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Klitgaard TL, Schjørring OL, Nielsen FM, Meyhoff CS, Perner A, Wetterslev J, Rasmussen BS, Barbateskovic M. Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit. Cochrane Database Syst Rev 2023; 9:CD012631. [PMID: 37700687 PMCID: PMC10498149 DOI: 10.1002/14651858.cd012631.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND This is an updated review concerning 'Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit'. Supplementary oxygen is provided to most patients in intensive care units (ICUs) to prevent global and organ hypoxia (inadequate oxygen levels). Oxygen has been administered liberally, resulting in high proportions of patients with hyperoxemia (exposure of tissues to abnormally high concentrations of oxygen). This has been associated with increased mortality and morbidity in some settings, but not in others. Thus far, only limited data have been available to inform clinical practice guidelines, and the optimum oxygenation target for ICU patients is uncertain. Because of the publication of new trial evidence, we have updated this review. OBJECTIVES To update the assessment of benefits and harms of higher versus lower fractions of inspired oxygen (FiO2) or targets of arterial oxygenation for adults admitted to the ICU. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Science Citation Index Expanded, BIOSIS Previews, and LILACS. We searched for ongoing or unpublished trials in clinical trial registers and scanned the reference lists and citations of included trials. Literature searches for this updated review were conducted in November 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared higher versus lower FiO2 or targets of arterial oxygenation (partial pressure of oxygen (PaO2), peripheral or arterial oxygen saturation (SpO2 or SaO2)) for adults admitted to the ICU. We included trials irrespective of publication type, publication status, and language. We excluded trials randomising participants to hypoxaemia (FiO2 below 0.21, SaO2/SpO2 below 80%, or PaO2 below 6 kPa) or to hyperbaric oxygen, and cross-over trials and quasi-randomised trials. DATA COLLECTION AND ANALYSIS Four review authors independently, and in pairs, screened the references identified in the literature searches and extracted the data. Our primary outcomes were all-cause mortality, the proportion of participants with one or more serious adverse events (SAEs), and quality of life. We analysed all outcomes at maximum follow-up. Only three trials reported the proportion of participants with one or more SAEs as a composite outcome. However, most trials reported on events categorised as SAEs according to the International Conference on Harmonisation Good Clinical Practice (ICH-GCP) criteria. We, therefore, conducted two analyses of the effect of higher versus lower oxygenation strategies using 1) the single SAE with the highest reported proportion in each trial, and 2) the cumulated proportion of participants with an SAE in each trial. Two trials reported on quality of life. Secondary outcomes were lung injury, myocardial infarction, stroke, and sepsis. No trial reported on lung injury as a composite outcome, but four trials reported on the occurrence of acute respiratory distress syndrome (ARDS) and five on pneumonia. We, therefore, conducted two analyses of the effect of higher versus lower oxygenation strategies using 1) the single lung injury event with the highest reported proportion in each trial, and 2) the cumulated proportion of participants with ARDS or pneumonia in each trial. We assessed the risk of systematic errors by evaluating the risk of bias in the included trials using the Risk of Bias 2 tool. We used the GRADEpro tool to assess the overall certainty of the evidence. We also evaluated the risk of publication bias for outcomes reported by 10b or more trials. MAIN RESULTS We included 19 RCTs (10,385 participants), of which 17 reported relevant outcomes for this review (10,248 participants). For all-cause mortality, 10 trials were judged to be at overall low risk of bias, and six at overall high risk of bias. For the reported SAEs, 10 trials were judged to be at overall low risk of bias, and seven at overall high risk of bias. Two trials reported on quality of life, of which one was judged to be at overall low risk of bias and one at high risk of bias for this outcome. Meta-analysis of all trials, regardless of risk of bias, indicated no significant difference from higher or lower oxygenation strategies at maximum follow-up with regard to mortality (risk ratio (RR) 1.01, 95% confidence interval (C)I 0.96 to 1.06; I2 = 14%; 16 trials; 9408 participants; very low-certainty evidence); occurrence of SAEs: the highest proportion of any specific SAE in each trial RR 1.01 (95% CI 0.96 to 1.06; I2 = 36%; 9466 participants; 17 trials; very low-certainty evidence), or quality of life (mean difference (MD) 0.5 points in participants assigned to higher oxygenation strategies (95% CI -2.75 to 1.75; I2 = 34%, 1649 participants; 2 trials; very low-certainty evidence)). Meta-analysis of the cumulated number of SAEs suggested benefit of a lower oxygenation strategy (RR 1.04 (95% CI 1.02 to 1.07; I2 = 74%; 9489 participants; 17 trials; very low certainty evidence)). However, trial sequential analyses, with correction for sparse data and repetitive testing, could reject a relative risk increase or reduction of 10% for mortality and the highest proportion of SAEs, and 20% for both the cumulated number of SAEs and quality of life. Given the very low-certainty of evidence, it is necessary to interpret these findings with caution. Meta-analysis of all trials indicated no statistically significant evidence of a difference between higher or lower oxygenation strategies on the occurrence of lung injuries at maximum follow-up (the highest reported proportion of lung injury RR 1.08, 95% CI 0.85 to 1.38; I2 = 0%; 2048 participants; 8 trials; very low-certainty evidence). Meta-analysis of all trials indicated harm from higher oxygenation strategies as compared with lower on the occurrence of sepsis at maximum follow-up (RR 1.85, 95% CI 1.17 to 2.93; I2 = 0%; 752 participants; 3 trials; very low-certainty evidence). Meta-analysis indicated no differences regarding the occurrences of myocardial infarction or stroke. AUTHORS' CONCLUSIONS In adult ICU patients, it is still not possible to draw clear conclusions about the effects of higher versus lower oxygenation strategies on all-cause mortality, SAEs, quality of life, lung injuries, myocardial infarction, stroke, and sepsis at maximum follow-up. This is due to low or very low-certainty evidence.
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Affiliation(s)
- Thomas L Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Olav L Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Frederik M Nielsen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørn Wetterslev
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Private Office, Hellerup, Denmark
| | - Bodil S Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Vali M, Paydar S, Seif M, Sabetian G, Abujaber A, Ghaem H. Prediction prolonged mechanical ventilation in trauma patients of the intensive care unit according to initial medical factors: a machine learning approach. Sci Rep 2023; 13:5925. [PMID: 37045979 PMCID: PMC10097728 DOI: 10.1038/s41598-023-33159-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 04/07/2023] [Indexed: 04/14/2023] Open
Abstract
The goal of this study was to develop a predictive machine learning model to predict the risk of prolonged mechanical ventilation (PMV) in patients admitted to the intensive care unit (ICU), with a focus on laboratory and Arterial Blood Gas (ABG) data. This retrospective cohort study included ICU patients admitted to Rajaei Hospital in Shiraz between 2016 and March 20, 2022. All adult patients requiring mechanical ventilation and seeking ICU admission had their data analyzed. Six models were created in this study using five machine learning models (PMV more than 3, 5, 7, 10, 14, and 23 days). Patients' demographic characteristics, Apache II, laboratory information, ABG, and comorbidity were predictors. This study used Logistic regression (LR), artificial neural networks (ANN), support vector machines (SVM), random forest (RF), and C.5 decision tree (C.5 DT) to predict PMV. The study enrolled 1138 eligible patients, excluding brain-dead patients and those without mechanical ventilation or a tracheostomy. The model PMV > 14 days showed the best performance (Accuracy: 83.63-98.54). The essential ABG variables in our two optimal models (artificial neural network and decision tree) in the PMV > 14 models include FiO2, paCO2, and paO2. This study provides evidence that machine learning methods outperform traditional methods and offer a perspective for achieving a consensus definition of PMV. It also introduces ABG and laboratory information as the two most important variables for predicting PMV. Therefore, there is significant value in deploying such models in clinical practice and making them accessible to clinicians to support their decision-making.
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Affiliation(s)
- Mohebat Vali
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahram Paydar
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mozhgan Seif
- Non-Communicable Research Center, Department of Epidemiology, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Golnar Sabetian
- Anesthesiology and Critical Care Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Haleh Ghaem
- Non-Communicable Diseases Research Center, Department of Epidemiology, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
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Choi C, Lemmink G, Humanez J. Postoperative Respiratory Failure and Advanced Ventilator Settings. Anesthesiol Clin 2023; 41:141-159. [PMID: 36871996 DOI: 10.1016/j.anclin.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Postoperative respiratory failure has a multifactorial etiology, of which atelectasis is the most common mechanism. Its injurious effects are magnified by surgical inflammation, high driving pressures, and postoperative pain. Chest physiotherapy and noninvasive ventilation are good options to prevent progression of respiratory failure. Acute respiratory disease syndrome is a late and severe finding, which is associated with high morbidity and mortality. If present, proning is a safe, effective, and underutilized therapy. Extracorporeal membrane oxygenation is an option only when traditional supportive measures have failed.
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Affiliation(s)
- Christopher Choi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9068, USA.
| | - Gretchen Lemmink
- Department of Anesthesiology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0531, USA
| | - Jose Humanez
- Department of Anesthesiology, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, C72, Jacksonville, FL 32209, USA
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Abstract
Aerosolized prostacyclins are frequently used in patients with severe acute respiratory distress syndrome and refractory hypoxia. Previous studies have shown improvement in oxygenation with use of pulmonary vasodilators such as iloprost and epoprostenol; however, there is no head-to-head comparison between these agents. OBJECTIVES To compare the effects of inhaled epoprostenol and inhaled iloprost in critically ill patients with refractory hypoxia. DESIGN SETTING AND PARTICIPANTS We performed a retrospective cohort analysis of patients admitted to the ICUs at the University of Oklahoma Health Sciences Center between 2015 and 2018. Adult patients who received aerosolized epoprostenol or iloprost for more than 4 hours were included in the analysis. MAIN OUTCOMES AND MEASURES The primary endpoint measured was to compare the change in Pao2/Fio2 ratio between patients treated with iloprost compared with epoprostenol. Secondary outcomes measured were 90-day in-hospital mortality and improvement in vasopressor requirements. RESULTS A total of 126 patients were included in the study, 95 of whom received iloprost (75%) and 31 patients (25%) received epoprostenol. There were significant improvements in Pao2/Fio2 ratio in both the iloprost and epoprostenol group. Patients in the epoprostenol group appeared to have a higher 90-day mortality compared with the iloprost group. However, our study was not powered to detect a mortality difference and this finding likely represents a sicker population in the epoprostenol group and prescription bias. The use of iloprost was associated with higher vasopressor requirements in the first 12 hours of administration, an association was not observed in the epoprostenol group. CONCLUSIONS AND RELEVANCE In this retrospective cohort analysis, use of both pulmonary vasodilators was associated with similar improvement in gas exchange. The mortality difference observed likely represents difference in severity of illness. Further studies are needed to corroborate these findings.
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Bajon F, Gauthier V. Management of refractory hypoxemia using recruitment maneuvers and rescue therapies: A comprehensive review. Front Vet Sci 2023; 10:1157026. [PMID: 37065238 PMCID: PMC10098094 DOI: 10.3389/fvets.2023.1157026] [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: 02/02/2023] [Accepted: 03/14/2023] [Indexed: 04/18/2023] Open
Abstract
Refractory hypoxemia in patients with acute respiratory distress syndrome treated with mechanical ventilation is one of the most challenging conditions in human and veterinary intensive care units. When a conventional lung protective approach fails to restore adequate oxygenation to the patient, the use of recruitment maneuvers and positive end-expiratory pressure to maximize alveolar recruitment, improve gas exchange and respiratory mechanics, while reducing the risk of ventilator-induced lung injury has been suggested in people as the open lung approach. Although the proposed physiological rationale of opening and keeping open previously collapsed or obstructed airways is sound, the technique for doing so, as well as the potential benefits regarding patient outcome are highly controversial in light of recent randomized controlled trials. Moreover, a variety of alternative therapies that provide even less robust evidence have been investigated, including prone positioning, neuromuscular blockade, inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, and unconventional ventilatory modes such as airway pressure release ventilation. With the exception of prone positioning, these modalities are limited by their own balance of risks and benefits, which can be significantly influenced by the practitioner's experience. This review explores the rationale, evidence, advantages and disadvantages of each of these therapies as well as available methods to identify suitable candidates for recruitment maneuvers, with a summary on their application in veterinary medicine. Undoubtedly, the heterogeneous and evolving nature of acute respiratory distress syndrome and individual lung phenotypes call for a personalized approach using new non-invasive bedside assessment tools, such as electrical impedance tomography, lung ultrasound, and the recruitment-to-inflation ratio to assess lung recruitability. Data available in human medicine provide valuable insights that could, and should, be used to improve the management of veterinary patients with severe respiratory failure with respect to their intrinsic anatomy and physiology.
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CORRELATION BETWEEN RED BLOOD CELL DISTRIBUTION WIDTH-TO-PLATELET RATIO AND MORTALITY IN PATIENTS WITH ACUTE RESPIRATORY DISTRESS SYNDROME: A RETROSPECTIVE COHORT STUDY. Shock 2022; 58:498-506. [PMID: 36548641 PMCID: PMC9803383 DOI: 10.1097/shk.0000000000002016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
ABSTRACT Background: This study aims to assess the prognostic value of red blood cell distribution width-to-platelet ratio (RPR) in acute respiratory distress syndrome (ARDS) patients. Methods: The data collected from 540 ARDS patients from 2001 to 2012 were obtained from the Medical Information Mart for Intensive Care III Database. The 28-day all-cause mortality risk was considered as the primary outcome parameter, and the secondary outcomes were 60- and 90-day all-cause mortality. The association between RPR (≥0.19 vs. <0.19) and mortality was assessed by Cox proportional hazards models, and potential nonlinear associations were assessed by restricted cubic spline regression analysis. Results: The 28-day all-cause mortality was 22.4%. Among the 121 deaths, 92 (20.0%) presented with an RPR <0.19, and 29 patients had RPR ≥0.19 ( P < 0.001). The 60- and 90-day all-cause mortality was 27% and 28.7%, respectively. After adjusting for the relevant factors in the multivariate model, RPR ≥0.19 was independently correlated with the 28-day all-cause mortality (hazard ratio, 2.74; 95% confidence interval, 1.46-5.15; P = 0.002). There was no nonlinear relationship between RPR and the risk of 28-day all-cause mortality ( P for overall association <0.001, P for nonlinear = 0.635). Similar results were observed for both the pneumonia and nonpneumonia subgroups and sensitivity analyses. Conclusions: The data promote the use of RPR as a valuable prognostic indicator for ARDS patients.
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Andrews P, Shiber J, Madden M, Nieman GF, Camporota L, Habashi NM. Myths and Misconceptions of Airway Pressure Release Ventilation: Getting Past the Noise and on to the Signal. Front Physiol 2022; 13:928562. [PMID: 35957991 PMCID: PMC9358044 DOI: 10.3389/fphys.2022.928562] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/21/2022] [Indexed: 12/16/2022] Open
Abstract
In the pursuit of science, competitive ideas and debate are necessary means to attain knowledge and expose our ignorance. To quote Murray Gell-Mann (1969 Nobel Prize laureate in Physics): "Scientific orthodoxy kills truth". In mechanical ventilation, the goal is to provide the best approach to support patients with respiratory failure until the underlying disease resolves, while minimizing iatrogenic damage. This compromise characterizes the philosophy behind the concept of "lung protective" ventilation. Unfortunately, inadequacies of the current conceptual model-that focuses exclusively on a nominal value of low tidal volume and promotes shrinking of the "baby lung" - is reflected in the high mortality rate of patients with moderate and severe acute respiratory distress syndrome. These data call for exploration and investigation of competitive models evaluated thoroughly through a scientific process. Airway Pressure Release Ventilation (APRV) is one of the most studied yet controversial modes of mechanical ventilation that shows promise in experimental and clinical data. Over the last 3 decades APRV has evolved from a rescue strategy to a preemptive lung injury prevention approach with potential to stabilize the lung and restore alveolar homogeneity. However, several obstacles have so far impeded the evaluation of APRV's clinical efficacy in large, randomized trials. For instance, there is no universally accepted standardized method of setting APRV and thus, it is not established whether its effects on clinical outcomes are due to the ventilator mode per se or the method applied. In addition, one distinctive issue that hinders proper scientific evaluation of APRV is the ubiquitous presence of myths and misconceptions repeatedly presented in the literature. In this review we discuss some of these misleading notions and present data to advance scientific discourse around the uses and misuses of APRV in the current literature.
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Affiliation(s)
- Penny Andrews
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Joseph Shiber
- University of Florida College of Medicine, Jacksonville, FL, United States
| | - Maria Madden
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Gary F. Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, United Kingdom
| | - Nader M. Habashi
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
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Krenn K, Tretter V, Kraft F, Ullrich R. The Renin-Angiotensin System as a Component of Biotrauma in Acute Respiratory Distress Syndrome. Front Physiol 2022; 12:806062. [PMID: 35498160 PMCID: PMC9043684 DOI: 10.3389/fphys.2021.806062] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/29/2021] [Indexed: 12/13/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a major concern in critical care medicine with a high mortality of over 30%. Injury to the lungs is caused not only by underlying pathological conditions such as pneumonia, sepsis, or trauma, but also by ventilator-induced lung injury (VILI) resulting from high positive pressure levels and a high inspiratory oxygen fraction. Apart from mechanical factors that stress the lungs with a specific physical power and cause volutrauma and barotrauma, it is increasingly recognized that lung injury is further aggravated by biological mediators. The COVID-19 pandemic has led to increased interest in the role of the renin-angiotensin system (RAS) in the context of ARDS, as the RAS enzyme angiotensin-converting enzyme 2 serves as the primary cell entry receptor for severe acute respiratory syndrome (SARS) coronavirus (CoV)-2. Even before this pandemic, studies have documented the involvement of the RAS in VILI and its dysregulation in clinical ARDS. In recent years, analytical tools for RAS investigation have made major advances based on the optimized precision and detail of mass spectrometry. Given that many clinical trials with pharmacological interventions in ARDS were negative, RAS-modifying drugs may represent an interesting starting point for novel therapeutic approaches. Results from animal models have highlighted the potential of RAS-modifying drugs to prevent VILI or treat ARDS. While these drugs have beneficial pulmonary effects, the best targets and application forms for intervention still have to be determined to avoid negative effects on the circulation in clinical settings.
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Schmid B, Kredel M, Ullrich R, Krenn K, Lucas R, Markstaller K, Fischer B, Kranke P, Meybohm P, Zwißler B, Frank S. Safety and preliminary efficacy of sequential multiple ascending doses of solnatide to treat pulmonary permeability edema in patients with moderate-to-severe ARDS-a randomized, placebo-controlled, double-blind trial. Trials 2021; 22:643. [PMID: 34544463 PMCID: PMC8450703 DOI: 10.1186/s13063-021-05588-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is a complex clinical diagnosis with various possible etiologies. One common feature, however, is pulmonary permeability edema, which leads to an increased alveolar diffusion pathway and, subsequently, impaired oxygenation and decarboxylation. A novel inhaled peptide agent (AP301, solnatide) was shown to markedly reduce pulmonary edema in animal models of ARDS and to be safe to administer to healthy humans in a Phase I clinical trial. Here, we present the protocol for a Phase IIB clinical trial investigating the safety and possible future efficacy endpoints in ARDS patients. Methods This is a randomized, placebo-controlled, double-blind intervention study. Patients with moderate to severe ARDS in need of mechanical ventilation will be randomized to parallel groups receiving escalating doses of solnatide or placebo, respectively. Before advancing to a higher dose, a data safety monitoring board will investigate the data from previous patients for any indication of patient safety violations. The intervention (application of the investigational drug) takes places twice daily over the course of 7 days, ensued by a follow-up period of another 21 days. Discussion The patients to be included in this trial will be severely sick and in need of mechanical ventilation. The amount of data to be collected upon screening and during the course of the intervention phase is substantial and the potential timeframe for inclusion of any given patient is short. However, when prepared properly, adherence to this protocol will make for the acquisition of reliable data. Particular diligence needs to be exercised with respect to informed consent, because eligible patients will most likely be comatose and/or deeply sedated at the time of inclusion. Trial registration This trial was prospectively registered with the EU Clinical trials register (clinicaltrialsregister.eu). EudraCT Number: 2017-003855-47.
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Affiliation(s)
- Benedikt Schmid
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Markus Kredel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Roman Ullrich
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Katharina Krenn
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Rudolf Lucas
- Vascular Biology Center, Division of Pulmonary Medicine, Medical College of Georgia, Augusta University, Augusta, USA
| | - Klaus Markstaller
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Bernhard Zwißler
- Department of Anesthesiology, University Hospital of Ludwig-Maximilians-University (LMU), Munich, Germany.,Comprehensive Pulmonary Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Sandra Frank
- Department of Anesthesiology, University Hospital of Ludwig-Maximilians-University (LMU), Munich, Germany
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Suwalski P, Staromłyński J, Brączkowski J, Bartczak M, Mariani S, Drobiński D, Szułdrzyński K, Smoczyński R, Franczyk M, Sarnowski W, Gajewska A, Witkowska A, Wierzba W, Zaczyński A, Król Z, Olek E, Pasierski M, Ravaux JM, de Piero ME, Lorusso R, Kowalewski M. Transition from Simple V-V to V-A and Hybrid ECMO Configurations in COVID-19 ARDS. MEMBRANES 2021; 11:membranes11060434. [PMID: 34207598 PMCID: PMC8228471 DOI: 10.3390/membranes11060434] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 05/27/2021] [Accepted: 06/04/2021] [Indexed: 12/27/2022]
Abstract
In SARS-CoV-2 patients with severe acute respiratory distress syndrome (ARDS), Veno-Venous Extracorporeal Membrane Oxygenation (V-V ECMO) was shown to provide valuable treatment with reasonable survival in large multi-centre investigations. However, in some patients, conversion to modified ECMO support forms may be needed. In this single-centre retrospective registry, all consecutive patients receiving V-V ECMO between 1 March 2020 to 1 May 2021 were included and analysed. The patient cohort was divided into two groups: those who remained on V-V ECMO and those who required conversion to other modalities. Seventy-eight patients were included, with fourteen cases (18%) requiring conversions to veno-arterial (V-A) or hybrid ECMO. The reasons for the ECMO mode configuration change were inadequate drainage (35.7%), inadequate perfusion (14.3%), myocardial infarction (7.1%), hypovolemic shock (14.3%), cardiogenic shock (14.3%) and septic shock (7.1%). In multivariable analysis, the use of dobutamine (p = 0.007) and a shorter ICU duration (p = 0.047) predicted the conversion. The 30-day mortality was higher in converted patients (log-rank p = 0.029). Overall, only 19 patients (24.4%) survived to discharge or lung transplantation. Adverse events were more common after conversion and included renal, cardiovascular and ECMO-circuit complications. Conversion itself was not associated with mortality in the multivariable analysis. In conclusion, as many as 18% of patients undergoing V-V ECMO for COVID-19 ARDS may require conversion to advanced ECMO support.
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Affiliation(s)
- Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland; (P.S.); (J.S.); (J.B.); (M.B.); (D.D.); (R.S.); (M.F.); (W.S.); (A.G.); (A.W.); (E.O.); (M.P.)
| | - Jakub Staromłyński
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland; (P.S.); (J.S.); (J.B.); (M.B.); (D.D.); (R.S.); (M.F.); (W.S.); (A.G.); (A.W.); (E.O.); (M.P.)
| | - Jakub Brączkowski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland; (P.S.); (J.S.); (J.B.); (M.B.); (D.D.); (R.S.); (M.F.); (W.S.); (A.G.); (A.W.); (E.O.); (M.P.)
| | - Maciej Bartczak
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland; (P.S.); (J.S.); (J.B.); (M.B.); (D.D.); (R.S.); (M.F.); (W.S.); (A.G.); (A.W.); (E.O.); (M.P.)
| | - Silvia Mariani
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (S.M.); (J.M.R.); (M.E.d.P.); (R.L.)
| | - Dominik Drobiński
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland; (P.S.); (J.S.); (J.B.); (M.B.); (D.D.); (R.S.); (M.F.); (W.S.); (A.G.); (A.W.); (E.O.); (M.P.)
| | - Konstanty Szułdrzyński
- Department of Anesthesiology and Intensive Care, Central Clinical Hospital of the Ministry of the Interior and Administration, 02-507 Warsaw, Poland;
| | - Radosław Smoczyński
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland; (P.S.); (J.S.); (J.B.); (M.B.); (D.D.); (R.S.); (M.F.); (W.S.); (A.G.); (A.W.); (E.O.); (M.P.)
| | - Marzena Franczyk
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland; (P.S.); (J.S.); (J.B.); (M.B.); (D.D.); (R.S.); (M.F.); (W.S.); (A.G.); (A.W.); (E.O.); (M.P.)
| | - Wojciech Sarnowski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland; (P.S.); (J.S.); (J.B.); (M.B.); (D.D.); (R.S.); (M.F.); (W.S.); (A.G.); (A.W.); (E.O.); (M.P.)
| | - Agnieszka Gajewska
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland; (P.S.); (J.S.); (J.B.); (M.B.); (D.D.); (R.S.); (M.F.); (W.S.); (A.G.); (A.W.); (E.O.); (M.P.)
| | - Anna Witkowska
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland; (P.S.); (J.S.); (J.B.); (M.B.); (D.D.); (R.S.); (M.F.); (W.S.); (A.G.); (A.W.); (E.O.); (M.P.)
| | - Waldemar Wierzba
- Central Clinical Hospital of the Ministry of the Interior and Administration, 02-507 Warsaw, Poland; (W.W.); (A.Z.); (Z.K.)
- Satellite Campus in Warsaw, University of Humanities and Economics in Lodz, 90-212 Warsaw, Poland
| | - Artur Zaczyński
- Central Clinical Hospital of the Ministry of the Interior and Administration, 02-507 Warsaw, Poland; (W.W.); (A.Z.); (Z.K.)
| | - Zbigniew Król
- Central Clinical Hospital of the Ministry of the Interior and Administration, 02-507 Warsaw, Poland; (W.W.); (A.Z.); (Z.K.)
| | - Ewa Olek
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland; (P.S.); (J.S.); (J.B.); (M.B.); (D.D.); (R.S.); (M.F.); (W.S.); (A.G.); (A.W.); (E.O.); (M.P.)
| | - Michał Pasierski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland; (P.S.); (J.S.); (J.B.); (M.B.); (D.D.); (R.S.); (M.F.); (W.S.); (A.G.); (A.W.); (E.O.); (M.P.)
| | - Justine Mafalda Ravaux
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (S.M.); (J.M.R.); (M.E.d.P.); (R.L.)
| | - Maria Elena de Piero
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (S.M.); (J.M.R.); (M.E.d.P.); (R.L.)
- Department Anaesthesia-Intensive Care, San Giovanni Bosco Hospital, 80144 Turin, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (S.M.); (J.M.R.); (M.E.d.P.); (R.L.)
| | - Mariusz Kowalewski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland; (P.S.); (J.S.); (J.B.); (M.B.); (D.D.); (R.S.); (M.F.); (W.S.); (A.G.); (A.W.); (E.O.); (M.P.)
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (S.M.); (J.M.R.); (M.E.d.P.); (R.L.)
- Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, 87-100 Bydgoszcz, Poland
- Correspondence: ; Tel.: +48-502269240
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Abstract
PURPOSE OF REVIEW Influenza represents a significant treatment burden to critical care services. A variety of treatment strategies exist, with more and more therapeutic avenues opening up as research progresses. We examined both pharmacological and supportive treatment strategies currently available to see how they might be applied in an ICU setting. RECENT FINDINGS Supportive care in Influenza centres around optimizing respiratory failure, particularly through well established and recognized ventilatory strategies. Noninvasive ventilation and high-flow nasal oxygen may have a limited role in selected patients under carefully monitored circumstances. Drug therapy exerts only a modest clinical effect and has been poorly studied in the critically ill, though there is some evidence to support the use of neuraminidase inhibitors (NAI) - particularly oseltamivir - as early as possible in this cohort. Newer agents have failed to demonstrate superiority over NAIs but may be useful options if the patient fails to respond or should resistant influenza strains emerge. Steroid therapy, in the absence of another indication, must be recommended against given the repeated trend towards increased mortality in this group. SUMMARY Influenza management is an evolving field of significant interest to any critical care provider. Currently, good respiratory supportive care and early enteral oseltamivir are the best supported treatment strategies. Further study in the intensive care setting will be needed before the use of novel agents can be recommended.
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Yener N, Üdürgücü M. Airway Pressure Release Ventilation as a Rescue Therapy in Pediatric Acute Respiratory Distress Syndrome. Indian J Pediatr 2020; 87:905-909. [PMID: 32125661 PMCID: PMC7223785 DOI: 10.1007/s12098-020-03235-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 02/03/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe experience with airway pressure release ventilation (APRV) in children with severe acute respiratory distress syndrome (ARDS) refractory to conventional low tidal volume ventilation. METHODS This retrospective observational study was performed in an 11-bed, level 3 pediatric intensive care unit. Evaluation was made of 30 pediatric patients receiving airway pressure release ventilation as rescue therapy for severe ARDS. RESULTS Patients were switched to APRV on an average 3.2 ± 2.6 d following intubation. When changed from conventional mechanical ventilation (CMV) to APRV, there was an expected increase in the SpO2/FiO2 ratio (165.1 ± 13.6 vs. 131.7 ± 10.2; p = 0.035). Mean peak inspiratory pressure was significantly lower during APRV (25.4 ± 1.26 vs. 29.8 ± 0.60, p < 0.001) compared to CMV prior to APRV but mean airway pressure (Paw) was significantly higher during APRV (19.1 ± 0.9 vs. 15.3 ± 1.3, p < 0.001). Hospital mortality in this study group was 16.6%. CONCLUSIONS The results of this study support the hypothesis that APRV may offer potential clinical advantages for ventilatory management and may be considered as an alternative rescue mechanical ventilation mode in pediatric ARDS patients refractory to conventional ventilation.
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Affiliation(s)
- Nazik Yener
- Division of Pediatric Critical Care, Ondokuz Mayıs University School of Medicine, Samsun, Turkey.
| | - Muhammed Üdürgücü
- Division of Pediatric Critical Care, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
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13
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Wallace DJ, Sappington P, Tisherman S, Stone M. Republication of “Ultrasonographic Appearance of Lung Sliding in a Patient With a Bronchopleural Fistula on a High-Frequency Oscillator Ventilator”. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2020. [DOI: 10.1177/8756479320924842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The patient with a bronchopleural fistula and acute respiratory distress syndrome can present a therapeutic challenge for the treating clinician. In this case, the authors describe the use of bedside thoracic sonography to show real-time improvement in a pneumothorax after initiation of high-frequency oscillatory ventilation. Sonography may have a role in the evaluation of ventilator strategies in the future, although validation of this application is still needed.
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14
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Torres A, Loeches IM, Sligl W, Lee N. Severe flu management: a point of view. Intensive Care Med 2020; 46:153-162. [PMID: 31912206 PMCID: PMC7095473 DOI: 10.1007/s00134-019-05868-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/13/2019] [Indexed: 12/12/2022]
Abstract
Annual flu seasons are typically characterized by changes in types and subtypes of influenza, with variations in terms of severity. Despite remarkable improvements in the prevention and management of patients with suspected or laboratory-confirmed diagnosis of influenza, annual seasonal influenza continues to be associated with a high morbidity and mortality. Admission to the intensive care unit is required for patients with severe forms of seasonal influenza infection, with primary pneumonia being present in most of the cases. This review summarizes the most recent knowledge on the diagnosis and treatment strategies in critically ill patients with influenza, focused on diagnostic testing methods, antiviral therapy, use of corticosteroids, antibacterial and antifungal therapy, and supportive measures. The review focuses on diagnostic testing methods, antiviral therapy, use of corticosteroids, antibacterial and antifungal therapy, supportive measures and relevant existing evidence, in order to provide the non-expert clinician a useful overview. An enhanced understanding of current diagnostic and treatment aspects of influenza infection can contribute to improve outcomes and reduce mortality among ICU patients with influenza.
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Affiliation(s)
- Antoni Torres
- Service of Pneumology, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigació August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red, Enfermedades Respiratorias (CIBERES), C/Villarroel 170, 08036, Barcelona, Spain.
| | - Ignacio-Martin- Loeches
- Service of Pneumology, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigació August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red, Enfermedades Respiratorias (CIBERES), C/Villarroel 170, 08036, Barcelona, Spain
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - Wendy Sligl
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Nelson Lee
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada
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15
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Acute and Chronic Respiratory Failure in Cancer Patients. ONCOLOGIC CRITICAL CARE 2020. [PMCID: PMC7123817 DOI: 10.1007/978-3-319-74588-6_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In 2016, there was an estimated 1.8 million new cases of cancer diagnosed in the United States. Remarkable advances have been made in cancer therapy and the 5-year survival has increased for most patients affected by malignancy. There are growing numbers of patients admitted to intensive care units (ICU) and up to 20% of all patients admitted to an ICU carry a diagnosis of malignancy. Respiratory failure remains the most common reason for ICU admission and remains the leading causes of death in oncology patients. There are many causes of respiratory failure in this population. Pneumonia is the most common cause of respiratory failure, yet there are many causes of respiratory insufficiency unique to the cancer patient. These causes are often a result of immunosuppression, chemotherapy, radiation treatment, or hematopoietic stem cell transplant (HCT). Treatment is focused on supportive care and specific therapy for the underlying cause of respiratory failure. Noninvasive modalities of respiratory support are available; however, careful patient selection is paramount as indiscriminate use of noninvasive positive pressure ventilation is associated with a higher mortality if mechanical ventilation is later required. Historically, respiratory failure in the cancer patient had a grim prognosis. Outcomes have improved over the past 20 years. Survivors are often left with significant disability.
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Barbateskovic M, Schjørring OL, Russo Krauss S, Jakobsen JC, Meyhoff CS, Dahl RM, Rasmussen BS, Perner A, Wetterslev J. Higher versus lower fraction of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit. Cochrane Database Syst Rev 2019; 2019:CD012631. [PMID: 31773728 PMCID: PMC6880382 DOI: 10.1002/14651858.cd012631.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The mainstay treatment for hypoxaemia is oxygen therapy, which is given to the vast majority of adults admitted to the intensive care unit (ICU). The practice of oxygen administration has been liberal, which may result in hyperoxaemia. Some studies have indicated an association between hyperoxaemia and mortality, whilst other studies have not. The ideal target for supplemental oxygen for adults admitted to the ICU is uncertain. Despite a lack of robust evidence of effectiveness, oxygen administration is widely recommended in international clinical practice guidelines. The potential benefit of supplemental oxygen must be weighed against the potentially harmful effects of hyperoxaemia. OBJECTIVES To assess the benefits and harms of higher versus lower fraction of inspired oxygen or targets of arterial oxygenation for adults admitted to the ICU. SEARCH METHODS We identified trials through electronic searches of CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, BIOSIS Previews, CINAHL, and LILACS. We searched for ongoing or unpublished trials in clinical trials registers. We also scanned the reference lists of included studies. We ran the searches in December 2018. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared higher versus lower fraction of inspired oxygen or targets of arterial oxygenation for adults admitted to the ICU. We included trials irrespective of publication type, publication status, and language. We included trials with a difference between the intervention and control groups of a minimum 1 kPa in partial pressure of arterial oxygen (PaO2), minimum 10% in fraction of inspired oxygen (FiO2), or minimum 2% in arterial oxygen saturation of haemoglobin/non-invasive peripheral oxygen saturation (SaO2/SpO2). We excluded trials randomizing participants to hypoxaemia (FiO2 below 0.21, SaO2/SpO2 below 80%, and PaO2 below 6 kPa) and to hyperbaric oxygen. DATA COLLECTION AND ANALYSIS Three review authors independently, and in pairs, screened the references retrieved in the literature searches and extracted data. Our primary outcomes were all-cause mortality, the proportion of participants with one or more serious adverse events, and quality of life. None of the trials reported the proportion of participants with one or more serious adverse events according to the International Conference on Harmonisation Good Clinical Practice (ICH-GCP) criteria. Nonetheless, most trials reported several serious adverse events. We therefore included an analysis of the effect of higher versus lower fraction of inspired oxygen, or targets using the highest reported proportion of participants with a serious adverse event in each trial. Our secondary outcomes were lung injury, acute myocardial infarction, stroke, and sepsis. None of the trials reported on lung injury as a composite outcome, however some trials reported on acute respiratory distress syndrome (ARDS) and pneumonia. We included an analysis of the effect of higher versus lower fraction of inspired oxygen or targets using the highest reported proportion of participants with ARDS or pneumonia in each trial. To assess the risk of systematic errors, we evaluated the risk of bias of the included trials. We used GRADE to assess the overall certainty of the evidence. MAIN RESULTS We included 10 RCTs (1458 participants), seven of which reported relevant outcomes for this review (1285 participants). All included trials had an overall high risk of bias, whilst two trials had a low risk of bias for all domains except blinding of participants and personnel. Meta-analysis indicated harm from higher fraction of inspired oxygen or targets as compared with lower fraction or targets of arterial oxygenation regarding mortality at the time point closest to three months (risk ratio (RR) 1.18, 95% confidence interval (CI) 1.01 to 1.37; I2 = 0%; 4 trials; 1135 participants; very low-certainty evidence). Meta-analysis indicated harm from higher fraction of inspired oxygen or targets as compared with lower fraction or targets of arterial oxygenation regarding serious adverse events at the time point closest to three months (estimated highest proportion of specific serious adverse events in each trial RR 1.13, 95% CI 1.04 to 1.23; I2 = 0%; 1234 participants; 6 trials; very low-certainty evidence). These findings should be interpreted with caution given that they are based on very low-certainty evidence. None of the included trials reported any data on quality of life at any time point. Meta-analysis indicated no evidence of a difference between higher fraction of inspired oxygen or targets as compared with lower fraction or targets of arterial oxygenation on lung injury at the time point closest to three months (estimated highest reported proportion of lung injury RR 1.03, 95% CI 0.78 to 1.36; I2 = 0%; 1167 participants; 5 trials; very low-certainty evidence). None of the included trials reported any data on acute myocardial infarction or stroke, and only one trial reported data on the effects on sepsis. AUTHORS' CONCLUSIONS We are very uncertain about the effects of higher versus lower fraction of inspired oxygen or targets of arterial oxygenation for adults admitted to the ICU on all-cause mortality, serious adverse events, and lung injuries at the time point closest to three months due to very low-certainty evidence. Our results indicate that oxygen supplementation with higher versus lower fractions or oxygenation targets may increase mortality. None of the trials reported the proportion of participants with one or more serious adverse events according to the ICH-GCP criteria, however we found that the trials reported an increase in the number of serious adverse events with higher fractions or oxygenation targets. The effects on quality of life, acute myocardial infarction, stroke, and sepsis are unknown due to insufficient data.
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Affiliation(s)
- Marija Barbateskovic
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Department 7831, Rigshospitalet, Copenhagen University HospitalCentre for Research in Intensive CareBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Olav L Schjørring
- Department 7831, Rigshospitalet, Copenhagen University HospitalCentre for Research in Intensive CareBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Aalborg University HospitalDepartment of Anaesthesia and Intensive CareHobrovej 18‐22AalborgDenmark9000
| | - Sara Russo Krauss
- Copenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9Copenhagen2100DenmarkØ
| | - Janus C Jakobsen
- Department 7831, Rigshospitalet, Copenhagen University HospitalCentre for Research in Intensive CareBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenSjællandDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
- Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812CopenhagenDenmark
| | - Christian S Meyhoff
- Bispebjerg and Frederiksberg Hospital, University of CopenhagenDepartment of Anaesthesia and Intensive CareBispebjerg Bakke 23CopenhagenDenmarkDK‐2400
| | - Rikke M Dahl
- Herlev Hospital, University of CopenhagenDepartment of AnaesthesiologyHerlev Ringvej 75, Pavillon 10, I65F10HerlevDenmark2730
| | - Bodil S Rasmussen
- Department 7831, Rigshospitalet, Copenhagen University HospitalCentre for Research in Intensive CareBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Aalborg University HospitalDepartment of Anaesthesia and Intensive CareHobrovej 18‐22AalborgDenmark9000
| | - Anders Perner
- Department 7831, Rigshospitalet, Copenhagen University HospitalCentre for Research in Intensive CareBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Righospitalet, Copenhagen University HospitalDepartment of Intensive CareCopenhagenDenmark
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Department 7831, Rigshospitalet, Copenhagen University HospitalCentre for Research in Intensive CareBlegdamsvej 9CopenhagenDenmarkDK‐2100
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17
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Salvage therapies for refractory hypoxemia in ARDS. Respir Med 2018; 141:150-158. [PMID: 30053961 DOI: 10.1016/j.rmed.2018.06.030] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/15/2018] [Accepted: 06/29/2018] [Indexed: 02/06/2023]
Abstract
Acute Respiratory Distress Syndrome (ARDS) is a condition of varied etiology characterized by the acute onset (within 1 week of the inciting event) of hypoxemia, reduced lung compliance, diffuse lung inflammation and bilateral opacities on chest imaging attributable to noncardiogenic (increased permeability) pulmonary edema. Although multi-organ failure is the most common cause of death in ARDS, an estimated 10-15% of the deaths in ARDS are caused due to refractory hypoxemia, i.e.- hypoxemia despite lung protective conventional ventilator modes. In these cases, clinicians may resort to other measures with less robust evidence -referred to as "salvage therapies". These include proning, 48 h of paralysis early in the course of ARDS, various recruitment maneuvers, unconventional ventilator modes, inhaled pulmonary vasodilators, and Extracorporeal membrane oxygenation (ECMO). All the salvage therapies described have been associated with improved oxygenation, but with the exception of proning and 48 h of paralysis early in the course of ARDS, none of them have a proven mortality benefit. Based on the current evidence, no salvage therapy has been shown to be superior to the others and each of them is associated with its own risks and benefits. Hence, the order of application of these therapies varies in different institutions and should be applied following a risk-benefit analysis specific to the patient and local experience. This review explores the rationale, evidence, advantages and risks behind each of these strategies.
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Korzhuk A, Afzal A, Wong I, Khusid F, Worku B, Gulkarov I. High-Frequency Percussive Ventilation Rescue Therapy in Morbidly Obese Patients Failing Conventional Mechanical Ventilation. J Intensive Care Med 2018; 35:583-587. [PMID: 29683055 DOI: 10.1177/0885066618769596] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Morbidly obese patients with respiratory failure who do not improve on conventional mechanical ventilation (CMV) often undergo rescue therapy with extracorporeal membrane oxygenation (ECMO). We describe our experience with high-frequency percussive ventilation (HFPV) as a rescue modality. METHODS In a retrospective analysis from 2009 to 2016, 12 morbidly obese patients underwent HFPV after failing to wean from CMV. Data were collected regarding demographics, cause of respiratory failure, ventilation settings, and hospital course outcomes. Our end point data were pre- and post-HFPV partial pressure of arterial oxygen and PaO2 to fraction of inspired oxygen (PF) ratios measured at initiation, 2, and 24 hours. RESULTS Twelve morbidly obese patients required HFPV for respiratory failure. Causes of respiratory failure overlapped and included cardiogenic pulmonary edema (n = 8), pneumonia (n = 5), septic shock (n = 5), and asthma (n = 1). After HFPV initiation, mean fraction of inspired oxygen FiO2 was tapered from 98% to 82% and 66% at 2 and 24 hours, respectively. Mean PaO2 increased from 60.9 mm Hg before HFPV to 175.1 mm Hg (P < .05) at initiation of HFPV, then sustained at 129.5 mm Hg (P < .05) and 88.1 mm Hg (P < .005) at 2 and 24 hours, respectively. Mean PF ratio improved from 66.1 before HFPV to 180.3 (P < .05), 181.0 (P < .05) and 148.9 (P < .0005) at initiation, 2, and 24 hours, respectively. The improvement in mean PaO2 and PF ratios was durable at 24 hours whether or not the patient was returned to CMV (n = 10) or remained on HFPV (n = 2). Survival to discharge was 66.7%. CONCLUSION In our cohort of morbidly obese patients, HFPV was successfully utilized as a rescue therapy precluding the need for ECMO. Despite our small sample size, HFPV should be considered as a rescue therapy in morbidly obese patients failing CMV prior to the initiation of ECMO. Our retrospective analysis supports consideration for HFPV as another form of rescue therapy for obese patients with refractory hypoxemia and respiratory failure who are not improving with CMV.
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Affiliation(s)
- Anatoliy Korzhuk
- Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Ashwad Afzal
- Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Ivan Wong
- Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Felix Khusid
- Department of Respiratory Therapy, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Berhane Worku
- Department of Cardiothoracic Surgery, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Iosif Gulkarov
- Department of Cardiothoracic Surgery, Staten Island University Hospital, Staten Island, NY, USA
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Cawley MJ. Advanced Modes of Mechanical Ventilation: Introduction for the Critical Care Pharmacist. J Pharm Pract 2017; 32:186-198. [PMID: 28982305 DOI: 10.1177/0897190017734766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Mechanical ventilation continues to be an evolving modality in the critical care environment. Technological advances in microprocessor-controlled ventilation integrated with the complexity of new ventilator modes has provided the multidisciplinary team opportunities to further improve the care of the critically ill ventilator patients. As members of the critical care multidisciplinary team, pharmacists require a basic understanding of both conventional and advanced modes of mechanical ventilation in order to assist in optimizing medication use and ultimately patient health-care outcomes. Pharmacists have a key responsibility to practice vigilance to maintain safe drug therapy use by preventing drug-drug or drug-disease interactions and optimal dose selection based upon pharmacokinetics and pharmacodynamics principles. Pharmacists also assist in the development of drug utilization guidelines and pharmacological ventilator-weaning protocols based upon evidence-based practice. The result of these responsibilities must include the continued longitudinal assessment and reporting of quality measures to assess ventilator weaning, time to liberation of mechanical ventilation, and length of care in intensive care unit. The purpose of this article is to provide the clinical pharmacist a guide to a basic understanding of advanced modes of mechanical ventilation in adults and to apply the knowledge gained to assist in the care of the critical care patients.
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Affiliation(s)
- Michael J Cawley
- 1 Department of Pharmacy Practice and Pharmacy Administration, Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA, USA
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20
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Is There a Preinterventional Mechanical Ventilation Time Limit for Candidates of Adult Respiratory Extracorporeal Membrane Oxygenation. ASAIO J 2017; 63:650-658. [DOI: 10.1097/mat.0000000000000577] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Wong I, Worku B, Weingarten JA, Ivanov A, Khusid F, Afzal A, Tranbaugh RF, Gulkarov I. High-frequency percussive ventilation in cardiac surgery patients failing mechanical conventional ventilation†. Interact Cardiovasc Thorac Surg 2017; 25:937-941. [DOI: 10.1093/icvts/ivx237] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 06/14/2017] [Indexed: 11/14/2022] Open
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Narendra DK, Hess DR, Sessler CN, Belete HM, Guntupalli KK, Khusid F, Carpati CM, Astiz ME, Raoof S. Update in Management of Severe Hypoxemic Respiratory Failure. Chest 2017; 152:867-879. [PMID: 28716645 DOI: 10.1016/j.chest.2017.06.039] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 06/17/2017] [Accepted: 06/25/2017] [Indexed: 02/07/2023] Open
Abstract
Mortality related to severe-moderate and severe ARDS remains high. We searched the literature to update this topic. We defined severe hypoxemic respiratory failure as Pao2/Fio2 < 150 mm Hg (ie, severe-moderate and severe ARDS). For these patients, we support setting the ventilator to a tidal volume of 4 to 8 mL/kg predicted body weight (PBW), with plateau pressure (Pplat) ≤ 30 cm H2O, and initial positive end-expiratory pressure (PEEP) of 10 to 12 cm H2O. To promote alveolar recruitment, we propose increasing PEEP in increments of 2 to 3 cm provided that Pplat remains ≤ 30 cm H2O and driving pressure does not increase. A fluid-restricted strategy is recommended, and nonrespiratory causes of hypoxemia should be considered. For patients who remain hypoxemic after PEEP optimization, neuromuscular blockade and prone positioning should be considered. Profound refractory hypoxemia (Pao2/Fio2 < 80 mm Hg) after PEEP titration is an indication to consider extracorporeal life support. This may necessitate early transfer to a center with expertise in these techniques. Inhaled vasodilators and nontraditional ventilator modes may improve oxygenation, but evidence for improved outcomes is weak.
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Affiliation(s)
- Dharani Kumari Narendra
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Dean R Hess
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Curtis N Sessler
- Division of Pulmonary Diseases and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, VA
| | - Habtamu M Belete
- Department of Medicine, Lenox Hill and Northwell Hofstra School of Medicine, New York, NY
| | - Kalpalatha K Guntupalli
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Felix Khusid
- Respiratory Therapy and Pulmonary Physiology Center, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
| | | | - Mark Elton Astiz
- Departments of Internal Medicine and Critical Care Medicine, Lenox Hill Hospital, New York, NY
| | - Suhail Raoof
- Division of Pulmonary Medicine, Lenox Hill Hospital, and Hofstra Northwell School of Medicine, New York, NY.
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Barbateskovic M, Schjørring OLL, Jakobsen JC, Meyhoff CS, Dahl RM, Rasmussen BS, Perner A, Wetterslev J. Higher versus lower inspiratory oxygen fraction or targets of arterial oxygenation for adult intensive care patients. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2017. [DOI: 10.1002/14651858.cd012631] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Marija Barbateskovic
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Olav Lilleholt L Schjørring
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Aalborg University Hospital; Department of Anaesthesia and Intensive Care Medicine; Hobrovej 18-22 Aalborg Denmark 9000
| | - Janus C Jakobsen
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Sjaelland Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
| | - Christian S Meyhoff
- Bispebjerg Hospital, University of Copenhagen; Department of Anaesthesiology; Copenhagen NV Denmark
| | - Rikke M Dahl
- Herlev Hospital, University of Copenhagen; Department of Anaesthesiology; Herlev Ringvej 75, Pavillon 10, I65F10 Herlev Denmark 2730
| | - Bodil S Rasmussen
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Aalborg University Hospital; Department of Anaesthesia and Intensive Care Medicine; Hobrovej 18-22 Aalborg Denmark 9000
| | - Anders Perner
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
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Ahn HJ, Lee JW, Ryu S, Cho YC, Jeong WJ. Refractory hypoxemic respiratory failure from metal fume inhalation: Emergency department procedures. Am J Emerg Med 2016; 35:809.e1-809.e3. [PMID: 28017465 DOI: 10.1016/j.ajem.2016.12.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 12/11/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
- Hong Joon Ahn
- Surgical ICU, Chungnam National University Hospital, Daejeon, South Korea
| | - Jun Wan Lee
- Emergency ICU, Regional Emergency Center, Chungnam National University Hospital, Daejeon, South Korea.
| | - Seung Ryu
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Yong Chul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Won Joon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
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25
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Pintado MC, de Pablo R, Trascasa M, Milicua JM, Sánchez-García M. Compliance-guided versus FiO 2-driven positive-end expiratory pressure in patients with moderate or severe acute respiratory distress syndrome according to the Berlin definition. Med Intensiva 2016; 41:277-284. [PMID: 27776936 DOI: 10.1016/j.medin.2016.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/23/2016] [Accepted: 08/24/2016] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To study the effect of setting positive end-expiratory pressure (PEEP) in an individualized manner (based on highest static compliance) compared to setting PEEP according to FiO2 upon mortality at 28 and 90 days, in patients with different severity acute respiratory distress syndrome (ARDS). SETTING A Spanish medical-surgical ICU. DESIGN A post hoc analysis of a randomized controlled pilot study. PATIENTS Patients with ARDS. INTERVENTIONS Ventilation with low tidal volumes and pressure limitation at 30cmH2O, randomized in two groups according to the method used to set PEEP: FiO2-guided PEEP group according to FiO2 applied and compliance-guided group according to the highest compliance. PRIMARY VARIABLES OF INTEREST Demographic data, risk factors and severity of ARDS, APACHE II and SOFA scores, daily Lung Injury Score, ventilatory measurements, ICU and hospital stay, organ failure and mortality at day 28 and 90 after inclusion. RESULTS A total of 159 patients with ARDS were evaluated, but just 70 patients were included. Severe ARDS patients showed more organ dysfunction-free days at 28 days (12.83±10.70 versus 3.09±7.23; p=0.04) and at 90 days (6.73±22.31 vs. 54.17±42.14, p=0.03), and a trend toward lower 90-days mortality (33.3% vs. 90.9%, p=0.02), when PEEP was applied according to the best static compliance. Patients with moderate ARDS did not show these effects. CONCLUSIONS In patients with severe ARDS, individualized PEEP selection based on the best static compliance was associated to lower mortality at 90 days, with an increase in organ dysfunction-free days at 28 and 90 days.
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Affiliation(s)
- M-C Pintado
- Unidad de Cuidados Intensivos, Hospital Universitario Príncipe de Asturias, Carretera Alcalá-Meco SN, Alcalá de Henares, Madrid 28805, Spain.
| | - R de Pablo
- Unidad de Cuidados Intensivos, Hospital Universitario Príncipe de Asturias, Carretera Alcalá-Meco SN, Alcalá de Henares, Madrid 28805, Spain
| | - M Trascasa
- Unidad de Cuidados Intensivos, Hospital Universitario Príncipe de Asturias, Carretera Alcalá-Meco SN, Alcalá de Henares, Madrid 28805, Spain
| | - J-M Milicua
- Unidad de Cuidados Intensivos, Hospital Universitario Príncipe de Asturias, Carretera Alcalá-Meco SN, Alcalá de Henares, Madrid 28805, Spain
| | - M Sánchez-García
- Unidad de Cuidados Intensivos, Hospital Universitario Príncipe de Asturias, Carretera Alcalá-Meco SN, Alcalá de Henares, Madrid 28805, Spain
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26
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Guo YX, Wang ZN, Li YT, Pan L, Yang LF, Hu Y, Sun YY, Cai LM, Chen ZG. High-frequency oscillatory ventilation is an effective treatment for severe pediatric acute respiratory distress syndrome with refractory hypoxemia. Ther Clin Risk Manag 2016; 12:1563-1571. [PMID: 27799777 PMCID: PMC5077263 DOI: 10.2147/tcrm.s115884] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and purpose Early or primary application of high-frequency oscillatory ventilation (HFOV) has been recently suggested not to offer benefit to patients with acute respiratory distress syndrome (ARDS). However, the rescue effects of HFOV on severe pediatric acute respiratory distress syndrome (PARDS) with hypoxemia refractory to conventional mechanical ventilation (CMV) remain unclear. This study aimed to determine whether severe PARDS children would benefit from HFOV when oxygenation deteriorated on CMV and to identify any potential risk factors related to mortality. Patients and methods In a retrospective and observational study, 48 children with severe PARDS between January 2009 and July 2015 were divided into two groups: 26 in HFOV group and 22 in CMV group. Data regarding demographic, underlying conditions, arterial blood gases and clinical outcomes were collected and analyzed. Results The arterial partial pressure of oxygen (PaO2)/fraction of inspiration oxygen (FiO2) ratio and PaO2 improved significantly during HFOV, whereas arterial partial pressure of carbon dioxide (PaCO2) and oxygenation index decreased. There was no statistical difference in the in-hospital mortality between the groups (P=0.367). The odds ratio of survival in HFOV group was 2.74 (95% confidence interval 0.52 to 14.58, P=0.237). The pediatric intensive care unit length of stay and total ventilation duration were longer in HFOV group (P=0.048 and P=0.000, respectively). Vasoactive agents were used more frequently in HFOV group (P=0.007). The incidence of new air leak was similar between the two groups (P=0.674). The presence of multiple organ dysfunction syndrome and heavier body weight were identified as predictors of mortality in the HFOV group (P=0.006 and P=0.020, respectively). Conclusion HFOV as an efficient alternative therapy could significantly improve hypoxemia and promote CO2 removal in severe PARDS children when oxygenation progressively worsens on CMV.
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Affiliation(s)
- Yu-Xiong Guo
- Pediatric Intensive Care Unit, Department of Pediatrics, Guangdong General Hospital, Guangdong Academy of Medical Sciences
| | - Zhao-Ni Wang
- Pediatric Intensive Care Unit, Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Ya-Ting Li
- Pediatric Intensive Care Unit, Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Li Pan
- Pediatric Intensive Care Unit, Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Li-Fen Yang
- Pediatric Intensive Care Unit, Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Yan Hu
- Pediatric Intensive Care Unit, Department of Pediatrics, Guangdong General Hospital, Guangdong Academy of Medical Sciences
| | - Yue-Yu Sun
- Pediatric Intensive Care Unit, Department of Pediatrics, Guangdong General Hospital, Guangdong Academy of Medical Sciences
| | - Liang-Ming Cai
- Pediatric Intensive Care Unit, Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Zhuang-Gui Chen
- Pediatric Intensive Care Unit, Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
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27
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Abstract
Mechanical ventilation remains the cornerstone in the management of severe acute respiratory failure. Acute respiratory distress syndrome (ARDS) is the most common cause of respiratory failure. It is associated with substantial mortality, and unmanageable refractory hypoxemia remains the most feared clinical possibility. If hypoxemia persists despite application of lung protective ventilation, additional therapies including inhaled vasodilators, prone positioning, recruitment maneuvers, high-frequency oscillatory ventilation, neuromuscular blockade (NMB), and extracorporeal membrane oxygenation may be needed. NMB and prone ventilation are modalities that have been clearly linked to reduced mortality in ARDS. Rescue therapies pose a clinical challenge requiring a precarious balance of risks and benefits, as well as, in-depth knowledge of therapeutic limitations.
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Affiliation(s)
- Chitra Mehta
- Institute of Critical Care and Anaesthesiology, Medanta The Medicity, Gurgaon, Haryana, India
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28
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Transferring patients with refractory hypoxemia to a regional extracorporeal membrane oxygenation center: key considerations for clinicians. AACN Adv Crit Care 2016; 25:351-64. [PMID: 25340417 DOI: 10.1097/nci.0000000000000054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Because of technological advancements and encouraging experiences during the 2009 influenza A (H1N1) epidemic, many critical care clinicians consider extracorporeal membrane oxygenation (ECMO) a reasonable strategy for managing patients with refractory hypoxemia when standardized therapies have failed. Although the literature remains unclear as to whether it should be considered a routine or a rescue strategy in the management of patients with severe acute respiratory distress syndrome, experts agree that ECMO therapy is most likely to result in positive outcomes and fewer complications when provided at regional ECMO centers. Some institutions have developed the expertise and resources required to provide this sophisticated therapy, but significantly more facilities may choose to send their patients to a tertiary ECMO center when they do not respond to usual care. This article provides information essential for health care teams who refer their patients to such centers. The clinical indications for, and the use of, ECMO therapy in the management of refractory hypoxemia is briefly reviewed, followed by a description of how ECMO works to provide gas exchange and tissue perfusion. The primary considerations for circuit management, hemodynamic support, and pulmonary care are described, and significant complications of the therapy are identified. The remainder of the article focuses on the patient care and preparatory activities that occur before and during ECMO initiation, so that health care teams, patients, and their families can be confident of an efficient, safe, and highly skilled transfer of care between institutions.
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29
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Refractory Hypoxemia and Use of Rescue Strategies. A U.S. National Survey of Adult Intensivists. Ann Am Thorac Soc 2016; 13:1105-14. [DOI: 10.1513/annalsats.201508-560oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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30
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Wilcox SR, Saia MS, Waden H, Frakes M, Wedel SK, Richards JB. Mechanical Ventilation in Critical Care Transport. Air Med J 2016; 35:161-5. [PMID: 27255879 DOI: 10.1016/j.amj.2016.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 01/20/2016] [Accepted: 01/31/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Although the benefit of transferring patients with hypoxemic respiratory failure to tertiary care centers has been shown, transporting hypoxemic patients remains controversial, given the risk of desaturation in transit. METHODS We performed a retrospective analysis of a database of critical care transports (CCTs) of patients with hypoxemic respiratory failure to quantify the number, types, and effects of ventilator changes performed by the CCT teams. We evaluated the changes in fraction of inspired oxygen (FiO2), positive end-expiratory pressure (PEEP), tidal volume, both FiO2 and PEEP, and the administration of a neuromuscular blocking medication to assess for an association with an improvement in the arterial partial pressure of oxygen (PaO2) from the sending to the receiving hospitals. RESULTS Ventilator changes were made in 211 (89%) of the 237 identified transports, with significant changes in the tidal volume, PEEP, and FiO2. Analysis of variance revealed a significant relationship between changes in FiO2, PEEP, tidal volume, FiO2 and PEEP, and the administration of neuromuscular blocking agents and change in PaO2 (F5,1037 = 119.6, P < .001). Multivariable regression analyses showed a significant association between an increase in PaO2 and increasing FiO2, increasing FiO2 and PEEP, and the administration of a neuromuscular blocking medication. CONCLUSION The CCT team performed multiple changes to ventilators. Complex ventilator management was associated with a higher PaO2 on arrival.
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Affiliation(s)
- Susan R Wilcox
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA; Division of Emergency Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | | | | | | | | | - Jeremy B Richards
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
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31
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Akkanti B, Gentry B, Kesavan R, Kar B. Acute eosinophilic pneumonia. BMJ Case Rep 2016; 2016:bcr2015212899. [PMID: 26891699 PMCID: PMC5483544 DOI: 10.1136/bcr-2015-212899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2016] [Indexed: 11/04/2022] Open
Abstract
We report the case of an 18-year-old woman who presented to an outside hospital in respiratory distress and was found to have pulmonary eosinophilia. She remained profoundly hypoxaemic despite maximal ventilatory strategies and underwent cannulation for veno-venous extra corporeal membrane oxygenation (ECMO). The respiratory failure improved with time, using corticosteroids, and the veno-venous ECMO helped in stabilisation of the patient in the setting of profound hypoxaemia.
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Affiliation(s)
- Bindu Akkanti
- Critical Care, Pulmonary and Sleep Division, University of Texas at Houston, Houston, Texas, USA
| | - Brandon Gentry
- Department of Medicine and Pediatrics, University of Texas at Houston, Houston, Texas, USA
| | - Ramesh Kesavan
- Kingwood Medical Center Pulmonology, Kingwood, Texas, USA
| | - Biswajit Kar
- Center for Advanced Heart Failure, University of Texas at Houston, Houston, Texas, USA
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Physiological Effects of the Open Lung Approach in Patients with Early, Mild, Diffuse Acute Respiratory Distress Syndrome: An Electrical Impedance Tomography Study. Anesthesiology 2016; 123:1113-21. [PMID: 26397017 DOI: 10.1097/aln.0000000000000862] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND To test the hypothesis that in early, mild, acute respiratory distress syndrome (ARDS) patients with diffuse loss of aeration, the application of the open lung approach (OLA) would improve homogeneity in lung aeration and lung mechanics, without affecting hemodynamics. METHODS Patients were ventilated according to the ARDS Network protocol at baseline (pre-OLA). OLA consisted in a recruitment maneuver followed by a decremental positive end-expiratory pressure trial. Respiratory mechanics, gas exchange, electrical impedance tomography (EIT), cardiac index, and stroke volume variation were measured at baseline and 20 min after OLA implementation (post-OLA). Esophageal pressure was used for lung and chest wall elastance partitioning. The tomographic lung image obtained at the fifth intercostal space by EIT was divided in two ventral and two dorsal regions of interest (ROIventral and ROIDorsal). RESULTS Fifteen consecutive patients were studied. The OLA increased arterial oxygen partial pressure/inspired oxygen fraction from 216 ± 13 to 311 ± 19 mmHg (P < 0.001) and decreased elastance of the respiratory system from 29.4 ± 3 cm H2O/l to 23.6 ± 1.7 cm H2O/l (P < 0.01). The driving pressure (airway opening plateau pressure - total positive end-expiratory pressure) decreased from 17.9 ± 1.5 cm H2O pre-OLA to 15.4 ± 2.1 post-OLA (P < 0.05). The tidal volume fraction reaching the dorsal ROIs increased, and consequently the ROIVentral/Dorsal impedance tidal variation decreased from 2.01 ± 0.36 to 1.19 ± 0.1 (P < 0.01). CONCLUSIONS The OLA decreases the driving pressure and improves the oxygenation and lung mechanics in patients with early, mild, diffuse ARDS. EIT is useful to assess the impact of OLA on regional tidal volume distribution.
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Wu MY, Huang CC, Wu TI, Wang CL, Lin PJ. Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome in Adults: Prognostic Factors for Outcomes. Medicine (Baltimore) 2016; 95:e2870. [PMID: 26937920 PMCID: PMC4779017 DOI: 10.1097/md.0000000000002870] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Despite a therapeutic option for severe acute respiratory distress syndrome (ARDS), the survival benefit of venovenous extracorporeal membrane oxygenation (VV-ECMO) is still controversial in adults. This study was aimed at investigating the prognostic factors for ECMO-treated ARDS in adult patients.From 2012 to 2015, 49 patients (median age: 57 years) received VV-ECMO in our institution and were included in this retrospective study. The indication of VV-ECMO was a severe hypoxemia (PaO2/FiO2 ratio <70 mmHg) under mechanical ventilation (MV) with a peak inspiratory pressure (PIP) >35 cmH2O and a FiO2 >0.8. To decrease the impact of pulmonary injuries associated with the high-pressure ventilation, the settings of MV on VV-ECMO were downgraded according to our protocol. Outcomes of this study were death on VV-ECMO and death in hospital. Important demographic and clinical data during the treatment were collected for outcome analyses.All patients experienced significant improvements in arterial oxygenation on VV-ECMO. Twenty-four hours after initiation of VV-ECMO, the median PaO2/FiO2 ratio increased from 58 to 172 mmHg (P < 0.001) and the median SaO2 increased from 86% to 97% (P < 0.001). In the meantime, the MV settings were also effectively downgraded. The median PIP decreased from 35 to 29 cmH2O (P < 0.001) and the median tidal volume decreased from 7 to 5 ml/kg/min (P < 0.001). Twelve patients died during the treatment of VV-ECMO and 21 patients died before hospital discharge. Among all of the pre-ECMO variables, the pre-ECMO pulmonary dynamic compliance (PCdyn) <20 mL/cmH2O was identified to be the prognostic factor of death on VV-ECMO (odds ratio [OR]: 6, 95% confidence interval [CI]: 1-35, P = 0.03), and the pre-ECMO duration of MV >90 hours was the prognostic factor of death before hospital discharge (OR: 7, 95% CI: 1-29, P = 0.01).VV-ECMO was a useful salvage therapy for severe ARDS in adults. However, the value of PCdyn and the duration of MV before intervention with VV-ECMO may significantly affect the patients' outcomes.
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Affiliation(s)
- Meng-Yu Wu
- From the Department of Cardiovascular Surgery (M-YW, P-JL); Department of Thoracic Medicine, Chang Gung Memorial Hospital and Chang Gung University (C-CH, C-LW) and Department of Obstetrics and Gynecology, Wan Fang Hospital, Taipei Medical University (T-IW), Taipei, Taiwan
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Kollengode R. Treatment of Refractory Hypoxemia in Adults With Acute Respiratory Distress Syndrome-What Is the Available Evidence? J Cardiothorac Vasc Anesth 2016; 30:791-9. [PMID: 27321795 DOI: 10.1053/j.jvca.2016.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Ramanathan Kollengode
- Department of Cardiothoracic and Vascular Surgery, National University Heart Centre, National University Hospital, Singapore.
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35
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Rittayamai N, Katsios CM, Beloncle F, Friedrich JO, Mancebo J, Brochard L. Pressure-Controlled vs Volume-Controlled Ventilation in Acute Respiratory Failure: A Physiology-Based Narrative and Systematic Review. Chest 2015; 148:340-355. [PMID: 25927671 DOI: 10.1378/chest.14-3169] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Mechanical ventilation is a cornerstone in the management of acute respiratory failure. Both volume-targeted and pressure-targeted ventilations are used, the latter modes being increasingly used. We provide a narrative review of the physiologic principles of these two types of breath delivery, performed a literature search, and analyzed published comparisons between modes. METHODS We performed a systematic review and meta-analysis to determine whether pressure control-continuous mandatory ventilation (PC-CMV) or pressure control-inverse ratio ventilation (PC-IRV) has demonstrated advantages over volume control-continuous mandatory ventilation (VC-CMV). The Cochrane tool for risk of bias was used for methodologic quality. We also introduced physiologic criteria as quality indicators for selecting the studies. Outcomes included compliance, gas exchange, hemodynamics, work of breathing, and clinical outcomes. Analyses were completed with RevMan5 using random effects models. RESULTS Thirty-four studies met inclusion criteria, many being at high risk of bias. Comparisons of PC-CMV/PC-IRV and VC-CMV did not show any difference for compliance or gas exchange, even when looking at PC-IRV. Calculating the oxygenation index suggested a poorer effect for PC-IRV. There was no difference between modes in terms of hemodynamics, work of breathing, or clinical outcomes. CONCLUSIONS The two modes have different working principles but clinical available data do not suggest any difference in the outcomes. We included all identified trials, enhancing generalizability, and attempted to include only sufficient quality physiologic studies. However, included trials were small and varied considerably in quality. These data should help to open the choice of ventilation of patients with acute respiratory failure.
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Affiliation(s)
- Nuttapol Rittayamai
- Li Ka Shing Knowledge Institute and Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Christina M Katsios
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - François Beloncle
- Li Ka Shing Knowledge Institute and Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Medical Intensive Care Unit, Hospital of Angers, Université d'Angers, Angers, France
| | - Jan O Friedrich
- Li Ka Shing Knowledge Institute and Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital Sant Pau, Barcelona, Spain
| | - Laurent Brochard
- Li Ka Shing Knowledge Institute and Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, St. Michael's Hospital, Toronto, ON, Canada.
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Spadaro S, Saturni S, Cadorin D, Colamussi MV, Bertini M, Galeotti R, Cappato R, Ravenna F, Volta CA. An unusual case of acute respiratory failure in a patient with pulmonary veins stenosis late after catheter ablation of atrial fibrillation: a case report and the review of the literature. BMC Pulm Med 2015; 15:128. [PMID: 26499985 PMCID: PMC4620024 DOI: 10.1186/s12890-015-0121-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 10/12/2015] [Indexed: 02/07/2023] Open
Abstract
Background Atrial fibrillation (AF) can be treated with percutaneous catheter ablation procedures into the left atrium. Pulmonary veins stenosis (PV) stenosis is a severe complication of this procedure. Case presentation we report a case of late hemoptysis secondary to severe PV stenosis in a man who underwent AF ablation 9 months before onset of symptoms. He presented four episodes of bleeding and developed an acute respiratory failure (ARF). Parameters of respiratory mechanics and medical investigation did not show any abnormalities. Only computed tomography (CT) angiography showed stenosis of 3 out of 4 native PVs. PV balloon dilatation in all affected PVs and a stent was implanted in 1 of the 3 PVs with full restoration of respiratory function during 1 year follow-up. Conclusion PV stenosis may be the underlying cause of recurrent haemoptysis after AF ablation in the presence of normal respiratory parameters. This diagnosis can be confirmed by means of CT angiography and magnetic resonance imaging can provide accurate localization of stenosis.
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Affiliation(s)
- Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesia and Intensive care, University of Ferrara, Via Aldo Moro, 8, Ferrara, 44121, Italy.
| | - Sara Saturni
- Department of Morphology, Surgery and Experimental Medicine, Respiratory Medicine, S.Anna Hospital, Ferrara, Italy.
| | - Delia Cadorin
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesia and Intensive care, University of Ferrara, Via Aldo Moro, 8, Ferrara, 44121, Italy.
| | - Maria V Colamussi
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesia and Intensive care, University of Ferrara, Via Aldo Moro, 8, Ferrara, 44121, Italy.
| | - Matteo Bertini
- Department of Cardiology, S. Anna Hospital, University of Ferrara, Ferrara, Italy.
| | - Roberto Galeotti
- Department of Morphology, Surgery and Experimental Medicine, Vascular and interventional radiology Unit. S. Anna Hospital, Ferrara, Italy.
| | - Riccardo Cappato
- Centro di Ricerca Aritmologia Clinica ed Elettrofisiologia, Milano, Rozzano, Italy.
| | - Franco Ravenna
- Department of Morphology, Surgery and Experimental Medicine, Respiratory Medicine, S.Anna Hospital, Ferrara, Italy.
| | - Carlo A Volta
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesia and Intensive care, University of Ferrara, Via Aldo Moro, 8, Ferrara, 44121, Italy.
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Lovas A, Németh MF, Trásy D, Molnár Z. Lung recruitment can improve oxygenation in patients ventilated in continuous positive airway pressure/pressure support mode. Front Med (Lausanne) 2015; 2:25. [PMID: 25954744 PMCID: PMC4404945 DOI: 10.3389/fmed.2015.00025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 04/05/2015] [Indexed: 11/28/2022] Open
Abstract
Background Recruitment maneuvers are often used in critical care patients with hypoxemic respiratory failure. Although continuous positive airway pressure/pressure support (CPAP/PS) ventilation is a frequently used approach, but whether lung recruitment also improves oxygenation in spontaneously breathing patients has not been investigated yet. The primary objective was to analyze the effect of recruitment maneuver on oxygenation in patients ventilated in CPAP/PS mode. Methods Following baseline measurements PEEP was increased by 5 cmH2O. Recruitment maneuver was applied for 40 s with 40 cmH2O of PS. Measurements of the difference in PaO2/FiO2 and airway parameters measured by the ventilator were recorded immediately after recruitment then 15 and 30 min later. Thirty patients ventilated in CPAP/PS mode with a PEEP ≥5 cmH2O were enrolled in this prospective, observational study if their PaO2/FiO2 ratio was <300 mmHg or required an FiO2 >0.5. Results Following recruitment maneuver patients were considered as non-responders (NR, n = 15) if difference of PaO2/FiO2 <20% and responders (R, n = 15) if difference of PaO2/FiO2 ≥20%. In the NR-group, PaO2/FiO2 decreased non-significantly from baseline: median [interquartile], PaO2/FiO2 = 176 [120–186] vs. after recruitment: 169 [121–182] mmHg, P = 0.307 while in the R-group there was significant improvement: 139 [117–164] vs. 230 [211–323] mmHg, P = 0.01. At the same time points, dead space to tidal volume ratio (Vds/Vte) significantly increased in the NR-group Vds/Vte = 32 [27–37] vs. 36 [25–42]%, P = 0.013 but no significant change was observed in the R-group: 26 [22–34] vs. 27 [24–33]%, P = 0.386. Conclusion Recruitment maneuver improved PaO2/FiO2 ratio by ≥20% in 50% of patients ventilated in CPAP/PS mode.
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Affiliation(s)
- András Lovas
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, University of Szeged , Szeged , Hungary
| | - Márton Ferenc Németh
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, University of Szeged , Szeged , Hungary
| | - Domonkos Trásy
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, University of Szeged , Szeged , Hungary
| | - Zsolt Molnár
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, University of Szeged , Szeged , Hungary
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Badenes R, Lozano A, Belda FJ. Postoperative pulmonary dysfunction and mechanical ventilation in cardiac surgery. Crit Care Res Pract 2015; 2015:420513. [PMID: 25705516 PMCID: PMC4332756 DOI: 10.1155/2015/420513] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 01/15/2015] [Accepted: 01/17/2015] [Indexed: 12/19/2022] Open
Abstract
Postoperative pulmonary dysfunction (PPD) is a frequent and significant complication after cardiac surgery. It contributes to morbidity and mortality and increases hospitalization stay and its associated costs. Its pathogenesis is not clear but it seems to be related to the development of a systemic inflammatory response with a subsequent pulmonary inflammation. Many factors have been described to contribute to this inflammatory response, including surgical procedure with sternotomy incision, effects of general anesthesia, topical cooling, and extracorporeal circulation (ECC) and mechanical ventilation (VM). Protective ventilation strategies can reduce the incidence of atelectasis (which still remains one of the principal causes of PDD) and pulmonary infections in surgical patients. In this way, the open lung approach (OLA), a protective ventilation strategy, has demonstrated attenuating the inflammatory response and improving gas exchange parameters and postoperative pulmonary functions with a better residual functional capacity (FRC) when compared with a conventional ventilatory strategy. Additionally, maintaining low frequency ventilation during ECC was shown to decrease the incidence of PDD after cardiac surgery, preserving lung function.
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Affiliation(s)
- Rafael Badenes
- Department of Anesthesiology and Surgical Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, 46010 Valencia, Spain
| | - Angels Lozano
- Department of Anesthesiology and Surgical Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, 46010 Valencia, Spain
| | - F. Javier Belda
- Department of Anesthesiology and Surgical Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, 46010 Valencia, Spain
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Wright BJ. Lung-protective Ventilation Strategies and Adjunctive Treatments for the Emergency Medicine Patient with Acute Respiratory Failure. Emerg Med Clin North Am 2014; 32:871-87. [DOI: 10.1016/j.emc.2014.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Schulman CS, Bibro C, Downey DB, Lasich C. Transferring Patients With Refractory Hypoxemia to a Regional Extracorporeal Membrane Oxygenation Center. AACN Adv Crit Care 2014. [DOI: 10.4037/nci.0000000000000054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Because of technological advancements and encouraging experiences during the 2009 influenza A (H1N1) epidemic, many critical care clinicians consider extracorporeal membrane oxygenation (ECMO) a reasonable strategy for managing patients with refractory hypoxemia when standardized therapies have failed. Although the literature remains unclear as to whether it should be considered a routine or a rescue strategy in the management of patients with severe acute respiratory distress syndrome, experts agree that ECMO therapy is most likely to result in positive outcomes and fewer complications when provided at regional ECMO centers. Some institutions have developed the expertise and resources required to provide this sophisticated therapy, but significantly more facilities may choose to send their patients to a tertiary ECMO center when they do not respond to usual care. This article provides information essential for health care teams who refer their patients to such centers. The clinical indications for, and the use of, ECMO therapy in the management of refractory hypoxemia is briefly reviewed, followed by a description of how ECMO works to provide gas exchange and tissue perfusion. The primary considerations for circuit management, hemodynamic support, and pulmonary care are described, and significant complications of the therapy are identified. The remainder of the article focuses on the patient care and preparatory activities that occur before and during ECMO initiation, so that health care teams, patients, and their families can be confident of an efficient, safe, and highly skilled transfer of care between institutions.
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Affiliation(s)
- Christine S. Schulman
- Christine S. Schulman is Critical Care Clinical Nurse Specialist, Legacy Health, 1225 NE 2nd Ave, Portland, OR 97232 . Christopher Bibro is Neurotrauma ICU Staff Nurse, ECMO Specialist, Legacy Health, Portland, Oregon. Diane Braxmeyer Downey is Neurotrauma ICU Supervisor, ECMO Specialist, Legacy Health, Portland, Oregon. Christine Lasich is Neurotrauma ICU Staff Nurse, ECMO Specialist, and Adult ECMO Education Coordinator, Legacy Health, Portland, Oregon
| | - Christopher Bibro
- Christine S. Schulman is Critical Care Clinical Nurse Specialist, Legacy Health, 1225 NE 2nd Ave, Portland, OR 97232 . Christopher Bibro is Neurotrauma ICU Staff Nurse, ECMO Specialist, Legacy Health, Portland, Oregon. Diane Braxmeyer Downey is Neurotrauma ICU Supervisor, ECMO Specialist, Legacy Health, Portland, Oregon. Christine Lasich is Neurotrauma ICU Staff Nurse, ECMO Specialist, and Adult ECMO Education Coordinator, Legacy Health, Portland, Oregon
| | - Diane Braxmeyer Downey
- Christine S. Schulman is Critical Care Clinical Nurse Specialist, Legacy Health, 1225 NE 2nd Ave, Portland, OR 97232 . Christopher Bibro is Neurotrauma ICU Staff Nurse, ECMO Specialist, Legacy Health, Portland, Oregon. Diane Braxmeyer Downey is Neurotrauma ICU Supervisor, ECMO Specialist, Legacy Health, Portland, Oregon. Christine Lasich is Neurotrauma ICU Staff Nurse, ECMO Specialist, and Adult ECMO Education Coordinator, Legacy Health, Portland, Oregon
| | - Christine Lasich
- Christine S. Schulman is Critical Care Clinical Nurse Specialist, Legacy Health, 1225 NE 2nd Ave, Portland, OR 97232 . Christopher Bibro is Neurotrauma ICU Staff Nurse, ECMO Specialist, Legacy Health, Portland, Oregon. Diane Braxmeyer Downey is Neurotrauma ICU Supervisor, ECMO Specialist, Legacy Health, Portland, Oregon. Christine Lasich is Neurotrauma ICU Staff Nurse, ECMO Specialist, and Adult ECMO Education Coordinator, Legacy Health, Portland, Oregon
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Bansal R, Esan A, Hess D, Angel LF, Levine SM, George T, Raoof S. Mechanical ventilatory support in potential lung donor patients. Chest 2014; 146:220-227. [PMID: 25010965 DOI: 10.1378/chest.12-2745] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Lung transplantation reduces mortality in patients with end-stage lung disease; however, only approximately 21% of lungs from potential donor patients undergo transplantation. A large number of donor lungs become categorized as unsuitable for lung transplantation as a result of lung injury around the time of brain death. Limiting this injury is key to increasing the number of successful lung procurements and subsequent transplants. This narrative review by a working group of pulmonologists, respiratory therapists, and lung transplant specialists elucidates principles of mechanical ventilatory support that can be used to limit lung injury in potential lung donor patients and examines the implementation of protocolized strategies in enhancing the procurement of donor lungs for transplantation.
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Affiliation(s)
- Ruchi Bansal
- Division of Pulmonary and Critical Care Medicine, New York Methodist Hospital, Brooklyn, NY
| | - Adebayo Esan
- Division of Pulmonary and Critical Care Medicine, New York Methodist Hospital, Brooklyn, NY
| | - Dean Hess
- Respiratory Care Services, Massachusetts General Hospital, Boston, MA
| | - Luis F Angel
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center, San Antonio, TX
| | - Stephanie M Levine
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center, San Antonio, TX
| | - Tony George
- Division of Pulmonary and Critical Care Medicine, New York Methodist Hospital, Brooklyn, NY
| | - Suhail Raoof
- Division of Pulmonary and Critical Care Medicine, New York Methodist Hospital, Brooklyn, NY.
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Automated inhaled nitric oxide alerts for adult extracorporeal membrane oxygenation patient identification. J Trauma Acute Care Surg 2014; 77:S184-9. [DOI: 10.1097/ta.0000000000000343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Long-term survival in patients with severe acute respiratory distress syndrome and rescue therapies for refractory hypoxemia*. Crit Care Med 2014; 42:1610-8. [PMID: 24732240 DOI: 10.1097/ccm.0000000000000322] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To describe long-term survival in patients with severe acute respiratory distress syndrome and assess differences in patient characteristics and outcomes among those who receive rescue therapies (prone position ventilation, inhaled nitric oxide, or inhaled epoprostenol) versus conventional treatment. DESIGN Cohort study of patients with severe hypoxemia. SETTING University-affiliated level 1 trauma center. PATIENTS Patients diagnosed with severe acute respiratory distress syndrome within 72 hours of ICU admission between January 1, 2008, and December 31, 2011. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data were abstracted from the medical record and included demographic and clinical variables, hospital and ICU length of stay, discharge disposition, and hospital costs. Patient-level data were linked to the Washington State Death Registry. Kaplan-Meier methods and Cox's proportional hazards models were used to estimate survival and hazard ratios. Four hundred twenty-eight patients meeting study inclusion criteria were identified; 62 (14%) were initiated on a rescue therapy. PaO2/FIO2 ratios were comparable at admission between patients treated with a rescue therapy and those treated conventionally but were substantially lower by 72 hours in those who received rescue therapies (54 ± 17 vs 69 ± 17 mm Hg; p < 0.01). For the entire cohort, estimated survival probability at 3 years was 55% (95% CI, 51-61%). Among 280 hospital survivors (65%), 3-year survival was 85% (95% CI, 80-89%). The relative hazard of in-hospital mortality was 68% higher among patients who received rescue therapy compared with patients treated conventionally (95% CI, 8-162%; p = 0.02). For long-term survival, the hazard ratio of death following ICU admission was 1.56 (95% CI, 1.02-2.37; p = 0.04), comparing rescue versus conventional treatment. CONCLUSIONS Despite high hospital mortality, severe acute respiratory distress syndrome patients surviving to hospital discharge have relatively good long-term survival. Worsening hypoxemia was associated with initiation of rescue therapy. Patients on rescue therapy had higher in-hospital mortality; however, survivors to hospital discharge had long-term survival that was comparable to other acute respiratory distress syndrome survivors.
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Ridler N, Plumb J, Grocott M. Oxygen Therapy in Critical Illness: Friend or Foe? A Review of Oxygen Therapy in Selected Acute Illnesses. J Intensive Care Soc 2014. [DOI: 10.1177/175114371401500303] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In recent years there has been a gradual shift away from using uncontrolled high concentrations of inspired oxygen in some acute illnesses. Oxygen is perhaps the most frequently used drug in medicine, and understanding the balance of benefits and harms is essential knowledge for all anaesthetists and intensivists. While current teaching and practice emphasise avoiding hypoxaemia over concerns about hyperoxaemia, it may transpire that oxygen excess is more harmful than previously thought. As with many interventions in intensive care medicine, striving to achieve physiological normality may sometimes do more harm than good, and tolerance of abnormal values may on occasion be in patients' best interests. Incorporating Single Best Answers (see page 197: answers on page 237).
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Gilbert‐Kawai ET, Mitchell K, Martin D, Carlisle J, Grocott MPW. Permissive hypoxaemia versus normoxaemia for mechanically ventilated critically ill patients. Cochrane Database Syst Rev 2014; 2014:CD009931. [PMID: 24801519 PMCID: PMC6465096 DOI: 10.1002/14651858.cd009931.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Permissive hypoxaemia describes a concept in which a lower level of arterial oxygenation (PaO2) than usual is accepted to avoid the detrimental effects of high fractional inspired oxygen and invasive mechanical ventilation. Currently however, no specific threshold is known that defines permissive hypoxaemia, and its use in adults remains formally untested. The importance of this systematic review is thus to determine whether any substantial evidence is available to support the notion that permissive hypoxaemia may improve clinical outcomes in mechanically ventilated critically ill patients. OBJECTIVES We assessed whether permissive hypoxaemia (accepting a lower PaO2 than is current practice) in mechanically ventilated critically ill patients affects patient morbidity and mortality. We planned to conduct subgroup and sensitivity analyses and to examine the role of bias to determine the level of evidence provided. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 11, part of The Cochrane Library; MEDLINE (1954 to November 2013); EMBASE (1980 to November 2013); CINAHL (1982 to November 2013) and ISI Web of Science (1946 to November 2013). We combined the sensitive search strategies described in the Cochrane Handbook for Systematic Reviews of Interventions to search for randomized controlled trials (RCTs) in MEDLINE and EMBASE. For ongoing trials, we also searched the following databases: MetaRegister of ControlledTrials and the National Research Register. We applied no language restrictions. SELECTION CRITERIA RCTs and quasi-RCTs that compared outcomes for mechanically ventilated critically ill participants, in which the intervention group was targeted to be hypoxaemic relative to the control group, and the control group was normoxaemic or was mildly hypoxaemic, were eligible for inclusion in this review. Exact values defining 'conventional' and 'permissive hypoxaemia' groupings were purposely not specified, and the manner in which these oxygenation goals were achieved also was not specified. We did state however that the intervention group required a target oxygenation level lower than that of the control group, and that the control group target levels should be in the range of normoxaemia or mild hypoxaemia (not hyperoxaemia). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. Using the results of the above searches, two review authors (EG-K and KM) independently screened all titles and abstracts for eligibility and duplication. No discrepancies were encountered, nor was it necessary for review authors to contact the first author of any trial to ask for additional information. MAIN RESULTS Our search strategy yielded a total of 2419 results. After exclusion of duplications, 1651 candidate studies were identified. Screening of titles and abstracts revealed that no studies met our inclusion criteria. AUTHORS' CONCLUSIONS This comprehensive review failed to identify any relevant studies evaluating permissive hypoxaemia versus normoxaemia in mechanically ventilated critically ill participants. Therefore we are unable to support or refute the hypothesis that this treatment strategy is of benefit to patients.Given the substantial amount of provocative evidence derived from related clinical contexts (resuscitation, myocardial infarction, stroke), we believe that this review highlights an important unanswered question within critical care. In the presence of two competing harms (hypoxia and hyperoxia), it will be important to carefully evaluate the safety and feasibility of permissive hypoxaemia before proceeding to efficacy and effectiveness trials.
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Affiliation(s)
- Edward T Gilbert‐Kawai
- Institute of Sport and Exercise HealthUniversity College London Centre for Altitude Space and Extreme Environment (CASE) Medicine, UCLH NIHR Biomedical Research Centre170 Tottenham Court RoadLondonUK
- University College London Institute of Child HealthCritical Care Group, Portex UnitLondonUK
| | - Kay Mitchell
- Institute of Sport and Exercise HealthUniversity College London Centre for Altitude Space and Extreme Environment (CASE) Medicine, UCLH NIHR Biomedical Research Centre170 Tottenham Court RoadLondonUK
- University of SouthamptonIntegrative Physiology and Critical Illness Group, Clinical and Experimental SciencesSouthamptonUK
- Southampton NIHR Respiratory Biomedical Research UnitCritical Care Research AreaSouthamptonUK
- University Hospital Southampton NHS Foundation TrustAnaesthesia and Critical Care Research UnitSouthamptonUK
| | - Daniel Martin
- University College London and Royal Free HospitalPerioperative & Critical Care MedicineLondonUKNW3 2QG
- University College London HospitalsInstitute of Sport and Exercise HealthFirst Floor, 170 Tottenham Court RoadLondonUKW1T 7HA
| | - John Carlisle
- Torbay Hospital, South Devon Healthcare NHS Foundation TrustDepartment of AnaestheticsLawes BridgeTorquayDevonUKTQ2 7AA
| | - Michael PW Grocott
- University of SouthamptonIntegrative Physiology and Critical Illness Group, Clinical and Experimental SciencesSouthamptonUK
- Southampton NIHR Respiratory Biomedical Research UnitCritical Care Research AreaSouthamptonUK
- University Hospital Southampton NHS Foundation TrustAnaesthesia and Critical Care Research UnitSouthamptonUK
- Faculty of Medicine, University of SouthamptonCritical Care Group, Clinical and Experimental SciencesTremona RoadSouthamptonHampshireUKSO16 6YD
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Venovenous extracorporeal life support improves survival in adult trauma patients with acute hypoxemic respiratory failure. J Trauma Acute Care Surg 2014; 76:1275-81. [DOI: 10.1097/ta.0000000000000213] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hodgson C, Carteaux G, Tuxen DV, Davies AR, Pellegrino V, Capellier G, Cooper DJ, Nichol A. Hypoxaemic rescue therapies in acute respiratory distress syndrome: Why, when, what and which one? Injury 2013; 44:1700-9. [PMID: 23261071 DOI: 10.1016/j.injury.2012.11.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 11/12/2012] [Accepted: 11/20/2012] [Indexed: 02/02/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is an inflammatory condition of the lungs which can result in refractory and life-threatening hypoxaemic respiratory failure. The risk factors for the development of ARDS are many but include trauma, multiple blood transfusions, burns and major surgery, therefore this condition is not uncommon in the severely injured patient. When ARDS is severe, high-inspired oxygen concentrations are frequently required to minimise hypoxaemia. In these situations clinicians commonly utilise interventions termed 'hypoxaemic rescue therapies' in an attempt to improve oxygenation, as without these, conventional mechanical ventilation can be associated with high mortality. However, their lack of efficacy on mortality when used prophylactically in generalised ARDS cohorts has resulted in their use being confined to clinical trials and the subset of ARDS patients with refractory hypoxaemia. First line hypoxaemic rescue therapies include inhaled nitric oxide, prone positioning, alveolar recruitment manoeuvres and high frequency oscillatory ventilation, which have all been shown to be effective in improving oxygenation. In situations where these first line rescue therapies are inadequate extra-corporeal membrane oxygenation has emerged as a lifesaving second line rescue therapy. Rescue therapies in critically ill patients with traumatic injuries presents specific challenges and requires careful assessment of both the short and longer term benefits, therapeutic limitations, and specific adverse effects before their use.
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Affiliation(s)
- Carol Hodgson
- Australia and New Zealand Intensive Care Research Centre, Department of Epidemiology & Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Australia; The Alfred Hospital, Melbourne 3181, Australia.
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Sessler CN. Counterpoint: Should Paralytic Agents Be Routinely Used in Severe ARDS? No. Chest 2013; 144:1442-1445. [DOI: 10.1378/chest.13-1462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Shekar K, Davies AR, Mullany DV, Tiruvoipati R, Fraser JF. To ventilate, oscillate, or cannulate? J Crit Care 2013; 28:655-62. [PMID: 23827735 DOI: 10.1016/j.jcrc.2013.04.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 03/09/2013] [Accepted: 04/17/2013] [Indexed: 02/05/2023]
Abstract
Ventilatory management of acute respiratory distress syndrome has evolved significantly in the last few decades. The aims have shifted from optimal gas transfer without concern for iatrogenic risks to adequate gas transfer while minimizing lung injury. This change in focus, along with improved ventilator and multiorgan system management, has resulted in a significant improvement in patient outcomes. Despite this, a number of patients develop hypoxemic respiratory failure refractory to lung-protective ventilation (LPV). The intensivist then faces the dilemma of either persisting with LPV using adjuncts (neuromuscular blocking agents, prone positioning, recruitment maneuvers, inhaled nitric oxide, inhaled prostacyclin, steroids, and surfactant) or making a transition to rescue therapies such as high-frequency oscillatory ventilation (HFOV) and/or extracorporeal membrane oxygenation (ECMO) when both these modalities are at their disposal. The lack of quality evidence and potential harm reported in recent studies question the use of HFOV as a routine rescue option. Based on current literature, the role for venovenous (VV) ECMO is probably sequential as a salvage therapy to ensure ultraprotective ventilation in selected young patients with potentially reversible respiratory failure who fail LPV despite neuromuscular paralysis and prone ventilation. Given the risk profile and the economic impact, future research should identify the patients who benefit most from VV ECMO. These choices may be further influenced by the emerging novel extracorporeal carbon dioxide removal devices that can compliment LPV. Given the heterogeneity of acute respiratory distress syndrome, each of these modalities may play a role in an individual patient. Future studies comparing LPV, HFOV, and VV ECMO should not only focus on defining the patients who benefit most from each of these therapies but also consider long-term functional outcomes.
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Affiliation(s)
- Kiran Shekar
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, The University of Queensland, Brisbane, Queensland, Australia.
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Estrategias frente a la hipoxemia refractaria en el síndrome de dificultad respiratoria del adulto. Med Intensiva 2013; 37:423-30. [DOI: 10.1016/j.medin.2012.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Revised: 11/27/2012] [Accepted: 12/13/2012] [Indexed: 11/20/2022]
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