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Granda ML, Tian F, Zelnick LR, Bhatraju PK, Wurfel MM, Hoofnagle A, Morrell E, Kestenbaum B. Kidney Outcomes and Trajectories of Tubular Injury and Function in Critically Ill Persons with and without Coronavirus-2019. RESEARCH SQUARE 2024:rs.3.rs-3974635. [PMID: 38464257 PMCID: PMC10925475 DOI: 10.21203/rs.3.rs-3974635/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Background Coronavirus disease-2019 (COVID-19) may injure the kidney tubules via activation of inflammatory host responses and/or direct viral infiltration. Most studies of kidney injury in COVID-19 lacked contemporaneous controls or measured kidney biomarkers at a single time point. To better understand mechanisms of AKI in COVID-19, we compared kidney outcomes and trajectories of tubular injury, viability, and function in prospectively enrolled critically ill adults with and without COVID-19. Methods The COVID-19 Host Response and Outcomes (CHROME) study prospectively enrolled patients admitted to intensive care units in Washington state with symptoms of lower respiratory tract infection, determining COVID-19 status by nucleic acid amplification on arrival. We evaluated major adverse kidney events (MAKE) defined as a doubling of serum creatinine, kidney replacement therapy, or death, in 330 patients after inverse probability weighting. In the 181 patients with available biosamples, we determined trajectories of urine kidney injury molecule-1 (KIM-1) and epithelial growth factor (EGF), and urine:plasma ratios of endogenous markers of tubular secretory clearance. Results At ICU admission, mean age was 55±16 years; 45% required mechanical ventilation; and mean serum creatinine concentration was 1.1 mg/dL. COVID-19 was associated with a 70% greater incidence of MAKE (95% CI 1.05, 2.74) and a 741% greater incidence of KRT (95% CI 1.69, 32.41). The biomarker cohort had a median of three follow-up measurements. Urine EGF, secretory clearance ratios, and eGFR increased over time in the COVID-19 negative group but remained unchanged in the COVID-19 positive group. In contrast, urine KIM-1 concentrations did not significantly change over the course of the study in either group. Conclusions Among critically ill adults, COVID-19 is associated with a more protracted course of proximal tubular dysfunction.
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Affiliation(s)
| | - Frances Tian
- University of Washington, Kidney Research Institute
| | | | - Pavan K Bhatraju
- University of Washington, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine
| | - Mark M Wurfel
- University of Washington, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine
| | | | - Eric Morrell
- University of Washington, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine
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Busico M, Fuentes NA, Gallardo A, Vitali A, Quintana J, Olmos M, Burns KEA, Esperatti M. The Predictive Validity of the Berlin Definition of Acute Respiratory Distress Syndrome for Patients With COVID-19-Related Respiratory Failure Treated With High-Flow Nasal Oxygen: A Multicenter, Prospective Cohort Study. Crit Care Med 2024; 52:92-101. [PMID: 37846935 DOI: 10.1097/ccm.0000000000006056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
OBJECTIVES The Berlin definition of acute respiratory distress syndrome (ARDS) was constructed for patients receiving invasive mechanical ventilation (IMV) with consideration given to issues related to reliability, feasibility, and validity. Notwithstanding, patients with acute respiratory failure (ARF) may be treated with high-flow nasal oxygen (HFNO) and may not fall within the scope of the original definition. We aimed to evaluate the predictive validity of the Berlin definition in HFNO-treated patients with COVID-19-related respiratory failure who otherwise met ARDS criteria. DESIGN Multicenter, prospective cohort study. SETTING Five ICUs of five centers in Argentina from March 2020 to September 2021. PATIENTS We consecutively included HFNO-treated patients older than 18 years with confirmed COVID-19-related ARF, a Pa o2 /F io2 of less than 300 mm Hg, bilateral infiltrates on imaging, and worsening respiratory symptoms for less than 1 week. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We evaluated the predictive validity of mortality at day 28 using the area under the receiver operating characteristics curve (AUC), compared the predictive validity across subgroups, and characterized relevant clinical outcomes. We screened 1,231 patients and included 696 ARDS patients [30 (4%) mild, 380 (55%) moderate, and 286 (41%) severe]. For the study cohort, the AUC for mortality at day 28 was 0.606 (95% CI, 0.561-0.651) with the AUC for subgroups being similar to that of the overall cohort. Two hundred fifty-six patients (37%) received IMV. By day 28, 142 patients (21%) had died, of whom 81 (57%) had severe ARDS. Mortality occurred primarily in patients who were transitioned to IMV. CONCLUSIONS The predictive validity of the Berlin ARDS definition was similar for HFNO-treated patients as compared with the original population of invasively ventilated patients. Our findings support the extension of the Berlin definition to HFNO-treated patients with ARDS.
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Affiliation(s)
- Marina Busico
- Intensive Care Unit, Clínica Olivos SMG, Olivos, Buenos Aires, Argentina
| | - Nora A Fuentes
- Intensive Care Unit, Hospital Privado de Comunidad, Universidad Nacional de Mar del Plata, Mar del Plata, Buenos Aires, Argentina
| | - Adrián Gallardo
- Intensive Care Unit, Sanatorio Clínica Modelo de Morón, Universidad de Morón, Morón, Buenos Aires, Argentina
| | - Alejandra Vitali
- Intensive Care Unit, Sanatorio de la Trinidad Palermo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Jorgelina Quintana
- Intensive Care Unit, Clínica Olivos SMG, Olivos, Buenos Aires, Argentina
| | - Matias Olmos
- Intensive Care Unit, Hospital Privado de Comunidad, Universidad Nacional de Mar del Plata, Mar del Plata, Buenos Aires, Argentina
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, Saint Michael's Hospital Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
| | - Mariano Esperatti
- Intensive Care Unit, Hospital Privado de Comunidad, Universidad Nacional de Mar del Plata, Mar del Plata, Buenos Aires, Argentina
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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: 49] [Impact Index Per Article: 49.0] [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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Michelson AP, Lyons PG, Nguyen NM, Reynolds D, McDonald R, McEvoy CA, Despotovic V, Brody SL, Kollef MH, Kraft BD. Use of Inhaled Epoprostenol in Patients With COVID-19 Receiving Humidified, High-Flow Nasal Oxygen Is Associated With Progressive Respiratory Failure. CHEST CRITICAL CARE 2023; 1:100019. [PMID: 38516615 PMCID: PMC10956404 DOI: 10.1016/j.chstcc.2023.100019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND The clinical benefit of using inhaled epoprostenol (iEpo) through a humidified high-flow nasal cannula (HHFNC) remains unknown for patients with COVID-19. RESEARCH QUESTION Can iEpo prevent respiratory deterioration for patients with positive SARS-CoV-2 findings receiving HHFNC? STUDY DESIGN AND METHODS This multicenter retrospective cohort analysis included patients aged 18 years or older with COVID-19 pneumonia who required HHFNC treatment. Patients who received iEpo were propensity score matched to patients who did not receive iEpo. The primary outcome was time to mechanical ventilation or death without mechanical ventilation and was assessed using Kaplan-Meier curves and Cox proportional hazard ratios. The effects of residual confounding were assessed using a multilevel analysis, and a secondary analysis adjusted for outcome propensity also was performed in a multivariable model that included the entire (unmatched) patient cohort. RESULTS Among 954 patients with positive SARS-CoV-2 findings receiving HHFNC therapy, 133 patients (13.9%) received iEpo. After propensity score matching, the median number of days until the composite outcome was similar between treatment groups (iEpo: 5.0 days [interquartile range, 2.0-10.0 days] vs no-iEpo: 6.5 days [interquartile range, 2.0-11.0 days]; P = .26), but patients who received iEpo were more likely to meet the composite outcome in the propensity score-matched, multilevel, and multivariable unmatched analyses (hazard ratio, 2.08 [95% CI, 1.73-2.50]; OR, 4.72 [95% CI, 3.01-7.41]; and OR, 1.35 [95% CI, 1.23-1.49]; respectively). INTERPRETATION In patients with COVID-19 receiving HHFNC therapy, use of iEpo was associated with the need for invasive mechanical ventilation.
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Affiliation(s)
- Andrew P Michelson
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO.; Department of Medicine, the Institute for Informatics, Washington University School of Medicine, Saint Louis, MO
| | - Patrick G Lyons
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Nguyet M Nguyen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Rachel McDonald
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Colleen A McEvoy
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Vladimir Despotovic
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Steven L Brody
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Bryan D Kraft
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
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Rodriguez Lima DR, Rubio Ramos C, Yepes Velasco AF, Gómez Cortes LA, Pinilla Rojas DI, Pinzón Rondón ÁM, Ruíz Sternberg ÁM. Prediction model for in-hospital mortality in patients at high altitudes with ARDS due to COVID-19. PLoS One 2023; 18:e0293476. [PMID: 37883460 PMCID: PMC10602283 DOI: 10.1371/journal.pone.0293476] [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: 05/23/2023] [Accepted: 10/13/2023] [Indexed: 10/28/2023] Open
Abstract
INTRODUCTION The diagnosis of acute respiratory distress syndrome (ARDS) includes the ratio of pressure arterial oxygen and inspired oxygen fraction (P/F) ≤ 300, which is often adjusted in locations more than 1,000 meters above sea level (masl) due to hypobaric hypoxemia. The main objective of this study was to develop a prediction model for in-hospital mortality among patients with ARDS due to coronavirus disease 2019 (COVID-19) (C-ARDS) at 2,600 masl with easily available variables at patient admission and to compare its discrimination capacity with a second model using the P/F adjusted for this high altitude. METHODS This study was an analysis of data from patients with C-ARDS treated between March 2020 and July 2021 in a university hospital located in the city of Bogotá, Colombia, at 2,600 masl. Demographic and laboratory data were extracted from electronic records. For the prediction model, univariate analyses were performed to screen variables with p <0.25. Then, these variables were automatically selected with a backward stepwise approach with a significance level of 0.1. The interaction terms and fractional polynomials were also examined in the final model. Multiple imputation procedures and bootstraps were used to obtain the coefficients with the best external validation. In addition, total adjustment of the model and logistic regression diagnostics were performed. The same methodology was used to develop a second model with the P/F adjusted for altitude. Finally, the areas under the curve (AUCs) of the receiver operating characteristic (ROC) curves of the two models were compared. RESULTS A total of 2,210 subjects were included in the final analysis. The final model included 11 variables without interaction terms or nonlinear functions. The coefficients are presented excluding influential observations. The final equation for the model fit was g(x) = age(0.04819)+weight(0.00653)+height(-0.01856)+haemoglobin(-0.0916)+platelet count(-0.003614)+ creatinine(0.0958)+lactate dehydrogenase(0.001589)+sodium(-0.02298)+potassium(0.1574)+systolic pressure(-0.00308)+if moderate ARDS(0.628)+if severe ARDS(1.379), and the probability of in-hospital death was p (x) = e g (x)/(1+ e g (x)). The AUC of the ROC curve was 0.7601 (95% confidence interval (CI) 0.74-0, 78). The second model with the adjusted P/F presented an AUC of 0.754 (95% CI 0.73-0.77). No statistically significant difference was found between the AUC curves (p value = 0.6795). CONCLUSION This study presents a prediction model for patients with C-ARDS at 2,600 masl with easily available admission variables for early stratification of in-hospital mortality risk. Adjusting the P/F for 2,600 masl did not improve the predictive capacity of the model. We do not recommend adjusting the P/F for altitude.
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Affiliation(s)
- David Rene Rodriguez Lima
- Critical and Intensive Care Medicine, Hospital Universitario Mayor‐Méderi, Bogotá, Colombia
- Grupo de Investigación Clínica, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Cristhian Rubio Ramos
- Critical and Intensive Care Medicine, Hospital Universitario Mayor‐Méderi, Bogotá, Colombia
| | | | | | | | - Ángela María Pinzón Rondón
- Grupo de Investigación Clínica, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Ángela María Ruíz Sternberg
- Grupo de Investigación Clínica, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
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Brown SM, Barkauskas CE, Grund B, Sharma S, Phillips AN, Leither L, Peltan ID, Lanspa M, Gilstrap DL, Mourad A, Lane K, Beitler JR, Serra AL, Garcia I, Almasri E, Fayed M, Hubel K, Harris ES, Middleton EA, Barrios MAG, Mathews KS, Goel NN, Acquah S, Mosier J, Hypes C, Salvagio Campbell E, Khan A, Hough CL, Wilson JG, Levitt JE, Duggal A, Dugar S, Goodwin AJ, Terry C, Chen P, Torbati S, Iyer N, Sandkovsky US, Johnson NJ, Robinson BRH, Matthay MA, Aggarwal NR, Douglas IS, Casey JD, Hache-Marliere M, Georges Youssef J, Nkemdirim W, Leshnower B, Awan O, Pannu S, O'Mahony DS, Manian P, Awori Hayanga JW, Wortmann GW, Tomazini BM, Miller RF, Jensen JU, Murray DD, Bickell NA, Zatakia J, Burris S, Higgs ES, Natarajan V, Dewar RL, Schechner A, Kang N, Arenas-Pinto A, Hudson F, Ginde AA, Self WH, Rogers AJ, Oldmixon CF, Morin H, Sanchez A, Weintrob AC, Cavalcanti AB, Davis-Karim A, Engen N, Denning E, Taylor Thompson B, Gelijns AC, Kan V, Davey VJ, Lundgren JD, Babiker AG, Neaton JD, Lane HC. Intravenous aviptadil and remdesivir for treatment of COVID-19-associated hypoxaemic respiratory failure in the USA (TESICO): a randomised, placebo-controlled trial. THE LANCET. RESPIRATORY MEDICINE 2023; 11:791-803. [PMID: 37348524 PMCID: PMC10527239 DOI: 10.1016/s2213-2600(23)00147-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/31/2023] [Accepted: 04/12/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND There is a clinical need for therapeutics for COVID-19 patients with acute hypoxemic respiratory failure whose 60-day mortality remains at 30-50%. Aviptadil, a lung-protective neuropeptide, and remdesivir, a nucleotide prodrug of an adenosine analog, were compared with placebo among patients with COVID-19 acute hypoxaemic respiratory failure. METHODS TESICO was a randomised trial of aviptadil and remdesivir versus placebo at 28 sites in the USA. Hospitalised adult patients were eligible for the study if they had acute hypoxaemic respiratory failure due to confirmed SARS-CoV-2 infection and were within 4 days of the onset of respiratory failure. Participants could be randomly assigned to both study treatments in a 2 × 2 factorial design or to just one of the agents. Participants were randomly assigned with a web-based application. For each site, randomisation was stratified by disease severity (high-flow nasal oxygen or non-invasive ventilation vs invasive mechanical ventilation or extracorporeal membrane oxygenation [ECMO]), and four strata were defined by remdesivir and aviptadil eligibility, as follows: (1) eligible for randomisation to aviptadil and remdesivir in the 2 × 2 factorial design; participants were equally randomly assigned (1:1:1:1) to intravenous aviptadil plus remdesivir, aviptadil plus remdesivir matched placebo, aviptadil matched placebo plus remdesvir, or aviptadil placebo plus remdesivir placebo; (2) eligible for randomisation to aviptadil only because remdesivir was started before randomisation; (3) eligible for randomisation to aviptadil only because remdesivir was contraindicated; and (4) eligible for randomisation to remdesivir only because aviptadil was contraindicated. For participants in strata 2-4, randomisation was 1:1 to the active agent or matched placebo. Aviptadil was administered as a daily 12-h infusion for 3 days, targeting 600 pmol/kg on infusion day 1, 1200 pmol/kg on day 2, and 1800 pmol/kg on day 3. Remdesivir was administered as a 200 mg loading dose, followed by 100 mg daily maintenance doses for up to a 10-day total course. For participants assigned to placebo for either agent, matched saline placebo was administered in identical volumes. For both treatment comparisons, the primary outcome, assessed at day 90, was a six-category ordinal outcome: (1) at home (defined as the type of residence before hospitalisation) and off oxygen (recovered) for at least 77 days, (2) at home and off oxygen for 49-76 days, (3) at home and off oxygen for 1-48 days, (4) not hospitalised but either on supplemental oxygen or not at home, (5) hospitalised or in hospice care, or (6) dead. Mortality up to day 90 was a key secondary outcome. The independent data and safety monitoring board recommended stopping the aviptadil trial on May 25, 2022, for futility. On June 9, 2022, the sponsor stopped the trial of remdesivir due to slow enrolment. The trial is registered with ClinicalTrials.gov, NCT04843761. FINDINGS Between April 21, 2021, and May 24, 2022, we enrolled 473 participants in the study. For the aviptadil comparison, 471 participants were randomly assigned to aviptadil or matched placebo. The modified intention-to-treat population comprised 461 participants who received at least a partial infusion of aviptadil (231 participants) or aviptadil matched placebo (230 participants). For the remdesivir comparison, 87 participants were randomly assigned to remdesivir or matched placebo and all received some infusion of remdesivir (44 participants) or remdesivir matched placebo (43 participants). 85 participants were included in the modified intention-to-treat analyses for both agents (ie, those enrolled in the 2 x 2 factorial). For the aviptadil versus placebo comparison, the median age was 57 years (IQR 46-66), 178 (39%) of 461 participants were female, and 246 (53%) were Black, Hispanic, Asian or other (vs 215 [47%] White participants). 431 (94%) of 461 participants were in an intensive care unit at baseline, with 271 (59%) receiving high-flow nasal oxygen or non-invasive ventiliation, 185 (40%) receiving invasive mechanical ventilation, and five (1%) receiving ECMO. The odds ratio (OR) for being in a better category of the primary efficacy endpoint for aviptadil versus placebo at day 90, from a model stratified by baseline disease severity, was 1·11 (95% CI 0·80-1·55; p=0·54). Up to day 90, 86 participants in the aviptadil group and 83 in the placebo group died. The cumulative percentage who died up to day 90 was 38% in the aviptadil group and 36% in the placebo group (hazard ratio 1·04, 95% CI 0·77-1·41; p=0·78). The primary safety outcome of death, serious adverse events, organ failure, serious infection, or grade 3 or 4 adverse events up to day 5 occurred in 146 (63%) of 231 patients in the aviptadil group compared with 129 (56%) of 230 participants in the placebo group (OR 1·40, 95% CI 0·94-2·08; p=0·10). INTERPRETATION Among patients with COVID-19-associated acute hypoxaemic respiratory failure, aviptadil did not significantly improve clinical outcomes up to day 90 when compared with placebo. The smaller than planned sample size for the remdesivir trial did not permit definitive conclusions regarding safety or efficacy. FUNDING National Institutes of Health.
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Affiliation(s)
- Samuel M Brown
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA; Department of Medicine, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Christina E Barkauskas
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Birgit Grund
- School of Statistics, University of Minnesota, Minneapolis, MN, USA
| | - Shweta Sharma
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Lindsay Leither
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA; Department of Medicine, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
| | - Ithan D Peltan
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA; Department of Medicine, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
| | - Michael Lanspa
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA; Department of Medicine, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
| | - Daniel L Gilstrap
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Ahmad Mourad
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Kathleen Lane
- Surgical Office of Clinical Research, Cardiothoracic Surgical Division, Duke University School of Medicine, Durham, NC, USA
| | - Jeremy R Beitler
- Columbia Respiratory Critical Care Trials Group and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Alexis L Serra
- Columbia Respiratory Critical Care Trials Group and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Ivan Garcia
- Columbia Respiratory Critical Care Trials Group and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Eyad Almasri
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, UCSF Fresno, Fresno, CA, USA
| | - Mohamed Fayed
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, UCSF Fresno, Fresno, CA, USA
| | - Kinsley Hubel
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, UCSF Fresno, Fresno, CA, USA
| | - Estelle S Harris
- Department of Medicine, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
| | - Elizabeth A Middleton
- Department of Medicine, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
| | - Macy A G Barrios
- Department of Medicine, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
| | - Kusum S Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Neha N Goel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel Acquah
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jarrod Mosier
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ; Division of Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ; Banner University Medical Center- Tucson, Tucson, AZ, USA
| | - Cameron Hypes
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ; Division of Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ
| | | | - Akram Khan
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Catherine L Hough
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer G Wilson
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Joseph E Levitt
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland OH, USA
| | - Siddharth Dugar
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland OH, USA
| | - Andrew J Goodwin
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Charles Terry
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Peter Chen
- Women's Guild Lung Institute, Department of Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sam Torbati
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nithya Iyer
- Division of of Pulmonary/Critical Care and Sleep Medicine, Department of Medicine, Baylor University Medical Center, Dallas, TX, USA; Texas A&M School of Medicine, Dallas, TX, USA
| | - Uriel S Sandkovsky
- Division of Infectious Diseases, Department of Medicine, Baylor University Medical Center, Dallas, TX, USA
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington Harborview Medical Center, Seattle, WA, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Harborview Medical Center, Seattle, WA, USA
| | - Bryce R H Robinson
- Department of Surgery, University of Washington Harborview Medical Center, Seattle, WA, USA
| | - Michael A Matthay
- Cardiovascular Research Institute and Departments of Medicine and Anesthesia, University of California-San Francisco, San Francisco, CA, USA
| | - Neil R Aggarwal
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ivor S Douglas
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Jonathan D Casey
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manuel Hache-Marliere
- Jacobi Medical Center, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - J Georges Youssef
- Department of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY, USA; JC Walter Jr Transplant Center Advanced Lung Diseases Program, Houston Methodist Hospital, Houston, TX, USA
| | - William Nkemdirim
- Jacobi Medical Center, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Brad Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Omar Awan
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, VA Medical Center and George Washington University, Washington, DC, USA
| | - Sonal Pannu
- Department of Medicine, Division of Pulmonary Critical Care and Sleep, Ohio State University, Columbus, OH, USA
| | | | - Prasad Manian
- Division of Pulmonary and Critical Medicine, Baylor College of Medicine, Texas Heart Institute, Houston, TX, USA
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery. Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Glenn W Wortmann
- Infectious Diseases Section, MedStar Washington Hospital Center and Georgetown University, Washington, DC, USA
| | - Bruno M Tomazini
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; HCor Research Institute, São Paulo, Brazil
| | - Robert F Miller
- Institute for Global Health, University College London, London, UK
| | - Jens-Ulrik Jensen
- Section of Respiratory Medicine, Department of Medicine, Herlev-Gentofte Hospital, Hellerup, Denmark; CHIP, Centre of Excellence for Health, Immunity and Infections, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Daniel D Murray
- CHIP, Centre of Excellence for Health, Immunity and Infections, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nina A Bickell
- Department of Population Health Science and Policy and Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jigna Zatakia
- Department of Medicine, Division of Pulmonary Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sarah Burris
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elizabeth S Higgs
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Ven Natarajan
- Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Robin L Dewar
- Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Adam Schechner
- Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Nayon Kang
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Alejandro Arenas-Pinto
- Institute for Global Health, University College London, London, UK; The Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | - Fleur Hudson
- The Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Angela J Rogers
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Cathryn F Oldmixon
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - Haley Morin
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Adriana Sanchez
- Infectious Diseases Section, Veteran Affairs Medical Center, Washington, DC, USA
| | - Amy C Weintrob
- Infectious Diseases Section, Veteran Affairs Medical Center, Washington, DC, USA
| | | | - Anne Davis-Karim
- Cooperative Studies Program, Clinical Research Pharmacy Coordinating Center, Office of Research & Development, Department of Veterans Affairs, Albuquerque, NM, USA
| | - Nicole Engen
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Eileen Denning
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital and Harvard Medical School; Boston, MA, USA
| | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Virginia Kan
- Infectious Diseases Section, Veteran Affairs Medical Center, Washington, DC, USA
| | - Victoria J Davey
- United States Department of Veterans Affairs; Washington, DC, USA
| | - Jens D Lundgren
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Abdel G Babiker
- The Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | - James D Neaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - H Clifford Lane
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
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7
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Kjellberg A, Douglas J, Hassler A, Al-Ezerjawi S, Boström E, Abdel-Halim L, Liwenborg L, Hetting E, Jonasdottir Njåstad AD, Kowalski J, Catrina SB, Rodriguez-Wallberg KA, Lindholm P. COVID-19-Induced Acute Respiratory Distress Syndrome Treated with Hyperbaric Oxygen: Interim Safety Report from a Randomized Clinical Trial (COVID-19-HBO). J Clin Med 2023; 12:4850. [PMID: 37510965 PMCID: PMC10381696 DOI: 10.3390/jcm12144850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 07/16/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND A few prospective trials and case series have suggested that hyperbaric oxygen therapy (HBOT) may be efficacious for the treatment of severe COVID-19, but safety is a concern for critically ill patients. We present an interim analysis of the safety of HBOT via a randomized controlled trial (COVID-19-HBO). METHODS A randomized controlled, open-label, clinical trial was conducted in compliance with good clinical practice to explore the safety and efficacy of HBOT for severe COVID-19 in critically ill patients with moderate acute respiratory distress syndrome (ARDS). Between 3 June 2020, and 17 May 2021, 31 patients with severe COVID-19 and moderate-to-severe ARDS, a ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) < 26.7 kPa (200 mmHg), and at least two defined risk factors for intensive care unit (ICU) admission and/or mortality were enrolled in the trial and randomized 1:1 to best practice, or HBOT in addition to best practice. The subjects allocated to HBOT received a maximum of five treatments at 2.4 atmospheres absolute (ATA) for 80 min over seven days. The subjects were followed up for 30 days. The safety endpoints were analyzed. RESULTS Adverse events (AEs) were common. Hypoxia was the most common adverse event reported. There was no statistically significant difference between the groups. Numerically, serious adverse events (SAEs) and barotrauma were more frequent in the control group, and the differences between groups were in favor of the HBOT in PaO2/FiO2 (PFI) and the national early warning score (NEWS); statistically, however, the differences were not significant at day 7, and no difference was observed for the total oxygen burden and cumulative pulmonary oxygen toxicity dose (CPTD). CONCLUSION HBOT appears to be safe as an intervention for critically ill patients with moderate-to-severe ARDS induced by COVID-19. CLINICAL TRIAL REGISTRATION NCT04327505 (31 March 2020) and EudraCT 2020-001349-37 (24 April 2020).
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Affiliation(s)
- Anders Kjellberg
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
- Perioperative Medicine and Intensive Care Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Johan Douglas
- Department of Anaesthesia and Intensive Care, Blekingesjukhuset, 371 85 Karlskrona, Sweden
| | - Adrian Hassler
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
- Acute and Reparative Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Sarah Al-Ezerjawi
- Acute and Reparative Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Emil Boström
- Acute and Reparative Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Lina Abdel-Halim
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Lovisa Liwenborg
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Eric Hetting
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
| | | | | | - Sergiu-Bogdan Catrina
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
- Academic Specialist Center, Center for Diabetes, 113 65 Stockholm, Sweden
| | - Kenny A Rodriguez-Wallberg
- Department of Oncology and Pathology, Karolinska Institutet, 171 64 Stockholm, Sweden
- Department of Reproductive Medicine, Division of Gynaecology and Reproduction, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Peter Lindholm
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
- Department of Emergency Medicine, Division of Hyperbaric Medicine, University of California San Diego, La Jolla, CA 92093, USA
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8
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Newly Proposed Diagnostic Criteria for Acute Respiratory Distress Syndrome: Does Inclusion of High Flow Nasal Cannula Solve the Problem? J Clin Med 2023; 12:jcm12031043. [PMID: 36769691 PMCID: PMC9917973 DOI: 10.3390/jcm12031043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 02/03/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a common life-threatening clinical syndrome which accounts for 10% of intensive care unit admissions. Since the Berlin definition was developed, the clinical diagnosis and therapy have changed dramatically by adding a minimum positive end-expiratory pressure (PEEP) to the assessment of hypoxemia compared to the American-European Consensus Conference (AECC) definition in 1994. High-flow nasal cannulas (HFNC) have become widely used as an effective respiratory support for hypoxemia to the extent that their use was proposed in the expansion of the ARDS criteria. However, there would be problems if the diagnosis of a specific disease or clinical syndrome occurred, based on therapeutic strategies.
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9
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Bhatraju PK, Morrell ED, Stanaway IB, Sathe NA, Srivastava A, Postelnicu R, Green R, Andrews A, Gonzalez M, Kratochvil CJ, Kumar VK, Hsiang TY, Gale M, Anesi GL, Wyles D, Broadhurst MJ, Brett-Major D, Mukherjee V, Sevransky JE, Landsittel D, Hung C, Altemeier WA, Gharib SA, Uyeki TM, Cobb JP, Liebler JM, Crosslin DR, Jarvik GP, Segal LN, Evans L, Mikacenic C, Wurfel MM. Angiopoietin-Like4 Is a Novel Marker of COVID-19 Severity. Crit Care Explor 2023; 5:e0827. [PMID: 36600780 PMCID: PMC9803343 DOI: 10.1097/cce.0000000000000827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Vascular dysfunction and capillary leak are common in critically ill COVID-19 patients, but identification of endothelial pathways involved in COVID-19 pathogenesis has been limited. Angiopoietin-like 4 (ANGPTL4) is a protein secreted in response to hypoxic and nutrient-poor conditions that has a variety of biological effects including vascular injury and capillary leak. OBJECTIVES To assess the role of ANGPTL4 in COVID-19-related outcomes. DESIGN SETTING AND PARTICIPANTS Two hundred twenty-five COVID-19 ICU patients were enrolled from April 2020 to May 2021 in a prospective, multicenter cohort study from three different medical centers, University of Washington, University of Southern California and New York University. MAIN OUTCOMES AND MEASURES Plasma ANGPTL4 was measured on days 1, 7, and 14 after ICU admission. We used previously published tissue proteomic data and lung single nucleus RNA (snRNA) sequencing data from specimens collected from COVID-19 patients to determine the tissues and cells that produce ANGPTL4. RESULTS Higher plasma ANGPTL4 concentrations were significantly associated with worse hospital mortality (adjusted odds ratio per log2 increase, 1.53; 95% CI, 1.17-2.00; p = 0.002). Higher ANGPTL4 concentrations were also associated with higher proportions of venous thromboembolism and acute respiratory distress syndrome. Longitudinal ANGPTL4 concentrations were significantly different during the first 2 weeks of hospitalization in patients who subsequently died compared with survivors (p for interaction = 8.1 × 10-5). Proteomics analysis demonstrated abundance of ANGPTL4 in lung tissue compared with other organs in COVID-19. ANGPTL4 single-nuclear RNA gene expression was significantly increased in pulmonary alveolar type 2 epithelial cells and fibroblasts in COVID-19 lung tissue compared with controls. CONCLUSIONS AND RELEVANCE ANGPTL4 is expressed in pulmonary epithelial cells and fibroblasts and is associated with clinical prognosis in critically ill COVID-19 patients.
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Affiliation(s)
- Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
- School of Medicine, University of Washington, Sepsis Center of Research Excellence-University of Washington (SCORE-UW), Seattle, WA
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Eric D Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Ian B Stanaway
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Neha A Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Avantika Srivastava
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Radu Postelnicu
- Division of Pulmonary, Critical Care, and Sleep Medicine, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Richard Green
- Departments of Medicine (Division of Medical Genetics) and Genome Sciences, University of Washington Medical Center, Seattle, WA
| | - Adair Andrews
- Society of Critical Care Medicine, Mount Prospect, IL
| | | | | | | | | | - Michael Gale
- Department of Immunology, University of Washington, Seattle, WA
| | - George L Anesi
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David Wyles
- Division of Infectious Diseases, Denver Health Medical Center, Denver, CO
| | - M Jana Broadhurst
- Global Center for Health Security, University of Nebraska Medical Center, Omaha, NE
| | - David Brett-Major
- Global Center for Health Security, University of Nebraska Medical Center, Omaha, NE
| | - Vikramjit Mukherjee
- Division of Pulmonary, Critical Care, and Sleep Medicine, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep, School of Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Douglas Landsittel
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN
| | - Chi Hung
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - William A Altemeier
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Sina A Gharib
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Timothy M Uyeki
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA
| | - J Perren Cobb
- Departments of Surgery and Anesthesiology, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA
| | - Janice M Liebler
- Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - David R Crosslin
- Division of Biomedical Informatics and Genomics, John W. Deming Department of Medicine, Tulane University, School of Medicine, New Orleans, LA
| | - Gail P Jarvik
- Departments of Medicine (Division of Medical Genetics) and Genome Sciences, University of Washington Medical Center, Seattle, WA
| | - Leopoldo N Segal
- Division of Pulmonary, Critical Care, and Sleep Medicine, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Carmen Mikacenic
- Translational Research, Benaroya Research Institute, Seattle, WA
| | - Mark M Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
- School of Medicine, University of Washington, Sepsis Center of Research Excellence-University of Washington (SCORE-UW), Seattle, WA
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, WA
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10
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Gorman EA, O'Kane CM, McAuley DF. Acute respiratory distress syndrome in adults: diagnosis, outcomes, long-term sequelae, and management. Lancet 2022; 400:1157-1170. [PMID: 36070788 DOI: 10.1016/s0140-6736(22)01439-8] [Citation(s) in RCA: 82] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/20/2022] [Accepted: 07/27/2022] [Indexed: 12/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is characterised by acute hypoxaemic respiratory failure with bilateral infiltrates on chest imaging, which is not fully explained by cardiac failure or fluid overload. ARDS is defined by the Berlin criteria. In this Series paper the diagnosis, management, outcomes, and long-term sequelae of ARDS are reviewed. Potential limitations of the ARDS definition and evidence that could inform future revisions are considered. Guideline recommendations, evidence, and uncertainties in relation to ARDS management are discussed. The future of ARDS strives towards a precision medicine approach, and the framework of treatable traits in ARDS diagnosis and management is explored.
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Affiliation(s)
- Ellen A Gorman
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Cecilia M O'Kane
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK.
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11
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Advances in Ventilator Management for Patients with Acute Respiratory Distress Syndrome. Clin Chest Med 2022; 43:499-509. [PMID: 36116817 PMCID: PMC9477439 DOI: 10.1016/j.ccm.2022.05.002] [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: 12/16/2022]
Abstract
The ventilatory care of patients with acute respiratory distress syndrome (ARDS) is evolving as our understanding of physiologic mechanisms of respiratory failure improves. Despite several decades of research, the mortality rate for ARDS remains high. Over the years, we continue to expand strategies to identify and mitigate ventilator-induced lung injury. This now includes a greater understanding of the benefits and harms associated with spontaneous breathing.
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12
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Ashra F, Chen R, Kang XL, Chiang KJ, Pien LC, Jen HJ, Liu D, Hsiao STS, Chou KR. Effectiveness of prone position in acute respiratory distress syndrome and moderating factors of obesity class and treatment durations for COVID-19 patients: A Meta-Analysis. Intensive Crit Care Nurs 2022; 72:103257. [PMID: 35672215 PMCID: PMC8995327 DOI: 10.1016/j.iccn.2022.103257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 04/01/2022] [Accepted: 04/06/2022] [Indexed: 12/20/2022]
Abstract
Objectives To examine the effectiveness of prone positioning on COVID-19 patients with acute respiratory distress syndrome with moderating factors in both traditional prone positioning (invasive mechanical ventilation) and awake self-prone positioning patients (non-invasive ventilation). Research methodology A comprehensive search was conducted in CINAHL, Cochrane library, Embase, Medline-OVID, NCBI SARS-CoV-2 Resources, ProQuest, Scopus, and Web of Science without language restrictions. All studies with prospective and experimental designs evaluating the effect of prone position patients with COVID-19 related to acute respiratory distress syndrome were included. Pooled standardised mean differences were calculated after prone position for primary (PaO2/FiO2) and secondary outcomes (SpO2 and PaO2) Results A total of 15 articles were eligible and included in the final analysis. Prone position had a statistically significant effect in improving PaO2/FiO2 with standardised mean difference of 1.10 (95%CI 0.60–1.59), SpO2 with standardised mean difference of 3.39 (95% CI 1.30–5.48), and PaO2 with standardised mean difference of 0.77 (95% CI 0.19–1.35). Patients with higher body mass index and longer duration/day are associated with larger standardised mean difference effect sizes for prone positioning. Conclusions Our findings demonstrate that prone position significantly improved oxygen saturation in COVID-19 patients with acute respiratory distress syndrome in both traditional prone positioning and awake self-prone positioning patients. Prone position should be recommended for patients with higher body mass index and longer durations to obtain the maximum effect.
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Affiliation(s)
- Fauzi Ashra
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Institut Kesehatan Prima Nusantara Bukittinggi, Bukittinggi, Indonesia
| | - Ruey Chen
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan; Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Xiao Linda Kang
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; School of Nursing, University of Pennsylvania, USA
| | - Kai-Jo Chiang
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; School of Nursing, National Defense Medical Center, Taipei, Taiwan; Department of Nursing, Tri-Service General Hospital Songshan Branch, Taipei, Taiwan
| | - Li-Chung Pien
- Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Hsiu-Ju Jen
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan
| | - Doresses Liu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Shu-Tai Shen Hsiao
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Superintendent Office, Taipei Medical University Hospital, Taipei, Taiwan
| | - Kuei-Ru Chou
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan; Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Neuroscience Research Center, Taipei Medical University, Taipei, Taiwan.
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13
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Comparison of high-dose, short-term steroid and low-dose long-term steroid use in ARDS caused by COVID-19: Retrospective cohort study. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.1058849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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14
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Ware LB. Go with the Flow: Expanding the Definition of ARDS to Include High Flow Nasal Oxygen. Am J Respir Crit Care Med 2022; 205:380-382. [PMID: 35007489 PMCID: PMC8886950 DOI: 10.1164/rccm.202112-2727ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Lorraine B Ware
- Vanderbilt University, Allergy, Pulmonary and Critical Care Medicine, Nashville, Tennessee, United States
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15
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Parsons PE. BIOMARKERS IN THE ACUTE RESPIRATORY DISTRESS SYNDROME: PAST, PRESENT, AND FUTURE. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2022; 132:107-116. [PMID: 36196169 PMCID: PMC9480556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Acute respiratory distress syndrome (ARDS), originally described in 1967, affects more than 3 million individuals each year throughout the world and accounts for approximately 10% of all admissions to the intensive care unit. Despite substantial progress in defining the epidemiology and pathogenesis of the syndrome, there is no specific treatment and mortality rates remain high. Barriers to finding specific therapeutic interventions include the inability to predict who will get ARDS, inadequate definitions and specific diagnostic markers, the heterogeneity of the patient population, complexities of the pathogenesis, and the impact of clinical care. Measurements of biomarkers have identified these barriers as well as contributed to the current understanding of the disease. The COVID-19 pandemic resulted in a dramatic increase in patients with ARDS, driving an urgent need to understand the pathogenesis and develop and implement therapeutic interventions. Past studies of biomarkers in ARDS can provide insight that could help to meet those needs more rapidly.
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Gattinoni L, Marini JJ. Isn't it time to abandon ARDS? The COVID-19 lesson. Crit Care 2021; 25:326. [PMID: 34488807 PMCID: PMC8419818 DOI: 10.1186/s13054-021-03748-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/25/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- L Gattinoni
- Department of Anesthesiology, Medical University of Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany. .,Department of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, MN, USA.
| | - J J Marini
- Department of Anesthesiology, Medical University of Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany.,Department of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, MN, USA
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