. METHODS The patients were divided into immunocompetent and immunocompromised groups according to their immune status. The basic clinical data of the two groups were collected and statistically analyzed, and the clinical characteristics and prognostic factors of ARDS caused by community-acquired pneumonia under different immune states were summarized. RESULTS 128 patients with ARDS caused by community-acquired pneumonia were enrolled. The chest High-Resolution Computed Tomography (HRCT) scores of patients with immunosuppression were higher (236.0 ± 55.0 vs. 207.5 ± 49.6, p < 0.05) and the score of APACHE II was higher (17.3 ± 4.8 vs. 15.1 ± 5.4, p < 0.05). The 28-day intensive care unit (ICU) mortality was higher in the immunocompromised group (54.5% vs. 34.7%, p = 0.045). The 28-day in-hospital mortality in the immunocompetent group was mainly related to NLR and the oxygenation index. The 28-day in-hospital mortality in the immunocompromised group was mainly related to LDH and APACHE II. CONCLUSION There are differences in clinical characteristics and mortality of ARDS patients caused by community-acquired pneumonia under different immune states.
Collapse
Affiliation(s)
- Zhipeng Cheng
- Department of Respiratory and Critical Care Medicine, First Medical Center, PLA General Hospital, Beijing, China
| | - Qiang Zhu
- Department of Respiratory and Critical Care Medicine, First Medical Center, PLA General Hospital, Beijing, China
| | - Jingyi Chen
- Department of Respiratory and Critical Care Medicine, First Medical Center, PLA General Hospital, Beijing, China
| | - Yanan Sun
- Department of Respiratory and Critical Care Medicine, First Medical Center, PLA General Hospital, Beijing, China
| | - Zhixin Liang
- Department of Respiratory and Critical Care Medicine, First Medical Center, PLA General Hospital, Beijing, China
| |
Collapse
|
17
|
ROBERT B, GUELLEC I, JEGARD J, JEAN S, GUILBERT J, SOREZE Y, STARCK J, PILOQUET JE, LEGER PL, RAMBAUD J. Extracorporeal membrane oxygenation for immunocompromised children with acute respiratory distress syndrome: a French referral center cohort. Minerva Pediatr (Torino) 2022; 74:537-544. [DOI: 10.23736/s2724-5276.20.05725-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
18
|
Nutritional support for successful weaning in patients undergoing prolonged mechanical ventilation. Sci Rep 2022; 12:12044. [PMID: 35835785 PMCID: PMC9283331 DOI: 10.1038/s41598-022-15917-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/01/2022] [Indexed: 11/13/2022] Open
Abstract
Successful weaning from ventilators not only improves the quality of life of patients, but also reduces medical expenses. The aim of this study was to explore the association between nutritional provision and successful ventilator weaning. In this retrospective study data from the Respiratory Care Center of Chung Shan Medical University Hospital between October, 2017 and July, 2019 on patient characteristics, amount of nutrition delivered, and clinical outcomes were retrieved. A total of 280 ventilated patients were enrolled and divided into successful extubation and failed weaning groups. There were 178 males (63.6%) and 102 females (36.4%) with a mean age of 67.3 ± 16.9 years. The successful extubation group consisted of patients who tended towards ideal body weight during the weaning process (BMI 23.9 ± 5.0 versus 22.7 ± 4.8 kg/m2, p < 0.001). Patients from both groups initially received the same nutritional intervention, while patients of successful extubation received significantly more calories and protein after weaning (23.8 ± 7.8 kcal versus 27.8 ± 9.1 kcal, p < 0.001 and 0.97 ± 0.36 g versus 1.14 ± 0.42 g, p < 0.001). Successful weaning was associated with higher survival rate (p = 0.016), shortened hospital stay (p = 0.001), and reduced medical costs (p < 0.001). Overall, nutritional support with high calories and protein was associated with the probability of successful ventilator weaning in patients undergoing prolonged mechanical ventilation. Adequate nutrition is a determinant of successful ventilator weaning.
Collapse
|
19
|
Gong X, He Y, Lu G, Zhang Y, Qiu Y, Qiao L, Li Y. Exome sequencing contributes to identify comorbidities in a rare case of infant ARDS induced by the CD40LG mutation. BMC Med Genomics 2022; 15:153. [PMID: 35804376 PMCID: PMC9264746 DOI: 10.1186/s12920-022-01303-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 07/01/2022] [Indexed: 11/22/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) causes significant mortality in young children with certain diseases. Early diagnosis and treatment can reduce infant mortality. Here, we report a rare case of exome sequencing in the early diagnosis of immunodeficiency in an infant. Case presentation A four-month-old full-term male infant presented with severe shortness of breath, hypoxemia, and unexplained parenchymal lung lesions. A series of examinations were performed to search for potential culprit viruses but negative results were obtained with the only exception being the rhinovirus that tested positive. The child’s family history revealed he had a brother who died of severe infection at the age of two years. We performed an exome sequencing analysis and a mutation analysis of CD40LG to obtain genetic data on the patient. Besides, we used flow cytometry to measure the CD40LG expression levels of activated T cells. A retrospective review of all the CD40LG mutant-induced X-linked hyper IgM syndromes (XHIGM) had been conducted to assess the differences between clinical and genetic molecular features. Finally, a regular intravenous immunoglobulin (IVIG) regimen led to steady breathing, the correction of hypoxemia, and a progressive improvement of lung CT scans. During follow-up, the patient received an IVIG regimen and his CT images improved. Moreover, his parents took advantage of pre-implantation genetic testing with in vitro fertilization to have a healthy twin offspring who did not carry such a mutation according to the early exome sequencing for the proband. Compared with other CD40LG mutant cases in our center, this proband displayed a normal plasma immunoglobulin level and he should be the youngest infant to have a molecular diagnosis of XHIGM. Conclusion Usually, XHIGM would not be suspected with a normal plasma immunoglobulin concentration. However, as we could not identify a potential comorbidity or risk factor, exome sequencing helps target this patient's real facts. Thus, this case report calls for exome sequencing to be performed in the case of unexplained infections when immunodeficiency is suspected after general immunological tests, especially for cases with a contributive family history among infants as the maternal transfused immunoglobulin might mask immune deficiency. Supplementary Information The online version contains supplementary material available at 10.1186/s12920-022-01303-y.
Collapse
Affiliation(s)
- Xue Gong
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
| | - Yunru He
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
| | - Guoyan Lu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
| | - Yulin Zhang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
| | - Yu Qiu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
| | - Lina Qiao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
| | - Yifei Li
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China.
| |
Collapse
|
20
|
Duan J, Chen L, Liu X, Bozbay S, Liu Y, Wang K, Esquinas AM, Shu W, Yang F, He D, Chen Q, Wei B, Chen B, Li L, Tang M, Yuan G, Ding F, Huang T, Zhang Z, Tang Z, Han X, Jiang L, Bai L, Hu W, Zhang R, Mina B. An updated HACOR score for predicting the failure of noninvasive ventilation: a multicenter prospective observational study. Crit Care 2022; 26:196. [PMID: 35786223 PMCID: PMC9250742 DOI: 10.1186/s13054-022-04060-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/05/2022] [Indexed: 12/11/2022] Open
Abstract
Background Heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR) have been used to predict noninvasive ventilation (NIV) failure. However, the HACOR score fails to consider baseline data. Here, we aimed to update the HACOR score to take into account baseline data and test its predictive power for NIV failure primarily after 1–2 h of NIV. Methods A multicenter prospective observational study was performed in 18 hospitals in China and Turkey. Patients who received NIV because of hypoxemic respiratory failure were enrolled. In Chongqing, China, 1451 patients were enrolled in the training cohort. Outside of Chongqing, another 728 patients were enrolled in the external validation cohort. Results Before NIV, the presence of pneumonia, cardiogenic pulmonary edema, pulmonary ARDS, immunosuppression, or septic shock and the SOFA score were strongly associated with NIV failure. These six variables as baseline data were added to the original HACOR score. The AUCs for predicting NIV failure were 0.85 (95% CI 0.84–0.87) and 0.78 (0.75–0.81) tested with the updated HACOR score assessed after 1–2 h of NIV in the training and validation cohorts, respectively. A higher AUC was observed when it was tested with the updated HACOR score compared to the original HACOR score in the training cohort (0.85 vs. 0.80, 0.86 vs. 0.81, and 0.85 vs. 0.82 after 1–2, 12, and 24 h of NIV, respectively; all p values < 0.01). Similar results were found in the validation cohort (0.78 vs. 0.71, 0.79 vs. 0.74, and 0.81 vs. 0.76, respectively; all p values < 0.01). When 7, 10.5, and 14 points of the updated HACOR score were used as cutoff values, the probability of NIV failure was 25%, 50%, and 75%, respectively. Among patients with updated HACOR scores of ≤ 7, 7.5–10.5, 11–14, and > 14 after 1–2 h of NIV, the rate of NIV failure was 12.4%, 38.2%, 67.1%, and 83.7%, respectively. Conclusions The updated HACOR score has high predictive power for NIV failure in patients with hypoxemic respiratory failure. It can be used to help in decision-making when NIV is used. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04060-7.
Collapse
Affiliation(s)
- Jun Duan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China.
| | - Lijuan Chen
- Department of Respiratory and Critical Care Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoyi Liu
- Department of Critical Care Medicine, Dazhou Central Hospital, Dazhou, Shichuan, China
| | - Suha Bozbay
- Intensive Care, Istanbul University Cerrahpasa-Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Yuliang Liu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Ke Wang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | | | - Weiwei Shu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China.,Department of Critical Care Medicine, Yongchuan Hospital of Chongqing Medical University, Yongchuan, Chongqing, China
| | - Fuxun Yang
- Department of ICU, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Dehua He
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Qimin Chen
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Bilin Wei
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Baixu Chen
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Liucun Li
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Manyun Tang
- Department of Traditional Medicine and Rehabilitation, The Chest Hospital of Xi'an, Xi'an, China
| | - Guodan Yuan
- Department of Critical Care Medicine, Chonqing Public Health Medical Center, Chongqing, China
| | - Fei Ding
- Department of Respiratory and Critical Care Medicine, Bishan Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Huang
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhongxing Zhang
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Chongqing Three Gorges Medical College, Chongqing, China
| | - ZhiJun Tang
- Department of Respiratory and Critical Care Medicine, The People's Hospital of Nanchuan, Chongqing, China
| | - Xiaoli Han
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Lei Jiang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Linfu Bai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Wenhui Hu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Rui Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Bushra Mina
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| |
Collapse
|
21
|
Extracorporeal membrane oxygenation in patients with hematologic malignancies: a systematic review and meta-analysis. Ann Hematol 2022; 101:1395-1406. [PMID: 35622097 DOI: 10.1007/s00277-022-04855-2] [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: 01/11/2022] [Accepted: 05/03/2022] [Indexed: 11/01/2022]
Abstract
Hematological malignancies (HM) have been, until recently, viewed as contraindications to extracorporeal membrane oxygenation (ECMO) due to bleeding and infectious complications. However, conflicting literature regarding whether ECMO should be used for patients with HM still exists. We conducted a random effects meta-analysis to investigate the outcomes of patients with HM on ECMO. We searched Medline, Embase, Scopus, and Cochrane through 10 October 2021. Risk of bias and certainty of evidence were assessed using the JBI checklists and GRADE approach respectively. Thirteen observational studies (422 patients with HM, 9778 controls without HM) were included. The pooled in-hospital mortality for patients with HM and those with hematopoietic stem cell transplants for HM indications needing ECMO were 79.1% (95%CI: 70.2-86.9%) and 87.7% (95%CI: 80.4-93.8%), respectively. Subgroup analyses found that mortality was higher in adults than children (85.1% vs 67.9%, pinteraction = 0.003), and in Asia compared to North America and Europe (93.8% vs 69.6%, pinteraction < 0.001). Pooled ECMO duration was 10.0 days (95%CI: 7.5-12.5); pooled ICU and hospital lengths of stay were 19.8 days (95%CI: 12.4-27.3) and 43.9 days (95%CI: 29.4-58.4) respectively. Age (regression coefficient [B]: 0.008, 95%CI: 0.003-0.014), proportion of males (B: 1.799, 95%CI: 0.079-3.519), and ECMO duration (B: - 0.022, 95%CI: - 0.043 to - 0.001) were significantly associated with higher mortality. In-hospital mortality of patients with HM who needed ECMO was 79.1%, with better outcomes in children, and in North America and Europe. ECMO should not be regarded as routine support therapy in these patients but can be carefully considered on a case-by-case basis.
Collapse
|
22
|
Association between timing of intubation and clinical outcomes of critically ill patients: A meta-analysis. J Crit Care 2022; 71:154062. [PMID: 35588639 DOI: 10.1016/j.jcrc.2022.154062] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Optimal timing of intubation is controversial. We attempted to investigate the association between timing of intubation and clinical outcomes of critically ill patients. METHODS PubMed was systematically searched for studies reporting on mortality of critically ill patients undergoing early versus late intubation. Studies involving patients with new coronavirus disease (COVID-19) were excluded because a relevant meta-analysis has been published. "Early" intubation was defined according to the authors of the included studies. All-cause mortality was the primary outcome. Pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using a random effects model. The meta-analysis was registered with PROSPERO (CRD42021284850). RESULTS In total, 27 studies involving 15,441 intubated patients (11,943 early, 3498 late) were included. All-cause mortality was lower in patients undergoing early versus late intubation (7338 deaths; 45.8% versus 53.5%; RR 0.92, 95% CI 0.87-0.97; p = 0.001). This was also the case in the sensitivity analysis of studies defining "early" as intubation within 24 h from admission in the intensive care unit (6279 deaths; 45.8% versus 53.6%; RR 0.93, 95% CI 0.89-0.98; p = 0.005). CONCLUSION Avoiding late intubation may be associated with lower mortality in critically ill patients without COVID-19.
Collapse
|
23
|
Jha OK, Kumar S, Mehra S, Sircar M, Gupta R. Helmet NIV in Acute Hypoxemic Respiratory Failure due to COVID-19: Change in PaO 2/FiO 2 Ratio a Predictor of Success. Indian J Crit Care Med 2021; 25:1137-1146. [PMID: 34916746 PMCID: PMC8645804 DOI: 10.5005/jp-journals-10071-23992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
In acute respiratory failure due to severe coronavirus disease 2019 (COVID-19) pneumonia, mechanical ventilation remains challenging and may result in high mortality. The use of noninvasive ventilation (NIV) may delay required invasive ventilation, increase adverse outcomes, and have a potential aerosol risk to caregivers. Data of 30 patients were collected from patient files and analyzed. Twenty-one (70%) patients were weaned successfully after helmet-NIV support (NIV success group), and invasive mechanical ventilation was required in 9 (30%) patients (NIV failure group) of which 8 (26.7%) patients died. In NIV success vs failure patients, the mean baseline PaO2/FiO2 ratio (PFR) (147.2 ± 57.9 vs 156.8 ± 59.0 mm Hg; p = 0.683) and PFR before initiation of helmet (132.3 ± 46.9 vs 121.6 ± 32.7 mm Hg; p = 0.541) were comparable. The NIV success group demonstrated a progressive improvement in PFR in comparison with the failure group at 2 hours (158.8 ± 56.1 vs 118.7 ± 40.7 mm Hg; p = 0.063) and 24 hours (PFR-24) (204.4 ± 94.3 vs 121.3 ± 32.6; p = 0.016). As predictor variables, PFR-24 and change (delta) in PFR at 24 hours from baseline or helmet initiation (dPFR-24) were significantly associated with NIV success in univariate analysis but similar significance could not be reflected in multivariate analysis perhaps due to a small sample size of the study. The PFR-24 cutoff of 161 mm Hg and dPFR-24 cutoff of -1.44 mm Hg discriminate NIV success and failure groups with the area under curve (confidence interval) of 0.78 (0.62-0.95); p = 0.015 and 0.74 (0.55-0.93); p = 0.039, respectively. Helmet interface NIV may be a safe and effective tool for the management of patients with severe COVID-19 pneumonia with acute respiratory failure. More studies are needed to further evaluate the role of helmet NIV especially in patients with initial PFR <150 mm Hg to define PFR/dPFR cutoff at the earliest time point for prediction of helmet-NIV success. How to cite this article Jha OK, Kumar S, Mehra S, Sircar M, Gupta R. Helmet NIV in Acute Hypoxemic Respiratory Failure due to COVID-19: Change in PaO2/FiO2 Ratio a Predictor of Success. Indian J Crit Care Med 2021;25(10):1137-1146.
Collapse
Affiliation(s)
- Onkar K Jha
- Department of Pulmonology and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
| | - Sunny Kumar
- Department of Pulmonology and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
| | - Saurabh Mehra
- Department of Pulmonology and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
| | - Mrinal Sircar
- Department of Pulmonology and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
| | - Rajesh Gupta
- Department of Pulmonology and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
| |
Collapse
|
24
|
Lemiale V, Yvin E, Kouatchet A, Mokart D, Demoule A, Dumas G. Oxygenation strategy during acute respiratory failure in immunocompromised patients. JOURNAL OF INTENSIVE MEDICINE 2021; 1:81-89. [PMID: 36788802 PMCID: PMC9923978 DOI: 10.1016/j.jointm.2021.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/02/2021] [Accepted: 09/20/2021] [Indexed: 12/12/2022]
Abstract
Acute respiratory failure (ARF) in immunocompromised patients remains challenging to treat. A large number of case require admission to intensive care unit (ICU) where mortality remains high. Oxygenation without intubation is important in this setting. This review summarizes recent studies assessing oxygenation devices for immunocompromised patients. Previous studies showed that non-invasive ventilation (NIV) has been associated with lower intubation and mortality rates. Indeed, in recent years, the outcomes of immunocompromised patients admitted to the ICU have improved. In the most recent randomized controlled trials, including immunocompromised patients admitted to the ICU with ARF, neither NIV nor high-flow nasal oxygen (HFNO) could reduce the mortality rate. In this setting, other strategies need to be tested to decrease the mortality rate. Early admission strategy and avoiding late failure of oxygenation strategy have been assessed in retrospective studies. However, objective criteria are still lacking to clearly discriminate time to admission or time to intubation. Also, diagnosis strategy may have an impact on intubation or mortality rates. On the other hand, lack of diagnosis has been associated with a higher mortality rate. In conclusion, improving outcomes in immunocompromised patients with ARF may include strategies other than the oxygenation strategy alone. This review discusses other unresolved questions to decrease mortality after ICU admission in such patients.
Collapse
Affiliation(s)
- Virginie Lemiale
- Service de Médecine Intensive et Réanimation, APHP Hopital Saint Louis, 1 Avenue Claude Vellefaux, Paris 75010, France,Corresponding author: Virginie Lemiale, Service de Médecine Intensive et Réanimation, APHP Hopital Saint Louis, 1 Avenue Claude Vellefaux, Paris 75010, France.
| | - Elise Yvin
- Service de Médecine Intensive et Réanimation, APHP Hopital Saint Louis, 1 Avenue Claude Vellefaux, Paris 75010, France
| | - Achille Kouatchet
- Service de Réanimation Médicale et Médecine Hyperbare, Angers 49100, France
| | - Djamel Mokart
- Institut Paoli-Calmettes, Réanimation Medico-Chirurgicale, Marseille 13009, France
| | - Alexandre Demoule
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), and Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris 75013, France
| | - Guillaume Dumas
- Service de Médecine Intensive et Réanimation, APHP Hopital Saint Louis, 1 Avenue Claude Vellefaux, Paris 75010, France
| | | |
Collapse
|
25
|
Na SJ, Park SH, Hong SB, Cho WH, Lee SM, Cho YJ, Park S, Koo SM, Park SY, Chang Y, Kang BJ, Kim JH, Oh JY, Jung JS, Yoo JW, Sim YS, Jeon K. Clinical outcomes of immunocompromised patients on extracorporeal membrane oxygenation support for severe acute respiratory failure. Eur J Cardiothorac Surg 2021; 57:788-795. [PMID: 31625551 DOI: 10.1093/ejcts/ezz276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/03/2019] [Accepted: 09/11/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES There are limited data regarding extracorporeal membrane oxygenation (ECMO) support in immunocompromised patients, despite an increase in ECMO use in patients with respiratory failure. The aim of this study was to investigate the clinical characteristics and outcomes of immunocompromised patients requiring ECMO support for severe acute respiratory failure. METHODS Between January 2012 and December 2015, all consecutive adult patients with severe acute respiratory failure who underwent ECMO for respiratory support at 16 tertiary or university-affiliated hospitals in South Korea were enrolled retrospectively. The patients were divided into 2 groups based on the immunocompromised status at the time of ECMO initiation. In-hospital and 6-month mortalities were compared between the 2 groups. In addition, association of immunocompromised status with 6-month mortality was evaluated with logistic regression analysis. RESULTS Among 461 patients, 118 (25.6%) were immunocompromised. Immunocompromised patients were younger and had lower haemoglobin and platelet counts than immunocompetent patients. Ventilatory parameters and the use of adjunctive/rescue therapies were similar between the 2 groups, but prone positioning was more commonly used in immunocompetent patients. Successful weaning rates from ECMO (46.6% vs 58.9%; P = 0.021) was lower and hospital mortality (66.1% vs 59.8%; P = 0.22) was higher in immunocompromised patients. In addition, immunocompromised status was associated with higher 6-month mortality (74.6% vs 64.7%, adjusted odds ratio 2.10, 95% confidence interval 1.02-4.35; P = 0.045). CONCLUSIONS Immunocompromised patients treated with ECMO support for severe acute respiratory failure had poorer short- and long-term prognoses than did immunocompetent patients.
Collapse
Affiliation(s)
- Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - So Hee Park
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Woo Hyun Cho
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Gyeongsangnam-do, Republic of Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Sunghoon Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hallym University Sacred Heart Hospital, Gyeonggi-do, Republic of Korea
| | - So-My Koo
- Division of Pulmonary and Allergy Medicine, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Republic of Korea
| | - Seung Yong Park
- Department of Internal Medicine, Chonbuk National University Hospital, Jeollabuk-do, Republic of Korea
| | - Youjin Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Byung Ju Kang
- Division of Pulmonology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Jung-Hyun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, CHA Bundang Medical Center, Gyeonggi-do, Republic of Korea
| | - Jin Young Oh
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Dongguk University Ilsan Hospital, Gyeonggi-do, Republic of Korea
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jung-Wan Yoo
- Department of Internal Medicine, College of Medicine, Gyeongsang National University Hospital, Gyeongsangnam-do, Republic of Korea
| | - Yun Su Sim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| |
Collapse
|
26
|
Shen J, Hu Y, Zhao H, Xiao Z, Zhao L, Du A, An Y. Risk factors of non-invasive ventilation failure in hematopoietic stem-cell transplantation patients with acute respiratory distress syndrome. Ther Adv Respir Dis 2021; 14:1753466620914220. [PMID: 32345137 PMCID: PMC7225805 DOI: 10.1177/1753466620914220] [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] [Indexed: 12/31/2022] Open
Abstract
Background: Non-invasive ventilation (NIV) was one of the first-line ventilation supports for hematopoietic stem-cell transplantation (HSCT) patients with acute respiratory distress syndrome (ARDS). Successful NIV may avoid need for intubation. However, the influence NIV failure had on patients’ outcome and its risk factors were hardly known. Methods: In this retrospective observational study, we reported risk factors and incidence of NIV failure in HSCT patients who were admitted to the Intensive Care Unit (ICU) with a diagnosis of ARDS and supported with mechanical ventilation, in a 5-year period. Patient outcomes, such as ventilator-free days, ICU-free days, and ICU mortality were also reported. Results: Of all the 94 patients included, 70 patients were initially supported with NIV. NIV failure occurred in 44 (63%) patients. Male sex, elevated serum galactomannan (GM) test, (1-3)-β-D-glucan (BG) assay, or elevated serum creatinine level were risk factors for NIV failure. When compared with the NIV success group, failure of NIV was associated with much fewer ICU-free days (22 versus 0, p < 0.001, Cohen’s d = 0.62) and higher ICU mortality (9.5% versus 75.5%, p < 0.001, Pearson’s r = 0.75). There was no difference in ICU-free days, ventilator-free days and ICU mortality between NIV failure and initial invasive mechanical ventilation (IMV) groups. Patients who failed in NIV support had a higher ICU mortality (75.5%) than those who succeeded (9.5%). Conclusion: In a small cohort of HSCT patients with mainly moderate severity of ARDS, male patients with elevated serum GM/BG test or serum creatinine level had a higher risk of NIV failure. Both NIV failure and initial IMV groups were characterized by high mortality rate and extremely low ICU-free days and ventilator-free days; failure of NIV support may further aggravate patient prognosis. The reviews of this paper are available via the supplemental material section.
Collapse
Affiliation(s)
- Jiawei Shen
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, People's Republic of China
| | - Yan Hu
- Department of Respiratory and Critical Care Medicine, Peking University International Hospital, Beijing, People's Republic of China
| | - Huiying Zhao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, People's Republic of China
| | - Zengli Xiao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, People's Republic of China
| | - Lianze Zhao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, People's Republic of China
| | - Anqi Du
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, People's Republic of China
| | - Youzhong An
- Department of Critical Care Medicine, Peking Univeristy People's Hospital, Beijing 100044, People's Republic of China
| |
Collapse
|
27
|
Pickkers P, van Haren FMP. Immunocompromised Patients with Acute Respiratory Failure: "Don't Wait to Intubate"? Am J Respir Crit Care Med 2021; 204:121-123. [PMID: 33945777 PMCID: PMC8650789 DOI: 10.1164/rccm.202103-0813ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Peter Pickkers
- Department Intensive Care Medicine Radboud University Medical Center Nijmegen, the Netherlands
| | - Frank M P van Haren
- Australian National University Medical School Australian National University Canberra, Australia
| |
Collapse
|
28
|
Rilinger J, Zotzmann V, Bemtgen X, Rieg S, Biever PM, Duerschmied D, Pottgiesser T, Kaier K, Bode C, Staudacher DL, Wengenmayer T. Influence of immunosuppression in patients with severe acute respiratory distress syndrome on veno-venous extracorporeal membrane oxygenation therapy. Artif Organs 2021; 45:1050-1060. [PMID: 33725377 PMCID: PMC8250998 DOI: 10.1111/aor.13954] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/15/2021] [Accepted: 03/09/2021] [Indexed: 12/11/2022]
Abstract
Prognosis of patients suffering from acute respiratory distress syndrome (ARDS) is poor. This is especially true for immunosuppressed patients. It is controverisal whether these patients should receive veno‐venous extracorporeal membrane oxygenation (VV ECMO) while evidence on this topic is sparse. We report retrospective data of a single‐center registry of patients with severe ARDS requiring ECMO support between October 2010 and June 2019. Patients were analyzed by their status of immunosuppression. ECMO weaning success and hospital survival were analyzed before and after propensity score matching (PSM). Moreover, ventilator free days (VFD) were compared. A total of 288 patients were analyzed (age 55 years, 67% male), 88 (31%) presented with immunosuppression. Survival rates were lower in immunosuppressed patients (27% vs. 53%, P < .001 and 27% vs. 48% after PSM, P = .006). VFD (60 days) were lower for patients with immunosuppression (11.9 vs. 22.4, P < .001), and immunosuppression was an independent predictor for mortality in multivariate analysis. Hospital survival was 20%, 14%, 35%, and 46% for patients with oncological malignancies, solid organ transplantation, autoimmune diseases, and HIV, respectively. In this analysis immunosuppression was an independent predictor for mortality. However, there were major differences in the weaning and survival rates between the etiologies of immunosuppression which should be considered in decision making.
Collapse
Affiliation(s)
- Jonathan Rilinger
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viviane Zotzmann
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Xavier Bemtgen
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul M Biever
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Torben Pottgiesser
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
29
|
Torres LK, Hoffman KL, Oromendia C, Diaz I, Harrington JS, Schenck EJ, Price DR, Gomez-Escobar L, Higuera A, Vera MP, Baron RM, Fredenburgh LE, Huh JW, Choi AMK, Siempos II. Attributable mortality of acute respiratory distress syndrome: a systematic review, meta-analysis and survival analysis using targeted minimum loss-based estimation. Thorax 2021; 76:1176-1185. [PMID: 33863829 DOI: 10.1136/thoraxjnl-2020-215950] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 03/15/2021] [Accepted: 03/24/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although acute respiratory distress syndrome (ARDS) is associated with high mortality, its direct causal link with death is unclear. Clarifying this link is important to justify costly research on prevention of ARDS. OBJECTIVE To estimate the attributable mortality, if any, of ARDS. DESIGN First, we performed a systematic review and meta-analysis of observational studies reporting mortality of critically ill patients with and without ARDS matched for underlying risk factor. Next, we conducted a survival analysis of prospectively collected patient-level data from subjects enrolled in three intensive care unit (ICU) cohorts to estimate the attributable mortality of critically ill septic patients with and without ARDS using a novel causal inference method. RESULTS In the meta-analysis, 44 studies (47 cohorts) involving 56 081 critically ill patients were included. Mortality was higher in patients with versus without ARDS (risk ratio 2.48, 95% CI 1.86 to 3.30; p<0.001) with a numerically stronger association between ARDS and mortality in trauma than sepsis. In the survival analysis of three ICU cohorts enrolling 1203 critically ill patients, 658 septic patients were included. After controlling for confounders, ARDS was found to increase the mortality rate by 15% (95% CI 3% to 26%; p=0.015). Significant increases in mortality were seen for severe (23%, 95% CI 3% to 44%; p=0.028) and moderate (16%, 95% CI 2% to 31%; p=0.031), but not for mild ARDS. CONCLUSIONS ARDS has a direct causal link with mortality. Our findings provide information about the extent to which continued funding of ARDS prevention trials has potential to impart survival benefit. PROSPERO REGISTRATION NUMBER CRD42017078313.
Collapse
Affiliation(s)
- Lisa K Torres
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Katherine L Hoffman
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA
| | - Clara Oromendia
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA
| | - Ivan Diaz
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA
| | - John S Harrington
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Edward J Schenck
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - David R Price
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Luis Gomez-Escobar
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Angelica Higuera
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mayra Pinilla Vera
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rebecca M Baron
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Laura E Fredenburgh
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jin-Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center/University of Ulsan College of Medicine, Seoul, South Korea
| | - Augustine M K Choi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Ilias I Siempos
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA .,First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Athens General Hospital/National and Kapodistrian University of Athens Medical School, Athens, Greece
| |
Collapse
|
30
|
Dumas G, Lemiale V, Rathi N, Cortegiani A, Pène F, Bonny V, Salluh J, Albaiceta GM, Soares M, Soubani AO, Canet E, Hanane T, Kouatchet A, Mokart D, Lebiedz P, Türkoğlu M, Coudroy R, Jeon K, Demoule A, Mehta S, Caruso P, Frat JP, Yang KY, Roca O, Laffey J, Timsit JF, Azoulay E, Darmon M. Survival in Immunocompromised Patients Ultimately Requiring Invasive Mechanical Ventilation: A Pooled Individual Patient Data Analysis. Am J Respir Crit Care Med 2021; 204:187-196. [PMID: 33751920 DOI: 10.1164/rccm.202009-3575oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Rationale: Acute respiratory failure (ARF) is associated with high mortality in immunocompromised patients, particularly when invasive mechanical ventilation is needed. Therefore, noninvasive oxygenation/ventilation strategies have been developed to avoid intubation, with uncertain impact on mortality, especially when intubation is delayed. Objectives: We sought to report trends of survival over time in immunocompromised patients receiving invasive mechanical ventilation. The impact of delayed intubation after failure of noninvasive strategies was also assessed. Methods: Systematic review and meta-analysis using individual patient data of studies that focused on immunocompromised adult patients with ARF requiring invasive mechanical ventilation. Studies published in English were identified through PubMed, Web of Science, and Cochrane Central (2008-2018). Individual patient data were requested from corresponding authors for all identified studies. We used mixed-effect models to estimate the effect of delayed intubation on hospital mortality and described mortality rates over time. Measurements and Main Results: A total of 11,087 patients were included (24 studies, three controlled trials, and 21 cohorts), of whom 7,736 (74%) were intubated within 24 hours of ICU admission (early intubation). The crude mortality rate was 53.2%. Adjusted survivals improved over time (from 1995 to 2017, odds ratio [OR] for hospital mortality per year, 0.96 [0.95-0.97]). For each elapsed day between ICU admission and intubation, mortality was higher (OR, 1.38 [1.26-1.52]; P < 0.001). Early intubation was significantly associated with lower mortality (OR, 0.83 [0.72-0.96]), regardless of initial oxygenation strategy. These results persisted after propensity score analysis (matched OR associated with delayed intubation, 1.56 [1.44-1.70]). Conclusions: In immunocompromised intubated patients, survival has improved over time. Time between ICU admission and intubation is a strong predictor of mortality, suggesting a detrimental effect of late initial oxygenation failure.
Collapse
Affiliation(s)
- Guillaume Dumas
- Medical ICU, Saint-Louis Teaching Hospital, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
| | - Virginie Lemiale
- Medical ICU, Saint-Louis Teaching Hospital, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
| | - Nisha Rathi
- Department of Critical Care, MD Anderson Cancer Center, Houston, Texas
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Frédéric Pène
- Medical ICU, Cochin Teaching Hospital, Paris, France
| | - Vincent Bonny
- Medical ICU, Saint-Louis Teaching Hospital, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
| | - Jorge Salluh
- The Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Guillermo M Albaiceta
- Instituto de Investigación Sanitaria del Principado de Asturias, Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Instituto Universitario de Oncología del Principado de Asturias, Oviedo, Spain.,CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Marcio Soares
- The Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, Michigan
| | | | - Tarik Hanane
- Department of Critical Care, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Pia Lebiedz
- ICU, Evangelisches Krankenhaus, Oldenburg, Germany
| | - Melda Türkoğlu
- Medical ICU, Gazi University School of Medicine, Ankara, Turkey
| | - Rémi Coudroy
- CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France.,INSERM CIC1402, groupe ALIVE, Université de Poitiers, Poitiers, France
| | - Kyeongman Jeon
- Department of Critical Care Medicine and.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Irwon-ro, Gangnam-gu, Seoul, Korea
| | - Alexandre Demoule
- APHP Sorbonne Université site Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S) and INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
| | - Sangeeta Mehta
- Medical Surgical ICU, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pedro Caruso
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil
| | - Jean-Pierre Frat
- CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France.,INSERM CIC1402, groupe ALIVE, Université de Poitiers, Poitiers, France
| | - Kuang-Yao Yang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Oriol Roca
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - John Laffey
- Department of Anesthesia and.,Department of Intensive Care Medicine, NUI Galway, Ireland; and
| | - Jean-François Timsit
- Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, UMR 1137 Inserm, Université de Paris, IAME, Paris, France
| | - Elie Azoulay
- Medical ICU, Saint-Louis Teaching Hospital, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
| | - Michael Darmon
- Medical ICU, Saint-Louis Teaching Hospital, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
| |
Collapse
|
31
|
Nachega JB, Kapata N, Sam-Agudu NA, Decloedt EH, Katoto PDMC, Nagu T, Mwaba P, Yeboah-Manu D, Chanda-Kapata P, Ntoumi F, Geng EH, Zumla A. Minimizing the impact of the triple burden of COVID-19, tuberculosis and HIV on health services in sub-Saharan Africa. Int J Infect Dis 2021; 113 Suppl 1:S16-S21. [PMID: 33757874 PMCID: PMC7980520 DOI: 10.1016/j.ijid.2021.03.038] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/28/2021] [Accepted: 03/10/2021] [Indexed: 02/08/2023] Open
Abstract
In this perspective, we discuss the impact of COVID-19 on tuberculosis (TB)/HIV health services and approaches to mitigating the growing burden of these three colliding epidemics in sub-Saharan Africa (SSA). SSA countries bear significantly high proportions of TB and HIV cases reported worldwide, compared to countries in the West. Whilst COVID-19 epidemiology appears to vary across Africa, most countries in this region have reported relatively lower-case counts compared to the West. Nevertheless, the COVID-19 pandemic has added an additional burden to already overstretched health systems in SSA, which, among other things, have been focused on the longstanding dual epidemics of TB and HIV. As with these dual epidemics, inadequate resources and poor case identification and reporting may be contributing to underestimations of the COVID-19 case burden in SSA. Modelling studies predict that the pandemic-related disruptions in TB and HIV services will result in significant increases in associated morbidity and mortality over the next five years. Furthermore, limited empirical evidence suggests that SARS-CoV-2 coinfections with TB and HIV are associated with increased mortality risk in SSA. However, predictive models require a better evidence-base to accurately define the impact of COVID-19, not only on communicable diseases such as TB and HIV, but on non-communicable disease comorbidities. Further research is needed to assess morbidity and mortality data among both adults and children across the African continent, paying attention to geographic disparities, as well as the clinical and socio-economic determinants of COVID-19 in the setting of TB and/or HIV.
Collapse
Affiliation(s)
- Jean B Nachega
- Department of Medicine and Center for Infectious Diseases, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa; Department of Epidemiology, Infectious Diseases and Microbiology, and Center for Global Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Nathan Kapata
- Zambia National Public Health Institute, University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Ministry of Health, Lusaka, Zambia.
| | - Nadia A Sam-Agudu
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria; Institute of Human Virology and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA; Department of Pediatrics and Child Health, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana.
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa.
| | - Patrick D M C Katoto
- Department of Medicine and Center for Infectious Diseases, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa.
| | - Tumaini Nagu
- School of Medicine, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania.
| | - Peter Mwaba
- Lusaka Apex Medical University, Lusaka, Zambia.
| | - Dorothy Yeboah-Manu
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana.
| | | | - Francine Ntoumi
- Fondation Congolaise pour la Recherche Médicale (FCRM), Brazzaville, Congo; Institute for Tropical Medicine, University of Tübingen, Tübingen, Germany.
| | - Elvin H Geng
- Division of Infectious Diseases, Department of Medicine, and Center for Dissemination and Implementation, Institute for Public Health, Washington University, St Louis, Missouri, USA.
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London, London, UK; NIHR Biomedical Research Centre, University College London Hospitals, London, UK.
| |
Collapse
|
32
|
Albumin replacement therapy in immunocompromised patients with sepsis - Secondary analysis of the ALBIOS trial. J Crit Care 2021; 63:83-91. [PMID: 33636427 DOI: 10.1016/j.jcrc.2021.01.016] [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: 12/09/2020] [Revised: 01/13/2021] [Accepted: 01/28/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The best fluid replacement strategy and the role of albumin in immunocompromised patients with sepsis is unclear. METHODS We performed a secondary analysis of immunocompromised patients enrolled in the ALBIOS trial which randomized patients with severe sepsis or septic shock to receive either 20% albumin (target 30 g per liter or more) and crystalloid or crystalloid alone during ICU stay. RESULTS Of 1818 patients originally enrolled, 304 (16.4%) were immunocompromised. One-hundred-thirty-nine (45.7%) patients were randomized in the albumin while 165 (54.2%) in the crystalloid group. At 90 days, 69 (49.6%) in the albumin group and 89 (53.9%) in the crystalloids group died (hazard ratio - HR - 0.94; 95% CI 0.69-1.29). No differences were observed with regards to 28-day mortality, SOFA score (and sub-scores), length of stay in the ICU and in the hospital, proportion of patients who had developed acute kidney injury or received renal replacement therapy, duration of mechanical ventilation. Albumin was not independently associated with a higher or lower 90-day mortality (HR 0.979, 95% CI 0.709-1.352) as compared to crystalloid. CONCLUSION Albumin replacement during the ICU stay, as compared with crystalloids alone, did not affect clinical outcomes in a cohort of immunocompromised patients with sepsis.
Collapse
|
33
|
Cirrhotic Patients on Mechanical Ventilation Have a Low Rate of Successful Extubation and Survival. Dig Dis Sci 2020; 65:3744-3752. [PMID: 31960201 PMCID: PMC8800450 DOI: 10.1007/s10620-020-06051-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 01/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS We hypothesized that mechanically ventilated cirrhotic patients not only have poor outcomes, but also that certain clinical variables are likely to be associated with mortality. We aimed to describe the predictors of mortality in these patients. METHODS This observational study examined 113 mechanically ventilated cirrhotic patients cared for at our institution between July 1, 2014, and February 28, 2018. We performed bivariate and multivariate analyses to identify risk factors for mortality on mechanical ventilation and created an equation to calculate probability of mortality based on these variables. RESULTS Seventy percent of patients had a history of a decompensating event. Altered mental status was the most frequently encountered indication for intubation (46%). 53% patients died on mechanical ventilation. After controlling for variables associated with increased mortality, multivariate analysis revealed that vasopressor use was the strongest predictor of mortality on mechanical ventilation (OR = 9.3) followed by sepsis (OR = 4.1). A formula with an area under the curve of 0.85 was obtained in order to predict the probability of mortality for cirrhotic patients on mechanical ventilation (available at https://medweb.musc.edu/mvcp/ ). This model (AUC = 0.85) outperformed the CLIF-SOFA score (AUC = 0.68) in predicting mortality in this cohort. CONCLUSION Cirrhotic patients requiring mechanical ventilation have an extremely poor prognosis, and in patients requiring vasopressors, having a history of decompensation, sepsis or low albumin, mortality is higher. Our data points to the clinical variables should be considered in the medical management of these patients and provide physicians with a formula to predict the probability of mortality.
Collapse
|
34
|
Cortegiani A, Grasselli G. Exploring Associations Between Respiratory Mechanics and Survival in Immunocompromised Patients With ARDS. Chest 2020; 158:1812-1813. [DOI: 10.1016/j.chest.2020.06.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022] Open
|
35
|
Crimi C, Noto A, Cortegiani A, Impellizzeri P, Elliott M, Ambrosino N, Gregoretti C. Noninvasive respiratory support in acute hypoxemic respiratory failure associated with COVID-19 and other viral infections. Minerva Anestesiol 2020; 86:1190-1204. [DOI: 10.23736/s0375-9393.20.14785-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
36
|
Fornwalt RA, Brigham EP, Scott Stephens R. Critical Care of Hematopoietic Stem Cell Transplant Patients. Crit Care Clin 2020; 37:29-46. [PMID: 33190774 DOI: 10.1016/j.ccc.2020.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Life-threatening complications are frequent after hematopoietic stem cell transplant (HSCT), and optimum critical care is essential to ensuring good outcomes. The immunologic consequences of HSCT result in a markedly different host response to critical illness. Infection is the most common cause of critical illness but noninfectious complications are frequent. Respiratory failure or sepsis are the typical presentations but the sequelae of HSCT can affect nearly any organ system. Pattern recognition can facilitate anticipation and early intervention in post-HSCT critical illness. HSCT critical care is a multidisciplinary endeavor. Continued investigation and focus on process improvement will continue to improve outcomes.
Collapse
Affiliation(s)
- Rachael A Fornwalt
- Oncology Intensive Care Unit, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Harry and Jeanette Weinberg Building, Pod 5C, 401 North Broadway, Baltimore, MD 21231, USA
| | - Emily P Brigham
- Oncology Intensive Care Unit, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, 1830 East Monument Street, 5th Floor, Baltimore, MD 21205, USA
| | - R Scott Stephens
- Oncology Intensive Care Unit, Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Oncology, Johns Hopkins University, 1800 Orleans Street, Suite 9121 Zayed Tower, Baltimore, MD 21287, USA.
| |
Collapse
|
37
|
Bogach J, Wright FC, Austin J, Cheng SY, Diong C, Sutradhar R, Baxter NN, Look Hong NJ. Medical Immunosuppression and Outcomes in Cutaneous Melanoma: A Population-Based Cohort Study. Ann Surg Oncol 2020; 28:3302-3311. [PMID: 33067747 DOI: 10.1245/s10434-020-09224-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Melanoma and the immune system are intimately related. However, the association of immunosuppressive medications (ISMs) with survival in melanoma is not well understood. The study evaluated this at a population level. METHODS A cohort of patients with a diagnosis of invasive cutaneous melanoma (2007-2015) was identified from the Ontario Cancer Registry and linked to identify demographics, stage at diagnosis, prescription of immunosuppressive medications (both before and after diagnosis), and outcomes. The demographics of patients with and without prescriptions for ISM were compared. Patients eligible for Ontario's Drug Benefit Plan were included to ensure accurate prescription data. The primary outcome was overall survival. Cox Proportional Hazards Regression models identified factors associated with mortality, including use of ISM as a time-varying covariate. RESULTS Of the 4954 patients with a diagnosis of cutaneous melanoma, 1601 had a prescription for ISM. The median age of the patients was 74 years. Overall, 58.4% of the patients were men (60.5% of those without ISM and 54% of those using ISM; p < 0.001). The use of oral immunosuppression was associated with an increased hazard of death (hazard ratio, 5.84; 95% confidence interval, 5.11-6.67; p < 0.0001) when control was used for age, disease stage at diagnosis, anatomic site, comorbidity, and treatment. Other factors associated with death were increasing age, male sex, increased disease stage, truncal location of primary melanoma, and inadequate treatment. In sensitivity analysis with steroid-only ISM use excluded, survival did not differ significantly (p = 0.355). CONCLUSIONS The use of immunosuppressive steroids for melanoma is associated with worse overall survival. Use of steroids should be limited when possible.
Collapse
Affiliation(s)
- Jessica Bogach
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Frances C Wright
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Janice Austin
- Department of Surgery, Joseph Brant Hospital, McMaster University, Hamilton, ON, Canada
| | | | | | - Rinku Sutradhar
- ICES, Toronto, ON, Canada.,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Nancy N Baxter
- Cancer Research Program, ICES, Toronto, ON, Canada.,Institute for Health Policy, Evaluation and Management, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Nicole J Look Hong
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| |
Collapse
|
38
|
Munshi L, Darmon M, Soares M, Pickkers P, Bauer P, Meert AP, Martin-Loeches I, Staudinger T, Pene F, Antonelli M, Barratt-Due A, Demoule A, Metaxa V, Lemiale V, Taccone F, Mokart D, Azoulay E, Mehta S. Acute Respiratory Failure Outcomes in Patients with Hematologic Malignancies and Hematopoietic Cell Transplant: A Secondary Analysis of the EFRAIM Study. Transplant Cell Ther 2020; 27:78.e1-78.e6. [PMID: 33011289 DOI: 10.1016/j.bbmt.2020.09.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/30/2020] [Accepted: 09/28/2020] [Indexed: 12/12/2022]
Abstract
Patients with allogeneic hematopoietic cell transplantation (HCT) who develop acute respiratory failure (ARF) are perceived to have worse outcomes than autologous HCT recipients and non-transplant patients with hematologic malignancy (HM). Within a large international prospective cohort, we evaluated clinical outcomes in these 3 populations. We conducted a secondary analysis of the EFRAIM study, a multicenter observational study of immunocompromised adults with ARF admitted to 62 intensive care units (ICUs) in 16 countries. We described characteristics and compared outcomes of patients with HM who did not undergo transplantation and patients who underwent autologous or allogeneic HCT using multivariable logistic regression and propensity score-matched analyses. A total of 801 patients were included: 570 who did not undergo transplantation, 86 autologous HCT recipients and 145 allogeneic HCT recipients. Acute myelogenous leukemia (171 of 570; 30%) was the most common HM and most common indication for allogeneic HCT (76 of 145; 52%). Compared with the patients who did not undergo HCT and autologous HCT recipients, allogeneic HCT recipients were younger, had fewer comorbid conditions, and were more likely to undergo diagnostic bronchoscopy in the ICU. Unadjusted ICU and hospital mortality were 35% and 45%, respectively, across the entire cohort. In multivariable regression analysis, autologous HCT (odds ratio [OR], 1.07; 95% confidence interval [CI], .57 to 2.03; P = .82) and allogeneic HCT (OR, .99; 95% CI, .60 to 1.66; P = .98) were not associated with higher hospital mortality compared with the no-HCT cohort, adjusting for demographic, functional, clinical, malignancy, and ARF characteristics. The results were similar when analyzed using propensity score-matching techniques. Our findings indicate that autologous and allogeneic HCT recipients who develop ARF and require ICU admission have similar hospital mortality as patients with HM not treated with HCT.
Collapse
Affiliation(s)
- Laveena Munshi
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Michael Darmon
- Department of Intensive-Resucitation Medicine, APHP, Hôpital Saint-Louis, Paris Diderot Sorbonne Université, Paris, France
| | - Marcio Soares
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Programa de Pós-Graduaçãoem Clínica Médica, Rio De Janeiro, Brazil
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne-Pascale Meert
- Internal Medicine Service, Soins Intensifs and Urgences Oncologique, Institute Jule Bordet, Brussels, Belgium
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization, St James's Hospital, Dublin, Ireland; Hospital Clinic, IDIBAPS, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - Thomas Staudinger
- Department of Medicine, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Frederic Pene
- Medical ICU, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and University Paris Descartes, Paris, France
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Institute of Anesthesiology and Resuscitation, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andreas Barratt-Due
- Department of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | | | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Virginie Lemiale
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA team, and Clinical Epidemiology, UMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Paris Diderot Sorbonne University, Paris, France
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Djamel Mokart
- Multipurpose Resuscitation Service and Department of Anesthesia and Resuscitation, Institut Paoli-Calmettes, Marseille, France
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA team, and Clinical Epidemiology, UMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Paris Diderot Sorbonne University, Paris, France
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | | |
Collapse
|
39
|
Graça L, Abreu IG, Santos AS, Graça L, Dias PF, Santos ML. Descriptive Acute Respiratory Distress Syndrome (ARDS) in adults with imported severe Plasmodium falciparum malaria: A 10 year-study in a Portuguese tertiary care hospital. PLoS One 2020; 15:e0235437. [PMID: 32645025 PMCID: PMC7347120 DOI: 10.1371/journal.pone.0235437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/15/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a severe complication of malaria that remains largely unstudied. We aim to describe the development of ARDS associated with severe P. falciparum malaria, its management and impact on clinical outcome. METHODS Retrospective observational study of adult patients admitted with severe P. falciparum malaria in an Intensive Care Unit (ICU) of a tertiary care hospital from Portugal from 2008 to 2018. A multivariate logistic regression analysis was used to identify factors associated with the development of ARDS, defined according to Berlin Criteria. Prognosis was assessed by case-fatality ratio, nosocomial infection and length of stay. RESULTS 98 patients were enrolled, of which 32 (33%) developed ARDS, a median of 2 days after starting antimalarial medication (IQR 0-4, range 0-6). Length of stay in ICU and in hospital were significantly longer in patients who developed ARDS: 13 days (IQR 10-18) vs 3 days (IQR 2-5) and 21 days (IQR 15-30.5) vs 7 days (IQR 6-10), respectively. Overall case-fatality ratio in ICU was 4.1% and did not differ between groups. The risk of ARDS development is difficult to establish. CONCLUSION ARDS is a hard to predict late complication of severe malaria. A low threshold for ICU admission and monitoring should be used. Ideally patients should be managed in a centre with experience and access to advanced techniques.
Collapse
Affiliation(s)
- Luísa Graça
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Isabel Gomes Abreu
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Ana Sofia Santos
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- * E-mail:
| | - Luís Graça
- Escola Superior de Saúde do Instituto Politécnico de Viana do Castelo, Viana do Castelo, Portugal
- Unidade de Investigação em Ciências da Saúde: Enfermagem da Escola Superior de Enfermagem de Coimbra, Coimbra, Portugal
| | - Paulo Figueiredo Dias
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Maria Lurdes Santos
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| |
Collapse
|
40
|
Demoule A, Antonelli M, Schellongowski P, Pickkers P, Soares M, Meyhoff T, Rello J, Bauer PR, van de Louw A, Lemiale V, Grimaldi D, Martin-Loeches I, Balik M, Mehta S, Kouatchet A, Barratt-Due A, Valkonen M, Reignier J, Metaxa V, Moreau AS, Burghi G, Mokart D, Mayaux J, Darmon M, Azoulay E. Respiratory Mechanics and Outcomes in Immunocompromised Patients With ARDS: A Secondary Analysis of the EFRAIM Study. Chest 2020; 158:1947-1957. [PMID: 32569634 DOI: 10.1016/j.chest.2020.05.602] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 05/06/2020] [Accepted: 05/29/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In view of the high mortality rate of immunocompromised patients with ARDS, it is important to identify targets for improvement. RESEARCH QUESTION This study investigated factors associated with mortality in this specific ARDS population, including factors related to respiratory mechanics (plateau pressure [Pplat,rs], compliance [Crs], and driving pressure [ΔPrs]). STUDY DESIGN AND METHODS This study consisted of a predefined secondary analysis of the EFRAIM data. Overall, 789 of 1,611 patients met the Berlin criteria for ARDS, and Pplat,rs, ΔPrs, and Crs were available for 494 patients. A hierarchical model was used to assess factors at ARDS onset independently associated with hospital mortality. RESULTS Hospital mortality was 56.3%. After adjustment, variables independently associated with hospital mortality included ARDS of undetermined etiology (OR, 1.66; 95% CI, 1.01-2.72), need for vasopressors (OR, 1.91; 95% CI, 1.27-2.88), and need for renal replacement therapy (OR, 2.02; 95% CI, 1.37-2.97). ARDS severity according to the Berlin definition, neutropenia on admission, and the type of underlying disease were not significantly associated with mortality. Before adjustment, higher Pplat,rs, higher ΔPrs, and lower Crs were associated with higher mortality. Addition of each of these individual variables to the final hierarchical model revealed a significant association with mortality: ΔPrs (OR, 1.08; 95% CI, 1.05-1.12), Pplat,rs (OR, 1.07; 95% CI, 1.04-1.11), and Crs (OR, 0.97; 95% CI, 0.95-0.98). Tidal volume was not associated with mortality. INTERPRETATION In immunocompromised patients with ARDS, respiratory mechanics provide additional prognostic information to predictors of hospital mortality. Studies designed to define lung-protective ventilation guided by these physiological variables may be warranted in this specific population.
Collapse
Affiliation(s)
- Alexandre Demoule
- AP-HP Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.
| | - Massimo Antonelli
- Department of Anesthesia, Intensive Care and Emergency Medicine, Fondazione Ospedale Universitario A. Gemelli IRCCS; Istituto di Anestesiologia e Rianimazione Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Peter Pickkers
- Department of Intensive Care Medicine (710), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcio Soares
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Programa de Pós-Graduação em Clínica Médica, Rio De Janeiro, Brazil
| | - Tine Meyhoff
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jordi Rello
- CIBERES, Universitat Autonòma de Barcelona, European Study Group of Infections in Critically Ill Patients (ESGCIP), Barcelona, Spain
| | - Philippe R Bauer
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Andry van de Louw
- Division of Pulmonary and Critical Care, Penn State University College of Medicine, Hershey, PA
| | - Virgine Lemiale
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA Team, and Clinical Epidemiology, UMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Paris Diderot Sorbonne University, Paris, France
| | - David Grimaldi
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO) and Department of Clinical Medicine, Trinity College, Wellcome Trust-HRB Clinical Research Facility, Caring for Critically Ill Immuno-compromised Patients Multinational Network (Nine-I). St James Hospital, Dublin, Ireland
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Achille Kouatchet
- Department of Medical Intensive Care Medicine, University Hospital of Angers, Angers, France
| | - Andreas Barratt-Due
- Department of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Miia Valkonen
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jean Reignier
- Medical Intensive Care Unit, Hôtel Dieu-HME University Hospital of Nantes, Nantes, France
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital, NHS Foundation Trust, London, England
| | - Anne-Sophie Moreau
- Critical Care Center, CHU Lille, School of Medicine, University of Lille, Lille, France
| | - Gaston Burghi
- Terapia Intensiva, Hospital Maciel, Montevideo, Uruguay
| | - Djamel Mokart
- Réanimation Polyvalente et Département d'Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Julien Mayaux
- AP-HP Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Michael Darmon
- Division of Pulmonary and Critical Care, Penn State University College of Medicine, Hershey, PA
| | - Elie Azoulay
- Division of Pulmonary and Critical Care, Penn State University College of Medicine, Hershey, PA
| |
Collapse
|
41
|
Prohaska S, Henn P, Wenz S, Frauenfeld L, Rosenberger P, Haeberle HA. A case report of fatal disseminated fungal sepsis in a patient with ARDS and extracorporeal membrane oxygenation. BMC Anesthesiol 2020; 20:107. [PMID: 32381041 PMCID: PMC7203726 DOI: 10.1186/s12871-020-01031-9] [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: 09/10/2019] [Accepted: 05/03/2020] [Indexed: 02/07/2023] Open
Abstract
Background With the following report we want to present an unusual case of a patient suffering from acute respiratory distress syndrome with early discovery of bacterial pathogens in bronchoalveolar liquid samples that developed a fatal undiscovered disseminated fungal infection. Case presentation A 67-year-old man was admitted to our university hospital with dyspnea. Progressive respiratory failure developed leading to admission to the intensive care unit, intubation and prone positioning was necessary. To ensure adequate oxygenation and lung protective ventilation veno-venous extracorporeal membrane oxygenation was established. Despite maximal therapy and adequate antiinfective therapy of all discovered pathogens the condition of the patient declined further and he deceased. Postmortem autopsy revealed Mucor and Aspergillus mycelium in multiple organs such as lung, heart and pancreas as the underlying cause of his deterioration and death. Conclusion Routine screening re-evaluation of every infection is essential for adequate initiation and discontinuation of every antiinfective therapy. In cases with unexplained deterioration and unsuccessful sampling the possibility for diagnostic biopsies should be considered.
Collapse
Affiliation(s)
- Stefanie Prohaska
- Department of Anesthesiology and Intensive Care Medicine, Intensivstation 39, Tübingen University Hospital, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.
| | - Philipp Henn
- Department of Anesthesiology and Intensive Care Medicine, Intensivstation 39, Tübingen University Hospital, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Svetlana Wenz
- Department of Pathology, Tübingen University Hospital, Eberhard-Karls-University, Tübingen, Germany
| | - Leonie Frauenfeld
- Department of Pathology, Tübingen University Hospital, Eberhard-Karls-University, Tübingen, Germany
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, Intensivstation 39, Tübingen University Hospital, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Helene A Haeberle
- Department of Anesthesiology and Intensive Care Medicine, Intensivstation 39, Tübingen University Hospital, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| |
Collapse
|
42
|
Longhini F, Bruni A, Garofalo E, Navalesi P, Grasselli G, Cosentini R, Foti G, Mattei A, Ippolito M, Accurso G, Vitale F, Cortegiani A, Gregoretti C. Helmet continuous positive airway pressure and prone positioning: A proposal for an early management of COVID-19 patients. Pulmonology 2020; 26:186-191. [PMID: 32386886 PMCID: PMC7190517 DOI: 10.1016/j.pulmoe.2020.04.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/20/2020] [Indexed: 02/08/2023] Open
Affiliation(s)
- F Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.
| | - A Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - E Garofalo
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - P Navalesi
- Anesthesia and Intensive Care, Padua Hospital, Department of Medicine - DIMED, University of Padua, Italy
| | - G Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Italy; Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - R Cosentini
- Emergency Medicine Department, ASST Papa Giovanni XIII, Bergamo, Italy
| | - G Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy
| | - A Mattei
- Department of Pneumology, A.O.U. Città della Salute e della Scienza of Turin, Turin, Italy
| | - M Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Italy
| | - G Accurso
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Italy
| | - F Vitale
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Italy
| | - A Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Italy
| | - C Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Italy
| |
Collapse
|
43
|
Song M, Liu Y, Lu Z, Luo H, Peng H, Chen P. Prognostic factors for ARDS: clinical, physiological and atypical immunodeficiency. BMC Pulm Med 2020; 20:102. [PMID: 32326923 PMCID: PMC7179796 DOI: 10.1186/s12890-020-1131-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 04/02/2020] [Indexed: 12/17/2022] Open
Abstract
Background Risk factors affecting the prognosis of acute respiratory distress syndrome (ARDS) in adults were investigated. The aim was to identify new predictors for ARDS patient prognosis, including those with clinical, pathophysiological, and atypical immunodeficiency. Methods ARDS patients were retrospectively included. The patients were grouped and analysed according to different oxygenation index grades and prognosis, and factors influencing prognosis and survival were examined. Adolescent patients, patients with typical immunodeficiency and patients who died within 24 h after being diagnosed with ARDS were excluded. The predictive value for mortality was determined by Cox proportional hazard analysis. Results In total, 201 patients who fulfilled the Berlin definition of ARDS were included. The severity of critical illness on the day of enrolment, as measured by the Acute Physiology and Chronic Health Evaluation (APACHE) II score (P = 0.016), Sequential Organ Failure Assessment (SOFA) score (P = 0.027), and PaO2/FiO2 (P = 0.000), worsened from mild to severe ARDS cases. Compared with survivors, non-survivors were significantly older and had higher APACHE II and SOFA scores. Moreover, significantly lower lymphocyte/neutrophil ratios and leukocyte counts were found among non-survivors than survivors (P = 0.008, P = 0.012). A moderate positive correlation between the lymphocyte/neutrophil and PaO2/FiO2 ratios (P = 0.023) was observed. In predicting 100-day survival in patients with ARDS, the area under the curve (AUC) for the lymphocyte/neutrophil ratio was significantly higher than those for the PaO2/FiO2 ratio alone, body mass index (BMI) alone, and the lymphocyte count alone (P = 0.0062, 0.0001, and 0.0154). Age (per log10 years), BMI < 24, SOFA score, leukocyte count, and the lymphocyte/neutrophil ratio were independent predictors of 28-day mortality in ARDS patients. Additionally, ARDS patients with a lymphocyte/neutrophil ratio < 0.0537 had increased 28-day mortality rates (P = 0.0283). Old age affected both 28-day and 100-day mortality rates (P = 0.0064,0.0057). Conclusions Age (per log10 years), BMI < 24, SOFA score, lymphocytes, and the lymphocyte/neutrophil ratio were independent predictors of 100-day mortality in patients with ARDS. The lymphocyte/neutrophil ratio may represent a potential molecular marker to evaluate atypical immunosuppression or impairment in patients with ARDS.
Collapse
Affiliation(s)
- Min Song
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, No.139 Renmin Road, Changsha, 410011, Hunan, China.,The Respiratory Disease Research Institute of Hunan Province; The Respiratory Disease Diagnosis and Treatment Center of Hunan Province, No.139 Renmin Road, Changsha, 410011, Hunan, China
| | - Yijie Liu
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, No.139 Renmin Road, Changsha, 410011, Hunan, China
| | - Zhiwen Lu
- School of Mathematics and Statistics, Hunan Normal University, Changsha, 410081, Hunan, China
| | - Hong Luo
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, No.139 Renmin Road, Changsha, 410011, Hunan, China. .,The Respiratory Disease Research Institute of Hunan Province; The Respiratory Disease Diagnosis and Treatment Center of Hunan Province, No.139 Renmin Road, Changsha, 410011, Hunan, China.
| | - Hong Peng
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, No.139 Renmin Road, Changsha, 410011, Hunan, China.,The Respiratory Disease Research Institute of Hunan Province; The Respiratory Disease Diagnosis and Treatment Center of Hunan Province, No.139 Renmin Road, Changsha, 410011, Hunan, China
| | - Ping Chen
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, No.139 Renmin Road, Changsha, 410011, Hunan, China.,The Respiratory Disease Research Institute of Hunan Province; The Respiratory Disease Diagnosis and Treatment Center of Hunan Province, No.139 Renmin Road, Changsha, 410011, Hunan, China
| |
Collapse
|
44
|
Wang Y, Ni Y, Sun J, Liang Z. Use of High-Flow Nasal Cannula for Immunocompromise and Acute Respiratory Failure: A Systematic Review and Meta-Analysis. J Emerg Med 2020; 58:413-423. [PMID: 32220545 DOI: 10.1016/j.jemermed.2020.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/10/2020] [Accepted: 01/20/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute respiratory failure (ARF) is a common cause of emergency department (ED) and intensive care unit (ICU) admissions. High-flow nasal cannula oxygen therapy (HFNC) is widely used for patients with ARF. OBJECTIVE Our aim was to evaluate the latest evidence regarding the application of HFNC in immunocompromised patients with ARF. METHODS We searched PubMed, Embase, and Cochrane databases from inception to January 2019. The primary outcome was short-term mortality and the secondary outcomes were intubation rate and length of ICU stay. RESULTS Eight studies involving 2,179 immunocompromised subjects with ARF were included. No significant differences for short-term mortality were observed when comparing HFNC with conventional oxygen therapy (COT) (risk ratio [RR] 0.89; 95% confidence interval [CI] 0.73 to 1.09; p = 0.25, I2 = 47%) and with noninvasive ventilation (NIV) (RR 0.66; 95% CI 0.37 to 1.18; p = 0.16, I2 = 58%). Lower intubation rates were found when comparing HFNC with COT (RR 0.89; 95% CI 0.80 to 0.99; p = 0.03, I2 = 0%) and no significant difference was found between HFNC and NIV (RR 0.74; 95% CI 0.46 to 1.19; p = 0.22, I2 = 67%). The length of ICU stay was similar when comparing HFNC with COT (mean difference [MD] 0.59; 95% CI -1.68 to 2.85; p = 0.61, I2 = 56%), but was significantly shorter when HFNC was compared with NIV (MD -2.13; 95% CI -3.98 to -0.29; p = 0.02, I2 = 0%). CONCLUSIONS There was no significant difference in short-term mortality with use of HFNC when compared with COT or NIV for immunocompromised patients with ARF. A lower intubation rate than COT and a shorter length of ICU stay than NIV were observed in the HFNC group.
Collapse
Affiliation(s)
- Yiwei Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Yuenan Ni
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Jikui Sun
- State Key Laboratory of Oral Diseases, West China School of Stomatology, Sichuan University, Chengdu, China
| | - Zongan Liang
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| |
Collapse
|
45
|
Niederman MS, Nair GB, Matt U, Herold S, Pennington K, Crothers K, Cummings M, Schluger NW. Update in Lung Infections and Tuberculosis 2018. Am J Respir Crit Care Med 2020; 200:414-422. [PMID: 31042415 DOI: 10.1164/rccm.201903-0606up] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Michael S Niederman
- 1Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Girish Balachandran Nair
- 2Division of Pulmonary and Critical Care Medicine, Beaumont Health, William Beaumont School of Medicine, Oakland University, Royal Oak, Michigan
| | - Ulrich Matt
- 3Department of Internal Medicine II, Universities of Giessen and Marburg Lung Center, member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | - Susanne Herold
- 3Department of Internal Medicine II, Universities of Giessen and Marburg Lung Center, member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | - Kelly Pennington
- 4Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kristina Crothers
- 5Pulmonary, Critical Care and Sleep Medicine, VA Puget Sound Health Care System, Seattle, Washington.,6University of Washington, Seattle, Washington; and
| | | | - Neil W Schluger
- 7Columbia University Irving Medical Center, New York, New York
| |
Collapse
|
46
|
Cortegiani A, Ippolito M, Luján M, Gregoretti C. Tidal volume and helmet: Is the never ending story coming to an end? Pulmonology 2020; 27:107-109. [PMID: 32127308 DOI: 10.1016/j.pulmoe.2020.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
- A Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Via del vespro 129, 90127, Palermo, Italy.
| | - M Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Via del vespro 129, 90127, Palermo, Italy.
| | - M Luján
- Department of Pneumology Hospital de Sabadell, Universitat Autònoma de Barcelona, Parc Taulí, 1, 08208 Sabadell, Spain.
| | - C Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Via del vespro 129, 90127, Palermo, Italy.
| |
Collapse
|
47
|
Editorial: Every breath you take…should be monitored. Curr Opin Crit Care 2020; 25:1-2. [PMID: 30516589 DOI: 10.1097/mcc.0000000000000576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
48
|
Abstract
PURPOSE OF REVIEW A wide spectrum of heterogeneous conditions can render a patient immunocompromised. Recent years have seen an increase in the number of immunocompromised patients given the earlier detection of conditions that require immunosuppressive therapies, changes in immunosuppressive regimens leading to increased survival or novel therapeutic advancements in oncologic care. Acute respiratory failure (ARF) is the leading cause of critical illness and mortality in this population. This review highlights the spectrum of causes of ARF in immunocompromised patients with a particular focus on acute toxicities of novel oncologic treatments. RECENT FINDINGS Recent years have seen improved survival amongst critically ill immunocompromised patients with ARF. This is likely attributable to patient selection of immunosuppressive therapy, improved noninvasive microbiologic diagnostic techniques, improved antimicrobial prophylaxis, treatment, stewardship, and advancements in supportive care including intensive care. Infectious complications remain the leading cause of ARF in this population. However, one of the greatest challenges physicians continue to face is accurate identification of the cause of ARF, given the vast (and increasing) noninfectious causes of ARF across these patients. Emerging therapies, such as immune checkpoint inhibitors (ICIs) and chimeric antigen receptor T-cell therapy (CAR T-cell) have contributed to this problem. Finally, undetermined ARF is reported in approximately 13% of immunocompromised and is associated with a worse prognosis. SUMMARY Infectious complications are still the leading cause of ARF in immunocompromised patients. However, noninfectious complications, derived from the underlying disease or treatment, should be always considered, including novel therapies, such as ICIs and CAR T cells. Further research should focus in improving the diagnostic rate in this subgroup.
Collapse
|
49
|
Chawla R, Dixit SB, Zirpe KG, Chaudhry D, Khilnani GC, Mehta Y, Khatib KI, Jagiasi BG, Chanchalani G, Mishra RC, Samavedam S, Govil D, Gupta S, Prayag S, Ramasubban S, Dobariya J, Marwah V, Sehgal I, Jog SA, Kulkarni AP. ISCCM Guidelines for the Use of Non-invasive Ventilation in Acute Respiratory Failure in Adult ICUs. Indian J Crit Care Med 2020; 24:S61-S81. [PMID: 32205957 PMCID: PMC7085817 DOI: 10.5005/jp-journals-10071-g23186] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A. ACUTE HYPERCAPNIC RESPIRATORY FAILURE A1. Acute Exacerbation of COPD: Recommendations: NIV should be used in management of acute exacerbation of COPD in patients with acute or acute-on-chronic respiratory acidosis (pH = 7.25-7.35). (1A) NIV should be attempted in patients with acute exacerbation of COPD (pH <7.25 & PaCO2 ≥ 45) before initiating invasive mechanical ventilation (IMV) except in patients requiring immediate intubation. (2A). Lower the pH higher the chance of failure of NIV. (2B) NIV should not to be used routinely in normo- or mildly hyper-capneic patients with acute exacerbation of COPD, without acidosis (pH > 7.35). (2B) A2. NIV in ARF due to Chest wall deformities/Neuromuscular diseases: Recommendations: NIV may be used in patients of ARF due to chest wall deformity/Neuromuscular diseases. (PaCO2 ≥ 45) (UPP) A3. NIV in ARF due to Obesity hypoventilation syndrome (OHS): Recommendations: NIV may be used in AHRF in OHS patients when they present with acute hypercapnic or acute on chronic respiratory failure (pH 45). (3B) NIV/CPAP may be used in obese, hypercapnic patients with OHS and/or right heart failure in the absence of acidosis. (UPP) B. NIV IN ACUTE HYPOXEMIC RESPIRATORY FAILURE: B1. NIV in Acute Cardiogenic Pulmonary Oedema: Recommendations: NIV is recommended in hospital patients with ARF, due to Cardiogenic pulmonary edema. (1A). NIV should be used in patients with acute heart failure/ cardiogenic pulmonary edema, right from emergency department itself. (1B) Both CPAP and BiPAP modes are safe and effective in patients with cardiogenic pulmonary edema. (1A). However, BPAP (NIV-PS) should be preferred in cardiogenic pulmonary edema with hypercapnia. (3A) B2. NIV in acute hypoxemic respiratory failure: Recommendations: NIV may be used over conventional oxygen therapy in mild early acute hypoxemic respiratory failure (P/F ratio <300 and >200 mmHg), under close supervision. (2B) We strongly recommend against a trial of NIV in patients with acute hypoxemic failure with P/F ratio <150. (2A) B3. NIV in ARF due to Chest Trauma: Recommendations: NIV may be used in traumatic flail chest along with adequate pain relief. (3B) B4. NIV in Immunocompromised Host: Recommendations: In Immunocompromised patients with early ARF, we may consider NIV over conventional oxygen. (2B). B5. NIV in Palliative Care: Recommendations: We strongly recommend use of NIV for reducing dyspnea in palliative care setting. (2A) B6. NIV in post-operative cases: Recommendations: NIV should be used in patients with post-operative acute respiratory failure. (2A) B6a. NIV in abdominal surgery: Recommendations: NIV may be used in patients with ARF following abdominal surgeries. (2A) B6b. NIV in bariatric surgery: Recommendations: NIV may be used in post-bariatric surgery patients with pre-existent OSA or OHS. (3A) B6c. NIV in Thoracic surgery: Recommendations: In cardiothoracic surgeries, use of NIV is recommended post operatively for acute respiratory failure to improve oxygenation and reduce chance of reintubation. (2A) NIV should not be used in patients undergoing esophageal surgery. (UPP) B6d. NIV in post lung transplant: Recommendations: NIV may be used for shortening weaning time and to avoid re-intubation following lung transplantation. (2B) B7. NIV during Procedures (ETI/Bronchoscopy/TEE/Endoscopy): Recommendations: NIV may be used for pre-oxygenation before intubation. (2B) NIV with appropriate interface may be used in patients of ARF during Bronchoscopy/Endoscopy to improve oxygenation. (3B) B8. NIV in Viral Pneumonitis ARDS: Recommendations: NIV cannot be considered as a treatment of choice for patients with acute respiratory failure with H1N1 pneumonia. However, it may be reasonable to use NIV in selected patients with single organ involvement, in a strictly controlled environment with close monitoring. (2B) B9. NIV and Acute exacerbation of Pulmonary Tuberculosis: Recommendations: Careful use of NIV in patients with acute Tuberculosis may be considered, with effective infection control precautions to prevent air-borne transmission. (3B) B10. NIV after planned extubation in high risk patients: Recommendation: We recommend that NIV may be used to wean high risk patients from invasive mechanical ventilation as it reduces re-intubation rate. (2B) B11. NIV for respiratory distress post extubation: Recommendations: We recommend that NIV therapy should not be used to manage respiratory distress post-extubation in high risk patients. (2B) C. APPLICATION OF NIV: Recommendation: Choice of mode should be mainly decided by factors like disease etiology and severity, the breathing effort by the patient and the operator familiarity and experience. (UPP) We suggest using flow trigger over pressure triggering in assisted modes, as it provides better patient ventilator synchrony. Especially in COPD patients, flow triggering has been found to benefit auto PEEP. (3B) D. MANAGEMENT OF PATIENT ON NIV: D1. Sedation: Recommendations: A non-pharmacological approach to calm the patient (Reassuring the patient, proper environment) should always be tried before administrating sedatives. (UPP) In patients on NIV, sedation may be used with extremely close monitoring and only in an ICU setting with lookout for signs of NIV failure. (UPP) E. EQUIPMENT: Recommendations: We recommend that portable bilevel ventilators or specifically designed ICU ventilators with non-invasive mode should be used for delivering Non–invasive ventilation in critically ill patients. (UPP) Both critical care ventilators with leak compensation and bi-level ventilators have been equally effective in decreasing the WOB, RR, and PaCO2. (3B) Currently, Oronasal mask is the most preferred interface for non-invasive ventilation for acute respiratory failure. (3B) F. WEANING: Recommendations: We recommend that weaning from NIV may be done by a standardized protocol driven approach of the unit. (2B) How to cite this article: Chawla R, Dixit SB, Zirpe KG, Chaudhry D, Khilnani GC, Mehta Y, et al. ISCCM Guidelines for the Use of Non-invasive Ventilation in Acute Respiratory Failure in Adult ICUs. Indian J Crit Care Med 2020;24(Suppl 1):S61–S81.
Collapse
Affiliation(s)
- Rajesh Chawla
- Department of Respiratory and Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India, , e-mail:
| | - Subhal B Dixit
- Department of Critical Care, Sanjeevan & MJM Hospital, Pune, Maharashtra, India, , 020-25531539 / 25539538, e-mail:
| | - Kapil Gangadhar Zirpe
- Department of Neurotrauma Unit, Ruby Hall Clinic, Pune, Maharashtra, India, , e-mail:
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, Haryana, India, , e-mail:
| | - G C Khilnani
- Department of PSRI Institute of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital, New Delhi, India, , e-mail:
| | - Yatin Mehta
- Department of Medanta Institute of Critical Care and Anesthesiology, Medanta The Medicity, Sector-38, Gurgaon-122001, Haryana, India, Extn. 3335, e-mail:
| | - Khalid Ismail Khatib
- Department of Medicine, SKN Medical College, Pune, Maharashtra, India, , e-mail:
| | - Bharat G Jagiasi
- Department of Critical Care, Reliance Hospital, Navi Mumbai, Maharashtra, India, , e-mail:
| | - Gunjan Chanchalani
- Department of Critical Care Medicine, Bhatia Hospital, Mumbai, Maharashtra, India, , e-mail:
| | - Rajesh C Mishra
- Department of Critical Care, Saneejivini Hospital, Vastrapur, Ahmedabad, Gujarat, India, , e-mail:
| | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Deepak Govil
- Department of Critical Care, Medanta Hospital, The Medicity, Gurugram, Haryana, India, , e-mail:
| | - Sachin Gupta
- Department of Critical Care Medicine, Narayana Superspeciality Hospital, Gurugram, Haryana, India, , e-mail:
| | - Shirish Prayag
- Department of Critical Care, Prayag Hospital, Pune, Maharashtra, India, , e-mail:
| | - Suresh Ramasubban
- Department of Critical Care, Apollo Gleneagles Hospital Limited, Kolkata, India, , e-mail:
| | - Jayesh Dobariya
- Department of critical care, Synergy Hospital Rajkot, Rajkot, Gujarat, India, , e-mail:
| | - Vikas Marwah
- Department of Pulmonary, Critical Care and Sleep Medicine, Military Hospital (CTC), Pune, Maharashtra, India, , e-mail:
| | - Inder Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India, , e-mail:
| | - Sameer Arvind Jog
- Department of Critical Care, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India, , 91-9823018178, e-mail:
| | - Atul Prabhakar Kulkarni
- Department of Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India, , e-mail:
| |
Collapse
|
50
|
Shein SL, Rotta AT. Risk Factors and Etiologies of Pediatric Acute Respiratory Distress Syndrome. PEDIATRIC ACUTE RESPIRATORY DISTRESS SYNDROME 2020. [PMCID: PMC7121855 DOI: 10.1007/978-3-030-21840-9_4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The risk factors for acute respiratory distress syndrome (ARDS) have been a focus for clinicians and researchers from the original description in 1967 to the most recent Pediatric Acute Lung Injury Consensus Conference (PALICC). Indeed, there are many comorbidities and risk factors that predispose a patient to develop pediatric ARDS (PARDS) including, but not limited to, immunodeficiency, weight extremes, genetics, and environmental factors. These are particularly important to investigators because accurate prediction of which patients are at greatest risk of PARDS – both the development of PARDS and worse clinical outcomes after PARDS has been established – is key to identifying the next generation of diagnostic techniques and preventative strategies. In addition to those risk factors, there are specific disease processes that lead to the development of PARDS, often divided into direct or pulmonary insults and indirect or extrapulmonary insults. Finally, beyond the clinically visible risk factors, researchers are attempting to identify novel biomarkers to uncover hidden phenotypes of PARDS and enrich the prognostication and prediction of patient outcomes. This chapter delves into each of these concepts.
Collapse
Affiliation(s)
- Steven L. Shein
- Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH USA
| | - Alexandre T. Rotta
- Duke University School of Medicine, Duke University Medical Center, Durham, NC USA
| |
Collapse
|