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Zhang H, Qian D, Zhang X, Meng P, Huang W, Gu T, Fan Y, Zhang Y, Wang Y, Yu M, Yuan Z, Chen X, Zhao Q, Ruan Z. Tree-based ensemble machine learning models in the prediction of acute respiratory distress syndrome following cardiac surgery: a multicenter cohort study. J Transl Med 2024; 22:772. [PMID: 39148090 PMCID: PMC11325832 DOI: 10.1186/s12967-024-05395-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/12/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) after cardiac surgery is a severe respiratory complication with high mortality and morbidity. Traditional clinical approaches may lead to under recognition of this heterogeneous syndrome, potentially resulting in diagnosis delay. This study aims to develop and external validate seven machine learning (ML) models, trained on electronic health records data, for predicting ARDS after cardiac surgery. METHODS This multicenter, observational cohort study included patients who underwent cardiac surgery in the training and testing cohorts (data from Nanjing First Hospital), as well as those patients who had cardiac surgery in a validation cohort (data from Shanghai General Hospital). The number of important features was determined using the sliding windows sequential forward feature selection method (SWSFS). We developed a set of tree-based ML models, including Decision Tree, GBDT, AdaBoost, XGBoost, LightGBM, Random Forest, and Deep Forest. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) and Brier score. The SHapley Additive exPlanation (SHAP) techinque was employed to interpret the ML model. Furthermore, a comparison was made between the ML models and traditional scoring systems. ARDS is defined according to the Berlin definition. RESULTS A total of 1996 patients who had cardiac surgery were included in the study. The top five important features identified by the SWSFS were chronic obstructive pulmonary disease, preoperative albumin, central venous pressure_T4, cardiopulmonary bypass time, and left ventricular ejection fraction. Among the seven ML models, Deep Forest demonstrated the best performance, with an AUC of 0.882 and a Brier score of 0.809 in the validation cohort. Notably, the SHAP values effectively illustrated the contribution of the 13 features attributed to the model output and the individual feature's effect on model prediction. In addition, the ensemble ML models demonstrated better performance than the other six traditional scoring systems. CONCLUSIONS Our study identified 13 important features and provided multiple ML models to enhance the risk stratification for ARDS after cardiac surgery. Using these predictors and ML models might provide a basis for early diagnostic and preventive strategies in the perioperative management of ARDS patients.
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Affiliation(s)
- Hang Zhang
- Department of Thoracic Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 650 Xinsongjiang Road, Shanghai, 201620, China
| | - Dewei Qian
- Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 85 Wujin Road, Shanghai, 200080, China
| | - Xiaomiao Zhang
- Department of Thoracic Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 650 Xinsongjiang Road, Shanghai, 201620, China
| | - Peize Meng
- Department of Thoracic Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 650 Xinsongjiang Road, Shanghai, 201620, China
| | - Weiran Huang
- Qing Yuan Research Institute, SEIEE, Shanghai Jiao Tong University, No. 800 Dongchuan Road, Shanghai, 200240, China
| | - Tongtong Gu
- Department of Pharmacy, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
| | - Yongliang Fan
- Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 85 Wujin Road, Shanghai, 200080, China
| | - Yi Zhang
- Department of Thoracic Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 650 Xinsongjiang Road, Shanghai, 201620, China
| | - Yuchen Wang
- Department of Thoracic Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 650 Xinsongjiang Road, Shanghai, 201620, China
| | - Min Yu
- Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 85 Wujin Road, Shanghai, 200080, China
| | - Zhongxiang Yuan
- Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 85 Wujin Road, Shanghai, 200080, China
| | - Xin Chen
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing, 210006, China.
| | - Qingnan Zhao
- Department of Clinical Pharmacy, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 650 Xinsongjiang Road, Shanghai, 201620, China.
| | - Zheng Ruan
- Department of Thoracic Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 650 Xinsongjiang Road, Shanghai, 201620, China.
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Ye RZ, Lipatov K, Diedrich D, Bhattacharyya A, Erickson BJ, Pickering BW, Herasevich V. Automatic ARDS surveillance with chest X-ray recognition using convolutional neural networks. J Crit Care 2024; 82:154794. [PMID: 38552452 DOI: 10.1016/j.jcrc.2024.154794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/20/2023] [Accepted: 12/01/2023] [Indexed: 06/01/2024]
Abstract
OBJECTIVE This study aims to design, validate and assess the accuracy a deep learning model capable of differentiation Chest X-Rays between pneumonia, acute respiratory distress syndrome (ARDS) and normal lungs. MATERIALS AND METHODS A diagnostic performance study was conducted using Chest X-Ray images from adult patients admitted to a medical intensive care unit between January 2003 and November 2014. X-ray images from 15,899 patients were assigned one of three prespecified categories: "ARDS", "Pneumonia", or "Normal". RESULTS A two-step convolutional neural network (CNN) pipeline was developed and tested to distinguish between the three patterns with sensitivity ranging from 91.8% to 97.8% and specificity ranging from 96.6% to 98.8%. The CNN model was validated with a sensitivity of 96.3% and specificity of 96.6% using a previous dataset of patients with Acute Lung Injury (ALI)/ARDS. DISCUSSION The results suggest that a deep learning model based on chest x-ray pattern recognition can be a useful tool in distinguishing patients with ARDS from patients with normal lungs, providing faster results than digital surveillance tools based on text reports. CONCLUSION A CNN-based deep learning model showed clinically significant performance, providing potential for faster ARDS identification. Future research should prospectively evaluate these tools in a clinical setting.
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Affiliation(s)
- Run Zhou Ye
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.; Division of Endocrinology, Department of Medicine, Centre de Recherche du CHUS, Sherbrooke QC J1H 5N4, Canada
| | - Kirill Lipatov
- Critical Care Medicine, Mayo Clinic, Eau Claire, WI, United States
| | - Daniel Diedrich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | | | - Bradley J Erickson
- Department of Diagnostic Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Brian W Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Vitaly Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA..
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Brooks D, Wright SE, Beattie A, McAllister N, Anderson NH, Roy AI, Gonsalves P, Yates B, Graziadio S, Mackie A, Davidson J, Gopal SV, Whittle R, Zahed A, Barton L, Elameer M, Tuckett J, Holmes R, Sutcliffe A, Santamaria N, de Lalouviere LLH, Gupta S, Subramaniam J, Pearson JA, Brandwood M, Burnham R, Rostron AJ, Simpson AJ. Assessment of the comparative agreement between chest radiographs and CT scans in intensive care units. J Crit Care 2024; 82:154760. [PMID: 38492522 DOI: 10.1016/j.jcrc.2024.154760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 02/13/2024] [Accepted: 02/23/2024] [Indexed: 03/18/2024]
Abstract
PURPOSE Chest radiographs in critically ill patients can be difficult to interpret due to technical and clinical factors. We sought to determine the agreement of chest radiographs and CT scans, and the inter-observer variation of chest radiograph interpretation, in intensive care units (ICUs). METHODS Chest radiographs and corresponding thoracic computerised tomography (CT) scans (as reference standard) were collected from 45 ICU patients. All radiographs were analysed by 20 doctors (radiology consultants, radiology trainees, ICU consultants, ICU trainees) from 4 different centres, blinded to CT results. Specificity/sensitivity were determined for pleural effusion, lobar collapse and consolidation/atelectasis. Separately, Fleiss' kappa for multiple raters was used to determine inter-observer variation for chest radiographs. RESULTS The median sensitivity and specificity of chest radiographs for detecting abnormalities seen on CTs scans were 43.2% and 85.9% respectively. Diagnostic sensitivity for pleural effusion was significantly higher among radiology consultants but no specialty/experience distinctions were observed for specificity. Median inter-observer kappa coefficient among assessors was 0.295 ("fair"). CONCLUSIONS Chest radiographs commonly miss important radiological features in critically ill patients. Inter-observer agreement in chest radiograph interpretation is only "fair". Consultant radiologists are least likely to miss thoracic radiological abnormalities. The consequences of misdiagnosis by chest radiographs remain to be determined.
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Affiliation(s)
- Daniel Brooks
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne NE2 4HH, UK; Emergency Department, John Hunter Hospital, New Lambton Heights, NSW 2305, Australia
| | - Stephen E Wright
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, High Heaton, Newcastle Upon Tyne NE7 7DN, UK
| | - Anna Beattie
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK
| | - Nadia McAllister
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, High Heaton, Newcastle Upon Tyne NE7 7DN, UK
| | - Niall H Anderson
- Usher Institute, University of Edinburgh, Old Medial School, Teviot Place, Edinburgh EH8 9AG, UK
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - Philip Gonsalves
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK
| | - Bryan Yates
- Critical Care Unit, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington NE23 6NZ, UK
| | - Sara Graziadio
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; York Health Economics Consortium, University of York, York YO10 5NQ, UK
| | - Alasdair Mackie
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK
| | - John Davidson
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, High Heaton, Newcastle Upon Tyne NE7 7DN, UK
| | - Sandeep Vijaya Gopal
- Department of Radiology, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - Robert Whittle
- Critical Care Unit, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington NE23 6NZ, UK
| | - Asef Zahed
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK
| | - Lorna Barton
- Critical Care Unit, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington NE23 6NZ, UK
| | - Mathew Elameer
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK
| | - John Tuckett
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK
| | - Rob Holmes
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK
| | - Alexandra Sutcliffe
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, High Heaton, Newcastle Upon Tyne NE7 7DN, UK
| | - Nuria Santamaria
- Department of Radiology, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK; Department of Radiology, Clatterbridge Cancer Centre, l, Liverpool L7 8YA, UK
| | - Luke la Hausse de Lalouviere
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, High Heaton, Newcastle Upon Tyne NE7 7DN, UK
| | - Sanjay Gupta
- Department of Radiology, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington NE23 6NZ, UK
| | - Jeevan Subramaniam
- Critical Care Unit, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington NE23 6NZ, UK
| | - Janaki A Pearson
- Integrated Critical Care Unit, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK; Intensive Care Unit, James Cook University Hospital, Middlesbrough TS4 3BW, UK
| | - Matthew Brandwood
- Integrated Critical Care Unit, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - Richard Burnham
- Critical Care Unit, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington NE23 6NZ, UK
| | - Anthony J Rostron
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne NE2 4HH, UK; Integrated Critical Care Unit, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne NE2 4HH, UK; NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; Respiratory Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK.
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Boumans MMA, Aerts W, Pisani L, Bos LDJ, Smit MR, Tuinman PR. Diagnostic accuracy of lung ultrasound in diagnosis of ARDS and identification of focal or non-focal ARDS subphenotypes: a systematic review and meta-analysis. Crit Care 2024; 28:224. [PMID: 38978055 PMCID: PMC11232316 DOI: 10.1186/s13054-024-04985-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 06/08/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a life-threatening respiratory condition with high mortality rates, accounting for 10% of all intensive care unit admissions. Lung ultrasound (LUS) as diagnostic tool for acute respiratory failure has garnered widespread recognition and was recently incorporated into the updated definitions of ARDS. This raised the hypothesis that LUS is a reliable method for diagnosing ARDS. OBJECTIVES We aimed to establish the accuracy of LUS for ARDS diagnosis and classification of focal versus non-focal ARDS subphenotypes. METHODS This systematic review and meta-analysis used a systematic search strategy, which was applied to PubMed, EMBASE and cochrane databases. Studies investigating the diagnostic accuracy of LUS compared to thoracic CT or chest radiography (CXR) in ARDS diagnosis or focal versus non-focal subphenotypes in adult patients were included. Quality of studies was evaluated using the QUADAS-2 tool. Statistical analyses were performed using "Mada" in Rstudio, version 4.0.3. Sensitivity and specificity with 95% confidence interval of each separate study were summarized in a Forest plot. RESULTS The search resulted in 2648 unique records. After selection, 11 reports were included, involving 2075 patients and 598 ARDS cases (29%). Nine studies reported on ARDS diagnosis and two reported on focal versus non-focal ARDS subphenotypes classification. Meta-analysis showed a pooled sensitivity of 0.631 (95% CI 0.450-0.782) and pooled specificity of 0.942 (95% CI 0.856-0.978) of LUS for ARDS diagnosis. In two studies, LUS could accurately differentiate between focal versus non-focal ARDS subphenotypes. Insufficient data was available to perform a meta-analysis. CONCLUSION This review confirms the hypothesis that LUS is a reliable method for diagnosing ARDS in adult patients. For the classification of focal or non-focal subphenotypes, LUS showed promising results, but more research is needed.
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Affiliation(s)
- Maud M A Boumans
- Department of Intensive Care Medicine, Noordwest Ziekenhuisgroep, Wilhelminalaan 12, Alkmaar, The Netherlands
| | - William Aerts
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Luigi Pisani
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, 10400, Thailand
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Lieuwe D J Bos
- Department of Intensive Care Medicine, Amsterdam UMC, Amsterdam Medisch Centrum, Meibergdreef 9, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Marry R Smit
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Institute for Immunity and Infectious Diseases, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands.
- Amsterdam Leiden IC Focused Echography (ALIFE), Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands.
- Amsterdam Institute for Immunity and Infectious Diseases, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands.
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5
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Sinnige JS, Smit MR, Ghose A, de Grooth HJ, Itenov TS, Ischaki E, Laffey J, Paulus F, Póvoa P, Pierrakos C, Pisani L, Roca O, Schultz MJ, Szuldrzynski K, Tuinman PR, Zimatore C, Bos LDJ. Personalized mechanical ventilation guided by ultrasound in patients with acute respiratory distress syndrome (PEGASUS): study protocol for an international randomized clinical trial. Trials 2024; 25:308. [PMID: 38715118 PMCID: PMC11077821 DOI: 10.1186/s13063-024-08140-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a frequent cause of hypoxemic respiratory failure with a mortality rate of approximately 30%. Identifying ARDS subphenotypes based on "focal" or "non-focal" lung morphology has the potential to better target mechanical ventilation strategies of individual patients. However, classifying morphology through chest radiography or computed tomography is either inaccurate or impractical. Lung ultrasound (LUS) is a non-invasive bedside tool that can accurately distinguish "focal" from "non-focal" lung morphology. We hypothesize that LUS-guided personalized mechanical ventilation in ARDS patients leads to a reduction in 90-day mortality compared to conventional mechanical ventilation. METHODS The Personalized Mechanical Ventilation Guided by UltraSound in Patients with Acute Respiratory Distress Syndrome (PEGASUS) study is an investigator-initiated, international, randomized clinical trial (RCT) that plans to enroll 538 invasively ventilated adult intensive care unit (ICU) patients with moderate to severe ARDS. Eligible patients will receive a LUS exam to classify lung morphology as "focal" or "non-focal". Thereafter, patients will be randomized within 12 h after ARDS diagnosis to receive standard care or personalized ventilation where the ventilation strategy is adjusted to the morphology subphenotype, i.e., higher positive end-expiratory pressure (PEEP) and recruitment maneuvers for "non-focal" ARDS and lower PEEP and prone positioning for "focal" ARDS. The primary endpoint is all-cause mortality at day 90. Secondary outcomes are mortality at day 28, ventilator-free days at day 28, ICU length of stay, ICU mortality, hospital length of stay, hospital mortality, and number of complications (ventilator-associated pneumonia, pneumothorax, and need for rescue therapy). After a pilot phase of 80 patients, the correct interpretation of LUS images and correct application of the intervention within the safe limits of mechanical ventilation will be evaluated. DISCUSSION PEGASUS is the first RCT that compares LUS-guided personalized mechanical ventilation with conventional ventilation in invasively ventilated patients with moderate and severe ARDS. If this study demonstrates that personalized ventilation guided by LUS can improve the outcomes of ARDS patients, it has the potential to shift the existing one-size-fits-all ventilation strategy towards a more individualized approach. TRIAL REGISTRATION The PEGASUS trial was registered before the inclusion of the first patient, https://clinicaltrials.gov/ (ID: NCT05492344).
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Affiliation(s)
- Jante S Sinnige
- Department of Intensive Care, Amsterdam University Medical Centres (UMC), University of Amsterdam, Meibergdreef 9, Amsterdam, AZ, 1105, The Netherlands.
| | - Marry R Smit
- Department of Intensive Care, Amsterdam University Medical Centres (UMC), University of Amsterdam, Meibergdreef 9, Amsterdam, AZ, 1105, The Netherlands
| | - Aniruddha Ghose
- Department of Medicine, Chattogram Medical Centre, Chattogram, Bangladesh
| | - Harm-Jan de Grooth
- Department of Intensive Care, UMC, Vrije Universiteit, Amsterdam, HV, 1081, The Netherlands
| | - Theis Skovsgaard Itenov
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Eleni Ischaki
- First Department of Intensive Care Medicine, University of Athens Medical School, 10676, Athens, AZ, Greece
| | - John Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, Galway University Hospitals, University of Galway, Galway, H91 TK33, Ireland
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centres (UMC), University of Amsterdam, Meibergdreef 9, Amsterdam, AZ, 1105, The Netherlands
| | - Pedro Póvoa
- NOVA Medical School, CHRC, NOVA University of Lisbon, Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
- Department of Intensive Care, Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal
| | - Charalampos Pierrakos
- Department of Intensive Care, Amsterdam University Medical Centres (UMC), University of Amsterdam, Meibergdreef 9, Amsterdam, AZ, 1105, The Netherlands
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, 1050, Brussels, Belgium
| | - Luigi Pisani
- Department of Intensive Care, Amsterdam University Medical Centres (UMC), University of Amsterdam, Meibergdreef 9, Amsterdam, AZ, 1105, The Netherlands
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Oriol Roca
- Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Institut de Recerca Part Taulí (I3PT-CERCA), Parc del Taulí 1, 08028, Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centres (UMC), University of Amsterdam, Meibergdreef 9, Amsterdam, AZ, 1105, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7BN, UK
| | - Konstanty Szuldrzynski
- Department of Anaesthesiology and Intensive Care, National Institute of Medicine of the Ministry of Interior and Administration, 02-507, Warsaw, Poland
| | - Pieter R Tuinman
- Department of Intensive Care, UMC, Vrije Universiteit, Amsterdam, HV, 1081, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - Claudio Zimatore
- Department of Intensive Care, Amsterdam University Medical Centres (UMC), University of Amsterdam, Meibergdreef 9, Amsterdam, AZ, 1105, The Netherlands
- Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, 70124, Bari, Italy
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam University Medical Centres (UMC), University of Amsterdam, Meibergdreef 9, Amsterdam, AZ, 1105, The Netherlands
- Department of Pulmonology, Amsterdam UMC, University of Amsterdam, Amsterdam, AZ, 1105, The Netherlands
- Laboratory of Experimental Intensive Care and Anaesthesiology (L.E.I.C.A.), University of Amsterdam, Amsterdam, AZ, 1105, The Netherlands
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Estenssoro E, González I, Plotnikow GA. Post-pandemic acute respiratory distress syndrome: A New Global Definition with extension to lower-resource regions. Med Intensiva 2024; 48:272-281. [PMID: 38644108 DOI: 10.1016/j.medine.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 04/23/2024]
Abstract
Acute respiratory distress syndrome (ARDS), first described in 1967, is characterized by acute respiratory failure causing profound hypoxemia, decreased pulmonary compliance, and bilateral CXR infiltrates. After several descriptions, the Berlin definition was adopted in 2012, which established three categories of severity according to hypoxemia (mild, moderate and severe), specified temporal aspects for diagnosis, and incorporated the use of non-invasive ventilation. The COVID-19 pandemic led to changes in ARDS management, focusing on continuous monitoring of oxygenation and on utilization of high-flow oxygen therapy and lung ultrasound. In 2021, a New Global Definition based on the Berlin definition of ARDS was proposed, which included a category for non-intubated patients, considered the use of SpO2, and established no particular requirement for oxygenation support in regions with limited resources. Although debates persist, the continuous evolution seeks to adapt to clinical and epidemiological needs, and to the search of personalized treatments.
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Affiliation(s)
- Elisa Estenssoro
- Escuela de Gobierno en Salud, Ministerio de Salud, Buenos Aires, Argentina; Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Buenos Aires, Argentina.
| | - Iván González
- Servicio de Rehabilitación, Área de Kinesiología Crítica, Hospital Británico de Buenos Aires, CABA, Argentina
| | - Gustavo A Plotnikow
- Servicio de Rehabilitación, Área de Kinesiología Crítica, Hospital Británico de Buenos Aires, CABA, Argentina; Facultad de Medicina y Ciencias de la Salud, Universidad Abierta Interamericana, Argentina
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7
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Yang P, Sjoding MW. Acute Respiratory Distress Syndrome: Definition, Diagnosis, and Routine Management. Crit Care Clin 2024; 40:309-327. [PMID: 38432698 DOI: 10.1016/j.ccc.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Acute respiratory distress syndrome (ARDS) is an acute inflammatory lung injury characterized by severe hypoxemic respiratory failure, bilateral opacities on chest imaging, and low lung compliance. ARDS is a heterogeneous syndrome that is the common end point of a wide variety of predisposing conditions, with complex pathophysiology and underlying mechanisms. Routine management of ARDS is centered on lung-protective ventilation strategies such as low tidal volume ventilation and targeting low airway pressures to avoid exacerbation of lung injury, as well as a conservative fluid management strategy.
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Affiliation(s)
- Philip Yang
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University, 6335 Hospital Parkway, Physicians Plaza Suite 310, Johns Creek, GA 30097, USA.
| | - Michael W Sjoding
- Division of Pulmonary and Critical Care Medicine, University of Michigan, 2800 Plymouth Road, NCRC, Building 16, G027W, Ann Arbor, MI 48109, USA
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8
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Altaf F, Bhatt V, Sekhon M, Shrivastava S, Mazhar N, Moore S. Segmental Shielding: A Rare Case of Acute Respiratory Distress Syndrome with Middle Lobe Sparing. Cureus 2024; 16:e57985. [PMID: 38738140 PMCID: PMC11087034 DOI: 10.7759/cureus.57985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2024] [Indexed: 05/14/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) presents a formidable challenge in critical care, often resulting in high mortality rates, particularly in severe cases or those compounded by preexisting conditions. Despite substantial advancements in critical care, the heterogeneous nature of ARDS necessitates nuanced clinical approaches. ARDS is generally diagnosed through clinical evaluation, radiographic imaging, and laboratory tests, as well as acute onset, bilateral lung infiltrates on imaging, and a partial pressure of oxygen in arterial blood (PaO2)/fraction of inspiratory oxygen concentration (FiO2) ratio of less than 300 mmHg. Management involves measurements to improve oxygenation and provide mechanical ventilation to assist breathing. The typical manifestation of ARDS is diffuse lung involvement, which affects multiple lobes symmetrically. Here, we report an unusual case of ARDS in a 53-year-old female who was brought into the hospital in an unresponsive state, exhibiting hypoxic and hypotension requiring intubation. Subsequent imaging revealed a distinctive pattern: the preservation of the right middle lobe, diverging from the conventional diffuse pulmonary affliction. This case underscores the need for clinical vigilance and adaptability, as such atypical presentations can confound diagnosis and management, posing unique clinical challenges. This case highlights the importance of recognizing ARDS' diverse presentations. Moreover, understanding the mechanisms behind the lobar sparing could provide greater insight into the disease heterogeneity and guide tailored therapeutic approaches. The imperative for further research into these uncommon presentations is clear, as it may be vital to improving outcomes for a broader spectrum of ARDS patients.
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Affiliation(s)
- Faryal Altaf
- Internal Medicine, BronxCare Health System, New York, USA
| | | | - Mohit Sekhon
- Internal Medicine, BronxCare Health System, New York, USA
| | - Shitij Shrivastava
- Internal Medicine, BronxCare Health System, New York, USA
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Naqash Mazhar
- Internal Medicine, BronxCare Health System, New York, USA
| | - Sarah Moore
- Obstetrics and Gynecology, American University of the Caribbean School of Medicine, Cupecoy, SXM
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9
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Matthay MA, Arabi Y, Arroliga AC, Bernard G, Bersten AD, Brochard LJ, Calfee CS, Combes A, Daniel BM, Ferguson ND, Gong MN, Gotts JE, Herridge MS, Laffey JG, Liu KD, Machado FR, Martin TR, McAuley DF, Mercat A, Moss M, Mularski RA, Pesenti A, Qiu H, Ramakrishnan N, Ranieri VM, Riviello ED, Rubin E, Slutsky AS, Thompson BT, Twagirumugabe T, Ware LB, Wick KD. A New Global Definition of Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:37-47. [PMID: 37487152 PMCID: PMC10870872 DOI: 10.1164/rccm.202303-0558ws] [Citation(s) in RCA: 74] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/24/2023] [Indexed: 07/26/2023] Open
Abstract
Background: Since publication of the 2012 Berlin definition of acute respiratory distress syndrome (ARDS), several developments have supported the need for an expansion of the definition, including the use of high-flow nasal oxygen, the expansion of the use of pulse oximetry in place of arterial blood gases, the use of ultrasound for chest imaging, and the need for applicability in resource-limited settings. Methods: A consensus conference of 32 critical care ARDS experts was convened, had six virtual meetings (June 2021 to March 2022), and subsequently obtained input from members of several critical care societies. The goal was to develop a definition that would 1) identify patients with the currently accepted conceptual framework for ARDS, 2) facilitate rapid ARDS diagnosis for clinical care and research, 3) be applicable in resource-limited settings, 4) be useful for testing specific therapies, and 5) be practical for communication to patients and caregivers. Results: The committee made four main recommendations: 1) include high-flow nasal oxygen with a minimum flow rate of ⩾30 L/min; 2) use PaO2:FiO2 ⩽ 300 mm Hg or oxygen saturation as measured by pulse oximetry SpO2:FiO2 ⩽ 315 (if oxygen saturation as measured by pulse oximetry is ⩽97%) to identify hypoxemia; 3) retain bilateral opacities for imaging criteria but add ultrasound as an imaging modality, especially in resource-limited areas; and 4) in resource-limited settings, do not require positive end-expiratory pressure, oxygen flow rate, or specific respiratory support devices. Conclusions: We propose a new global definition of ARDS that builds on the Berlin definition. The recommendations also identify areas for future research, including the need for prospective assessments of the feasibility, reliability, and prognostic validity of the proposed global definition.
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Affiliation(s)
- Michael A. Matthay
- Department of Medicine
- Department of Anesthesia
- Cardiovascular Research Institute, and
| | - Yaseen Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Gordon Bernard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Lung Research, and
| | | | - Laurent J. Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Carolyn S. Calfee
- Department of Medicine
- Department of Anesthesia
- Cardiovascular Research Institute, and
| | - Alain Combes
- Médecine Intensive – Réanimation, Sorbonne Université, APHP Hôpital Pitié-Salpêtrière, Paris, France
| | - Brian M. Daniel
- Respiratory Therapy, University of California, San Francisco, San Francisco, California
| | - Niall D. Ferguson
- Interdepartmental Division of Critical Care Medicine and
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michelle N. Gong
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Jeffrey E. Gotts
- Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | | | - John G. Laffey
- Anesthesia, University Hospital Galway, University of Galway, Galway, Ireland
| | | | - Flavia R. Machado
- Intensive Care Department, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Thomas R. Martin
- Department of Medicine, University of Washington, Seattle, Washington
| | - Danny F. McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Alain Mercat
- Medical ICU, Angers University Hospital, Angers, France
| | - Marc Moss
- Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | | | - Antonio Pesenti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Haibo Qiu
- Critical Care Medicine, Zhongda Hospital, Nanjing, China
| | | | - V. Marco Ranieri
- Emergency and Intensive Care Medicine, Alma Mater Studorium University of Bologna, Bologna, Italy
| | - Elisabeth D. Riviello
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Arthur S. Slutsky
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Theogene Twagirumugabe
- Department of Anesthesia, Critical Care, and Emergency Medicine, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda; and
| | - Lorraine B. Ware
- Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Katherine D. Wick
- Department of Medicine, University of California, Davis, Davis, California
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10
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Saha R, Pham T, Sinha P, Maddali MV, Bellani G, Fan E, Summers C, Douiri A, Rubenfeld GD, Calfee CS, Laffey JG, McAuley DF, Shankar-Hari M. Estimating the attributable fraction of mortality from acute respiratory distress syndrome to inform enrichment in future randomised clinical trials. Thorax 2023; 78:990-1003. [PMID: 37495364 PMCID: PMC10581447 DOI: 10.1136/thorax-2023-220262] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/03/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Efficiency of randomised clinical trials of acute respiratory distress syndrome (ARDS) depends on the fraction of deaths attributable to ARDS (AFARDS) to which interventions are targeted. Estimates of AFARDS in subpopulations of ARDS could improve design of ARDS trials. METHODS We performed a matched case-control study using the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE cohort. Primary outcome was intensive care unit mortality. We used nearest neighbour propensity score matching without replacement to match ARDS to non-ARDS populations. We derived two separate AFARDS estimates by matching patients with ARDS to patients with non-acute hypoxaemic respiratory failure (non-AHRF) and to patients with AHRF with unilateral infiltrates only (AHRF-UL). We also estimated AFARDS in subgroups based on severity of hypoxaemia, number of lung quadrants involved and hyperinflammatory versus hypoinflammatory phenotypes. Additionally, we derived AFAHRF estimates by matching patients with AHRF to non-AHRF controls, and AFAHRF-UL estimates by matching patients with AHRF-UL to non-AHRF controls. RESULTS Estimated AFARDS was 20.9% (95% CI 10.5% to 31.4%) when compared with AHRF-UL controls and 38.0% (95% CI 34.4% to 41.6%) compared with non-AHRF controls. Within subgroups, estimates for AFARDS compared with AHRF-UL controls were highest in patients with severe hypoxaemia (41.1% (95% CI 25.2% to 57.1%)), in those with four quadrant involvement on chest radiography (28.9% (95% CI 13.4% to 44.3%)) and in the hyperinflammatory subphenotype (26.8% (95% CI 6.9% to 46.7%)). Estimated AFAHRF was 33.8% (95% CI 30.5% to 37.1%) compared with non-AHRF controls. Estimated AFAHRF-UL was 21.3% (95% CI 312.8% to 29.7%) compared with non-AHRF controls. CONCLUSIONS Overall AFARDS mean values were between 20.9% and 38.0%, with higher AFARDS seen with severe hypoxaemia, four quadrant involvement on chest radiography and hyperinflammatory ARDS.
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Affiliation(s)
- Rohit Saha
- Criticlal Care, King's College Hospital NHS Trust, London, UK
- School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Tài Pham
- Service de médecine intensive-réanimation, Paris-Saclay University Faculty of Medicine, Le Kremlin-Bicetre, France
- Equipe d'Epidémiologie respiratoire intégrative, CESP, Paris-Saclay University, Gif-sur-Yvette, France
| | - Pratik Sinha
- Department of Anaesthesiology, Washington University in St Louis, St Louis, Missouri, USA
| | - Manoj V Maddali
- Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, California, USA
| | - Giacomo Bellani
- Emergency and Intensive Care, University of Milan-Bicocca, Monza, Italy
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Charlotte Summers
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, King's College London, London, UK
| | - Gordon D Rubenfeld
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Carolyn S Calfee
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, USA
| | - John Gerard Laffey
- Anaesthesia, School of Medicine, National University of Ireland Galway, Galway, Ireland
- National Centre for Biomedical Engineering Sciences, National University of Ireland Galway, Galway, Ireland
| | - Daniel Francis McAuley
- ICU, QUB, Belfast, UK
- School of Medicine,Dentistry and Biomedical Sciences, Queen's University Belfast Wellcome-Wolfson Institute for Experimental Medicine, Belfast, UK
| | - Manu Shankar-Hari
- Centre for Inflammation Research, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
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11
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Liu L, Zhang Y, Wang Y, He Y, Ding X, Chen L, Shi Y. The perinatal period should be considered in neonatal acute respiratory distress syndrome: comparison of the Montreux definition vs. the second pediatric acute lung injury consensus conference definition. Front Pediatr 2023; 11:1216073. [PMID: 37842021 PMCID: PMC10568643 DOI: 10.3389/fped.2023.1216073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/19/2023] [Indexed: 10/17/2023] Open
Abstract
Background The recently developed Montreux definition for neonatal acute respiratory distress syndrome (ARDS) partially differs from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) definition. Here, we compare the Montreux and PALICC-2 definitions regarding morbidity, mortality, and prognosis of neonatal cases of ARDS in order to evaluate which definition is more appropriate for newborns. Methods Neonates admitted to our neonatal intensive care unit between 1 January 2018 and 30 September 2019 who met the Montreux or PALICC-2 definition of neonatal ARDS were retrospectively analyzed (n = 472). One comparison was made between application of the Montreux and PALICC-2 definitions to neonates outside the perinatal period (> 7 d after birth). A second comparison was made between a diagnosis of neonatal ARDS within (≤ 7 d of birth) and outside (> 7 d after birth) the perinatal period using the Montreux definition. Results No significant differences in morbidity, mortality, severity, therapies, or prognosis were observed between neonates in the extra perinatal group according to the Montreux and PALICC-2 definitions. However, epidemiology, clinical course, and prognosis of neonatal ARDS within the perinatal period did differ from those outside the perinatal period according to the Montreux definition. Conclusion Neonates with ARDS within the perinatal period have unique triggers, epidemiology, clinical course, and prognosis, yet a similar pathobiology pattern, to neonates at other ages. Therefore, it may be essential to consider the perinatal period when defining neonatal ARDS.
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Affiliation(s)
- Liting Liu
- Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yihan Zhang
- Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yiran Wang
- Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yu He
- Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xionghui Ding
- Department of Burn and Plastic Surgery, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Long Chen
- Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yuan Shi
- Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China
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12
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Sathe NA, Xian S, Mabrey FL, Crosslin DR, Mooney SD, Morrell ED, Lybarger K, Yetisgen M, Jarvik GP, Bhatraju PK, Wurfel MM. Evaluating construct validity of computable acute respiratory distress syndrome definitions in adults hospitalized with COVID-19: an electronic health records based approach. BMC Pulm Med 2023; 23:292. [PMID: 37559024 PMCID: PMC10413524 DOI: 10.1186/s12890-023-02560-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/11/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Evolving ARDS epidemiology and management during COVID-19 have prompted calls to reexamine the construct validity of Berlin criteria, which have been rarely evaluated in real-world data. We developed a Berlin ARDS definition (EHR-Berlin) computable in electronic health records (EHR) to (1) assess its construct validity, and (2) assess how expanding its criteria affected validity. METHODS We performed a retrospective cohort study at two tertiary care hospitals with one EHR, among adults hospitalized with COVID-19 February 2020-March 2021. We assessed five candidate definitions for ARDS: the EHR-Berlin definition modeled on Berlin criteria, and four alternatives informed by recent proposals to expand criteria and include patients on high-flow oxygen (EHR-Alternative 1), relax imaging criteria (EHR-Alternatives 2-3), and extend timing windows (EHR-Alternative 4). We evaluated two aspects of construct validity for the EHR-Berlin definition: (1) criterion validity: agreement with manual ARDS classification by experts, available in 175 patients; (2) predictive validity: relationships with hospital mortality, assessed by Pearson r and by area under the receiver operating curve (AUROC). We assessed predictive validity and timing of identification of EHR-Berlin definition compared to alternative definitions. RESULTS Among 765 patients, mean (SD) age was 57 (18) years and 471 (62%) were male. The EHR-Berlin definition classified 171 (22%) patients as ARDS, which had high agreement with manual classification (kappa 0.85), and was associated with mortality (Pearson r = 0.39; AUROC 0.72, 95% CI 0.68, 0.77). In comparison, EHR-Alternative 1 classified 219 (29%) patients as ARDS, maintained similar relationships to mortality (r = 0.40; AUROC 0.74, 95% CI 0.70, 0.79, Delong test P = 0.14), and identified patients earlier in their hospitalization (median 13 vs. 15 h from admission, Wilcoxon signed-rank test P < 0.001). EHR-Alternative 3, which removed imaging criteria, had similar correlation (r = 0.41) but better discrimination for mortality (AUROC 0.76, 95% CI 0.72, 0.80; P = 0.036), and identified patients median 2 h (P < 0.001) from admission. CONCLUSIONS The EHR-Berlin definition can enable ARDS identification with high criterion validity, supporting large-scale study and surveillance. There are opportunities to expand the Berlin criteria that preserve predictive validity and facilitate earlier identification.
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Affiliation(s)
- Neha A Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA.
| | - Su Xian
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA
| | - F Linzee Mabrey
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA
| | - David R Crosslin
- Division of Biomedical Informatics and Genomics, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Sean D Mooney
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA
| | - Eric D Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA
| | - Kevin Lybarger
- Department of Information Sciences and Technology, George Mason University, Fairfax, VA, USA
| | - Meliha Yetisgen
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA
| | - Gail P Jarvik
- Department of Genome Sciences and Division of Medical Genetics, Department of Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA
| | - Mark M Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA
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13
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Grasselli G, Calfee CS, Camporota L, Poole D, Amato MBP, Antonelli M, Arabi YM, Baroncelli F, Beitler JR, Bellani G, Bellingan G, Blackwood B, Bos LDJ, Brochard L, Brodie D, Burns KEA, Combes A, D'Arrigo S, De Backer D, Demoule A, Einav S, Fan E, Ferguson ND, Frat JP, Gattinoni L, Guérin C, Herridge MS, Hodgson C, Hough CL, Jaber S, Juffermans NP, Karagiannidis C, Kesecioglu J, Kwizera A, Laffey JG, Mancebo J, Matthay MA, McAuley DF, Mercat A, Meyer NJ, Moss M, Munshi L, Myatra SN, Ng Gong M, Papazian L, Patel BK, Pellegrini M, Perner A, Pesenti A, Piquilloud L, Qiu H, Ranieri MV, Riviello E, Slutsky AS, Stapleton RD, Summers C, Thompson TB, Valente Barbas CS, Villar J, Ware LB, Weiss B, Zampieri FG, Azoulay E, Cecconi M. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med 2023; 49:727-759. [PMID: 37326646 PMCID: PMC10354163 DOI: 10.1007/s00134-023-07050-7] [Citation(s) in RCA: 172] [Impact Index Per Article: 172.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.
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Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | | | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Francesca Baroncelli
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Geoff Bellingan
- Intensive Care Medicine, University College London, NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurent Brochard
- Keenan Research Center, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Critical Care, Unity Health Toronto - Saint Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013, Paris, France
| | - Sonia D'Arrigo
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Sharon Einav
- Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology and Critical Care, Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Departments of Medicine and Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jean-Pierre Frat
- CHU De Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM, CIC-1402, IS-ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Claude Guérin
- University of Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7200, Créteil, France
| | - Margaret S Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Catherine L Hough
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi Teaching Hospital, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier, France
| | - Nicole P Juffermans
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken Der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arthur Kwizera
- Makerere University College of Health Sciences, School of Medicine, Department of Anesthesia and Intensive Care, Kampala, Uganda
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, College of Medicine Nursing and Health Sciences, University of Galway, Galway, Ireland
- Anesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospitals Groups, Galway, Ireland
| | - Jordi Mancebo
- Intensive Care Department, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Alain Mercat
- Département de Médecine Intensive Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - Nuala J Meyer
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Canada
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Michelle Ng Gong
- Division of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Laurent Papazian
- Bastia General Hospital Intensive Care Unit, Bastia, France
- Aix-Marseille University, Faculté de Médecine, Marseille, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mariangela Pellegrini
- Anesthesia and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Marco V Ranieri
- Alma Mater Studiorum - Università di Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Elisabeth Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charlotte Summers
- Department of Medicine, University of Cambridge Medical School, Cambridge, UK
| | - Taylor B Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Carmen S Valente Barbas
- University of São Paulo Medical School, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jesús Villar
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM CVK), Charitè - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Fernando G Zampieri
- Academic Research Organization, Albert Einstein Hospital, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris Cité University, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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14
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Tommasino N, Koolhaas A, Mizraji R, Zamit O, Lacuesta G. Ultrasound Scanning in Lung Procurement. Protocol for Decision-Making With the Purpose of Increasing Transplant Eligible Lungs. Transplant Proc 2023; 55:1463-1465. [PMID: 36973147 DOI: 10.1016/j.transproceed.2023.02.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/08/2023] [Accepted: 02/20/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND The main obstacle to obtaining lungs for transplantation is the shortage of donors. Once potential donors have been offered to transplant programs, the acceptance rate is highly variable, ranging from 5% to 20%. Minimizing donor leakage by converting potential lung donors into real donors is one of the key elements to improve results, and it is essential to have tools that facilitate decision-making in this scenario. The selection and rejection of transplantation-eligible lungs are usually made with chest x-rays; however, lung ultrasound scanning has shown better sensitivity and specificity for diagnosing pulmonary pathologies. Lung ultrasound scanning allows us to identify the reversible causes of low PaO2/fraction of inspired oxygen (FIO2) ratio, thus enabling the establishment of specific interventions, which, if proved successful, could turn lungs into transplant-eligible lungs. The available literature on its use in managing brain death donors and lung procurement is extremely scarce. METHODS A simple protocol aimed at identifying and treating the main reversible causes of low PaO2/FIO2 ratio to aid in decision-making is presented in this paper. CONCLUSION Lung ultrasound is a powerful, useful, and cheap technique available at the donor's bedside. It is conspicuously underused, despite being potentially helpful in decision-making by minimizing the discarding of donors, thus probably increasing the number of lungs sui for transplantation.
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Affiliation(s)
- Nicolas Tommasino
- National Lung Transplant Program, National Resources Fund, Montevideo, Uruguay; Procurement Department, National Institute for Donation and Transplantation, Montevideo, Uruguay.
| | - Andrea Koolhaas
- Critical Care Department, Evangelic Hospital, Montevideo, Uruguay
| | - Raul Mizraji
- Procurement Department, National Institute for Donation and Transplantation, Montevideo, Uruguay
| | - Olga Zamit
- Procurement Department, National Institute for Donation and Transplantation, Montevideo, Uruguay
| | - Gonzalo Lacuesta
- Procurement Department, National Institute for Donation and Transplantation, Montevideo, Uruguay
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15
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Smit MR, Hagens LA, Heijnen NFL, Pisani L, Cherpanath TGV, Dongelmans DA, de Grooth HJS, Pierrakos C, Tuinman PR, Zimatore C, Paulus F, Schnabel RM, Schultz MJ, Bergmans DCJJ, Bos LDJ. Lung Ultrasound Prediction Model for Acute Respiratory Distress Syndrome: A Multicenter Prospective Observational Study. Am J Respir Crit Care Med 2023; 207:1591-1601. [PMID: 36790377 PMCID: PMC10273105 DOI: 10.1164/rccm.202210-1882oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 02/14/2023] [Indexed: 02/16/2023] Open
Abstract
Rationale: Lung ultrasound (LUS) is a promising tool for diagnosis of acute respiratory distress syndrome (ARDS), but adequately sized studies with external validation are lacking. Objectives: To develop and validate a data-driven LUS score for diagnosis of ARDS and compare its performance with that of chest radiography (CXR). Methods: This multicenter prospective observational study included invasively ventilated ICU patients who were divided into a derivation cohort and a validation cohort. Three raters scored ARDS according to the Berlin criteria, resulting in a classification of "certain no ARDS," or "certain ARDS" when experts agreed or "uncertain ARDS" when evaluations conflicted. Uncertain cases were classified in a consensus meeting. Results of a 12-region LUS exam were used in a logistic regression model to develop the LUS-ARDS score. Measurements and Main Results: Three hundred twenty-four (16% certain ARDS) and 129 (34% certain ARDS) patients were included in the derivation cohort and the validation cohort, respectively. With an ARDS diagnosis by the expert panel as the reference test, the LUS-ARDS score, including the left and right LUS aeration scores and anterolateral pleural line abnormalities, had an area under the receiver operating characteristic (ROC) curve of 0.90 (95% confidence interval [CI], 0.85-0.95) in certain patients of the derivation cohort and 0.80 (95% CI, 0.72-0.87) in all patients of the validation cohort. Within patients who had imaging-gold standard chest computed tomography available, diagnostic accuracy of eight independent CXR readers followed the ROC curve of the LUS-ARDS score. Conclusions: The LUS-ARDS score can be used to accurately diagnose ARDS also after external validation. The LUS-ARDS score may be a useful adjunct to a diagnosis of ARDS after further validation, as it showed performance comparable with that of the current practice with experienced CXR readers but more objectifiable diagnostic accuracy at each cutoff.
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Affiliation(s)
- Marry R. Smit
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Laura A. Hagens
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | | | - Luigi Pisani
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Department of Anesthesia and Intensive Care, Miulli Regional Hospital, Acquaviva delle Fonti, Italy
| | - Thomas G. V. Cherpanath
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Dave A. Dongelmans
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Harm-Jan S. de Grooth
- Intensive Care, Amsterdam UMC, locatie Vrije Universiteit Amsterdam, Amsterdam, Nederland
| | - Charalampos Pierrakos
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Department of Intensive Care, Brugmann University Hospital, Free University of Brussels, Brussels, Belgium
| | - Pieter Roel Tuinman
- Intensive Care, Amsterdam UMC, locatie Vrije Universiteit Amsterdam, Amsterdam, Nederland
| | - Claudio Zimatore
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Intensive Care Unit, Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Ronny M. Schnabel
- Department of Intensive Care, Maastricht UMC+, Maastricht, the Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom; and
| | - Dennis C. J. J. Bergmans
- Department of Intensive Care, Maastricht UMC+, Maastricht, the Netherlands
- School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
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16
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Ramji HF, Hafiz M, Altaq HH, Hussain ST, Chaudry F. Acute Respiratory Distress Syndrome; A Review of Recent Updates and a Glance into the Future. Diagnostics (Basel) 2023; 13:diagnostics13091528. [PMID: 37174920 PMCID: PMC10177247 DOI: 10.3390/diagnostics13091528] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 05/15/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a rapidly progressive form of respiratory failure that accounts for 10% of admissions to the ICU and is associated with approximately 40% mortality in severe cases. Despite significant mortality and healthcare burden, the mainstay of management remains supportive care. The recent pandemic of SARS-CoV-2 has re-ignited a worldwide interest in exploring the pathophysiology of ARDS, looking for innovative ideas to treat this disease. Recently, many trials have been published utilizing different pharmacotherapy targets; however, the long-term benefits of these agents remain unknown. Metabolomics profiling and stem cell transplantation offer strong enthusiasm and may completely change the outlook of ARDS management in the near future.
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Affiliation(s)
- Husayn F Ramji
- University of Oklahoma College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Maida Hafiz
- Department of Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Hiba Hammad Altaq
- Department of Pulmonary, Critical Care & Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Syed Talal Hussain
- Department of Pulmonary, Critical Care & Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Fawad Chaudry
- Department of Pulmonary, Critical Care & Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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17
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Ramsey WA, O'Neil CF, Saberi RA, Meece MS, Gilna GP, Kaufman JI, Lieberman HM, Lineen EB, Meizoso JP, Pizano LR, Satahoo SS, Danton GH, Proctor KG, Namias N. Examining the Definition of Ventilator-Associated Pneumonia in the Trauma Setting: A Single-Center Analysis. Surg Infect (Larchmt) 2023; 24:322-326. [PMID: 36944154 DOI: 10.1089/sur.2022.272] [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: 03/23/2023] Open
Abstract
Background: Ventilator associated pneumonia (VAP) is defined by the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) using laboratory findings, pathophysiologic signs/symptoms, and imaging criteria. However, many critically ill trauma patients meet the non-specific laboratory and sign/symptom thresholds for VAP, so the TQIP designation of VAP depends heavily upon imaging evidence. We hypothesized that physician opinions widely vary regarding chest radiograph findings significant for VAP. Patients and Methods: The TQIP Spring 2021 Benchmark Report (BR) was used to identify 14 patients with VAP at an academic Level 1 Trauma Center. Critically ill trauma patients (n = 7) who spent at least four days intubated and met TQIP's laboratory and sign/symptom thresholds for VAP but did not appear as VAPs on the BR comprised the control group. For each deidentified patient, four successive chest radiographic images were compiled and arranged chronologically. Cases and controls were randomly arranged in digital format. Blinded physicians (n = 27) were asked to identify patients with VAP based solely on imaging evidence. Results: Radiographic evidence of VAP was highly subjective (Krippendorff α = 0.134). Among physicians of the same job description, inter-rater reliability remained low (α = 0.137 for trauma attending physicians; α = 0.141 for trauma fellows; α = 0.271 for radiologists). When majority judgment was compared to the TQIP BR, there was disagreement between the two tests (Cohen κ = -0.071; sensitivity, 64.3%; specificity, 28.6%). Conclusions: Current definitions of VAP rely on subjective imaging interpretation and ignore the reality that there are numerous explanations for opacities on CXR. The inconsistency of physicians' imaging interpretation and protean physiologic findings for VAP in trauma patients should preclude the current definition of VAP from being used as a quality improvement metric in TQIP.
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Affiliation(s)
- Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Christopher F O'Neil
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Rebecca A Saberi
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Matthew S Meece
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Gareth P Gilna
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Joyce I Kaufman
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Howard M Lieberman
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Edward B Lineen
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Louis R Pizano
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Shevonne S Satahoo
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Gary H Danton
- Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Kenneth G Proctor
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
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18
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Acute Respiratory Distress Syndrome in Pregnancy: Updates in Principles and Practice. Clin Obstet Gynecol 2023; 66:208-222. [PMID: 36657055 DOI: 10.1097/grf.0000000000000763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Acute respiratory failure occurs in 0.05% to 0.3% of pregnancies and is precipitated by pulmonary and nonpulmonary insults. Acute respiratory distress syndrome (ARDS) is the rapid onset of hypoxemic respiratory failure associated with bilateral pulmonary opacities on chest imaging attributed to noncardiogenic pulmonary edema. The pathophysiological features of ARDS include hypoxemia, diminished lung volumes, and decreased lung compliance. While there is a paucity of data concerning ARDS in the pregnant individual, management principles do not vary significantly between pregnant and nonpregnant patients. The following review will discuss the diagnosis and management of the pregnant patient with ARDS.
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19
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Ranieri VM, Rubenfeld G, Slutsky AS. Rethinking Acute Respiratory Distress Syndrome after COVID-19: If a "Better" Definition Is the Answer, What Is the Question? Am J Respir Crit Care Med 2023; 207:255-260. [PMID: 36150099 PMCID: PMC9896638 DOI: 10.1164/rccm.202206-1048cp] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The definition of acute respiratory distress syndrome (ARDS) has a somewhat controversial history, with some even questioning the need for the term "ARDS." This controversy has been amplified by the coronavirus disease (COVID-19) pandemic given the marked increase in the incidence of ARDS, the relatively new treatment modalities that do not fit neatly with the Berlin definition, and the difficulty of making the diagnosis in resource-limited settings. We propose that attempts to revise the definition of ARDS should apply the framework originally developed by psychologists and social scientists and used by other medical disciplines to generate and assess definitions of clinical syndromes that do not have gold standards. This framework is structured around measures of reliability, feasibility, and validity. Future revisions of the definition of ARDS should contain the purpose, the methodology, and the framework for empirically testing any proposed definition. Attempts to revise critical illness syndromes' definitions usually hope to make them "better"; our recommendation is that future attempts use the same criteria used by other fields in defining what "better" means.
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Affiliation(s)
- V Marco Ranieri
- Alma Mater Studiorum - Università di Bologna, Dipartimento di Scienze Mediche e Chirurgiche, IRCCS Policlinico di Sant'Orsola, Anesthesia and Intensive Care Medicine, Bologna, Italy
| | - Gordon Rubenfeld
- Department of Critical Care, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Arthur S Slutsky
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; and.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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20
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Blanchard F, James A, Assefi M, Kapandji N, Constantin JM. Personalized medicine targeting different ARDS phenotypes: The future of pharmacotherapy for ARDS? Expert Rev Respir Med 2023; 17:41-52. [PMID: 36724878 DOI: 10.1080/17476348.2023.2176302] [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: 02/03/2023]
Abstract
INTRODUCTION Acute respiratory distress syndrome (ARDS) still represents a major challenge with high mortality rates and altered quality of life. Many well-designed studies have failed to improve ARDS outcomes. Heterogeneity of etiologies, mechanisms of lung damage, different lung mechanics, and different treatment approaches may explain these failures. At the era of personalized medicine, ARDS phenotyping is not only a field of research, but a bedside consideration when implementing therapy. ARDS has moved from being a simple syndrome to a more complex area of subgrouping. Intensivists must understand these phenotypes and therapies associated with a better outcome. AREAS COVERED After a brief sum-up of the different type of ARDS phenotypes, we will present some relevant therapy that may be impacted by phenotyping. A focus on pharmacotherapy will be realized before a section on non-pharmaceutical strategies. Eventually, we will highlight the limits of our knowledge of phenotyping and the pitfalls of personalized medicine. EXPERT OPINION Biological and morphological ARDS phenotypes are now well studied. The future of ARDS therapy will go through phenotyping that allows a personalized medication for each patient. However, a better assessment of these phenotypes is required, and clinical trials should be conducted with an ad-hoc phenotyping before randomization.
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Affiliation(s)
- Florian Blanchard
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France.,Antimicrobial Stewardship Team GH Paris Centre, Cochin Hospital, APHP, Paris, France
| | - Arthur James
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Mona Assefi
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Natacha Kapandji
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Jean-Michel Constantin
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
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21
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Worku ET, Yeung F, Anstey C, Shekar K. The impact of reduction in intensity of mechanical ventilation upon venovenous ECMO initiation on radiographically assessed lung edema scores: A retrospective observational study. Front Med (Lausanne) 2022; 9:1005192. [PMID: 36203770 PMCID: PMC9531725 DOI: 10.3389/fmed.2022.1005192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/26/2022] [Indexed: 11/26/2022] Open
Abstract
Background Patients with severe acute respiratory distress syndrome (ARDS) typically receive ultra-protective ventilation after extracorporeal membrane oxygenation (ECMO) is initiated. While the benefit of ECMO appears to derive from supporting “lung rest”, reductions in the intensity of mechanical ventilation, principally tidal volume limitation, may manifest radiologically. This study evaluated the relative changes in radiographic assessment of lung edema (RALE) score upon venovenous ECMO initiation in patients with severe ARDS. Methods Digital chest x-rays (CXR) performed at baseline immediately before initiation of ECMO, and at intervals post (median 1.1, 2.1, and 9.6 days) were reviewed in 39 Adult ARDS patients. One hundred fifty-six digital images were scored by two independent, blinded radiologists according to the RALE (Radiographic Assessment of Lung Edema) scoring criteria. Ventilatory data, ECMO parameters and fluid balance were recorded at corresponding time points. Multivariable analysis was performed analyzing the change in RALE score over time relative to baseline. Results The RALE score demonstrated excellent inter-rater agreement in this novel application in an ECMO cohort. Mean RALE scores increased from 28 (22–37) at baseline to 35 (26–42) (p < 0.001) on D1 of ECMO; increasing RALE was associated with higher baseline APACHE III scores [ß value +0.19 (0.08, 0.30) p = 0.001], and greater reductions in tidal volume [ß value −2.08 (−3.07, −1.10) p < 0.001] after ECMO initiation. Duration of mechanical ventilation, and ECMO support did not differ between survivors and non-survivors. Conclusions The magnitude of reductions in delivered tidal volumes correlated with increasing RALE scores (radiographic worsening) in ARDS patients receiving ECMO. Implications for patient centered outcomes remain unclear. There is a need to define appropriate ventilator settings on venovenous ECMO, counterbalancing the risks vs. benefits of optimal “lung rest” against potential atelectrauma.
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Affiliation(s)
- Elliott T. Worku
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- *Correspondence: Elliott T. Worku
| | - Francis Yeung
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Chris Anstey
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- School of Medicine, Griffith University, Sunshine Coast Campus, Birtinya, QLD, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
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22
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Hagens LA, Van der Ven FLIM, Heijnen NFL, Smit MR, Gietema HA, Gerretsen SC, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Improvement of an interobserver agreement of ARDS diagnosis by adding additional imaging and a confidence scale. Front Med (Lausanne) 2022; 9:950827. [PMID: 36117964 PMCID: PMC9473335 DOI: 10.3389/fmed.2022.950827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) often is not recognized in clinical practice, largely due to variation in the interpretation of chest x-ray (CXR) leading to poor interobserver reliability. We hypothesized that the agreement in the interpretation of chest imaging for the diagnosis of ARDS in invasively ventilated intensive care unit patients between experts improves when using an 8-grade confidence scale compared to using a dichotomous assessment and that the agreement increases after adding chest computed tomography (CT) or lung ultrasound (LUS) to CXR. Three experts scored ARDS according to the Berlin definition based on case records from an observational cohort study using a dichotomous assessment and an 8-grade confidence scale. The intraclass correlation (ICC), imaging modality, and the scoring method were calculated per day and compared using bootstrapping. A consensus judgement on the presence of ARDS was based on the combined confidence grades of the experts, followed by a consensus meeting for conflicting scores. In total, 401 patients were included in the analysis. The best ICC was found using an 8-grade confidence scale for LUS (ICC: 0.49; 95%-CI: 0.29–0.63) and CT evaluation (ICC: 0.49; 95%-CI: 0.34–0.61). The ICC of CXR increased by 0.022 and of CT by 0.065 when 8-grade scoring was used instead of the dichotomous assessment. Adding information from LUS or chest CT increased the ICC by 0.25 when using the 8-grade confidence assessment. An agreement on the diagnosis of ARDS can increase substantially by adapting the scoring system from a dichotomous assessment to an 8-grade confidence scale and by adding additional imaging modalities such as LUS or chest CT. This suggests that a simple assessment of the diagnosis of ARDS with a chart review by one assessor is insufficient to define ARDS in future studies.
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Affiliation(s)
- Laura A. Hagens
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- *Correspondence: Laura A. Hagens
| | - Fleur L. I. M. Van der Ven
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Intensive Care, Rode Kruis Ziekenhuis, Brandwondencentrum, Beverwijk, Netherlands
| | - Nanon F. L. Heijnen
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Marry R. Smit
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Hester A. Gietema
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands
| | - Suzanne C. Gerretsen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Medical Affairs, Hamilton Medical AG, Bonaduz, Switzerland
| | - Dennis C. J. J. Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, Netherlands
| | - Ronny M. Schnabel
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands
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23
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Hanley C, Giacomini C, Brennan A, McNicholas B, Laffey JG. Insights Regarding the Berlin Definition of ARDS from Prospective Observational Studies. Semin Respir Crit Care Med 2022; 43:379-389. [PMID: 35679873 DOI: 10.1055/s-0042-1744306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The definition of acute respiratory distress syndrome (ARDS), has evolved since it was first described in 1967 by Ashbaugh and Petty to the current "Berlin" definition of ARDS developed in 2012 by an expert panel, that provided clarification on the definition of "acute," and on the cardiac failure criteria. It expanded the definition to include patients receiving non-invasive ventilation, and removed the term "acute lung injury" and added a requirement of patients to be receiving a minimum 5 cmH2O expiratory pressure.Since 2012, a series of observational cohort studies have generated insights into the utility and robustness of this definition. This review will examine novel insights into the epidemiology of ARDS, failures in ARDS diagnosis, the role of lung imaging in ARDS, the novel ARDS cohort that is not invasively ventilated, lung compliance profiles in patients with ARDS, sex differences that exist in ARDS management and outcomes, the progression of ARDS following initial diagnosis, and the clinical profile and outcomes of confirmed versus resolved ARDS. Furthermore, we will discuss studies that challenge the utility of distinguishing ARDS from other causes of acute hypoxemic respiratory failure (AHRF) and identify issues that may need to be addressed in a revised definition.
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Affiliation(s)
- Ciara Hanley
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - Camilla Giacomini
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - Aoife Brennan
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - Bairbre McNicholas
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - John G Laffey
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland.,Regenerative Medicine Institute, National University of Ireland, Galway, Ireland
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24
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Valk CMA, Zimatore C, Mazzinari G, Pierrakos C, Sivakorn C, Dechsanga J, Grasso S, Beenen L, Bos LDJ, Paulus F, Schultz MJ, Pisani L. The Prognostic Capacity of the Radiographic Assessment for Lung Edema Score in Patients With COVID-19 Acute Respiratory Distress Syndrome-An International Multicenter Observational Study. Front Med (Lausanne) 2022; 8:772056. [PMID: 35071263 PMCID: PMC8766516 DOI: 10.3389/fmed.2021.772056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/24/2021] [Indexed: 01/08/2023] Open
Abstract
Background: The radiographic assessment for lung edema (RALE) score has an association with mortality in patients with acute respiratory distress syndrome (ARDS). It is uncertain whether the RALE scores at the start of invasive ventilation or changes thereof in the next days have prognostic capacities in patients with COVID-19 ARDS. Aims and Objectives: To determine the prognostic capacity of the RALE score for mortality and duration of invasive ventilation in patients with COVID-19 ARDS. Methods: An international multicenter observational study included consecutive patients from 6 ICUs. Trained observers scored the first available chest X-ray (CXR) obtained within 48 h after the start of invasive ventilation (“baseline CXR”) and each CXRs thereafter up to day 14 (“follow-up CXR”). The primary endpoint was mortality at day 90. The secondary endpoint was the number of days free from the ventilator and alive at day 28 (VFD-28). Results: A total of 350 CXRs were scored in 139 patients with COVID-19 ARDS. The RALE score of the baseline CXR was high and was not different between survivors and non-survivors (33 [24–38] vs. 30 [25–38], P = 0.602). The RALE score of the baseline CXR had no association with mortality (hazard ratio [HR], 1.24 [95% CI 0.88–1.76]; P = 0.222; area under the receiver operating characteristic curve (AUROC) 0.50 [0.40–0.60]). A change in the RALE score over the first 14 days of invasive ventilation, however, had an independent association with mortality (HR, 1.03 [95% CI 1.01–1.05]; P < 0.001). When the event of death was considered, there was no significant association between the RALE score of the baseline CXR and the probability of being liberated from the ventilator (HR 1.02 [95% CI 0.99–1.04]; P = 0.08). Conclusion: In this cohort of patients with COVID-19 ARDS, with high RALE scores of the baseline CXR, the RALE score of the baseline CXR had no prognostic capacity, but an increase in the RALE score in the next days had an association with higher mortality.
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Affiliation(s)
- Christel M A Valk
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Amsterdam, Netherlands
| | - Claudio Zimatore
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Amsterdam, Netherlands.,Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Guido Mazzinari
- Department of Anaesthesiology and Critical Care, Hospital Universitario y Politecnico la Fe, Valencia, Spain.,Perioperative Medicine Research Group, Instituto de Investigación Sanitaria la Fe, Valencia, Spain
| | - Charalampos Pierrakos
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Amsterdam, Netherlands.,Department of Intensive Care, Centre Hospitalier Universitaire Brussels, Brussels, Belgium
| | - Chaisith Sivakorn
- Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Jutamas Dechsanga
- Division of Pulmonary and Critical Care, Department of Medicine, Chonburi Hospital, Chonburi, Thailand
| | - Salvatore Grasso
- Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Ludo Beenen
- Department of Radiology, Amsterdam UMC, Amsterdam, Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Amsterdam, Netherlands.,Department of Pulmonology, Amsterdam UMC, Amsterdam, Netherlands
| | - Frederique Paulus
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Amsterdam, Netherlands.,Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Marcus J Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Amsterdam, Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Luigi Pisani
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Amsterdam, Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Anaesthesia and Intensive Care Unit, Miulli Regional Hospital, Acquaviva delle Fonti, Italy
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25
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Brown SM, Peltan ID, Barkauskas C, Rogers AJ, Kan V, Gelijns A, Thompson BT. What Does Acute Respiratory Distress Syndrome Mean during the COVID-19 Pandemic? Ann Am Thorac Soc 2021; 18:1948-1950. [PMID: 34288834 PMCID: PMC8641820 DOI: 10.1513/annalsats.202105-534ps] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/21/2021] [Indexed: 12/21/2022] Open
Affiliation(s)
- Samuel M. Brown
- Intermountain Medical Center and University of Utah, Salt Lake City, Utah
| | - Ithan D. Peltan
- Intermountain Medical Center and University of Utah, Salt Lake City, Utah
| | | | | | - Virginia Kan
- VA Medical Center and George Washington University, Washington, DC
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26
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Rudolph M, van Dijk J, de Jager P, Dijkstra SK, Burgerhof JGM, Blokpoel RGT, Kneyber MCJ. Performance of acute respiratory distress syndrome definitions in a high acuity paediatric intensive care unit. Respir Res 2021; 22:256. [PMID: 34587946 PMCID: PMC8480111 DOI: 10.1186/s12931-021-01848-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND For years, paediatric critical care practitioners used the adult American European Consensus Conference (AECC) and revised Berlin Definition (BD) for acute respiratory distress syndrome (ARDS) to study the epidemiology of paediatric ARDS (PARDS). In 2015, the paediatric specific definition, Paediatric Acute Lung Injury Consensus Conference (PALICC) was developed. The use of non-invasive metrics of oxygenation to stratify disease severity were introduced in this definition, although this potentially may lead to a confounding effect of disease severity since it is more common to place indwelling arterial lines in sicker patients. We tested the hypothesis that PALICC outperforms AECC/BD in our high acuity PICU, which employs a liberal use of indwelling arterial lines and high-frequency oscillatory ventilation (HFOV). METHODS We retrospectively collected data from children < 18 years mechanically ventilated for at least 24 h in our tertiary care, university-affiliated paediatric intensive care unit. The primary endpoint was the difference in the number of PARDS cases between AECC/BD and PALICC. Secondary endpoints included mortality and ventilator free days. Performance was assessed by the area under the receiver operating characteristics curve (AUC-ROC). RESULTS Data from 909 out of 2433 patients was eligible for analysis. AECC/BD identified 35 (1.4%) patients (mortality 25.7%), whereas PALICC identified 135 (5.5%) patients (mortality 14.1%). All but two patients meeting AECC/Berlin criteria were also identified by PALICC. Almost half of the cohort (45.2%) had mild, 33.3% moderate and 21.5% severe PALICC PARDS at onset. Highest mortality rates were seen in patients with AECC acute lung injury (ALI)/mild Berlin and severe PALICC PARDS. The AUC-ROC for Berlin was the highest 24 h (0.392 [0.124-0.659]) after onset. PALICC showed the highest AUC-ROC at the same moment however higher than Berlin (0.531 [0.345-0.716]). Mortality rates were significantly increased in patients with bilateral consolidations (9.3% unilateral vs 26.3% bilateral, p = 0.025). CONCLUSIONS PALICC identified more new cases PARDS than the AECC/Berlin definition. However, both PALICC and Berlin performed poorly in terms of mortality risk stratification. The presence of bilateral consolidations was associated with a higher mortality rate. Our findings may be considered in future modifications of the PALICC criteria.
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Affiliation(s)
- Michelle Rudolph
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands.
| | - Jefta van Dijk
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands
| | - Pauline de Jager
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands
| | - Sandra K Dijkstra
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands
| | - Johannes G M Burgerhof
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert G T Blokpoel
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands.,Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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27
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Kotas ME, Thompson BT. Toward Optimal Acute Respiratory Distress Syndrome Outcomes: Recognizing the Syndrome and Identifying Its Causes. Crit Care Clin 2021; 37:733-748. [PMID: 34548131 PMCID: PMC8449137 DOI: 10.1016/j.ccc.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Maya E Kotas
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, 505 Parnassus Avenue, Box 0111, San Francisco, CA 94143, USA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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28
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Sathe NA, Zelnick LR, Mikacenic C, Morrell ED, Bhatraju PK, McNeil JB, Kosamo S, Hough CL, Liles WC, Ware LB, Wurfel MM. Identification of persistent and resolving subphenotypes of acute hypoxemic respiratory failure in two independent cohorts. Crit Care 2021; 25:336. [PMID: 34526076 PMCID: PMC8442814 DOI: 10.1186/s13054-021-03755-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/31/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Acute hypoxemic respiratory failure (HRF) is associated with high morbidity and mortality, but its heterogeneity challenges the identification of effective therapies. Defining subphenotypes with distinct prognoses or biologic features can improve therapeutic trials, but prior work has focused on ARDS, which excludes many acute HRF patients. We aimed to characterize persistent and resolving subphenotypes in the broader HRF population. METHODS In this secondary analysis of 2 independent prospective ICU cohorts, we included adults with acute HRF, defined by invasive mechanical ventilation and PaO2-to-FIO2 ratio ≤ 300 on cohort enrollment (n = 768 in the discovery cohort and n = 1715 in the validation cohort). We classified patients as persistent HRF if still requiring mechanical ventilation with PaO2-to-FIO2 ratio ≤ 300 on day 3 following ICU admission, or resolving HRF if otherwise. We estimated relative risk of 28-day hospital mortality associated with persistent HRF, compared to resolving HRF, using generalized linear models. We also estimated fold difference in circulating biomarkers of inflammation and endothelial activation on cohort enrollment among persistent HRF compared to resolving HRF. Finally, we stratified our analyses by ARDS to understand whether this was driving differences between persistent and resolving HRF. RESULTS Over 50% developed persistent HRF in both the discovery (n = 386) and validation (n = 1032) cohorts. Persistent HRF was associated with higher risk of death relative to resolving HRF in both the discovery (1.68-fold, 95% CI 1.11, 2.54) and validation cohorts (1.93-fold, 95% CI 1.50, 2.47), after adjustment for age, sex, chronic respiratory illness, and acute illness severity on enrollment (APACHE-III in discovery, APACHE-II in validation). Patients with persistent HRF displayed higher biomarkers of inflammation (interleukin-6, interleukin-8) and endothelial dysfunction (angiopoietin-2) than resolving HRF after adjustment. Only half of persistent HRF patients had ARDS, yet exhibited higher mortality and biomarkers than resolving HRF regardless of whether they qualified for ARDS. CONCLUSION Patients with persistent HRF are common and have higher mortality and elevated circulating markers of lung injury compared to resolving HRF, and yet only a subset are captured by ARDS definitions. Persistent HRF may represent a clinically important, inclusive target for future therapeutic trials in HRF.
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Affiliation(s)
- Neha A Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA.
| | - Leila R Zelnick
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Carmen Mikacenic
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA
- Benaroya Research Institute, Seattle, WA, USA
| | - Eric D Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA
- Sepsis Center of Research Excellence, University of Washington, Seattle, WA, USA
| | - J Brennan McNeil
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Susanna Kosamo
- Department of Biochemistry and Molecular Medicine, University of Oulu, Oulu, Finland
| | - Catherine L Hough
- Division of Pulmonary and Critical Care, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - W Conrad Liles
- Sepsis Center of Research Excellence, University of Washington, Seattle, WA, USA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Mark M Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA
- Sepsis Center of Research Excellence, University of Washington, Seattle, WA, USA
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29
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Lam C, Tso CF, Green-Saxena A, Pellegrini E, Iqbal Z, Evans D, Hoffman J, Calvert J, Mao Q, Das R. Semi-supervised deep learning from time series clinical data for acute respiratory distress syndrome prediction: model development and validation study. JMIR Form Res 2021; 5:e28028. [PMID: 34398784 PMCID: PMC8447921 DOI: 10.2196/28028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/18/2021] [Accepted: 08/01/2021] [Indexed: 11/23/2022] Open
Abstract
Background A high number of patients who are hospitalized with COVID-19 develop acute respiratory distress syndrome (ARDS). Objective In response to the need for clinical decision support tools to help manage the next pandemic during the early stages (ie, when limited labeled data are present), we developed machine learning algorithms that use semisupervised learning (SSL) techniques to predict ARDS development in general and COVID-19 populations based on limited labeled data. Methods SSL techniques were applied to 29,127 encounters with patients who were admitted to 7 US hospitals from May 1, 2019, to May 1, 2021. A recurrent neural network that used a time series of electronic health record data was applied to data that were collected when a patient’s peripheral oxygen saturation level fell below the normal range (<97%) to predict the subsequent development of ARDS during the remaining duration of patients’ hospital stay. Model performance was assessed with the area under the receiver operating characteristic curve and area under the precision recall curve of an external hold-out test set. Results For the whole data set, the median time between the first peripheral oxygen saturation measurement of <97% and subsequent respiratory failure was 21 hours. The area under the receiver operating characteristic curve for predicting subsequent ARDS development was 0.73 when the model was trained on a labeled data set of 6930 patients, 0.78 when the model was trained on the labeled data set that had been augmented with the unlabeled data set of 16,173 patients by using SSL techniques, and 0.84 when the model was trained on the entire training set of 23,103 labeled patients. Conclusions In the context of using time-series inpatient data and a careful model training design, unlabeled data can be used to improve the performance of machine learning models when labeled data for predicting ARDS development are scarce or expensive.
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Affiliation(s)
- Carson Lam
- Dascena, Inc., 12333 Sowden Rd Ste B PMB 65148, Houston, US
| | - Chak Foon Tso
- Dascena, Inc., 12333 Sowden Rd Ste B PMB 65148, Houston, US
| | | | | | - Zohora Iqbal
- Dascena, Inc., 12333 Sowden Rd Ste B PMB 65148, Houston, US
| | - Daniel Evans
- Dascena, Inc., 12333 Sowden Rd Ste B PMB 65148, Houston, US
| | - Jana Hoffman
- Dascena, Inc., 12333 Sowden Rd Ste B PMB 65148, Houston, US
| | - Jacob Calvert
- Dascena, Inc., 12333 Sowden Rd Ste B PMB 65148, Houston, US
| | - Qingqing Mao
- Dascena, Inc., 12333 Sowden Rd Ste B PMB 65148, Houston, US
| | - Ritankar Das
- Dascena, Inc., 12333 Sowden Rd Ste B PMB 65148, Houston, US
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30
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Punsmann S, Hellige M, Hoppe J, Freise F, Venner M. Diagnostic imaging in acute interstitial pneumonia in foals: High variability of interpretation of chest radiographs and good conformity between ultrasonographic and post-mortem findings. Vet Radiol Ultrasound 2021; 62:490-497. [PMID: 33823075 DOI: 10.1111/vru.12972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 02/11/2021] [Accepted: 02/14/2021] [Indexed: 11/28/2022] Open
Abstract
Acute interstitial pneumonia (AIP) in foals is a rare but challenging syndrome. Diagnostic imaging is crucial for its diagnosis. While there are some reports on radiographic findings, ultrasound is sparsely described. Variability in the evaluation of radiographs in AIP has been well described in human literature. Part one of this study is a prospective, observational, observer agreement study investigating inter- and intraobserver agreement in the assessment of thoracic radiographs. Part two is a prospective, controlled, descriptive study on thoracic ultrasonography in foals with AIP. Eighteen foals with AIP were examined daily by thoracic ultrasound. Thoracic radiographs were taken on three successive occasions. Blinded radiographs were assessed by three observers based on two semi-quantitative scores (pattern recognition, subjective evaluation). Foals that died underwent postmortem examination (n = 9); postmortem findings were compared to ultrasound findings on the day of death. Ultrasonographic findings were consistent with postmortem findings. Comet tail scores in foals with AIP were significantly higher (p < 0.0001) than in control foals. Interrater agreement for the assessment of radiographs was none to moderate (κ = 0.07-0.65) for pattern recognition and weak to moderate (κ = 0.58-0.62) for subjective scoring. Intrarater agreement varied from minimal to strong (κ = 0.30-0.80) for pattern recognition but was strong (κ = 0.83) for subjective scoring. In conclusion, the diagnostic value of thoracic ultrasound in foals with AIP is high due to good conformity with postmortem findings. The evaluation of thoracic radiographs showed high variability in inter- and intra-agreement.
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Affiliation(s)
- Sophia Punsmann
- Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Maren Hellige
- Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Judith Hoppe
- Department of Veterinary Pathology, Freie Universität Berlin, Berlin, Germany
| | - Fritjof Freise
- Institute for Biometry, Epidemiology, and Information Processing, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
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31
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Pham T, Pesenti A, Bellani G, Rubenfeld G, Fan E, Bugedo G, Lorente JA, Fernandes ADV, Van Haren F, Bruhn A, Rios F, Esteban A, Gattinoni L, Larsson A, McAuley DF, Ranieri M, Thompson BT, Wrigge H, Brochard LJ, Laffey JG. Outcome of acute hypoxaemic respiratory failure: insights from the LUNG SAFE Study. Eur Respir J 2021; 57:13993003.03317-2020. [PMID: 33334944 DOI: 10.1183/13993003.03317-2020] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/21/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Current incidence and outcome of patients with acute hypoxaemic respiratory failure requiring mechanical ventilation in the intensive care unit (ICU) are unknown, especially for patients not meeting criteria for acute respiratory distress syndrome (ARDS). METHODS An international, multicentre, prospective cohort study of patients presenting with hypoxaemia early in the course of mechanical ventilation, conducted during four consecutive weeks in the winter of 2014 in 459 ICUs from 50 countries (LUNG SAFE). Patients were enrolled with arterial oxygen tension/inspiratory oxygen fraction ratio ≤300 mmHg, new pulmonary infiltrates and need for mechanical ventilation with a positive end-expiratory pressure of ≥5 cmH2O. ICU prevalence, causes of hypoxaemia, hospital survival and factors associated with hospital mortality were measured. Patients with unilateral versus bilateral opacities were compared. FINDINGS 12 906 critically ill patients received mechanical ventilation and 34.9% with hypoxaemia and new infiltrates were enrolled, separated into ARDS (69.0%), unilateral infiltrate (22.7%) and congestive heart failure (CHF; 8.2%). The global hospital mortality was 38.6%. CHF patients had a mortality comparable to ARDS (44.1% versus 40.4%). Patients with unilateral-infiltrate had lower unadjusted mortality, but similar adjusted mortality compared to those with ARDS. The number of quadrants on chest imaging was associated with an increased risk of death. There was no difference in mortality comparing patients with unilateral-infiltrate and ARDS with only two quadrants involved. INTERPRETATION More than one-third of patients receiving mechanical ventilation have hypoxaemia and new infiltrates with a hospital mortality of 38.6%. Survival is dependent on the degree of pulmonary involvement whether or not ARDS criteria are reached.
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Affiliation(s)
- Tài Pham
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Heath Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France.,Université Paris-Saclay, UVSQ, Université Paris-Sud, Inserm, Equipe d'Epidémiologie respiratoire intégrative, CESP, Villejuif, France
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Dept of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Gordon Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto and Program in Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Eddy Fan
- Dept of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - José Angel Lorente
- Critical Care Dept, Hospital Universitario de Getafe, Madrid, Spain.,CIBER Enfermedades Respiratorias, Madrid, Spain.,Universidad Europea, Madrid, Spain
| | | | - Frank Van Haren
- Intensive Care Unit, Canberra Hospital, Garran, Australia.,Australian National University Medical School, Canberra Hospital, Garran, Australia.,University of Canberra, Faculty of Health, Canberra, Australia
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Fernando Rios
- Intensive Care Unit, Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - Andres Esteban
- Hospital Universitario de Getafe, Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Luciano Gattinoni
- University of Göttingen, Dept of Anaesthesiology, Emergency and Intensive Care Medicine, Göttingen, Germany
| | - Anders Larsson
- Dept of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Daniel F McAuley
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK.,Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | - Marco Ranieri
- Alma Mater Studiorum-Università di Bologna, Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Bologna, Italy
| | - B Taylor Thompson
- Massachusetts General Hospital, Harvard School of Medicine, Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Boston, MA, USA
| | - Hermann Wrigge
- Dept of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany.,Dept of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Laurent J Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Heath Toronto, Toronto, ON, Canada .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Co-senior authors
| | - John G Laffey
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Heath Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Dept of Anesthesia, St Michael's Hospital and University of Toronto, Toronto, ON, Canada.,School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.,Co-senior authors
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32
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Al-Omari B, McMeekin P, Allen AJ, Akram AR, Graziadio S, Suklan J, Jones WS, Lendrem BC, Winter A, Cullinan M, Gray J, Dhaliwal K, Walsh TS, Craven TH. Systematic review of studies investigating ventilator associated pneumonia diagnostics in intensive care. BMC Pulm Med 2021; 21:196. [PMID: 34107929 PMCID: PMC8189711 DOI: 10.1186/s12890-021-01560-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/02/2021] [Indexed: 02/06/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is an important diagnosis in critical care. VAP research is complicated by the lack of agreed diagnostic criteria and reference standard test criteria. Our aim was to review which reference standard tests are used to evaluate novel index tests for suspected VAP. Methods We conducted a comprehensive search using electronic databases and hand reference checks. The Cochrane Library, MEDLINE, CINHAL, EMBASE, and web of science were searched from 2008 until November 2018. All terms related to VAP diagnostics in the intensive treatment unit were used to conduct the search. We adopted a checklist from the critical appraisal skills programme checklist for diagnostic studies to assess the quality of the included studies. Results We identified 2441 records, of which 178 were selected for full-text review. Following methodological examination and quality assessment, 44 studies were included in narrative data synthesis. Thirty-two (72.7%) studies utilised a sole microbiological reference standard; the remaining 12 studies utilised a composite reference standard, nine of which included a mandatory microbiological criterion. Histopathological criteria were optional in four studies but mandatory in none. Conclusions Nearly all reference standards for VAP used in diagnostic test research required some microbiological confirmation of infection, with BAL culture being the most common reference standard used. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01560-0.
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Affiliation(s)
- Basem Al-Omari
- College of Medicine and Health Sciences, Khalifa University, PO Box 127788, Abu Dhabi, UAE. .,Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK.
| | - Peter McMeekin
- School of Health and Life Science, University of Northumbria, Newcastle upon Tyne, UK
| | - A Joy Allen
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ahsan R Akram
- Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Sara Graziadio
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,York Health Economics Consortium, Enterprise House, Innovation Way, University of York, York, UK
| | - Jana Suklan
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - William S Jones
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - B Clare Lendrem
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Amanda Winter
- NIHR Newcastle In Vitro Diagnostics Co-operative, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Milo Cullinan
- Laboratory Medicine, Newcastle-Upon-Tyne Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Joanne Gray
- School of Health and Life Science, University of Northumbria, Newcastle upon Tyne, UK
| | - Kevin Dhaliwal
- Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Timothy S Walsh
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Thomas H Craven
- Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK.,Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
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Zimatore C, Pisani L, Lippolis V, Warren MA, Calfee CS, Ware LB, Algera AG, Smit MR, Grasso S, Schultz MJ. Accuracy of the Radiographic Assessment of Lung Edema Score for the Diagnosis of ARDS. Front Physiol 2021; 12:672823. [PMID: 34122143 PMCID: PMC8188799 DOI: 10.3389/fphys.2021.672823] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Bilateral opacities on chest radiographs are part of the Berlin Definition for Acute Respiratory Distress Syndrome (ARDS) but have poor interobserver reliability. The “Radiographic Assessment of Lung Edema” (RALE) score was recently proposed for evaluation of the extent and density of alveolar opacities on chest radiographs of ARDS patients. The current study determined the accuracy of the RALE score for the diagnosis and the prognosis of ARDS. Methods:Post-hoc analysis of a cohort of invasively ventilated intensive care unit (ICU) patients expected to need invasive ventilation for >24 h. The Berlin Definition was used as the gold standard. The RALE score was calculated for the first available chest radiograph after start of ventilation in the ICU. The primary endpoint was the diagnostic accuracy for ARDS of the RALE score. Secondary endpoints included the prognostic value of the RALE score for ICU and hospital mortality, and the association with ARDS severity, and the PaO2/FiO2. Receiver operating characteristic (ROC) curves were constructed, and the optimal cutoff was used to determine sensitivity, specificity and the negative and positive predictive value of the RALE score for ARDS. Results: The study included 131 patients, of whom 30 had ARDS (11 mild, 15 moderate, and 4 severe ARDS). The first available chest radiograph was obtained median 0 [0 to 1] days after start of invasive ventilation in ICU. Compared to patients without ARDS, a higher RALE score was found in patients with ARDS (24 [interquartile range (IQR) 16–30] vs. 6 [IQR 3–11]; P < 0.001), with RALE scores of 20 [IQR 14–24], 26 [IQR 16–32], and 32 [IQR 19–36] for mild, moderate and severe ARDS, respectively, (P = 0.166). The area under the ROC for ARDS was excellent (0.91 [0.86–0.96]). The best cutoff for ARDS diagnosis was 10 with 100% sensitivity, 71% specificity, 51% positive predictive value and 100% negative predictive value. The RALE score was not associated with ICU or hospital mortality, and weakly correlated with the PaO2/FiO2. Conclusion: In this cohort of invasively ventilated ICU patients, the RALE score had excellent diagnostic accuracy for ARDS.
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Affiliation(s)
- Claudio Zimatore
- Department of Intensive Care, Academic Medical Center, Amsterdam, Netherlands.,Department of Emergency and Organ Transplantation, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Luigi Pisani
- Department of Intensive Care, Academic Medical Center, Amsterdam, Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Department of Anesthesia and Perioperative Medicine, Regional General Hospital F. Miulli, Acquaviva delle Fonti, Italy
| | | | - Melissa A Warren
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Carolyn S Calfee
- Department of Medicine and Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, United States
| | - Lorraine B Ware
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States.,Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Anna Geke Algera
- Department of Intensive Care, Academic Medical Center, Amsterdam, Netherlands
| | - Marry R Smit
- Department of Intensive Care, Academic Medical Center, Amsterdam, Netherlands
| | - Salvatore Grasso
- Department of Emergency and Organ Transplantation, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, Amsterdam, Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
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Omar AS, Shoman B, Sudarsanan S, Shouman Y. Chest radiography requirements for patients with asymptomatic COVID-19 undergoing coronary artery bypass surgery: Three case reports. World J Virol 2021; 10:130-136. [PMID: 34079694 PMCID: PMC8152452 DOI: 10.5501/wjv.v10.i3.130] [Citation(s) in RCA: 3] [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: 01/06/2021] [Revised: 02/03/2021] [Accepted: 03/31/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2, represents a major challenge to health care systems both globally and regionally, with many opting by cancelling elective surgeries. Cardiac operations in patients diagnosed with COVID-19 have been imperative due to their emergency nature, critical condition of patients awaiting cardiac surgery, and accumulated number of cardiac surgical interventions throughout the last months.
CASE SUMMARY Here we describe three COVID-19 positive cases who underwent coronary surgery, on an urgent basis. We did not experience worsening of the patients’ clinical condition due to COVID-19 and therefore a routine post-operative chest X-ray (CXR) was not required. None of the health care providers attending the patients endured cross infection. Further trials would be needed in order to confirm these results.
CONCLUSION While the pandemic has adversely hit the health systems worldwide, cardiac surgical patients who concomitantly contracted COVID-19 may undergo a smooth post-operative course as a routine post-operative CXR may not be required.
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Affiliation(s)
- Amr Salah Omar
- Department of Cardiothoracic Surgery, Heart Hospital, Hamad Medical Corporation, Doha 3050, DA, Qatar
- Department of Critical Care Medicine, Beni Suef University, Beni Suef 3050, DA, Qatar
- Department of Medicine, Weill Cornell Medical College, Doha 3050, DA, Qatar
| | - Bassam Shoman
- Department of Cardiothoracic Surgery, Heart Hospital, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Suraj Sudarsanan
- Department of Cardiothoracic Surgery, Heart Hospital, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Yasser Shouman
- Department of Cardiothoracic Surgery, Heart Hospital, Hamad Medical Corporation, Doha 3050, DA, Qatar
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35
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Omar AS, Shoman B, Sudarsanan S, Shouman Y. Chest radiography requirements for patients with asymptomatic COVID-19 undergoing coronary artery bypass surgery: Three case reports. World J Virol 2021. [PMID: 34079694 DOI: 10.5501/wjv.v10.i3.130.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2, represents a major challenge to health care systems both globally and regionally, with many opting by cancelling elective surgeries. Cardiac operations in patients diagnosed with COVID-19 have been imperative due to their emergency nature, critical condition of patients awaiting cardiac surgery, and accumulated number of cardiac surgical interventions throughout the last months. CASE SUMMARY Here we describe three COVID-19 positive cases who underwent coronary surgery, on an urgent basis. We did not experience worsening of the patients' clinical condition due to COVID-19 and therefore a routine post-operative chest X-ray (CXR) was not required. None of the health care providers attending the patients endured cross infection. Further trials would be needed in order to confirm these results. CONCLUSION While the pandemic has adversely hit the health systems worldwide, cardiac surgical patients who concomitantly contracted COVID-19 may undergo a smooth post-operative course as a routine post-operative CXR may not be required.
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Affiliation(s)
- Amr Salah Omar
- Department of Cardiothoracic Surgery, Heart Hospital, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Bassam Shoman
- Department of Cardiothoracic Surgery, Heart Hospital, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Suraj Sudarsanan
- Department of Cardiothoracic Surgery, Heart Hospital, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Yasser Shouman
- Department of Cardiothoracic Surgery, Heart Hospital, Hamad Medical Corporation, Doha 3050, DA, Qatar
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Clinician Recognition of the Acute Respiratory Distress Syndrome: Risk Factors for Under-Recognition and Trends Over Time. Crit Care Med 2021; 48:830-837. [PMID: 32317598 DOI: 10.1097/ccm.0000000000004328] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The acute respiratory distress syndrome is common in critically ill patients. Recognition is crucial because acute respiratory distress syndrome is associated with a high mortality rate, and low tidal volume ventilation improves mortality. However, acute respiratory distress syndrome often goes unrecognized. Risk factors for under-recognition and trends over time have not been fully described. DESIGN Retrospective chart review of patients with acute respiratory distress syndrome from a prospective cohort study of critically ill patients. For each patient's ICU stay, we searched the chart for terms that indicated that acute respiratory distress syndrome was diagnosed, in the differential diagnosis, or treated with low tidal volume ventilation. SETTING ICUs at a tertiary hospital at the University of California, San Francisco between 2008 and 2016. PATIENTS Critically ill patients with acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Acute respiratory distress syndrome was recognized in 70% of patients, and recognition increased from 60% in 2008-2009 to 92% in 2016 (p = 0.004). Use of tidal volumes less than 6.5 mL/kg also increased (p < 0.001) from 20% to 92%. Increased acute respiratory distress syndrome severity (p = 0.01) and vasopressor use (p = 0.04) were associated with greater recognition. Clinician diagnosis of acute respiratory distress syndrome and inclusion of acute respiratory distress syndrome in the differential diagnosis were associated with tidal volumes less than 6.5 mL/kg (51% use of tidal volume ≤ 6.5 mL/kg if acute respiratory distress syndrome recognized vs 15% if not recognized; p = 0.002). Diagnosing acute respiratory distress syndrome was associated with lower tidal volume in multivariate analysis. CONCLUSIONS Although acute respiratory distress syndrome recognition and low tidal volume ventilation use have increased over time, they remain less than universal. Clinician recognition of acute respiratory distress syndrome is associated with both systemic and respiratory severity of illness and is also associated with use of low tidal volume ventilation.
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37
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Leng X, Onaitis MW, Zhao Y, Xuan Y, Leng S, Jiao W, Sun X, Qin Y, Liu D, Wang M, Yang R. Risk of Acute Lung Injury after Esophagectomy. Semin Thorac Cardiovasc Surg 2021; 34:737-746. [PMID: 33984482 DOI: 10.1053/j.semtcvs.2021.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 12/25/2022]
Abstract
To develop a new approach for identifying acute lung injury (ALI) in surgical ward setting and to assess incidence rate, clinical outcomes, and risk factors for ALI cases after esophagectomy. We also compare the degree of lung injury between operative and non-operative sides. Consecutive esophageal cancer patients (n=1022) who underwent esophagectomy from Dec 2012 to Nov 2018 in our hospital were studied. An approach for identifying ALI was proposed that integrated radiographic assessment of lung edema (RALE) score to quantify degree of lung edema. Stepwise logistic regression identified risk factors for postoperative ALI incidence. The degree of bilateral lung injury was compared using the RALE score. The approach for identifying ALI in surgical ward setting was defined as acute onset, PaO2/FiO2≤300 mmHg, bilateral opacities on bedside chest radiograph with a RALE score≥16, and exclusion of cardiogenic pulmonary edema. Incidence rate of ALI was estimated to be 9.7%. ALI diagnosis was associated with multiple clinical complications, prolonged hospital stay, higher medical bills, and higher perioperative mortality. Nine risk factors including BMI, ASA class, DLCO%, duration of surgery, neutrophil percentage, high-density lipoprotein, and electrolyte disorders were identified. The RALE score of the lung lobes of the operative side was higher than the non-operative side. A new approach for identifying ALI in esophageal cancer patients receiving esophagectomy was proposed and several risk factors were identified. ALI is common and has severe outcomes. The lung lobes on the operative side are more likely to be affected than the non-operative side.
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Affiliation(s)
- Xiaoliang Leng
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Mark W Onaitis
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, San Diego, CA, USA
| | - Yandong Zhao
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yunpeng Xuan
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shuguang Leng
- Division of Epidemiology, Biostatistics, and Preventive Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA; Cancer Control and Population Sciences, Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM, USA; Division of Occupational and Environmental Health, School of Public Health, Qingdao University, Qingdao, China.
| | - Wenjie Jiao
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China.
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- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China; Surgery, Health management center, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiao Sun
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yi Qin
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Dahai Liu
- Surgery, Health management center, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Maolong Wang
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ronghua Yang
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
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Metwaly S, Côté A, Donnelly SJ, Banoei MM, Lee CH, Andonegui G, Yipp BG, Vogel HJ, Fiehn O, Winston BW. ARDS metabolic fingerprints: characterization, benchmarking, and potential mechanistic interpretation. Am J Physiol Lung Cell Mol Physiol 2021; 321:L79-L90. [PMID: 33949201 DOI: 10.1152/ajplung.00077.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In this study, we aimed to identify acute respiratory distress syndrome (ARDS) metabolic fingerprints in selected patient cohorts and compare the metabolic profiles of direct versus indirect ARDS and hypoinflammatory versus hyperinflammatory ARDS. We hypothesized that the biological and inflammatory processes in ARDS would manifest as unique metabolomic fingerprints that set ARDS apart from other intensive care unit (ICU) conditions and could help examine ARDS subphenotypes and clinical subgroups. Patients with ARDS (n = 108) and ICU ventilated controls (n = 27) were included. Samples were randomly divided into 2/3 training and 1/3 test sets. Samples were analyzed using 1H nuclear magnetic resonance spectroscopy and gas chromatography-mass spectrometry. Twelve proteins/cytokines were also measured. Orthogonal partial least squares discriminant analysis (OPLS-DA) was used to select the most differentiating ARDS metabolites and protein/cytokines. Predictive performance of OPLS-DA models was measured in the test set. Temporal changes of metabolites were examined as patients progressed through ARDS until clinical recovery. Metabolic profiles of direct versus indirect ARDS subgroups and hypoinflammatory versus hyperinflammatory ARDS subgroups were compared. Serum metabolomics and proteins/cytokines had similar area under receiver operator curves when distinguishing ARDS from ICU controls. Pathway analysis of ARDS differentiating metabolites identified a dominant involvement of serine-glycine metabolism. In longitudinal tracking, the identified pathway metabolites generally exhibited correction by 7-14 days, coinciding with clinical improvement. ARDS subphenotypes and clinical subgroups were metabolically distinct. However, our identified metabolic fingerprints are not ARDS diagnostic biomarkers, and further research is required to ascertain generalizability. In conclusion, patients with ARDS are metabolically different from ICU controls. ARDS subphenotypes and clinical subgroups are metabolically distinct.
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Affiliation(s)
- Sayed Metwaly
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom.,Department of Internal Medicine, Aberdeen Royal Infirmary, NHS Scotland, Aberdeen, United Kingdom.,Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andréanne Côté
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Montreal, Québec, Canada
| | - Sarah J Donnelly
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mohammad M Banoei
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Chel H Lee
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Graciela Andonegui
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bryan G Yipp
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hans J Vogel
- Bio-NMR Center, Department of Biological Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Oliver Fiehn
- West Coast Metabolomics Center, University of California, Davis, California
| | - Brent W Winston
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Biochemistry and Molecular Biology, University of Calgary, Calgary, Alberta, Canada
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Wendel Garcia PD, Caccioppola A, Coppola S, Pozzi T, Ciabattoni A, Cenci S, Chiumello D. Latent class analysis to predict intensive care outcomes in Acute Respiratory Distress Syndrome: a proposal of two pulmonary phenotypes. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:154. [PMID: 33888134 PMCID: PMC8060783 DOI: 10.1186/s13054-021-03578-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/13/2021] [Indexed: 02/07/2023]
Abstract
Background Acute respiratory distress syndrome remains a heterogeneous syndrome for clinicians and researchers difficulting successful tailoring of interventions and trials. To this moment, phenotyping of this syndrome has been approached by means of inflammatory laboratory panels. Nevertheless, the systemic and inflammatory expression of acute respiratory distress syndrome might not reflect its respiratory mechanics and gas exchange. Methods Retrospective analysis of a prospective cohort of two hundred thirty-eight patients consecutively admitted patients under mechanical ventilation presenting with acute respiratory distress syndrome. All patients received standardized monitoring of clinical variables, respiratory mechanics and computed tomography scans at predefined PEEP levels. Employing latent class analysis, an unsupervised structural equation modelling method, on respiratory mechanics, gas-exchange and computed tomography-derived gas- and tissue-volumes at a PEEP level of 5cmH2O, distinct pulmonary phenotypes of acute respiratory distress syndrome were identified. Results Latent class analysis was applied to 54 respiratory mechanics, gas-exchange and CT-derived gas- and tissue-volume variables, and a two-class model identified as best fitting. Phenotype 1 (non-recruitable) presented lower respiratory system elastance, alveolar dead space and amount of potentially recruitable lung volume than phenotype 2 (recruitable). Phenotype 2 (recruitable) responded with an increase in ventilated lung tissue, compliance and PaO2/FiO2 ratio (p < 0.001), in addition to a decrease in alveolar dead space (p < 0.001), to a standardized recruitment manoeuvre. Patients belonging to phenotype 2 (recruitable) presented a higher intensive care mortality (hazard ratio 2.9, 95% confidence interval 1.7–2.7, p = 0.001). Conclusions The present study identifies two ARDS phenotypes based on respiratory mechanics, gas-exchange and computed tomography-derived gas- and tissue-volumes. These phenotypes are characterized by distinctly diverse responses to a standardized recruitment manoeuvre and by a diverging mortality. Given multicentre validation, the simple and rapid identification of these pulmonary phenotypes could facilitate enrichment of future prospective clinical trials addressing mechanical ventilation strategies in ARDS. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03578-6.
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Affiliation(s)
- Pedro D Wendel Garcia
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Alessio Caccioppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, San Paolo University Hospital, Via Di Rudinì, Milan, Italy.,Department of Health Sciences, University of Milan, Milan, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, San Paolo University Hospital, Via Di Rudinì, Milan, Italy
| | - Tommaso Pozzi
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, San Paolo University Hospital, Via Di Rudinì, Milan, Italy.,Department of Health Sciences, University of Milan, Milan, Italy
| | - Arianna Ciabattoni
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, San Paolo University Hospital, Via Di Rudinì, Milan, Italy.,Department of Health Sciences, University of Milan, Milan, Italy
| | - Stefano Cenci
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, San Paolo University Hospital, Via Di Rudinì, Milan, Italy.,Department of Health Sciences, University of Milan, Milan, Italy
| | - Davide Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, San Paolo University Hospital, Via Di Rudinì, Milan, Italy. .,Department of Health Sciences, University of Milan, Milan, Italy. .,Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy.
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Arenas-Jiménez J, Plasencia-Martínez J, García-Garrigós E. When pneumonia is not COVID-19. RADIOLOGIA 2021. [PMCID: PMC7813497 DOI: 10.1016/j.rxeng.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
During the COVID-19 epidemic, the prevalence of the disease means that practically any lung opacity on an X-ray could represent pneumonia due to infection with SARS-CoV-2. Nevertheless, atypical radiologic findings add weight to negative microbiological or serological tests. Likewise, outside the epidemic wave and with the return of other respiratory diseases, radiologists can play an important role in decision making about diagnoses, treatment, or preventive measures (isolation), provided they know the key findings for entities that can simulate COVID-19 pneumonia. Unifocal opacities or opacities located in upper lung fields and predominant airway involvement, in addition to other key radiologic and clinical findings detailed in this paper, make it necessary to widen the spectrum of possible diagnoses.
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Arenas-Jiménez JJ, Plasencia-Martínez JM, García-Garrigós E. When pneumonia is not COVID-19. RADIOLOGIA 2021; 63:180-192. [PMID: 33339621 PMCID: PMC7699022 DOI: 10.1016/j.rx.2020.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/04/2020] [Accepted: 11/13/2020] [Indexed: 01/08/2023]
Abstract
During the COVID-19 epidemic, the prevalence of the disease means that practically any lung opacity on an X-ray could represent pneumonia due to infection with SARS-CoV-2. Nevertheless, atypical radiologic findings add weight to negative microbiological or serological tests. Likewise, outside the epidemic wave and with the return of other respiratory diseases, radiologists can play an important role in decision making about diagnoses, treatment, or preventive measures (isolation), provided they know the key findings for entities that can simulate COVID-19 pneumonia. Unifocal opacities or opacities located in upper lung fields and predominant airway involvement, in addition to other key radiologic and clinical findings detailed in this paper, make it necessary to widen the spectrum of possible diagnoses.
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Affiliation(s)
- J J Arenas-Jiménez
- Servicio de Radiodiagnóstico, Hospital General Universitario de Alicante. Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, España.
| | - J M Plasencia-Martínez
- Área de Urgencias y de Imagen Cardiaca, Servicio de Radiodiagnóstico, Hospital Universitario Morales Meseguer, Murcia, España
| | - E García-Garrigós
- Servicio de Radiodiagnóstico, Hospital General Universitario de Alicante. Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, España
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Use of Machine Learning to Screen for Acute Respiratory Distress Syndrome Using Raw Ventilator Waveform Data. Crit Care Explor 2021; 3:e0313. [PMID: 33458681 PMCID: PMC7803688 DOI: 10.1097/cce.0000000000000313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To develop and characterize a machine learning algorithm to discriminate acute respiratory distress syndrome from other causes of respiratory failure using only ventilator waveform data. Design Retrospective, observational cohort study. Setting Academic medical center ICU. Patients Adults admitted to the ICU requiring invasive mechanical ventilation, including 50 patients with acute respiratory distress syndrome and 50 patients with primary indications for mechanical ventilation other than hypoxemic respiratory failure. Interventions None. Measurements and Main Results Pressure and flow time series data from mechanical ventilation during the first 24-hours after meeting acute respiratory distress syndrome criteria (or first 24-hr of mechanical ventilation for non-acute respiratory distress syndrome patients) were processed to extract nine physiologic features. A random forest machine learning algorithm was trained to discriminate between the patients with and without acute respiratory distress syndrome. Model performance was assessed using the area under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, and negative predictive value. Analyses examined performance when the model was trained using data from the first 24 hours and tested using withheld data from either the first 24 hours (24/24 model) or 6 hours (24/6 model). Area under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, and negative predictive value were 0.88, 0.90, 0.71, 0.77, and 0.90 (24/24); and 0.89, 0.90, 0.75, 0.83, and 0.83 (24/6). Conclusions Use of machine learning and physiologic information derived from raw ventilator waveform data may enable acute respiratory distress syndrome screening at early time points after intubation. This approach, combined with traditional diagnostic criteria, could improve timely acute respiratory distress syndrome recognition and enable automated clinical decision support, especially in settings with limited availability of conventional diagnostic tests and electronic health records.
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Radiologists and Clinical Trials: Part 1 The Truth About Reader Disagreements. Ther Innov Regul Sci 2021; 55:1111-1121. [PMID: 34228319 PMCID: PMC8259547 DOI: 10.1007/s43441-021-00316-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 06/18/2021] [Indexed: 02/06/2023]
Abstract
The debate over human visual perception and how medical images should be interpreted have persisted since X-rays were the only imaging technique available. Concerns over rates of disagreement between expert image readers are associated with much of the clinical research and at times driven by the belief that any image endpoint variability is problematic. The deeper understanding of the reasons, value, and risk of disagreement are somewhat siloed, leading, at times, to costly and risky approaches, especially in clinical trials. Although artificial intelligence promises some relief from mistakes, its routine application for assessing tumors within cancer trials is still an aspiration. Our consortium of international experts in medical imaging for drug development research, the Pharma Imaging Network for Therapeutics and Diagnostics (PINTAD), tapped the collective knowledge of its members to ground expectations, summarize common reasons for reader discordance, identify what factors can be controlled and which actions are likely to be effective in reducing discordance. Reinforced by an exhaustive literature review, our work defines the forces that shape reader variability. This review article aims to produce a singular authoritative resource outlining reader performance's practical realities within cancer trials, whether they occur within a clinical or an independent central review.
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Sivapackiam J, Liao F, Zhou D, Shoghi KI, Gropler RJ, Gelman AE, Sharma V. Galuminox: Preclinical validation of a novel PET tracer for non-invasive imaging of oxidative stress in vivo. Redox Biol 2020; 37:101690. [PMID: 33039825 PMCID: PMC7648173 DOI: 10.1016/j.redox.2020.101690] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 12/07/2022] Open
Abstract
Overproduction of reactive oxygen species (ROS) is a well-established indicator of ongoing tissue inflammation. However, there is a scarcity of molecular imaging probes capable of providing noninvasive sensitive detection of ROS for allowing longitudinal studies of disease pathology and/or monitoring therapeutic efficacy of ROS scavengers. Herein, we report synthesis and chemical characterization of a novel metalloprobe, Galuminox, a moderately fluorescent agent that detects superoxide and hydrogen peroxide generation. Using live-cell fluorescence imaging analysis, Galuminox demonstrates ability to detect superoxide and monitor effects of ROS-attenuating agents, such as Carvedilol, Dexrazoxane, and mitoTempo in lung epithelial A549 cells. Furthermore, LPS stimulation of A549 cells that either express the mitochondria targeted fluorescent protein Keima or are stained with MitoSOX, a mitochondria-specific superoxide probe, indicates preferential co-localization of Galuminox with mitochondria producing elevated amounts of superoxide. Dynamic PET/CT scans 45 min post tail-vein administration of 68Ga-Galuminox show 4-fold higher uptake and stable retention in lungs of LPS treated mice compared to their saline-only treated counterparts. Post preclinical PET imaging, quantitative biodistribution studies also correlate with 4-fold higher retention of the radiotracer in lungs of LPS treated mice compared with their saline-only treated control counterparts. Consistent with these observations, lung cells isolated from LPS-treated mice demonstrated elevated ROS production deploying CellROX, the ROS probe. Finally, Galuminox uptake correlates with histological and physiological evidence of acute lung injury as evident by polynuclear infiltration, thickening of the alveolar epithelial membranes and increased bronchioalveolar lavage protein content. Taken collectively, these data indicate that 68Ga-Galuminox tracer uptake is a measure of ROS activity in acutely injured lungs and suggests its potential utility in monitoring oxidative stress in other diseases.
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Affiliation(s)
| | - Fuyi Liao
- Departments of Surgery, Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Dequan Zhou
- Departments of Surgery, Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Kooresh I Shoghi
- Mallinckrodt Institute of Radiology, USA; Department of Biomedical Engineering, School of Engineering & Applied Science, Washington University, St. Louis, 63105, USA
| | - Robert J Gropler
- Mallinckrodt Institute of Radiology, USA; Department of Biomedical Engineering, School of Engineering & Applied Science, Washington University, St. Louis, 63105, USA
| | - Andrew E Gelman
- Departments of Surgery, Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Vijay Sharma
- Mallinckrodt Institute of Radiology, USA; Department of Neurology, Washington University School of Medicine, St. Louis, MO, 63110, USA; Department of Biomedical Engineering, School of Engineering & Applied Science, Washington University, St. Louis, 63105, USA.
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Supervised machine learning for the early prediction of acute respiratory distress syndrome (ARDS). J Crit Care 2020; 60:96-102. [PMID: 32777759 DOI: 10.1016/j.jcrc.2020.07.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 06/25/2020] [Accepted: 07/19/2020] [Indexed: 01/28/2023]
Abstract
PURPOSE Acute respiratory distress syndrome (ARDS) is a serious respiratory condition with high mortality and associated morbidity. The objective of this study is to develop and evaluate a novel application of gradient boosted tree models trained on patient health record data for the early prediction of ARDS. MATERIALS AND METHODS 9919 patient encounters were retrospectively analyzed from the Medical Information Mart for Intensive Care III (MIMIC-III) data base. XGBoost gradient boosted tree models for early ARDS prediction were created using routinely collected clinical variables and numerical representations of radiology reports as inputs. XGBoost models were iteratively trained and validated using 10-fold cross validation. RESULTS On a hold-out test set, algorithm classifiers attained area under the receiver operating characteristic curve (AUROC) values of 0.905 when tested for the detection of ARDS at onset and 0.827, 0.810, and 0.790 for the prediction of ARDS at 12-, 24-, and 48-h windows prior to onset, respectively. CONCLUSION Supervised machine learning predictions may help predict patients with ARDS up to 48 h prior to onset.
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Tobin MJ. Does Making a Diagnosis of ARDS in Patients With Coronavirus Disease 2019 Matter? Chest 2020; 158:2275-2277. [PMID: 32707184 PMCID: PMC7373003 DOI: 10.1016/j.chest.2020.07.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/19/2020] [Indexed: 01/07/2023] Open
Affiliation(s)
- Martin J Tobin
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL 60141.
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Panizo-Alcañiz J, Frutos-Vivar F, Thille AW, Peñuelas Ó, Aguilar-Rivilla E, Muriel A, Rodríguez-Barbero JM, Jaramillo C, Nin N, Esteban A. Diagnostic accuracy of portable chest radiograph in mechanically ventilated patients when compared with autopsy findings. J Crit Care 2020; 60:6-9. [PMID: 32731104 DOI: 10.1016/j.jcrc.2020.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 06/13/2020] [Accepted: 06/27/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Evaluate diagnostic accuracy of portable chest radiograph in mechanically ventilated patients taking autopsy findings as the gold standard and the interobserver agreement among intensivists and radiologists. MATERIALS AND METHODS Retrospective study of 422 patients over 22 years who died in the ICU, underwent an autopsy, and had at least one portable chest radiograph 72 h prior to death. Two intensivists and two radiologists independently read each chest radiograph. Sensitivity, specificity, positive and negative likelihood ratios were evaluated. Overall performance metrics accuracy between intensivists and radiologists were compared using a generalized estimating equation. Cohen's kappa coefficient was used to evaluate the interobserver agreement with the following values: <0.20:poor, 0.21-0.40:fair, 0.41-0.60:moderate, 0.61-0.80:good, 0.81-1.00:excellent. RESULTS Overall sensitivity and specificity for pneumonia was 24% and 91% respectively. Overall sensitivity and specificity for ARDS was 68% and 74% respectively. Sensitivity for pneumonia was higher among radiologists (p < 0,05). Specificity for ADRS was higher among radiologists (p < 0,05). Good interobserver agreement among radiologists and poor correlation between intensivists was found. CONCLUSIONS Chest radiographs has a moderate specificity for ARDS and a high specificity for pneumonia, with limited sensitivity in both entities. Interobserver agreement of portable chest radiograph in the mechanically ventilated patients is higher between radiologists than intensivists.
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Affiliation(s)
| | - Fernando Frutos-Vivar
- Servicio de Cuidados Intensivos y Grandes Quemados, CIBER de Enfermedades Respiratorias, Hospital Universitario de Getafe, Madrid, Spain
| | - Arnaud W Thille
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation CHU de Poitiers, ALIVE research group, INSERM CIC 1402, University of Poitiers, Poitiers, France
| | - Óscar Peñuelas
- Servicio de Cuidados Intensivos y Grandes Quemados, CIBER de Enfermedades Respiratorias, Hospital Universitario de Getafe, Madrid, Spain
| | - Eva Aguilar-Rivilla
- Servicio de Radiología, Unidad de tórax, Hospital Universitario de Getafe, Madrid, Spain
| | - Alfonso Muriel
- Hospital Ramón y Cajal, Unidad de Bioestadistica Clínica, Hospital Ramón y Cajal IRYCIS, CIBERESP, Departamento Enfermeria y Fisioterapia, Universidad de Alcalá, Madrid, Spain.
| | | | - Carlos Jaramillo
- Servicio de Cuidados Intensivos y Grandes Quemados, CIBER de Enfermedades Respiratorias, Hospital Universitario de Getafe, Madrid, Spain
| | - Nicolás Nin
- Hospital Español Juan José Crottogini, Unidad de Cuidados Intensivos, Montevideo, Uruguay
| | - Andrés Esteban
- Servicio de Cuidados Intensivos y Grandes Quemados, CIBER de Enfermedades Respiratorias, Hospital Universitario de Getafe, Madrid, Spain
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Abstract
BACKGROUND The acute respiratory distress syndrome (ARDS) results in substantial mortality but remains underdiagnosed in clinical practice. Automated ARDS "sniffer" systems, tools that can automatically analyze electronic medical record data, have been developed to improve recognition of ARDS in clinical practice. OBJECTIVES To perform a systematic review examining the evidence underlying automated sniffer systems for ARDS detection. DATA SOURCES MEDLINE and Scopus databases through November 2018 to identify studies of tools using routinely available clinical data to detect patients with ARDS. DATA EXTRACTION Study design, tool description, and diagnostic performance were extracted by two reviewers. The Quality Assessment of Diagnostic Accuracy Studies-2 was used to evaluate each study for risk of bias in four domains: patient selection, index test, reference standard, and study flow and timing. SYNTHESIS Among 480 studies identified, 9 met inclusion criteria, and they evaluated six unique ARDS sniffer tools. Eight studies had derivation and/or temporal validation designs, with one also evaluating the effects of implementing a tool in clinical practice. A single study performed an external validation of previously published ARDS sniffer tools. Studies reported a wide range of sensitivities (43-98%) and positive predictive values (26-90%) for detection of ARDS. Most studies had potential for high risk of bias identified in their study design, including patient selection (five of nine), reference standard (four of nine), and flow and timing (three of nine). In the single external validation without any perceived risks of biases, the performance of ARDS sniffer tools was worse. CONCLUSIONS Sniffer systems developed to detect ARDS had moderate to high predictive value in their derivation cohorts, although most studies had the potential for high risks of bias in study design. Methodological issues may explain some of the variability in tool performance. There remains an ongoing need for robust evaluation of ARDS sniffer systems and their impact on clinical practice. Systematic review registered with PROSPERO (CRD42015026584).
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Global and Regional Diagnostic Accuracy of Lung Ultrasound Compared to CT in Patients With Acute Respiratory Distress Syndrome. Crit Care Med 2020; 47:1599-1606. [PMID: 31464770 DOI: 10.1097/ccm.0000000000003971] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Lung CT is the reference imaging technique for acute respiratory distress syndrome, but requires transportation outside the intensive care and x-ray exposure. Lung ultrasound is a promising, inexpensive, radiation-free, tool for bedside imaging. Aim of the present study was to compare the global and regional diagnostic accuracy of lung ultrasound and CT scan. DESIGN A prospective, observational study. SETTING Intensive care and radiology departments of a University hospital. PATIENTS Thirty-two sedated, paralyzed acute respiratory distress syndrome patients (age 65 ± 14 yr, body mass index 25.9 ± 6.5 kg/m, and PaO2/FIO2 139 ± 47). INTERVENTIONS Lung CT scan and lung ultrasound were performed at positive end-expiratory pressure 5 cm H2O. A standardized assessment of six regions per hemithorax was used; each region was classified for the presence of normal aeration, alveolar-interstitial syndrome, consolidation, and pleural effusion. Agreement between the two techniques was calculated, and diagnostic variables were assessed for lung ultrasound using lung CT as a reference. MEASUREMENTS AND MAIN RESULTS Global agreement between lung ultrasound and CT ranged from 0.640 (0.391-0.889) to 0.934 (0.605-1.000) and was on average 0.775 (0.577-0.973). The overall sensitivity and specificity of lung ultrasound ranged from 82.7% to 92.3% and from 90.2% to 98.6%, respectively. Similar results were found with regional analysis. The diagnostic accuracy of lung ultrasound was significantly higher when those patterns not reaching the pleural surface were excluded (area under the receiver operating characteristic curve: alveolar-interstitial syndrome 0.854 [0.821-0.887] vs 0.903 [0.852-0.954]; p = 0.049 and consolidation 0.851 [0.818-0.884] vs 0.896 [0.862-0.929]; p = 0.044). CONCLUSIONS Lung ultrasound is a reproducible, sensitive, and specific tool, which allows for bedside detections of the morphologic patterns in acute respiratory distress syndrome. The presence of deep lung alterations may impact the diagnostic performance of this technique.
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López-Fernández YM, Smith LS, Kohne JG, Weinman JP, Modesto-Alapont V, Reyes-Dominguez SB, Medina A, Piñeres-Olave BE, Mahieu N, Klein MJ, Flori HR, Jouvet P, Khemani RG. Prognostic relevance and inter-observer reliability of chest-imaging in pediatric ARDS: a pediatric acute respiratory distress incidence and epidemiology (PARDIE) study. Intensive Care Med 2020; 46:1382-1393. [PMID: 32451578 PMCID: PMC7246298 DOI: 10.1007/s00134-020-06074-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/27/2020] [Indexed: 11/29/2022]
Abstract
Purpose Definitions of acute respiratory distress syndrome (ARDS) include radiographic criteria, but there are concerns about reliability and prognostic relevance. This study aimed to evaluate the independent relationship between chest imaging and mortality and examine the inter-rater variability of interpretations of chest radiographs (CXR) in pediatric ARDS (PARDS). Methods Prospective, international observational study in children meeting Pediatric Acute Lung Injury Consensus Conference (PALICC) criteria for PARDS, which requires new infiltrate(s) consistent with pulmonary parenchymal disease, without mandating bilateral infiltrates. Mortality analysis focused on the entire cohort, whereas inter-observer variability used a subset of patients with blinded, simultaneous interpretation of CXRs by intensivists and radiologists. Results Bilateral infiltrates and four quadrants of alveolar consolidation were associated with mortality on a univariable basis, using CXRs from 708 patients with PARDS. For patients on either invasive (IMV) or non-invasive ventilation (NIV) with PaO2/FiO2 (PF) ratios (or SpO2/FiO2 (SF) ratio equivalent) > 100, neither bilateral infiltrates (OR 1.3 (95% CI 0.68, 2.5), p = 0.43), nor 4 quadrants of alveolar consolidation (OR 1.6 (0.85, 3), p = 0.14) were associated with mortality. For patients with PF ≤ 100, bilateral infiltrates (OR 3.6 (1.4, 9.4), p = 0.01) and four quadrants of consolidation (OR 2.0 (1.14, 3.5), p = 0.02) were associated with higher mortality. A subset of 702 CXRs from 233 patients had simultaneous interpretations. Interobserver agreement for bilateral infiltrates and quadrants was “slight” (kappa 0.31 and 0.33). Subgroup analysis showed agreement did not differ when stratified by PARDS severity but was slightly higher for children with chronic respiratory support (kappa 0.62), NIV at PARDS diagnosis (kappa 0.53), age > 10 years (kappa 0.43) and fluid balance > 40 ml/kg (kappa 0.48). Conclusion Bilateral infiltrates and quadrants of alveolar consolidation are associated with mortality only for those with PF ratio ≤ 100, although there is high- inter-rater variability in these chest-x ray parameters. Electronic supplementary material The online version of this article (10.1007/s00134-020-06074-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yolanda M López-Fernández
- Pediatric Intensive Care Unit, Department of Pediatrics, Biocruces Health Research Institute, Cruces University Hospital, Plaza Cruces 12, 48903, Barakaldo, Bizkaia, Basque Country, Spain.
| | - Lincoln S Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Joseph G Kohne
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan CS. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Jason P Weinman
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Alberto Medina
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Byron E Piñeres-Olave
- Department of Pediatric Critical Care Medicine, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Natalie Mahieu
- Department of Radiology, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA.,Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Margaret J Klein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan CS. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Philippe Jouvet
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA
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