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Masi P, Gouriet L, Radu C, Folliguet T, Fiore A, Gallet R, Bagate F, Mekontso Dessap A, De Prost N. Immediate Clinical Complications Occurring During Membrane Change in Patients on Veno-Venous Extracorporeal Membrane Oxygenation. ASAIO J 2024:00002480-990000000-00530. [PMID: 39052935 DOI: 10.1097/mat.0000000000002270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
The clinical tolerance of extracorporeal membrane oxygenation (ECMO) membrane changes in acute respiratory distress syndrome (ARDS) patients under veno-venous ECMO (VV-ECMO) has not been reported. The aim of this study was to describe the tolerance of membrane change. Patients requiring VV-ECMO were retrospectively included between March 2020 and May 2022. In case of membrane dysfunction or an increase in hemolysis markers or an alteration in gas exchange, a membrane change was performed. The primary outcome was a composite measure defined as the occurrence of at least one of the following events within 1 hour of membrane change: severe hypoxemia, hemodynamic collapse, bradycardia, arrhythmia, cardiac arrest, and death. During the study period, 70 patients required a VV-ECMO, 29 (41%) of whom died. Thirty-two patients required a membrane change for a total of 56 changes. The primary outcome occurred for 33 (59%) changes. Arterial desaturation <80% occurred for all complicated membrane changes and cardiac arrest concerned nine changes (16%). Low tidal volume (VT), respiratory system compliance (Crs), PaO2, and high ECMO blood flow (QECMO) were associated with poor tolerance of membrane change. Threshold values of 130 ml for VT, 9.3 cm H2O for Crs, 72 mm Hg for PaO2, and 3.65 L/minute for QECMO best determined the risk of poor tolerance of membrane change.
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Affiliation(s)
- Paul Masi
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
| | - Loic Gouriet
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
| | - Costin Radu
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de chirurgie cardiaque, Departement Medico-Universitaire (DMU) CARE, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France; and
| | - Thierry Folliguet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de chirurgie cardiaque, Departement Medico-Universitaire (DMU) CARE, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France; and
| | - Antonio Fiore
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de chirurgie cardiaque, Departement Medico-Universitaire (DMU) CARE, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France; and
| | - Romain Gallet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de cardiologie, Créteil, France
| | - François Bagate
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
| | - Armand Mekontso Dessap
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
| | - Nicolas De Prost
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
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Le Pape S, Joly F, Arrivé F, Frat JP, Rodriguez M, Joos M, Marchasson L, Wairy M, Thille AW, Coudroy R. Factors associated with decreased compliance after on-site extracorporeal membrane oxygenation cannulation for acute respiratory distress syndrome: A retrospective, observational cohort study. JOURNAL OF INTENSIVE MEDICINE 2024; 4:194-201. [PMID: 38681786 PMCID: PMC11043634 DOI: 10.1016/j.jointm.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/11/2023] [Accepted: 09/26/2023] [Indexed: 05/01/2024]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) is systematically associated with decreased respiratory system compliance (CRS). It remains unclear whether transportation to the referral ECMO center, changes in ventilatory mode or settings to achieve ultra-protective ventilation, or the natural evolution of ARDS drives this change in respiratory mechanics. Herein, we assessed the precise moment when CRS decreases after ECMO cannulation and identified factors associated with decreased CRS. Methods To rule out the effect of transportation and the different modes of ventilation on CRS, we conducted a retrospective, single-center, observational cohort study from January 2013 to May 2020, on 22 patients with severe ARDS requiring on-site ECMO and ventilated in pressure-controlled mode to achieve ultra-protective ventilation. CRS was assessed at different time points ranging from 12 h before ECMO cannulation to 72 h after ECMO cannulation. The primary outcome was the relative change in CRS between 3 h before and 3 h after ECMO cannulation. The secondary outcomes included variables associated with the relative changes in CRS within the first 3 h after ECMO cannulation and the relative changes in CRS at each time point. Results CRS decreased within the first 3 h after ECMO cannulation (-28.3%, 95% confidence interval [CI]: -38.8 to -17.9, P<0.001), while the decrease was mild before and after these first 3 h after ECMO cannulation. To achieve ultra-protective ventilation, respiratory rate decreased in the mean by -13 breaths/min (95% CI: -15 to -11) and driving pressure by -8.3 cmH2O (95% CI: -11.2 to -5.3), resulting in decreased tidal volume by -3.3 mL/kg of predicted body weight (95% CI: -3.9 to -2.6) as compared to before ECMO cannulation (P <0.001 for all). Plateau pressure reduction, driving pressure reduction, and tidal volume reduction were significantly associated with decreased CRS after ECMO cannulation, whereas neither respiratory rate, positive end-expiratory pressure, inspired fraction of oxygen, fluid balance, nor mean airway pressure was associated with decreased CRS. Conclusions Decreased driving pressure resulting in lower tidal volume to achieve ultra-protective ventilation after ECMO cannulation was associated with a marked decrease in CRS in ARDS patients with on-site ECMO cannulation.
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Affiliation(s)
- Sylvain Le Pape
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Florent Joly
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - François Arrivé
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Jean-Pierre Frat
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Maeva Rodriguez
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Maïa Joos
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Laura Marchasson
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Mathilde Wairy
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Arnaud W. Thille
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Rémi Coudroy
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
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Fisher AB, Zani B, Han T, Dodia C, Melidone R, Keller S. Decreased LPS-induced lung injury in pigs treated with a lung surfactant protein A-derived nonapeptide that inhibits peroxiredoxin 6 activity and subsequent NOX1,2 activation. Am J Physiol Lung Cell Mol Physiol 2024; 326:L458-L467. [PMID: 38349117 DOI: 10.1152/ajplung.00325.2023] [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: 10/21/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 03/28/2024] Open
Abstract
This study addressed the efficacy of a liposome-encapsulated nine amino acid peptide [peroxiredoxin 6 PLA2 inhibitory peptide-2 (PIP-2)] for the prevention or treatment of acute lung injury (ALI) +/- sepsis. PIP-2 inhibits the PLA2 activity of peroxiredoxin 6 (Prdx6), thereby preventing rac release and activation of NADPH oxidases (NOXes), types 1 and 2. Female Yorkshire pigs were infused intravenously with lipopolysaccharide (LPS) + liposomes (untreated) or LPS + PIP-2 encapsulated in liposomes (treated). Pigs were mechanically ventilated and continuously monitored; they were euthanized after 8 h or earlier if preestablished humane endpoints were reached. Control pigs (mechanical ventilation, no LPS) were essentially unchanged over the 8 h study. LPS administration resulted in systemic inflammation with manifestations of clinical sepsis-like syndrome, decreased lung compliance, and a marked decrease in the arterial Po2 with vascular instability leading to early euthanasia of 50% of untreated animals. PIP-2 treatment significantly reduced the requirement for supportive vasopressors and the manifestations of lung injury so that only 25% of animals required early euthanasia. Bronchoalveolar lavage fluid from PIP-2-treated versus untreated pigs showed markedly lower levels of total protein, cytokines (TNF-α, IL-6, IL-1β), and myeloperoxidase. Thus, the porcine LPS-induced sepsis-like model was associated with moderate to severe lung pathophysiology compatible with ALI, whereas treatment with PIP-2 markedly decreased lung injury, cardiovascular instability, and early euthanasia. These results indicate that inhibition of reactive oxygen species (ROS) production via NOX1/2 has a beneficial effect in treating pigs with LPS-induced ALI plus or minus a sepsis-like syndrome, suggesting a potential role for PIP-2 in the treatment of ALI and/or sepsis in humans.NEW & NOTEWORTHY Currently available treatments that can alter lung inflammation have failed to significantly alter mortality of acute lung injury (ALI). Peroxiredoxin 6 PLA2 inhibitory peptide-2 (PIP-2) targets the liberation of reactive O2 species (ROS) that is associated with adverse cell signaling events, thereby decreasing the tissue oxidative injury that occurs early in the ALI syndrome. We propose that treatment with PIP-2 may be effective in preventing progression of early disease into its later stages with irreversible lung damage and relatively high mortality.
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Affiliation(s)
- Aron B Fisher
- Institute for Environmental Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
- Peroxitech, Inc., Philadelphia, Pennsylvania, United States
| | - Brett Zani
- CBSET, Inc., Lexington, Massachusetts, United States
| | - Thomas Han
- Peroxitech, Inc., Philadelphia, Pennsylvania, United States
| | - Chandra Dodia
- Institute for Environmental Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | | | - Steven Keller
- CBSET, Inc., Lexington, Massachusetts, United States
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
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Menga LS, Subirà C, Wong A, Sousa M, Brochard LJ. Setting positive end-expiratory pressure: does the 'best compliance' concept really work? Curr Opin Crit Care 2024; 30:20-27. [PMID: 38085857 DOI: 10.1097/mcc.0000000000001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
PURPOSE OF REVIEW Determining the optimal positive end-expiratory pressure (PEEP) setting remains a central yet debated issue in the management of acute respiratory distress syndrome (ARDS).The 'best compliance' strategy set the PEEP to coincide with the peak respiratory system compliance (or 2 cmH 2 O higher) during a decremental PEEP trial, but evidence is conflicting. RECENT FINDINGS The physiological rationale that best compliance is always representative of functional residual capacity and recruitment has raised serious concerns about its efficacy and safety, due to its association with increased 28-day all-cause mortality in a randomized clinical trial in ARDS patients.Moreover, compliance measurement was shown to underestimate the effects of overdistension, and neglect intra-tidal recruitment, airway closure, and the interaction between lung and chest wall mechanics, especially in obese patients. In response to these concerns, alternative approaches such as recruitment-to-inflation ratio, the nitrogen wash-in/wash-out technique, and electrical impedance tomography (EIT) are gaining attention to assess recruitment and overdistention more reliably and precisely. SUMMARY The traditional 'best compliance' strategy for determining optimal PEEP settings in ARDS carries risks and overlooks some key physiological aspects. The advent of new technologies and methods presents more reliable strategies to assess recruitment and overdistention, facilitating personalized approaches to PEEP optimization.
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Affiliation(s)
- Luca S Menga
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
- Università Cattolica del Sacro Cuore, Facoltà di Medicina e Chirurgia, Anesthesiology and Intensive Care Medicine
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Anesthesia, Emergency and Intensive Care Medicine, Roma, Italy
| | - Carles Subirà
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid
- Critical Care Department, Althaia Xarxa Assistencial Universitària de Manresa, IRIS Research Institute, Manresa, Spain
- Grup de Recerca de Malalt Crític (GMC). Institut de Recerca Biomèdica Catalunya Central IRIS-CC
| | - Alfred Wong
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Mayson Sousa
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Laurent J Brochard
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
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