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Sathe NA, Zelnick LR, Morrell ED, Bhatraju PK, Kerchberger VE, Hough CL, Ware LB, Fohner AE, Wurfel MM. Development and External Validation of Models to Predict Persistent Hypoxemic Respiratory Failure for Clinical Trial Enrichment. Crit Care Med 2024; 52:764-774. [PMID: 38197736 PMCID: PMC11018468 DOI: 10.1097/ccm.0000000000006181] [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: 01/11/2024]
Abstract
OBJECTIVES Improving the efficiency of clinical trials in acute hypoxemic respiratory failure (HRF) depends on enrichment strategies that minimize enrollment of patients who quickly resolve with existing care and focus on patients at high risk for persistent HRF. We aimed to develop parsimonious models predicting risk of persistent HRF using routine data from ICU admission and select research immune biomarkers. DESIGN Prospective cohorts for derivation ( n = 630) and external validation ( n = 511). SETTING Medical and surgical ICUs at two U.S. medical centers. PATIENTS Adults with acute HRF defined as new invasive mechanical ventilation (IMV) and hypoxemia on the first calendar day after ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We evaluated discrimination, calibration, and practical utility of models predicting persistent HRF risk (defined as ongoing IMV and hypoxemia on the third calendar day after admission): 1) a clinical model with least absolute shrinkage and selection operator (LASSO) selecting Pa o2 /F io2 , vasopressors, mean arterial pressure, bicarbonate, and acute respiratory distress syndrome as predictors; 2) a model adding interleukin-6 (IL-6) to clinical predictors; and 3) a comparator model with Pa o2 /F io2 alone, representing an existing strategy for enrichment. Forty-nine percent and 69% of patients had persistent HRF in derivation and validation sets, respectively. In validation, both LASSO (area under the receiver operating characteristic curve, 0.68; 95% CI, 0.64-0.73) and LASSO + IL-6 (0.71; 95% CI, 0.66-0.76) models had better discrimination than Pa o2 /F io2 (0.64; 95% CI, 0.59-0.69). Both models underestimated risk in lower risk deciles, but exhibited better calibration at relevant risk thresholds. Evaluating practical utility, both LASSO and LASSO + IL-6 models exhibited greater net benefit in decision curve analysis, and greater sample size savings in enrichment analysis, compared with Pa o2 /F io2 . The added utility of LASSO + IL-6 model over LASSO was modest. CONCLUSIONS Parsimonious, interpretable models that predict persistent HRF may improve enrichment of trials testing HRF-targeted therapies and warrant future validation.
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Affiliation(s)
- Neha A. Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Leila R. Zelnick
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Eric D. Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence, University of Washington
| | - V. Eric Kerchberger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Catherine L. Hough
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Lorraine B, Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Alison E Fohner
- Department of Epidemiology, School of Public Health, University of Washington
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence, University of Washington
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Valda Toro PL, Willmore A, Wu NE, Delucchi KL, Jauregui A, Sinha P, Liu KD, Hendrickson CM, Sarma A, Neyton LPA, Leligdowicz A, Langelier CR, Zhuo H, Jones C, Kangelaris KN, Gomez AD, Matthay MA, Calfee CS. Rapidly improving ARDS differs clinically and biologically from persistent ARDS. Crit Care 2024; 28:132. [PMID: 38649920 PMCID: PMC11034037 DOI: 10.1186/s13054-024-04883-6] [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: 01/10/2024] [Accepted: 03/20/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Rapidly improving acute respiratory distress syndrome (RIARDS) is an increasingly appreciated subgroup of ARDS in which hypoxemia improves within 24 h after initiation of mechanical ventilation. Detailed clinical and biological features of RIARDS have not been clearly defined, and it is unknown whether RIARDS is associated with the hypoinflammatory or hyperinflammatory phenotype of ARDS. The purpose of this study was to define the clinical and biological features of RIARDS and its association with inflammatory subphenotypes. METHODS We analyzed data from 215 patients who met Berlin criteria for ARDS (endotracheally intubated) and were enrolled in a prospective observational cohort conducted at two sites, one tertiary care center and one urban safety net hospital. RIARDS was defined according to previous studies as improvement of hypoxemia defined as (i) PaO2:FiO2 > 300 or (ii) SpO2: FiO2 > 315 on the day following diagnosis of ARDS (day 2) or (iii) unassisted breathing by day 2 and for the next 48 h (defined as absence of endotracheal intubation on day 2 through day 4). Plasma biomarkers were measured on samples collected on the day of study enrollment, and ARDS phenotypes were allocated as previously described. RESULTS RIARDS accounted for 21% of all ARDS participants. Patients with RIARDS had better clinical outcomes compared to those with persistent ARDS, with lower hospital mortality (13% vs. 57%; p value < 0.001) and more ICU-free days (median 24 vs. 0; p value < 0.001). Plasma levels of interleukin-6, interleukin-8, and plasminogen activator inhibitor-1 were significantly lower among patients with RIARDS. The hypoinflammatory phenotype of ARDS was more common among patients with RIARDS (78% vs. 51% in persistent ARDS; p value = 0.001). CONCLUSIONS This study identifies a high prevalence of RIARDS in a multicenter observational cohort and confirms the more benign clinical course of these patients. We report the novel finding that RIARDS is characterized by lower concentrations of plasma biomarkers of inflammation compared to persistent ARDS, and that hypoinflammatory ARDS is more prevalent among patients with RIARDS. Identification and exclusion of RIARDS could potentially improve prognostic and predictive enrichment in clinical trials.
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Affiliation(s)
- Patricia L Valda Toro
- Department of Medicine, Division of Pulmonary and Critical Care, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Internal Medicine, University of California San Francisco, San Francisco, USA.
| | - Andrew Willmore
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Nelson E Wu
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Kevin L Delucchi
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Alejandra Jauregui
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Pratik Sinha
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kathleen D Liu
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Carolyn M Hendrickson
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Aartik Sarma
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Lucile P A Neyton
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Charles R Langelier
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Hanjing Zhuo
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Chayse Jones
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Kirsten N Kangelaris
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Antonio D Gomez
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Michael A Matthay
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
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3
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Azoulay E, Maertens J, Lemiale V. How I manage acute respiratory failure in patients with hematological malignancies. Blood 2024; 143:971-982. [PMID: 38232056 DOI: 10.1182/blood.2023021414] [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: 09/18/2023] [Revised: 11/29/2023] [Accepted: 12/04/2023] [Indexed: 01/19/2024] Open
Abstract
ABSTRACT Acute respiratory failure (ARF) is common in patients with hematological malignancies notably those with acute leukemia, myelodysplastic syndrome, or allogeneic stem cell transplantation. ARF is the leading reason for intensive care unit (ICU) admission, with a 35% case fatality rate. Failure to identify the ARF cause is associated with mortality. A prompt, well-designed diagnostic workup is crucial. The investigations are chosen according to pretest diagnostic probabilities, estimated by the DIRECT approach: D stands for delay, or time since diagnosis; I for pattern of immune deficiency; R and T for radiological evaluation; E refers to clinical experience, and C to the clinical picture. Thorough familiarity with rapid diagnostic tests helps to decrease the use of bronchoscopy with bronchoalveolar lavage, which can cause respiratory status deterioration in those patients with hypoxemia. A prompt etiological diagnosis shortens the time on unnecessary empirical treatments, decreasing iatrogenic harm and costs. High-quality collaboration between intensivists and hematologists and all crossdisciplinary health care workers is paramount. All oxygen delivery systems should be considered to minimize invasive mechanical ventilation. Treatment of the malignancy is started or continued in the ICU under the guidance of the hematologists. The goal is to use the ICU as a bridge to recovery, with the patient returning to the hematology ward in sufficiently good clinical condition to receive optimal anticancer treatment.
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Affiliation(s)
- Elie Azoulay
- Intensive Care Department, Saint-Louis University Hospital, Paris-Cité University, Paris, France
| | - Johan Maertens
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Virginie Lemiale
- Intensive Care Department, Saint-Louis University Hospital, Paris-Cité University, Paris, France
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4
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Gradel KO. Interpretations of the Role of Plasma Albumin in Prognostic Indices: A Literature Review. J Clin Med 2023; 12:6132. [PMID: 37834777 PMCID: PMC10573484 DOI: 10.3390/jcm12196132] [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: 07/07/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
This review assesses how publications interpret factors that influence the serum or plasma albumin (PA) level in prognostic indices, focusing on inflammation and nutrition. On PubMed, a search for "albumin AND prognosis" yielded 23,919 results. From these records, prognostic indices were retrieved, and their names were used as search strings on PubMed. Indices found in 10 or more original research articles were included. The same search strings, restricted to "Review" or "Systematic review", retrieved yielded on the indices. The data comprised the 10 latest original research articles and up to 10 of the latest reviews. Thirty indices had 294 original research articles (6 covering two indices) and 131 reviews, most of which were from recent years. A total of 106 articles related the PA level to inflammation, and 136 related the PA level to nutrition. For the reviews, the equivalent numbers were 54 and 65. In conclusion, more publications mention the PA level as a marker of nutrition rather than inflammation. This is in contrast to several general reviews on albumin and nutritional guidelines, which state that the PA level is a marker of inflammation but not nutrition. Hypoalbuminemia should prompt clinicians to focus on the inflammatory aspects in their patients.
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Affiliation(s)
- Kim Oren Gradel
- Center for Clinical Epidemiology, Odense University Hospital, 5000 Odense, Denmark; ; Tel.: +45-21-15-80-85
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
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5
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Papathanakos G, Andrianopoulos I, Xenikakis M, Papathanasiou A, Koulenti D, Blot S, Koulouras V. Clinical Sepsis Phenotypes in Critically Ill Patients. Microorganisms 2023; 11:2165. [PMID: 37764009 PMCID: PMC10538192 DOI: 10.3390/microorganisms11092165] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/10/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Sepsis, defined as the life-threatening dysregulated host response to an infection leading to organ dysfunction, is considered as one of the leading causes of mortality worldwide, especially in intensive care units (ICU). Moreover, sepsis remains an enigmatic clinical syndrome, with complex pathophysiology incompletely understood and a great heterogeneity both in terms of clinical expression, patient response to currently available therapeutic interventions and outcomes. This heterogeneity proves to be a major obstacle in our quest to deliver improved treatment in septic critical care patients; thus, identification of clinical phenotypes is absolutely necessary. Although this might be seen as an extremely difficult task, nowadays, artificial intelligence and machine learning techniques can be recruited to quantify similarities between individuals within sepsis population and differentiate them into distinct phenotypes regarding not only temperature, hemodynamics or type of organ dysfunction, but also fluid status/responsiveness, trajectories in ICU and outcome. Hopefully, we will eventually manage to determine both the subgroup of septic patients that will benefit from a therapeutic intervention and the correct timing of applying the intervention during the disease process.
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Affiliation(s)
- Georgios Papathanakos
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
| | - Ioannis Andrianopoulos
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
| | - Menelaos Xenikakis
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
| | - Athanasios Papathanasiou
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
| | - Despoina Koulenti
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QL 4029, Australia;
- Second Critical Care Department, Attikon University Hospital, Rimini Street, 12462 Athens, Greece
| | - Stijn Blot
- Department of Internal Medicine & Pediatrics, Ghent University, 9000 Ghent, Belgium;
| | - Vasilios Koulouras
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
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Sathe NA, Xian S, Mabrey FL, Crosslin DR, Mooney SD, Morrell ED, Lybarger K, Yetisgen M, Jarvik GP, Bhatraju PK, Wurfel MM. Evaluating construct validity of computable acute respiratory distress syndrome definitions in adults hospitalized with COVID-19: an electronic health records based approach. BMC Pulm Med 2023; 23:292. [PMID: 37559024 PMCID: PMC10413524 DOI: 10.1186/s12890-023-02560-y] [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: 03/08/2023] [Accepted: 07/11/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Evolving ARDS epidemiology and management during COVID-19 have prompted calls to reexamine the construct validity of Berlin criteria, which have been rarely evaluated in real-world data. We developed a Berlin ARDS definition (EHR-Berlin) computable in electronic health records (EHR) to (1) assess its construct validity, and (2) assess how expanding its criteria affected validity. METHODS We performed a retrospective cohort study at two tertiary care hospitals with one EHR, among adults hospitalized with COVID-19 February 2020-March 2021. We assessed five candidate definitions for ARDS: the EHR-Berlin definition modeled on Berlin criteria, and four alternatives informed by recent proposals to expand criteria and include patients on high-flow oxygen (EHR-Alternative 1), relax imaging criteria (EHR-Alternatives 2-3), and extend timing windows (EHR-Alternative 4). We evaluated two aspects of construct validity for the EHR-Berlin definition: (1) criterion validity: agreement with manual ARDS classification by experts, available in 175 patients; (2) predictive validity: relationships with hospital mortality, assessed by Pearson r and by area under the receiver operating curve (AUROC). We assessed predictive validity and timing of identification of EHR-Berlin definition compared to alternative definitions. RESULTS Among 765 patients, mean (SD) age was 57 (18) years and 471 (62%) were male. The EHR-Berlin definition classified 171 (22%) patients as ARDS, which had high agreement with manual classification (kappa 0.85), and was associated with mortality (Pearson r = 0.39; AUROC 0.72, 95% CI 0.68, 0.77). In comparison, EHR-Alternative 1 classified 219 (29%) patients as ARDS, maintained similar relationships to mortality (r = 0.40; AUROC 0.74, 95% CI 0.70, 0.79, Delong test P = 0.14), and identified patients earlier in their hospitalization (median 13 vs. 15 h from admission, Wilcoxon signed-rank test P < 0.001). EHR-Alternative 3, which removed imaging criteria, had similar correlation (r = 0.41) but better discrimination for mortality (AUROC 0.76, 95% CI 0.72, 0.80; P = 0.036), and identified patients median 2 h (P < 0.001) from admission. CONCLUSIONS The EHR-Berlin definition can enable ARDS identification with high criterion validity, supporting large-scale study and surveillance. There are opportunities to expand the Berlin criteria that preserve predictive validity and facilitate earlier identification.
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Affiliation(s)
- Neha A Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA.
| | - Su Xian
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA
| | - F Linzee Mabrey
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA
| | - David R Crosslin
- Division of Biomedical Informatics and Genomics, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Sean D Mooney
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA
| | - Eric D Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA
| | - Kevin Lybarger
- Department of Information Sciences and Technology, George Mason University, Fairfax, VA, USA
| | - Meliha Yetisgen
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA
| | - Gail P Jarvik
- Department of Genome Sciences and Division of Medical Genetics, Department of Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA
| | - Mark M Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA
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Liles WC. MICROVASCULAR ENDOTHELIAL ACTIVATION/DYSFUNCTION AND DYSREGULATION OF THE ANGIOPOIETIN-TIE2 SYSTEM IN THE PATHOGENESIS OF LIFE-THREATENING INFECTIONS. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2023; 133:234-246. [PMID: 37701588 PMCID: PMC10493726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
Microvascular endothelial activation/dysfunction has emerged as an important mechanistic pathophysiological process in the development of morbidity and mortality in life-threatening infections. The angiopoietin-Tie2 system plays an integral role in the regulation of microvascular endothelial integrity. Angiopoietin-1 (Ang-1), produced by platelets and pericytes, is the cognate agonistic ligand for Tie2, promoting endothelial quiescence and inhibiting microvascular leak. Angiopoietin-2 (Ang-2), released from activated endothelial cells in Weibel-Palade bodies, competes with Ang-1 for binding to Tie-2, thereby promoting endothelial activation/dysfunction and microvascular leak. In healthy homeostasis, levels of Ang-1 far exceed Ang-2 in circulating serum/plasma. In diseases associated with systemic inflammation, Ang-1 falls and Ang-2 rises (i.e., Ang-1/2 dysregulation). Our research has shown that Ang-1/2 dysregulation is a prominent feature in a number of life-threatening infections and critical illnesses, including sepsis, cerebral malaria, COVID-19, streptococcal toxic shock syndrome (STSS), hemolytic-uremic syndrome (HUS), dengue, and CAR T-cell-associated neurotoxicity. Further work has implicated Ang-1/2 dysregulation in the development of end-organ injury, including acute lung injury/ARDS, acute kidney injury (AKI), and blood-brain-barrier (BBB) breakdown. Current studies are focused in three areas: (a) translation of Ang-1 and -2 as clinically informative prognostic and "theranostic" biomarkers in critically ill individuals; (b) incorporation of Ang-1/2 assays in a point of care device for clinical triage decision making; and (c) development of an engineered Ang-1 super agonist nanoparticle as a novel pathogen-agnostic therapeutic to prevent and/or mitigate end-organ dysfunction in individuals with life-threatening infections and critical illnesses associated with systemic inflammation.
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Martin TR, Zemans RL, Ware LB, Schmidt EP, Riches DWH, Bastarache L, Calfee CS, Desai TJ, Herold S, Hough CL, Looney MR, Matthay MA, Meyer N, Parikh SM, Stevens T, Thompson BT. New Insights into Clinical and Mechanistic Heterogeneity of the Acute Respiratory Distress Syndrome: Summary of the Aspen Lung Conference 2021. Am J Respir Cell Mol Biol 2022; 67:284-308. [PMID: 35679511 PMCID: PMC9447141 DOI: 10.1165/rcmb.2022-0089ws] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/09/2022] [Indexed: 12/15/2022] Open
Abstract
Clinical and molecular heterogeneity are common features of human disease. Understanding the basis for heterogeneity has led to major advances in therapy for many cancers and pulmonary diseases such as cystic fibrosis and asthma. Although heterogeneity of risk factors, disease severity, and outcomes in survivors are common features of the acute respiratory distress syndrome (ARDS), many challenges exist in understanding the clinical and molecular basis for disease heterogeneity and using heterogeneity to tailor therapy for individual patients. This report summarizes the proceedings of the 2021 Aspen Lung Conference, which was organized to review key issues related to understanding clinical and molecular heterogeneity in ARDS. The goals were to review new information about ARDS phenotypes, to explore multicellular and multisystem mechanisms responsible for heterogeneity, and to review how best to account for clinical and molecular heterogeneity in clinical trial design and assessment of outcomes. The report concludes with recommendations for future research to understand the clinical and basic mechanisms underlying heterogeneity in ARDS to advance the development of new treatments for this life-threatening critical illness.
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Affiliation(s)
- Thomas R. Martin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Rachel L. Zemans
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Program in Cellular and Molecular Biology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine and
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eric P. Schmidt
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - David W. H. Riches
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Program in Cell Biology, Department of Pediatrics, National Jewish Health, Denver, Colorado
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carolyn S. Calfee
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Anesthesia
| | - Tushar J. Desai
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Stem Cell Institute, Stanford University School of Medicine, Stanford, California
| | - Susanne Herold
- Department of Internal Medicine VI and Cardio-Pulmonary Institute (CPI), Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Catherine L. Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Michael A. Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | - Nuala Meyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samir M. Parikh
- Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Division of Nephrology, University of Texas Southwestern, Dallas, Texas
| | - Troy Stevens
- Department of Physiology and Cell Biology, College of Medicine, Center for Lung Biology, University of South Alabama, Mobile, Alabama; and
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
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9
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Hanley C, Giacomini C, Brennan A, McNicholas B, Laffey JG. Insights Regarding the Berlin Definition of ARDS from Prospective Observational Studies. Semin Respir Crit Care Med 2022; 43:379-389. [PMID: 35679873 DOI: 10.1055/s-0042-1744306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The definition of acute respiratory distress syndrome (ARDS), has evolved since it was first described in 1967 by Ashbaugh and Petty to the current "Berlin" definition of ARDS developed in 2012 by an expert panel, that provided clarification on the definition of "acute," and on the cardiac failure criteria. It expanded the definition to include patients receiving non-invasive ventilation, and removed the term "acute lung injury" and added a requirement of patients to be receiving a minimum 5 cmH2O expiratory pressure.Since 2012, a series of observational cohort studies have generated insights into the utility and robustness of this definition. This review will examine novel insights into the epidemiology of ARDS, failures in ARDS diagnosis, the role of lung imaging in ARDS, the novel ARDS cohort that is not invasively ventilated, lung compliance profiles in patients with ARDS, sex differences that exist in ARDS management and outcomes, the progression of ARDS following initial diagnosis, and the clinical profile and outcomes of confirmed versus resolved ARDS. Furthermore, we will discuss studies that challenge the utility of distinguishing ARDS from other causes of acute hypoxemic respiratory failure (AHRF) and identify issues that may need to be addressed in a revised definition.
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Affiliation(s)
- Ciara Hanley
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - Camilla Giacomini
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - Aoife Brennan
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - Bairbre McNicholas
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - John G Laffey
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland.,Regenerative Medicine Institute, National University of Ireland, Galway, Ireland
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Abstract
Contemplating the future should be grounded in history. The rise of post-polio ICUs was inextricably related to mechanical ventilation. Critically ill patients who developed acute respiratory failure often had "congestive atelectasis" (ie, a term used to describe ARDS prior to 1967). Initial mechanical ventilation strategies for treating this condition and others inadvertently led to ventilator-induced lung injury. Both injurious ventilation and later use of overly cautious weaning practices resulted from both limited technology and understanding of ARDS and other aspects of critical illness. The resulting misperceptions, misconceptions, and missed opportunities took decades to rectify and in some instances still persist. This suggests a reluctance to acknowledge that all therapeutic strategies reflect the historical period in which they were developed and the corresponding limited understanding of ARDS pathophysiology at that time. We are at the threshold of a revolutionary moment in critical care. The confluence of enormous clinical data production, massive computing power, advances in understanding the biomolecular and genetic aspects of critical illness, and the emergence of neural networks will have enormous impact on how critical care is practiced in the decades to come. Therefore, it is imperative we understand the long-crooked path needed to reach the era of protective ventilation in order to avoid similar mistakes moving forward. The emerging era is as difficult to fathom as our current practices and technologies were to those practicing 60 years ago. This review explores the history of mechanical ventilation in treating ARDS, describes current protective ventilation strategies, and speculates how ARDS management might look 20 years from now.
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Affiliation(s)
- Richard H Kallet
- Department of Anesthesia and Perioperative Care, University of California, San Francisco at San Francisco General Hospital, San Francisco, California.
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11
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Pathogenesis of pneumonia and acute lung injury. Clin Sci (Lond) 2022; 136:747-769. [PMID: 35621124 DOI: 10.1042/cs20210879] [Citation(s) in RCA: 72] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/29/2022] [Accepted: 05/09/2022] [Indexed: 12/15/2022]
Abstract
Pneumonia and its sequelae, acute lung injury, present unique challenges for pulmonary and critical care healthcare professionals, and these challenges have recently garnered global attention due to the ongoing Sars-CoV-2 pandemic. One limitation to translational investigation of acute lung injury, including its most severe manifestation (acute respiratory distress syndrome, ARDS) has been heterogeneity resulting from the clinical and physiologic diagnosis that represents a wide variety of etiologies. Recent efforts have improved our understanding and approach to heterogeneity by defining sub-phenotypes of ARDS although significant gaps in knowledge remain. Improving our mechanistic understanding of acute lung injury and its most common cause, infectious pneumonia, can advance our approach to precision targeted clinical interventions. Here, we review the pathogenesis of pneumonia and acute lung injury, including how respiratory infections and lung injury disrupt lung homoeostasis, and provide an overview of respiratory microbial pathogenesis, the lung microbiome, and interventions that have been demonstrated to improve outcomes-or not-in human clinical trials.
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12
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Gavrielatou E, Vaporidi K, Tsolaki V, Tserlikakis N, Zakynthinos GE, Papoutsi E, Maragkuti A, Mantelou AG, Karayiannis D, Mastora Z, Georgopoulos D, Zakynthinos E, Routsi C, Zakynthinos SG, Schenck EJ, Kotanidou A, Siempos II. Rapidly improving acute respiratory distress syndrome in COVID-19: a multi-centre observational study. Respir Res 2022; 23:94. [PMID: 35422037 PMCID: PMC9008400 DOI: 10.1186/s12931-022-02015-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 04/02/2022] [Indexed: 11/23/2022] Open
Abstract
Background Before the pandemic of coronavirus disease (COVID-19), rapidly improving acute respiratory distress syndrome (ARDS), mostly defined by early extubation, had been recognized as an increasingly prevalent subphenotype (making up 15–24% of all ARDS cases), associated with good prognosis (10% mortality in ARDSNet trials). We attempted to determine the prevalence and prognosis of rapidly improving ARDS and of persistent severe ARDS related to COVID-19. Methods We included consecutive patients with COVID-19 receiving invasive mechanical ventilation in three intensive care units (ICU) during the second pandemic wave in Greece. We defined rapidly improving ARDS as extubation or a partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2:FiO2) greater than 300 on the first day following intubation. We defined persistent severe ARDS as PaO2:FiO2 of equal to or less than 100 on the second day following intubation. Results A total of 280 intubated patients met criteria of ARDS with a median PaO2:FiO2 of 125.0 (interquartile range 93.0–161.0) on day of intubation, and overall ICU-mortality of 52.5% (ranging from 24.3 to 66.9% across the three participating sites). Prevalence of rapidly improving ARDS was 3.9% (11 of 280 patients); no extubation occurred on the first day following intubation. ICU-mortality of patients with rapidly improving ARDS was 54.5%. This low prevalence and high mortality rate of rapidly improving ARDS were consistent across participating sites. Prevalence of persistent severe ARDS was 12.1% and corresponding mortality was 82.4%. Conclusions Rapidly improving ARDS was not prevalent and was not associated with good prognosis among patients with COVID-19. This is starkly different from what has been previously reported for patients with ARDS not related to COVID-19. Our results on both rapidly improving ARDS and persistent severe ARDS may contribute to our understanding of trajectory of ARDS and its association with prognosis in patients with COVID-19. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-02015-8.
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