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Li G, Chen D, Gao F, Huang W, Wang J, Li Y, Chen B, Zhong Y, Chen R, Huang M. Efficacy of corticosteroids in patients with acute respiratory distress syndrome: a meta-analysis. Ann Med 2024; 56:2381086. [PMID: 39165240 PMCID: PMC11340212 DOI: 10.1080/07853890.2024.2381086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 04/04/2024] [Accepted: 04/20/2024] [Indexed: 08/22/2024] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS), are respiratory diseases with high morbidity and mortality. Clinical trials investigating the efficacy of corticosteroids in the treatment of ARDS often yield contradictory results. We hereby conducted a systematic review and meta-analysis to investigate the efficacy of corticosteroids in ARDS management. MATERIALS AND METHODS We conducted a search for randomized clinical trials (RCT) and observational studies that utilized corticosteroids for patients with ARDS in Web of Science, PubMed, and Embase. The primary outcome was mortality. Risk of bias was assessed using Cochrane or NOS scales. Statistical effect size was analyzed using the Mantel-Haenszel method. RESULTS A total of 20 studies, comprising 11 observational studies and 9 RCTs, were eligible for analysis. In RCTs, corticosteroids were associated with a reduction of mortality in ARDS patients (relative risk [RR] = 0.80, 95%CI: 0.71-0.91, p = 0.001). Further subgroup analysis indicated that specific variables, such as low-dose (RR = 0.81; 95%CI: 0.67-0.98; p = 0.034), methylprednisolone (RR = 0.70; 95%CI: 0.49-0.98; p = 0.035), and dexamethasone (RR = 0.82; 95%CI: 0.69-0.98; p = 0.029) were associated with mortality among patients receiving corticosteroids. However, in observational studies, corticosteroids increased the risk of death (RR = 1.16, 95%CI: 1.04-1.29; p = 0.001). Subgroup analysis showed that the use of high-dose corticosteroids was associated with higher patient mortality (RR = 1.20; 95%CI: 1.04-1.38; p = 0.001). CONCLUSIONS The efficacy of corticosteroids on the mortality of ARDS differed by the type and dosage of corticosteroids used, as well as the etiologies. Current data do not support routine use of corticosteroids in ARDS since protective effects were observed in RCTs but increased mortality was found in observational studies. More well designed and large clinical trials are needed to specify the favorable subgroups for corticosteroid therapy.
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Affiliation(s)
- Guowei Li
- Emergency Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Dunfan Chen
- Emergency Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Feng Gao
- Emergency Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wei Huang
- Emergency Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jin Wang
- Emergency Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yonglin Li
- Emergency Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Baijian Chen
- Emergency Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuejia Zhong
- Emergency Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Rui Chen
- Emergency Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Manhua Huang
- Emergency Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Yoshida T, Shimizu S, Fushimi K, Mihara T. Changing clinical practice and prognosis for severe respiratory failure over time: A nationwide inpatient database study. Respir Investig 2024; 62:778-784. [PMID: 38986214 DOI: 10.1016/j.resinv.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/26/2024] [Accepted: 07/05/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Severe respiratory failure requires numerous interventions and its clinical implementation changes over time. We aimed to clarify the clinical practice and prognosis of severe respiratory failure and its changes over time. METHODS In a nationwide Japanese administrative database from 2016 to 2019, we identified nonoperative patients with severe respiratory failure without congestive heart failure as the main diagnosis who received mechanical ventilation (MV) for more than four days. We examined trends in patient characteristics, adjunctive interventions, and prognosis. RESULTS Among 66,905 patients included in this study, patients received antibiotics (90%), high-dose corticosteroids (14%), low-dose corticosteroids (18%), and 51% were admitted to the critical care unit. Hospital mortality was 35%. Median mechanical ventilation lasted 10 days. Tracheostomy occurred in 23% of cases. Median critical care and hospital stays were 10 and 25 days, respectively. Among survivors, 23% had mechanical ventilation dependency at hospital discharge. Large relative changes in adjunctive therapies included fentanyl (30%-38%), rocuronium (4.4%-6.7%), vasopressin (3.8%-6.0%), early rehabilitation (27%-38%), extracorporeal membrane oxygenation (0.7%-1.2%), dopamine (15%-10%), and sivelestat (8.6%-3.5%). No notable changes were seen in mechanical ventilation duration, tracheostomy, critical care unit stay, hospital stay, or ventilator dependency at discharge, except for a slight reduction in hospital mortality (36%-34%). CONCLUSIONS Several adjunctive therapies for severe respiratory failure changed from 2016 to 2019, with an increase in evidence-based practices and a slight decrease in hospital mortality.
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Affiliation(s)
- Takuo Yoshida
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2, Seto, Kanazawa, Yokohama, 236-0027, Japan; Department of Emergency Medicine, The Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo 105-8471, Japan.
| | - Sayuri Shimizu
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2, Seto, Kanazawa, Yokohama, 236-0027, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Takahiro Mihara
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2, Seto, Kanazawa, Yokohama, 236-0027, Japan; Department of Anesthesiology, Yokohama City University School of Medicine, 3-9, Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
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Jenkins P, Cross C, Abdo T, Youness H, Keddissi J. A Review of Current Evidence for the Use of Steroids in the Medical Intensive Care Unit. Diagnostics (Basel) 2024; 14:1565. [PMID: 39061701 PMCID: PMC11276593 DOI: 10.3390/diagnostics14141565] [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: 05/24/2024] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 07/28/2024] Open
Abstract
Systemic steroids are frequently used in critically ill patients for their anti-inflammatory properties. Potential benefits of these agents should be balanced against their known side effects. In this paper, we review trials assessing the use of systemic steroids in common conditions requiring admission to the intensive care unit. These include septic shock, the acute respiratory distress syndrome, severe pneumonia, COVID-19, and hypercapnic respiratory failure due to chronic obstructive pulmonary disease. We will mainly focus on well-conducted randomized controlled trials to determine whether steroids should be administered to critically ill patients presenting with these conditions.
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Affiliation(s)
| | | | | | | | - Jean Keddissi
- Section of Pulmonary, Critical Care and Sleep Medicine, The Oklahoma City VA Healthcare System and The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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Haan BJ, Blackmon SN, Cobb AM, Cohen HE, DeVier MT, Perez MM, Winslow SF. Corticosteroids in critically ill patients: A narrative review. Pharmacotherapy 2024; 44:581-602. [PMID: 38872437 DOI: 10.1002/phar.2944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/15/2024] [Accepted: 05/15/2024] [Indexed: 06/15/2024]
Abstract
Corticosteroids have been utilized in modern medicine for decades. Many indications have been investigated across various treatment settings with both benefit and harm observed. Given the instability of critically ill patients, the increased risk of corticosteroid-related complications, and the pervasive comorbidities, patients who receive corticosteroids must be carefully managed. Common critical care disease states in which corticosteroids have been studied and are routinely utilized include acute respiratory distress syndrome, adrenal insufficiency, angioedema, asthma, chronic obstructive pulmonary disease, community-acquired pneumonia, coronavirus disease 2019, septic shock, and spinal cord injury. Benefits of corticosteroids include an improvement in disease state-specific outcomes, decreased hospital length of stay, decreased mechanical ventilatory support, and decreased mortality. The harm of corticosteroids is well documented through adverse effects that include, but are not limited to, hyperglycemia, tachycardia, hypertension, agitation, delirium, anxiety, immunosuppression, gastrointestinal bleeding, fluid retention, and muscle weakness. Furthermore, corticosteroids are associated with increased health care costs through adverse effects as well as drug acquisition and administration costs. Given the assortment of agents, dosing, benefits, risks, and utilization in the critical care setting, there may be difficulty with identifying the appropriate places for use of corticosteroids in therapy. There currently exists no comprehensive report detailing the use of corticosteroids in the aforementioned disease states within the critical care setting. This narrative review sets out to describe these in detail.
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Affiliation(s)
- Bradley J Haan
- Department of Pharmacy, Ascension Genesys Hospital, Grand Blanc, Michigan, USA
| | - Samantha N Blackmon
- Department of Pharmacy, Ascension St Vincent's Birmingham Hospital, Birmingham, Alabama, USA
| | - Alex M Cobb
- Department of Pharmacy, Ascension St. John Medical Center, Tulsa, Oklahoma, USA
| | - Heather E Cohen
- Department of Pharmacy, Ascension Illinois Metro Region, Chicago, Illinois, USA
| | - Margaret T DeVier
- Department of Pharmacy, Ascension Saint Thomas Hospital Midtown, Nashville, Tennessee, USA
| | - Mary M Perez
- Department of Pharmacy, Ascension St Vincent's Birmingham Hospital, Birmingham, Alabama, USA
| | - Samuel F Winslow
- Department of Pharmacy, Ascension Providence Hospital, Southfield, Michigan, USA
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Sinha S, Patnaik R, Behera S. Steroids in acute respiratory distress syndrome: A panacea or still a puzzle? World J Crit Care Med 2024; 13:91225. [PMID: 38855281 PMCID: PMC11155495 DOI: 10.5492/wjccm.v13.i2.91225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 04/28/2024] [Accepted: 05/15/2024] [Indexed: 06/03/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a unique entity marked by various etiologies and heterogenous pathophysiologies. There remain concerns regarding the efficacy of particular medications for each severity level apart from respiratory support. Among several pharmacotherapies which have been examined in the treatment of ARDS, corticosteroids, in particular, have demonstrated potential for improving the resolution of ARDS. Nevertheless, it is imperative to consider the potential adverse effects of hyperglycemia, susceptibility to hospital-acquired infections, and the development of intensive care unit acquired weakness when administering corticosteroids. Thus far, a multitude of trials spanning several decades have investigated the role of corticosteroids in ARDS. Further stringent trials are necessary to identify particular subgroups before implementing corticosteroids more widely in the treatment of ARDS. This review article provides a concise overview of the most recent evidence regarding the role and impact of corticosteroids in the management of ARDS.
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Affiliation(s)
- Sharmili Sinha
- Department of Critical Care Medicine, Apollo Hospitals, Bhubaneswar 751005, Odisha, India
| | - Rohit Patnaik
- Department of Critical Care Medicine, Medeor 24x7 Hospital, Al Danah 40330, Abu Dhabi, United Arab Emirates
| | - Srikant Behera
- Department of Internal Medicine and Critical Care, All India Institute of Medical Sciences, Bhubaneswar 751019, Odisha, India
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Battaglini D, Iavarone IG, Rocco PRM. An update on the pharmacological management of acute respiratory distress syndrome. Expert Opin Pharmacother 2024; 25:1229-1247. [PMID: 38940703 DOI: 10.1080/14656566.2024.2374461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 06/26/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION Acute respiratory distress syndrome (ARDS) is characterized by acute inflammatory injury to the lungs, alterations in vascular permeability, loss of aerated tissue, bilateral infiltrates, and refractory hypoxemia. ARDS is considered a heterogeneous syndrome, which complicates the search for effective therapies. The goal of this review is to provide an update on the pharmacological management of ARDS. AREAS COVERED The difficulties in finding effective pharmacological therapies are mainly due to the challenges in designing clinical trials for this unique, varied population of critically ill patients. Recently, some trials have been retrospectively analyzed by dividing patients into hyper-inflammatory and hypo-inflammatory sub-phenotypes. This approach has led to significant outcome improvements with some pharmacological treatments that previously failed to demonstrate efficacy, which suggests that a more precise selection of ARDS patients for clinical trials could be the key to identifying effective pharmacotherapies. This review is provided after searching the main studies on this topics on the PubMed and clinicaltrials.gov databases. EXPERT OPINION The future of ARDS therapy lies in precision medicine, innovative approaches to drug delivery, immunomodulation, cell-based therapies, and robust clinical trial designs. These should lead to more effective and personalized treatments for patients with ARDS.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genova, Italy
| | - Ida Giorgia Iavarone
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genova, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Dhege CT, Kumar P, Choonara YE. Pulmonary drug delivery devices and nanosystems as potential treatment strategies for acute respiratory distress syndrome (ARDS). Int J Pharm 2024; 657:124182. [PMID: 38697584 DOI: 10.1016/j.ijpharm.2024.124182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/10/2024] [Accepted: 04/28/2024] [Indexed: 05/05/2024]
Abstract
Despite advances in drug delivery technologies, treating acute respiratory distress syndrome (ARDS) is challenging due to pathophysiological barriers such as lung injury, oedema fluid build-up, and lung inflammation. Active pharmaceutical ingredients (API) can be delivered directly to the lung site of action with the use of aerosol-based drug delivery devices, and this circumvents the hepatic first-pass effect and improves the bioavailability of drugs. This review discusses the various challenges and barriers for pulmonary drug delivery, current interventions for delivery, considerations for effective drug delivery, and the use of nanoparticle drug delivery carriers as potential strategies for delivering therapeutics in ARDS. Nanosystems have the added benefit of entrapping drugs, increase pulmonary drug bioavailability, and using biocompatible and biodegradable excipients that can facilitate targeted and/or controlled delivery. These systems provide an alternative to existing conventional systems. An effective way to deliver drugs for the treatment of ARDS can be by using colloidal systems that are aerosolized or inhaled. Drug distribution to the deeper pulmonary tissues is necessary due to the significant endothelial cell destruction that is prevalent in ARDS. The particle size of nanoparticles (<0.5 μm) makes them ideal candidates for treating ARDS as they can reach the alveoli. A look into the various potential benefits and limitations of nanosystems used for other lung disorders is also considered to indicate how they may be useful for the potential treatment of ARDS.
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Affiliation(s)
- Clarence T Dhege
- Wits Advanced Drug Delivery Platform Research Unit, Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown 2193, South Africa
| | - Pradeep Kumar
- Wits Advanced Drug Delivery Platform Research Unit, Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown 2193, South Africa
| | - Yahya E Choonara
- Wits Advanced Drug Delivery Platform Research Unit, Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown 2193, South Africa.
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Wu D, Li Y, Dong SH, Gao Y. Clinical outcomes of corticosteroid administration for acute respiratory distress syndrome in adults based on meta-analyses and trial sequential analysis. Ann Saudi Med 2024; 44:167-182. [PMID: 38853475 PMCID: PMC11268472 DOI: 10.5144/0256-4947.2024.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 04/27/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS), which results in lung injury as a consequence of sepsis and septic shock, is associated with severe systemic inflammation and is responsible for a high worldwide mortality rate. OBJECTIVE Investigate whether corticosteroids could benefit clinical outcomes in adult with ARDS. METHODS A comprehensive search of electronic databases Ovid MEDLINE, Ovid EMbase, and Cochrane Library from their inception to 7 May 2023 was conducted to identify studies that met the eligibility criteria, including only randomized controlled trials. The study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the methods of trial sequential analysis. MAIN OUTCOME MEASURES Mortality rates, including including the 14-, 28-, 45-, and 60-day mortality, hospital mortality, and intensive care unit (ICU) mortality. SAMPLE SIZE 17 studies with 2508 patients. RESULTS Data relating to mortality at 14, 28, 45, and 60 days were not significantly different when treatments with corticosteroids and placebo were compared. In terms of hospital and ICU mortality, the mortality of those who had received corticosteroids was significantly lower than that of those who had not. ARDS patients who received assisted ventilation benefited from corticosteroid therapy, as revealed by the significant difference in outcome days between those who received assisted ventilation and those who did not. Corticosteroid had significantly more days free from mechanical ventilation, ICU-free days, and MODS-free days during the first 28 days, but not more organ support-free days up to day 28. CONCLUSION Although corticosteroid therapy did not reduce mortality rates at different observation periods, it significantly reduced hospital and ICU mortality. Administering corticosteroids to ARDS patients significantly decreased the days of assisted ventilation and time cost consumption. This study confirmed that long-term use of low-dose glucocorticoids may have a positive effect on early ARDS. LIMITATION Risk of bias due to the differences in patient characteristics.
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Affiliation(s)
- Di Wu
- From the Department of Pharmacy, Hubei Provincial Hospital of Traditional Chinese Medicine/Affiliated Hospital of Hubei University of Chinese Medicine, Wuhan, China
| | - Yue Li
- From the Department of Respiratory Medicine, Hubei Provincial Hospital of Traditional Chinese Medicine/Affiliated Hospital of Hubei University of Chinese Medicine, Wuhan, China
| | - Shao-Hua Dong
- From the Department of Pharmacy, Hubei Provincial Hospital of Traditional Chinese Medicine/Affiliated Hospital of Hubei University of Chinese Medicine, Wuhan, China
| | - Yue Gao
- From the Department of Pharmacy, Hubei Provincial Hospital of Traditional Chinese Medicine/Affiliated Hospital of Hubei University of Chinese Medicine, Wuhan, China
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Latronico N, Eikermann M, Ely EW, Needham DM. Improving management of ARDS: uniting acute management and long-term recovery. Crit Care 2024; 28:58. [PMID: 38395902 PMCID: PMC10893724 DOI: 10.1186/s13054-024-04810-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/12/2024] [Indexed: 02/25/2024] Open
Abstract
Acute Respiratory Distress Syndrome (ARDS) is an important global health issue with high in-hospital mortality. Importantly, the impact of ARDS extends beyond the acute phase, with increased mortality and disability for months to years after hospitalization. These findings underscore the importance of extended follow-up to assess and address the Post-Intensive Care Syndrome (PICS), characterized by persistent impairments in physical, cognitive, and/or mental health status that impair quality of life over the long-term. Persistent muscle weakness is a common physical problem for ARDS survivors, affecting mobility and activities of daily living. Critical illness and related interventions, including prolonged bed rest and overuse of sedatives and neuromuscular blocking agents during mechanical ventilation, are important risk factors for ICU-acquired weakness. Deep sedation also increases the risk of delirium in the ICU, and long-term cognitive impairment. Corticosteroids also may be used during management of ARDS, particularly in the setting of COVID-19. Corticosteroids can be associated with myopathy and muscle weakness, as well as prolonged delirium that increases the risk of long-term cognitive impairment. The optimal duration and dosage of corticosteroids remain uncertain, and there's limited long-term data on their effects on muscle weakness and cognition in ARDS survivors. In addition to physical and cognitive issues, mental health challenges, such as depression, anxiety, and post-traumatic stress disorder, are common in ARDS survivors. Strategies to address these complications emphasize the need for consistent implementation of the evidence-based ABCDEF bundle, which includes daily management of analgesia in concert with early cessation of sedatives, avoidance of benzodiazepines, daily delirium monitoring and management, early mobilization, and incorporation of family at the bedside. In conclusion, ARDS is a complex global health challenge with consequences extending beyond the acute phase. Understanding the links between critical care management and long-term consequences is vital for developing effective therapeutic strategies and improving the quality of life for ARDS survivors.
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Affiliation(s)
- Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
- Department of Emergency, Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123, Brescia, Italy.
- "Alessandra BONO" Interdepartmental University Research Center on Long-Term Outcome (LOTO) in Critical Illness Survivors, University of Brescia, Brescia, Italy.
| | - M Eikermann
- Department of Anesthesiology, Albert Einstein College of Medicine, Montefiore Medical Center, New York, USA
- Klinik fur Anästhesiologie und Intensivmedizin, Universitaet Duisburg-Essen, Essen, Germany
| | - E W Ely
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - D M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
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Jiang X, Zhao C, Hu W, Lu D, Chen C, Gong S, Yan J, Mao W. Efficacy and Safety of Glucocorticoid in the Treatment of Acute Respiratory Distress Syndrome caused by Covid-19: A Systematic Review and Meta-Analysis. CLIN INVEST MED 2023; 46:E03-E18. [PMID: 38330183 DOI: 10.3138/cim.v46i4e03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
BACKGROUND Glucocorticoids are often used to treat acute respiratory distress syndrome (ARDS) and novel coronavirus disease 2019 (COVID-19). However, the efficacy and safety of glucocorticoids in the treatment of ARDS caused by COVID-19 are still controversial; therefore, we conducted this meta-analysis of the literature on this topic. METHODS Four databases (PubMed, EMBASE, Cochrane Library, and Web of Science) were searched from the establishment of the databases to August 16, 2023. Randomized controlled trials (RCTs) and cohort studies that compared glucocorticoid versus standard treatment for ARDS caused by COVID-19 were included. The Newcastle-Ottawa Scale (NOS) checklist and the Cochrane Handbook for Systematic Reviews of Interventions were used to evaluate the risk of bias. Review Manager 5.4 software and STATA 17.0 were used for meta-analy-sis, and the relative risk (RR), mean difference, and 95% confidence intervals (CIs) were then determined. Results: A total of 17 studies involving 8592 patients were evaluated, including 14 retrospective studies and 3 RCTs. Sixteen studies reported data on all-cause mortality. The results of the meta-analysis showed that glucocorticoids did not reduce all-cause (RR, 0.96; 95% CI 0.82-1.13, P = .62) or 28-day (RR, 1.01; 95% CI 0.78-1.32, P = .93) mortality. Subgroup analysis showed that only methylprednisolone reduced all-cause mortality. No matter whether glucocorticoid use was early or delayed, high-dose or low-dose, long-term or short-term, no regimen reduced all-cause mortality. Furthermore, there were no significant differences in length of intensive care unit (ICU) stay, length of hospital stay, hyperglycemia, and ventilator-associated pneumonia (VAP); how-ever, glucocorticoids increased the number of ventilator-free days. CONCLUSIONS Although methylprednisolone may reduce all-cause mortality from ARDS caused by COVID-19, this effect was not found with other types of glucocorticoids. At the same time, glucocorticoid use was associ-ated with more ventilator-free days, without increasing the incidence of hyperglycemic events or VAP. Con-sidering that almost all of the included studies were retrospective cohort studies, more RCTs are needed to confirm these findings.
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Affiliation(s)
- Xiangyang Jiang
- Department of Critical Care Medicine, Zhejiang Hospital, Lingyin Road 12, Hangzhou, 310013, Zhejiang, China
| | - Changyun Zhao
- Department of Critical Care Medicine, Zhejiang Hospital, Lingyin Road 12, Hangzhou, 310013, Zhejiang, China
| | - Weihang Hu
- Department of Critical Care Medicine, Zhejiang Hospital, Lingyin Road 12, Hangzhou, 310013, Zhejiang, China
| | - Difan Lu
- Cardiovascular Ultrasound Center of the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310000, Zhejiang, China
| | - Changqin Chen
- Department of Critical Care Medicine, Zhejiang Hospital, Lingyin Road 12, Hangzhou, 310013, Zhejiang, China
| | - Shijin Gong
- Department of Critical Care Medicine, Zhejiang Hospital, Lingyin Road 12, Hangzhou, 310013, Zhejiang, China
| | - Jing Yan
- Department of Critical Care Medicine, Zhejiang Hospital, Lingyin Road 12, Hangzhou, 310013, Zhejiang, China
| | - Wenchao Mao
- Department of Critical Care Medicine, Zhejiang Hospital, Lingyin Road 12, Hangzhou, 310013, Zhejiang, China
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Melani AS, Croce S, Cassai L, Montuori G, Fabbri G, Messina M, Viani M, Bargagli E. Systemic Corticosteroids for Treating Respiratory Diseases: Less Is Better, but… When and How Is It Possible in Real Life? Pulm Ther 2023; 9:329-344. [PMID: 37356085 PMCID: PMC10447722 DOI: 10.1007/s41030-023-00227-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/28/2023] [Indexed: 06/27/2023] Open
Abstract
Systemic corticosteroids (CSs), a keystone in pulmonology, are drugs with strong antiinflammatory activity. They are cheap, easily available, and accessible, but with common and serious side effects. Moreover, the use of exogenous CSs may suppress the hypothalamic-pituitary-adrenal (HPA) axis, predisposing to adrenal insufficiency. Safe CS treatment is a challenge of pharmacological research. This narrative review examined the indications of CSs in some respiratory diseases, analyzing what types, dosages, and length of treatment are required as the dosage and duration of CS treatments need to be minimized. Chronic maintenance treatments with CSs are associated with poor prognosis, but they are still prescribed in patients with severe asthma, Chronic obstructive pulmonary disease (COPD), and interstitial lung diseases. When CS discontinuation is not possible, all efforts should be made to achieve clinically meaningful reductions. Guidelines suggest the use of methylprednisolone at a dose of 20-40 mg/day or equivalent for up to 10 days in subjects with COVID-19 pneumonia (but not other respiratory viral diseases) and respiratory failure, exacerbations of asthma, and COPD. Some guidelines suggest that CS treatment shorter than 10-14 days can be abruptly stopped, strictly monitoring subjects with unexplained symptoms after CS withdrawal, who should promptly be tested for adrenal insufficiency (AI) and eventually treated. CSs are often used in severe community-acquired pneumonia associated with markedly increased serum inflammation markers, in acute respiratory distress syndrome (ARDS), in septic shock unresponsive to hydro-saline replenishment and vasopressors, and acute exacerbations of interstitial lung diseases. As these cases often require higher doses and longer duration of CS treatment, CS tapering should be gradual and, when useful, supported by an evaluation of HPA axis function.
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Affiliation(s)
- Andrea S. Melani
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
| | - Sara Croce
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
| | - Lucia Cassai
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
| | - Giusy Montuori
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
| | - Gaia Fabbri
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
| | - Maddalena Messina
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
| | - Magda Viani
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
| | - Elena Bargagli
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
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12
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Yoshihro S, Taito S, Yatabe T. The influence of steroid type on outcomes in patients with acute respiratory distress syndrome. J Intensive Care 2023; 11:32. [PMID: 37430366 DOI: 10.1186/s40560-023-00681-4] [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: 04/06/2023] [Accepted: 07/05/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Recent systematic reviews and meta-analyses have suggested that low-dose steroids are effective in the treatment of acute respiratory distress syndrome (ARDS). Recent guidelines recommend the use of low-dose steroids instead of high-dose steroids. These systematic reviews were conducted based on the concept that the effect of steroids is constant regardless of their type. We discuss whether the type of steroid used influences the outcomes in patients with ARDS. MAIN BODY From a pharmacological standpoint, methylprednisolone has little activity as a mineralocorticoid and may cause pulmonary hypertension. The results of the rank probability of our previous network meta-analysis revealed that low-dose methylprednisolone might be an optimal treatment compared to using other types of steroids or no steroids in terms of ventilator-free days. Similarly, an analysis of individual data from four randomized controlled trials suggested that low-dose methylprednisolone was associated with decreased mortality in patients with ARDS. Dexamethasone has attracted the attention of clinicians as a novel adjunct therapy for ARDS. CONCLUSION Recent evidence has shown that low-dose methylprednisolone may be an effective treatment option for ARDS. The timing of initiation and duration of low-dose methylprednisolone therapy should be verified in future studies.
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Affiliation(s)
- Shodai Yoshihro
- Department of Pharmaceutical Services, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Tomoaki Yatabe
- Emergency Department, Nishichita General Hospital, 3-1, Nakanoike, Tokai-Shi, Aichi, 477-8522, Japan.
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13
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Battaglini D, Iavarone IG, Al-Husinat L, Ball L, Robba C, Silva PL, Cruz FF, Rocco PR. Anti-inflammatory therapies for acute respiratory distress syndrome. Expert Opin Investig Drugs 2023; 32:1143-1155. [PMID: 37996088 DOI: 10.1080/13543784.2023.2288080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 11/22/2023] [Indexed: 11/25/2023]
Abstract
INTRODUCTION Treatments for the acute respiratory distress syndrome (ARDS) are mainly supportive, and ventilatory management represents a key approach in these patients. Despite progress in pharmacotherapy, anti-inflammatory strategies for the treatment of ARDS have shown controversial results. Positive outcomes with pharmacologic and nonpharmacologic treatments have been found in two different biological subphenotypes of ARDS, suggesting that, with a personalized medicine approach, pharmacotherapy for ARDS can be effective. AREAS COVERED This article reviews the literature concerning anti-inflammatory therapies for ARDS, focusing on pharmacological and stem-cell therapies, including extracellular vesicles. EXPERT OPINION Despite advances, ARDS treatments remain primarily supportive. Ventilatory and fluid management are important strategies in these patients that have demonstrated significant impacts on outcome. Anti-inflammatory drugs have shown some benefits, primarily in preclinical research and in specific clinical scenarios, but no recommendations are available from guidelines to support their use in patients with ARDS, except in particular settings such as different subphenotypes, specific etiologies, or clinical trials. Personalized medicine seems promising insofar as it may identify specific subgroups of patients with ARDS who may benefit from anti-inflammatory treatment. However, additional efforts are needed to move subphenotype characterization from bench to bedside.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Ida Giorgia Iavarone
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Lou'i Al-Husinat
- Department of Clinical Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Lorenzo Ball
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fernanda F Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia Rm Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- National Institute of Science and Technology for Regenerative Medicine, Rio de Janeiro, Brazil
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14
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Al-Sofyani KA. Corticosteroids treatment for pediatric acute respiratory syndrome: A critical review. Saudi Med J 2023; 44:440-449. [PMID: 37182909 PMCID: PMC10187748 DOI: 10.15537/smj.2023.44.5.20220672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Approximately 25% of all pediatric consultations are due to respiratory conditions, 10% of which are for asthma. Regarding prevalence, bronchiolitis, acute bronchitis, and respiratory infections are other leading pediatric respiratory illnesses. Compared to the aforementioned diseases, pediatric acute respiratory distress syndrome (PARDS) is rare but lethal in the Intensive Care Unit patients. According to global studies, the mortality in PARDS ranges from 13.3% to 60.7%. Before the Pediatric Acute Lung Injury Consensus Conference (PALICC), adult acute respiratory distress syndrome (ARDS) management guidelines were used for PARDS. The PALICC set new criteria to identify PARDS with a different treatment and management approach. Steroids have been used to treat ARDS in some cases, although their effectiveness in treating pediatric patients is highly debated in the scientific community. This review examines steroid use in treating PARDS, emphasizes current developments in the field, and gives a broad overview of PARDS management.
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Affiliation(s)
- Khouloud A. Al-Sofyani
- From the Department of Pediatric, Pediatric Critical Care Unit, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
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15
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Battaglini D, Fazzini B, Silva PL, Cruz FF, Ball L, Robba C, Rocco PRM, Pelosi P. Challenges in ARDS Definition, Management, and Identification of Effective Personalized Therapies. J Clin Med 2023; 12:1381. [PMID: 36835919 PMCID: PMC9967510 DOI: 10.3390/jcm12041381] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023] Open
Abstract
Over the last decade, the management of acute respiratory distress syndrome (ARDS) has made considerable progress both regarding supportive and pharmacologic therapies. Lung protective mechanical ventilation is the cornerstone of ARDS management. Current recommendations on mechanical ventilation in ARDS include the use of low tidal volume (VT) 4-6 mL/kg of predicted body weight, plateau pressure (PPLAT) < 30 cmH2O, and driving pressure (∆P) < 14 cmH2O. Moreover, positive end-expiratory pressure should be individualized. Recently, variables such as mechanical power and transpulmonary pressure seem promising for limiting ventilator-induced lung injury and optimizing ventilator settings. Rescue therapies such as recruitment maneuvers, vasodilators, prone positioning, extracorporeal membrane oxygenation, and extracorporeal carbon dioxide removal have been considered for patients with severe ARDS. Regarding pharmacotherapies, despite more than 50 years of research, no effective treatment has yet been found. However, the identification of ARDS sub-phenotypes has revealed that some pharmacologic therapies that have failed to provide benefits when considering all patients with ARDS can show beneficial effects when these patients were stratified into specific sub-populations; for example, those with hyperinflammation/hypoinflammation. The aim of this narrative review is to provide an overview on current advances in the management of ARDS from mechanical ventilation to pharmacological treatments, including personalized therapy.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy
| | - Brigitta Fazzini
- Adult Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, Whitechapel, London E1 1BB, UK
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Fernanda Ferreira Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, 15145 Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, 15145 Genoa, Italy
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, 15145 Genoa, Italy
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16
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Liu C, Xiao K, Xie L. Advances in mesenchymal stromal cell therapy for acute lung injury/acute respiratory distress syndrome. Front Cell Dev Biol 2022; 10:951764. [PMID: 36036014 PMCID: PMC9399751 DOI: 10.3389/fcell.2022.951764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/19/2022] [Indexed: 11/29/2022] Open
Abstract
Acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) develops rapidly and has high mortality. ALI/ARDS is mainly manifested as acute or progressive hypoxic respiratory failure. At present, there is no effective clinical intervention for the treatment of ALI/ARDS. Mesenchymal stromal cells (MSCs) show promise for ALI/ARDS treatment due to their biological characteristics, easy cultivation, low immunogenicity, and abundant sources. The therapeutic mechanisms of MSCs in diseases are related to their homing capability, multidirectional differentiation, anti-inflammatory effect, paracrine signaling, macrophage polarization, the polarization of the MSCs themselves, and MSCs-derived exosomes. In this review, we discuss the pathogenesis of ALI/ARDS along with the biological characteristics and mechanisms of MSCs in the treatment of ALI/ARDS.
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Affiliation(s)
- Chang Liu
- School of Medicine, Nankai University, Tianjin, China
- Center of Pulmonary and Critical Care Medicine, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- Medical School of Chinese People’s Liberation Army (PLA), Beijing, China
| | - Kun Xiao
- Center of Pulmonary and Critical Care Medicine, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- Medical School of Chinese People’s Liberation Army (PLA), Beijing, China
- *Correspondence: Kun Xiao, ; Lixin Xie,
| | - Lixin Xie
- School of Medicine, Nankai University, Tianjin, China
- Center of Pulmonary and Critical Care Medicine, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- Medical School of Chinese People’s Liberation Army (PLA), Beijing, China
- *Correspondence: Kun Xiao, ; Lixin Xie,
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17
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Battaglini D, Robba C, Pelosi P, Rocco PRM. Treatment for acute respiratory distress syndrome in adults: A narrative review of phase 2 and 3 trials. Expert Opin Emerg Drugs 2022; 27:187-209. [PMID: 35868654 DOI: 10.1080/14728214.2022.2105833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Ventilatory management and general supportive care of acute respiratory distress syndrome (ARDS) in the adult population have led to significant clinical improvements, but morbidity and mortality remain high. Pharmacologic strategies acting on the coagulation cascade, inflammation, oxidative stress, and endothelial cell injury have been targeted in the last decade for patients with ARDS, but only a few of these have shown potential benefits with a meaningful clinical response and improved patient outcomes. The lack of availability of specific pharmacologic treatments for ARDS can be attributed to its complex pathophysiology, different risk factors, huge heterogeneity, and difficult classification into specific biological phenotypes and genotypes. AREAS COVERED In this narrative review, we briefly discuss the relevance and current advances in pharmacologic treatments for ARDS in adults and the need for the development of new pharmacological strategies. EXPERT OPINION Identification of ARDS phenotypes, risk factors, heterogeneity, and pathophysiology may help to design clinical trials personalized according to ARDS-specific features, thus hopefully decreasing the rate of failed clinical pharmacologic trials. This concept is still under clinical investigation and needs further development.
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Affiliation(s)
- Denise Battaglini
- Dipartimento di Anestesia e Rianimazione, Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - Chiara Robba
- Dipartimento di Anestesia e Rianimazione, Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Largo Rosanna Benzi, 10, 16132, Genoa, Italy.,Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - Paolo Pelosi
- Dipartimento di Anestesia e Rianimazione, Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Largo Rosanna Benzi, 10, 16132, Genoa, Italy.,Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, RJ 21941-902, Brazil.,COVID-19 Virus Network from Ministry of Science, Technology, and Innovation, Brazilian Council for Scientific and Technological Development, and Foundation Carlos Chagas Filho Research Support of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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18
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Safety and efficacy of corticosteroids in ARDS patients: a systematic review and meta-analysis of RCT data. Respir Res 2022; 23:301. [PMID: 36333729 PMCID: PMC9635104 DOI: 10.1186/s12931-022-02186-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/14/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose Acute respiratory distress syndrome (ARDS) is an acute and critical disease among children and adults, and previous studies have shown that the administration of corticosteroids remains controversial. Therefore, a meta-analysis of randomized controlled trials (RCTs) was performed to evaluate the safety and efficacy of corticosteroids. Methods The RCTs investigating the safety and efficacy of corticosteroids in ARDS were searched from electronic databases (Embase, Medline, and the Cochrane Central Register of Controlled Trials). The primary outcome was 28-day mortality. Heterogeneity was assessed using the Chi square test and I2 with the inspection level of 0.1 and 50%, respectively. Results Fourteen RCTs (n = 1607) were included for analysis. Corticosteroids were found to reduce the risk of death in patients with ARDS (relative risk (RR) = 0.78, 95% confidence interval (CI): 0.70–0.87; P < 0.01). Moreover, no significant adverse events were observed, compared to placebo or standard support therapy. Further subgroup analysis showed that variables, such as adults (RR = 0.78; 95% CI: 0.70–0.88; P < 0.01), non-COVID-19 (RR = 0.71; 95% CI: 0.62–0.83; P < 0.01), methylprednisolone (RR = 0.70; 95% CI: 0.56–0.88; P < 0.01), and hydrocortisone (RR = 0.79; 95% CI: 0.63–0.98; P = 0.03) were associated with 28-day mortality among patients who used corticosteroids. However, no association was found, regarding children (RR = 0.21; 95% CI: 0.01–4.10; P = 0.30). Conclusion The use of corticosteroids is an effective approach to reduce the risk of death in ARDS patients. However, this effect is associated with age, non-COVID-19 diseases, and methylprednisolone and hydrocortisone use. Therefore, evidence suggests patients with age ≥ 18 years and non-COVID-19 should be encouraged during the corticosteroid treatment. However, due to substantial differences in the use of corticosteroids among these studies, questions still remain regarding the dosage, optimal corticosteroid agent, and treatment duration in patients with ARDS. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-02186-4.
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Wang Q, Xie T, Gao R, Long X, Wei J, Ye L, Jiang J, Kang L, Wang J, Jun C, Lyu J. Neutrophil-to-lymphocyte ratio is a powerful predictor of adult patients with acute respiratory distress syndrome who might benefit from corticosteroid therapy. Am J Transl Res 2021; 13:11556-11570. [PMID: 34786082 PMCID: PMC8581852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 08/11/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND There is no convincing pharmacological treatment for patients withacute respiratory distress syndrome (ARDS). The efficacy of corticosteroids in ARDS patients remains controversial. Neutrophil-to-Lymphocyte Ratio (NLR) has displayed as a good biomarker for inflammation and immune status, and thus a prognostic marker in some critical patients of ARDS. In this study, we hypothesized that NLR could also serve as an indicator for the efficacy of corticosteroid therapy in ARDS patients. METHODS Subjects included in this retrospective cohort study with ARDS patients who were admitted to an academic hospital in Wuhan, China, from May 1st, 2020 to April 20th, 2021. Multivariable logisitic regression model was used to evaluate risk factors of 30-day in-hospital mortality and ventilator-free days. Multi-Cox regression model was used to assess the efficacy of corticosteroid treatment in terms of NLR cutoff value. RESULTS Among the 357 patients in our study, 89 (24.9%) had NLR≥14.35 and 268 (75.1%) had NLR<14.35. Among them, 53 patients with NLR≥14.35 (58.9%) received corticosteroids and 99 patients with NLR<14.35 (37.1%) received corticosteroids. Post-adjustment analysis (by APACHE II score and age) revealed that corticosteroid treatment was associated with a decreased risk of 30-day mortality in the NLR≥14.35 group but with an increased risk of death in the NLR<14.35 group. Use of corticosteroid in NLR≥14.35 group significantly increased ventilator-free days (7.0 vs. 13.0, P<0.001). CONCLUSION NLR may be used to help identify ARDS patients who may benefit from corticosteroid treatment. Large-sized randomized controlled trials are warranted to determine the optimal cutoff value of NLR.
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Affiliation(s)
- Qingyuan Wang
- Department of Emergency (The Center of Emergency and Critical Care Medicine), Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Tuxiu Xie
- Department of General Practice, Guanggu Zone, Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Rukai Gao
- Wuhan Britain-China SchoolWuhan, Hubei Province, China
| | - Xiaobing Long
- Department of Emergency (The Center of Emergency and Critical Care Medicine), Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Jie Wei
- Department of Emergency (The Center of Emergency and Critical Care Medicine), Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Lu Ye
- Department of Emergency (The Center of Emergency and Critical Care Medicine), Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Jie Jiang
- Department of Emergency, Guanggu Zone, Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Lulu Kang
- Department of Emergency (The Center of Emergency and Critical Care Medicine), Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Jing Wang
- Department of Emergency (The Center of Emergency and Critical Care Medicine), Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Chen Jun
- Department of Radiology, Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
| | - Jingjun Lyu
- Department of Emergency (The Center of Emergency and Critical Care Medicine), Renmin Hospital of Wuhan UniversityWuhan, Hubei Province, China
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Chiu LC, Chuang LP, Lin SW, Li HH, Leu SW, Chang KW, Huang CH, Chiu TH, Wu HP, Tsai FC, Huang CC, Hu HC, Kao KC. Comparisons of Outcomes between Patients with Direct and Indirect Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation. MEMBRANES 2021; 11:membranes11080644. [PMID: 34436407 PMCID: PMC8397979 DOI: 10.3390/membranes11080644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/10/2021] [Accepted: 08/18/2021] [Indexed: 11/20/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a heterogeneous syndrome caused by direct (local damage to lung parenchyma) or indirect lung injury (insults from extrapulmonary sites with acute systemic inflammatory response), the clinical and biological complexity can have a profound effect on clinical outcomes. We performed a retrospective analysis of 152 severe ARDS patients receiving extracorporeal membrane oxygenation (ECMO). Our objective was to assess the differences in clinical characteristics and outcomes of direct and indirect ARDS patients receiving ECMO. Overall hospital mortality was 53.3%. A total of 118 patients were assigned to the direct ARDS group, and 34 patients were assigned to the indirect ARDS group. The 28-, 60-, and 90-day hospital mortality rates were significantly higher among indirect ARDS patients (all p < 0.05). Cox regression models demonstrated that among direct ARDS patients, diabetes mellitus, immunocompromised status, ARDS duration before ECMO, and SOFA score during the first 3 days of ECMO were independently associated with mortality. In indirect ARDS patients, SOFA score and dynamic compliance during the first 3 days of ECMO were independently associated with mortality. Our findings revealed that among patients receiving ECMO, direct and indirect subphenotypes of ARDS have distinct clinical outcomes and different predictors for mortality.
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Affiliation(s)
- Li-Chung Chiu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Thoracic Medicine, New Taipei Municipal TuCheng Hospital and Chang Gung University, Taoyuan 33302, Taiwan
| | - Li-Pang Chuang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
| | - Shih-Wei Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
| | - Hsin-Hsien Li
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan;
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan 33302, Taiwan
| | - Shaw-Woei Leu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
| | - Ko-Wei Chang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
| | - Chi-Hsien Huang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
| | - Tzu-Hsuan Chiu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
| | - Huang-Pin Wu
- Division of Pulmonary, Critical Care and Sleep Medicine, Chang Gung Memorial Hospital, Keelung 20401, Taiwan;
| | - Feng-Chun Tsai
- Division of Cardiovascular Surgery, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan;
| | - Chung-Chi Huang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan 33302, Taiwan
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
| | - Han-Chung Hu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan 33302, Taiwan
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
- Correspondence: ; Tel.: +886-3-3281200 (ext. 8467)
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (L.-C.C.); (L.-P.C.); (S.-W.L.); (S.-W.L.); (K.-W.C.); (C.-H.H.); (T.-H.C.); (C.-C.H.); (K.-C.K.)
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan 33302, Taiwan
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
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