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Gao YC, Shi L, Zhang YW, Gao W, Tian X, Cao MM, Li YJ, Chen H, Rui YF. Postoperative awake prone position in geriatric patients with hip fractures: a protocol for a randomized controlled trial on the efficacy of postoperative prone position in reducing pulmonary complications and improving oxygenation. Trials 2023; 24:280. [PMID: 37069686 PMCID: PMC10110345 DOI: 10.1186/s13063-023-07308-x] [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: 03/03/2023] [Accepted: 04/11/2023] [Indexed: 04/19/2023] Open
Abstract
INTRODUCTION Postoperative pulmonary complications (PPCs) are prevalent in geriatric patients with hip fractures. Low oxygen level is one of the most important risk factors for PPCs. Prone position has been proven efficacy in improving oxygenation and delaying the progress of pulmonary diseases, especially in patients with acute respiratory distress syndrome induced by multiple etiologies. The application of awake prone position (APP) has also attracted widespread attention in recent years. A randomized controlled trial (RCT) will be carried out to measure the effect of postoperative APP in a population of geriatric patients undergoing hip fracture surgery. METHODS This is an RCT. Patients older than 65 years old admitted through the emergency department and diagnosed with an intertrochanteric or femoral neck fracture will be eligible for enrollment and assigned randomly to the control group with routine postoperative management of orthopedics or APP group with an additional prone position for the first three consecutive postoperative days (PODs). Patients receiving conservative treatment will not be eligible for enrollment. We will record the difference in the patient's room-air-breathing arterial partial pressure of oxygen (PaO2) values between the 4th POD (POD 4) and emergency visits, the morbidity of PPCs and other postoperative complications, and length of stay. The incidence of PPCs, readmission rates, and mortality rates will be followed up for 90 PODs. DISCUSSION We describe the protocol for a single-center RCT that will evaluate the efficacy of postoperative APP treatment in reducing pulmonary complications and improving oxygenation in geriatric patients with hip fractures. ETHICS AND DISSEMINATION This protocol was approved by the independent ethics committee (IEC) for Clinical Research of Zhongda Hospital, Affiliated to Southeast University, and is registered on the Chinese Clinical Trial Registry. The findings of the trial will be disseminated through peer-reviewed journals. ETHICS APPROVAL NUMBER 2021ZDSYLL203-P01 TRIAL REGISTRATION: ChiCTR ChiCTR2100049311 . Registered on 29 July 2021. TRIAL STATUS Recruiting. Recruitment is expected to be completed in December 2024.
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Affiliation(s)
- Yu-Cheng Gao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Liu Shi
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Wang Gao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Xie Tian
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Mu-Min Cao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Ying-Juan Li
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China.
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China.
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China.
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China.
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Al-Rekabi Z, Dondi C, Faruqui N, Siddiqui NS, Elowsson L, Rissler J, Kåredal M, Mudway I, Larsson-Callerfelt AK, Shaw M. Uncovering the cytotoxic effects of air pollution with multi-modal imaging of in vitro respiratory models. ROYAL SOCIETY OPEN SCIENCE 2023; 10:221426. [PMID: 37063998 PMCID: PMC10090883 DOI: 10.1098/rsos.221426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/17/2023] [Indexed: 06/19/2023]
Abstract
Annually, an estimated seven million deaths are linked to exposure to airborne pollutants. Despite extensive epidemiological evidence supporting clear associations between poor air quality and a range of short- and long-term health effects, there are considerable gaps in our understanding of the specific mechanisms by which pollutant exposure induces adverse biological responses at the cellular and tissue levels. The development of more complex, predictive, in vitro respiratory models, including two- and three-dimensional cell cultures, spheroids, organoids and tissue cultures, along with more realistic aerosol exposure systems, offers new opportunities to investigate the cytotoxic effects of airborne particulates under controlled laboratory conditions. Parallel advances in high-resolution microscopy have resulted in a range of in vitro imaging tools capable of visualizing and analysing biological systems across unprecedented scales of length, time and complexity. This article considers state-of-the-art in vitro respiratory models and aerosol exposure systems and how they can be interrogated using high-resolution microscopy techniques to investigate cell-pollutant interactions, from the uptake and trafficking of particles to structural and functional modification of subcellular organelles and cells. These data can provide a mechanistic basis from which to advance our understanding of the health effects of airborne particulate pollution and develop improved mitigation measures.
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Affiliation(s)
- Zeinab Al-Rekabi
- Department of Chemical and Biological Sciences, National Physical Laboratory, Teddington, UK
| | - Camilla Dondi
- Department of Chemical and Biological Sciences, National Physical Laboratory, Teddington, UK
| | - Nilofar Faruqui
- Department of Chemical and Biological Sciences, National Physical Laboratory, Teddington, UK
| | - Nazia S. Siddiqui
- Faculty of Medical Sciences, University College London, London, UK
- Kingston Hospital NHS Foundation Trust, Kingston upon Thames, UK
| | - Linda Elowsson
- Lung Biology, Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Jenny Rissler
- Bioeconomy and Health, RISE Research Institutes of Sweden, Lund, Sweden
- Ergonomics and Aerosol Technology, Lund University, Lund, Sweden
| | - Monica Kåredal
- Occupational and Environmental Medicine, Lund University, Lund, Sweden
| | - Ian Mudway
- MRC Centre for Environment and Health, Imperial College London, London, UK
- National Institute of Health Protection Research Unit in Environmental Exposures and Health, London, UK
- Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | | | - Michael Shaw
- Department of Chemical and Biological Sciences, National Physical Laboratory, Teddington, UK
- Department of Computer Science, University College London, London, UK
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Acute Respiratory Distress Syndrome, Mechanical Ventilation, and Inhalation Injury in Burn Patients. Surg Clin North Am 2023; 103:439-451. [PMID: 37149380 PMCID: PMC10028407 DOI: 10.1016/j.suc.2023.01.006] [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: 03/24/2023]
Abstract
Respiratory failure occurs with some frequency in seriously burned patients, driven by a combination of inflammatory and infection factors. Inhalation injury contributes to respiratory failure in some burn patients via direct mucosal injury and indirect inflammation. In burn patients, respiratory failure leading to acute respiratory distress syndrome, with or without inhalation injury, is effectively managed using principles evolved for non-burn critically ill patients.
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Body position for preventing ventilator-associated pneumonia for critically ill patients: a systematic review and network meta-analysis. J Intensive Care 2022; 10:9. [PMID: 35193688 PMCID: PMC8864849 DOI: 10.1186/s40560-022-00600-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/09/2022] [Indexed: 02/06/2023] Open
Abstract
Background The evidence about the best body position to prevent ventilator-associated pneumonia (VAP) is unclear. The aim of this study was to know what the best body position is to prevent VAP, shorten the length of intensive care unit (ICU) and hospital stay, and reduce mortality among patients undergoing mechanical ventilation (MV). Methods We performed a network meta-analysis of randomized controlled trials including intubated patients undergoing MV and admitted to an ICU. The assessed interventions were different body positions (i.e., lateral, prone, semi-recumbent) or alternative degrees of positioning in mechanically ventilated patients. Results Semi-recumbent and prone positions showed a risk reduction of VAP incidence (RR: 0.38, 95% CI: 0.25–0.52) and mortality (RR: 0.70, 95% CI: 0.50–0.91), respectively, compared to the supine position. The ranking probabilities and the surface under the cumulative ranking displayed as the first best option of treatment the semi-recumbent position to reduce the incidence of VAP (71.4%), the hospital length of stay (68.9%), and the duration of MV (67.6%); and the prone position to decrease the mortality (89.3%) and to reduce the ICU length of stay (59.3%). Conclusions Cautiously, semi-recumbent seems to be the best position to reduce VAP incidence, hospital length of stay and the duration of MV. Prone is the most effective position to reduce the risk of mortality and the ICU length of stay, but it showed no effect on the VAP incidence. Registration PROSPERO CRD42021247547 Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00600-z.
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Ryan P, Fine C, DeForge C. An Evidence-Based Protocol for Manual Prone Positioning of Patients With ARDS. Crit Care Nurse 2021; 41:55-60. [PMID: 34851387 DOI: 10.4037/ccn2021900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Manual prone positioning has been shown to reduce mortality among patients with moderate to severe acute respiratory distress syndrome, but it is associated with a high incidence of pressure injuries and unplanned extubations. This study investigated the feasibility of safely implementing a manual prone positioning protocol that uses a dedicated device. REVIEW OF EVIDENCE A search of CINAHL and Medline identified multiple randomized controlled trials and meta-analyses that demonstrated both the reduction of mortality when prone positioning is used for more than 12 hours per day in patients with acute respiratory distress syndrome and the most common complications of this treatment. IMPLEMENTATION An existing safe patient-handling device was modified to enable staff to safely perform manual prone positioning with few complications for patients receiving mechanical ventilation. All staff received training on the protocol and use of the device before implementation. EVALUATION This study included 36 consecutive patients who were admitted to the medical intensive care unit at a large academic medical center because of hypoxemic respiratory failure/acute respiratory distress syndrome and received mechanical ventilation and prone positioning. Data were collected on clinical presentation, interventions, and complications. SUSTAINABILITY Using the robust protocol and the low-cost device, staff can safely perform a low-volume, high-risk maneuver. This method provides cost savings compared with other prone positioning methods. CONCLUSIONS Implementing a prone positioning protocol with a dedicated device is feasible, with fewer complications and lower costs than anticipated.
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Affiliation(s)
- Patrick Ryan
- Patrick Ryan is a clinical nurse specialist-medicine, New York Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Cynthia Fine
- Cynthia Fine is a clinical program coordinator, New York Presbyterian/Columbia University Irving Medical Center
| | - Christine DeForge
- Christine DeForge is a PhD student, Columbia University School of Nursing, New York, New York
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González-Seguel F, Pinto-Concha JJ, Aranis N, Leppe J. Adverse Events of Prone Positioning in Mechanically Ventilated Adults With ARDS. Respir Care 2021; 66:1898-1911. [PMID: 34301802 PMCID: PMC9993788 DOI: 10.4187/respcare.09194] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Prone positioning is a therapy utilized globally to improve gas exchange, minimize ventilator-induced lung injury, and reduce mortality in ARDS, particularly during the ongoing coronavirus disease 2019 (COVID-19) pandemic. Whereas the respiratory benefits of prone positioning in ARDS have been accepted, the concurrent complications could be undervalued. Therefore, this study aimed to identify the adverse events (AEs) related to prone positioning in ARDS and, secondarily, to collect strategies and recommendations to mitigate these AEs. METHODS In this scoping review, we searched recommendation documents and original studies published between June 2013 and November 2020 from 6 relevant electronic databases and the websites of intensive care societies. RESULTS We selected 41 documents from 121 eligible documents, comprising 13 recommendation documents and 28 original studies (involving 1,578 subjects and 994 prone maneuvers). We identified > 40 individual AEs, and the highest-pooled occurrence rates were those of severe desaturation (37.9%), barotrauma (30.5%), pressure sores (29.7%), ventilation-associated pneumonia (28.2%), facial edema (16.7%), arrhythmia (15.4%), hypotension (10.2%), and peripheral nerve injuries (8.1%). The reported mitigation strategies during prone positioning included alternate face rotation (18 [43.9%]), repositioning every 2 h (17 [41.5%]), and the use of pillows under the chest and pelvis (14 [34.1%]). The reported mitigation strategies for performing the prone maneuver comprised one person being at the headboard (23 [56.1%]), the use of a pre-maneuver safety checklist (18 [43.9%]), vital sign monitoring (15 [36.6%]), and ensuring appropriate ventilator settings (12 [29.3%]). CONCLUSIONS We identified > 40 AEs reported in prone positioning ARDS studies, including additional AEs not yet reported by previous systematic reviews. The pooled AE proportions collected in this review could guide research and clinical practice decisions, and the strategies to mitigate AEs could promote future consensus-based recommendations.
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Affiliation(s)
- Felipe González-Seguel
- Servicio de Medicina Física y Rehabilitación and Departamento de Paciente Crítico, Clínica Alemana Universidad del Desarrollo, Santiago, Chile.
- Master Program in Physical Therapy and Rehabilitation, School of Physical Therapy, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Juan José Pinto-Concha
- Master Program in Physical Therapy and Rehabilitation, School of Physical Therapy, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
- Centro de Paciente Crítico Adulto, Clínica INDISA, Santiago, Chile
| | - Nadine Aranis
- Servicio de Medicina Física y Rehabilitación and Departamento de Paciente Crítico, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
- Master Program in Physical Therapy and Rehabilitation, School of Physical Therapy, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Jaime Leppe
- Master Program in Physical Therapy and Rehabilitation, School of Physical Therapy, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
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Yang X, An X, Wang C, Gao F, Lin Y, Chen W, Deng Q, Xu D, Li S, Zhang P, Sun B, Hou Y, Wu J. Protective Effect of Oxytocin on Ventilator-Induced Lung Injury Through NLRP3-Mediated Pathways. Front Pharmacol 2021; 12:722907. [PMID: 34733156 PMCID: PMC8558354 DOI: 10.3389/fphar.2021.722907] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
Mechanical ventilation is an indispensable life-support treatment for acute respiratory failure in critically ill patients, which is generally believed to involve uncontrolled inflammatory responses. Oxytocin (OT) has been reported to be effective in animal models of acute lung injury. However, it is not clear whether Oxytocin has a protective effect on ventilator-induced lung injury (VILI). Therefore, in this study, we aimed to determine whether OT can attenuate VILI and explore the possible mechanism of this protection. To this end, a mouse VILI model was employed. Mice were pretreated with OT 30 min before the intraperitoneal injection of saline or nigericin and ventilation for 4 h, after which they were euthanized. Pathological changes, lung wet/dry (W/D) weight ratio, myeloperoxidase (MPO) activity, the levels of inflammatory cytokines [i.e., interleukin (IL)-1β, IL-6, and IL-18] in lung tissues and bronchoalveolar lavage fluid (BALF), and expression of NLRP3, Toll-like receptor 4 (TLR4), caspase-1, nuclear factor (NF)-κB, and GSDMD in lung tissues were measured. OT treatment could reduce pathological injury, the W/D ratio, and MPO activity in VILI mice. Our data also indicated that OT administration alleviated the expression of TLR4/My-D88 and the activation of NF-κB, NLRP3, and caspase-1 in lung tissues from the VILI mice model. Furthermore, OT also decreased the levels of IL-1β, IL-6, and IL-18 in the bronchoalveolar lavage fluid. Moreover, the OT administration may alleviate the activation of GSDMD partially through its effects on the NLRP3-mediated pathway. Collectively, OT exerted a beneficial effect on VILI by downregulating TLR4-and NLRP3-mediated inflammatory pathways.
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Affiliation(s)
- Xiaomei Yang
- Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,School of Medicine, Cheeloo College of medicine, Shandong University, Jinan, China.,Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaona An
- Department of Anesthesiology, Zibo Central Hospital, Shandong University, Zibo, China
| | - Cheng Wang
- Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,School of Medicine, Cheeloo College of medicine, Shandong University, Jinan, China
| | - Feng Gao
- School of Medicine, Cheeloo College of medicine, Shandong University, Jinan, China
| | - Yicheng Lin
- Shandong Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wenjing Chen
- Department of Cardiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Qiming Deng
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Dongsheng Xu
- Department of Kidney Transplantation, The Second Hospital, Shandong University, Jinan, China
| | - Shengqiang Li
- Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Peng Zhang
- Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Baozhu Sun
- Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yuedong Hou
- Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jianbo Wu
- Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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Parashar S, Karthik AR, Gupta R, Malviya D. Awake Proning for Nonintubated Adult Hypoxic Patients with COVID-19: A Systematic Review of the Published Evidence. Indian J Crit Care Med 2021; 25:906-916. [PMID: 34733032 PMCID: PMC8559734 DOI: 10.5005/jp-journals-10071-23910] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective: Awake proning is an intervention that is being advocated for COVID-19 patients and has been suggested to improve the oxygenation, thereby decreasing oxygen requirements. We performed this systematic review with the aim of appraising the latest published evidence on the clinical effectiveness of awake proning in COVID-19 patients. Data sources: PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Google Scholar, and one trial registry were searched until September 23, 2020, for studies on the use of awake proning for nonintubated COVID-19 patients. Study selection: Published or in-press peer-reviewed randomized control trials, case-control trials, and prospective or retrospective cohort studies in English language only were sought, assessing the effectiveness of awake proning for nonintubated patients diagnosed with COVID-19. Data results: We included 21 published studies (19 single arm and 2 with comparison group). Twenty-three registered clinical trials were identified. No randomized clinical trial has been published so far. Conclusions: Awake proning is probably safe and effective in enhancing oxygenation in nonintubated COVID-19 patients; however, there is insufficient evidence. Further high-quality clinical trials are urgently needed to assess the effectiveness of awake proning on a variety of patient-centered outcomes. How to cite this article: Parashar S, Karthik AR, Gupta R, Malviya D. Awake Proning for Nonintubated Adult Hypoxic Patients with COVID-19: A Systematic Review of the Published Evidence. Indian J Crit Care Med 2021;25(8):906–916.
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Affiliation(s)
- Samiksha Parashar
- Department of Anaesthesiology and Critical Care, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - A R Karthik
- Department of Oncoanaesthesia and Palliative Medicine, BRAIRCH, AIIMS, Delhi
| | - Ravi Gupta
- Department of General Surgery, AIIMS, Gorakhpur, Uttar Pradesh, India
| | - Deepak Malviya
- Department of Anaesthesiology and Critical Care, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Chang KW, Hu HC, Chiu LC, Chan MC, Liang SJ, Yang KY, Chen WC, Fang WF, Chen YM, Sheu CC, Chang WA, Wang HC, Chien YC, Peng CK, Wu CL, Kao KC. Comparison of prone positioning and extracorporeal membrane oxygenation in acute respiratory distress syndrome: A multicenter cohort study and propensity-matched analysis. J Formos Med Assoc 2021; 121:1149-1158. [PMID: 34740489 PMCID: PMC8519810 DOI: 10.1016/j.jfma.2021.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 10/06/2021] [Accepted: 10/09/2021] [Indexed: 01/17/2023] Open
Abstract
Background/Purpose Both prone positioning and extracorporeal membrane oxygenation (ECMO) are used as rescue therapies for severe hypoxemia in patients with acute respiratory distress syndrome (ARDS). This study compared outcomes between patients with severe influenza pneumonia-related ARDS who received prone positioning and those who received ECMO. Methods This retrospective cohort study included eight tertiary referral centers in Taiwan. All patients who were diagnosed as having influenza pneumonia-related severe ARDS were enrolled between January and March 2016. We collected their demographic data and prone positioning and ECMO outcomes from medical records. Results In total, 263 patients diagnosed as having ARDS were included, and 65 and 53 of them received prone positioning and ECMO, respectively. The baseline PaO2/FiO2 ratio, Acute Physiology and Chronic Health Evaluation II score and Sequential Organ Failure Assessment score did not significantly differ between the two groups. The 60-day mortality rate was significantly higher in the ECMO group than in the prone positioning group (60% vs. 28%, p = 0.001). A significantly higher mortality rate was still observed in the ECMO group after propensity score matching (59% vs. 36%, p = 0.033). In the multivariate Cox regression analysis, usage of prone positioning or ECMO was the single independent predictor for 60-day mortality (hazard ratio: 2.177, p = 0.034). Conclusion While the patients receiving prone positioning had better outcome, the causality between prone positioning and the prognosis is unknown. However, the current data suggested that patients with influenza-related ARDS may receive prone positioning before ECMO support.
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Affiliation(s)
- Ko-Wei Chang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Han-Chung Hu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Respiratory Therapy, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Li-Chung Chiu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Cheng Chan
- Division of Critical Care and Respiratory Therapy, Department of Internal Medicine, Taichung Veterans General Hospital, Taiwan; College of Science, Tunghai University, Taiwan
| | - Shinn-Jye Liang
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Kuang-Yao Yang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Chih Chen
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Yu-Mu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-An Chang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hao-Chien Wang
- Division of Chest Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Chun Chien
- Division of Chest Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Kan Peng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chieh-Liang Wu
- Center for Quality Management, Taichung Veterans General Hospital, Taichung, Taiwan; Office of Medical Administration, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Respiratory Therapy, Chang-Gung University College of Medicine, Taoyuan, Taiwan.
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Ceruti S, Glotta A, Biggiogero M, Bona G, Saporito A, Faldarini N, Olivieri D, Molteni C, Petazzi S, Capdevila X. Multidisciplinary team approach in critically ill COVID-19 patients reduced pronation-related complications rate: A retrospective cohort study. Ann Med Surg (Lond) 2021; 70:102836. [PMID: 34518782 PMCID: PMC8427910 DOI: 10.1016/j.amsu.2021.102836] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/06/2021] [Accepted: 09/06/2021] [Indexed: 12/23/2022] Open
Abstract
Background In the pandemic scenario, critically ill COVID-19 patients' management presented an increased workload for Intensive Care Unit (ICU) nursing staff, particularly during pronation maneuvers, with high risk of complications. In this contest, some authors described an increase in complications incidence after pronation. An ICU Pronation Team (IPT) was implemented to support this maneuver. Material and methods Retrospective analysis was conducted on consecutive critically ill COVID-19 patients in COVID-19 Center in southern Switzerland, between March and April 2020. Aim of the study was to determine rates and characteristics of pronation-related complications managed by IPT according to standard protocols. Results Forty-two patients undergoing mechanical ventilation (MV) were enrolled; 296 prone/supine positioning were performed, with 3.52 cycles/patient. All patients were equipped with arterial line, central venous catheter, urinary catheter, 28 (66%) endotracheal tube, 8 (19%), tracheostomy, 6 (14%) dialysis catheter, 3 (7%) abdominal drainage and 8 (19%) femoral thermodilution catheter; mean BMI was 28.3 kg/m2. One (0.3%) major complication was observed, while fourteen (33.3%) patients developed minor complications (pressure injuries). ICU length-of-stay and MV days correlated with both incidence (p = 0.029 and p = 0.015 respectively) and number (p = 0.001 and p = 0.001 respectively) of pressure sores (n = 27). Propensity matching score analysis did not show any protective factor of pronation regarding pressure injuries (p = 0.448). No other significant correlation was found. Conclusion Multidisciplinary healthcare professional management can reduce most severe complication related to pronation in critical care setting. Rather than from pronation, the persistent high rate of minor complications appeared to be related to disease severity.
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Affiliation(s)
- Samuele Ceruti
- Clinica Luganese Moncucco, Critical Care Department, Lugano, Switzerland
| | - Andrea Glotta
- Clinica Luganese Moncucco, Critical Care Department, Lugano, Switzerland
| | - Maira Biggiogero
- Clinica Luganese Moncucco, Clinical Research Unit, Lugano, Switzerland
| | - Giovanni Bona
- Clinica Luganese Moncucco, Clinical Research Unit, Lugano, Switzerland
| | - Andrea Saporito
- Ente Ospedaliero Cantonale, Bellinzona Regional Hospital, Service of Anaesthesia, Switzerland
| | - Nicola Faldarini
- Clinica Luganese Moncucco, Physiotherapy Service, Lugano, Switzerland
| | - Diana Olivieri
- Clinica Luganese Moncucco, Physiotherapy Service, Lugano, Switzerland
| | - Claudia Molteni
- Clinica Luganese Moncucco, Physiotherapy Service, Lugano, Switzerland
| | - Stefano Petazzi
- Clinica Luganese Moncucco, Physiotherapy Service, Lugano, Switzerland
| | - Xavier Capdevila
- Centre Hospitalier Universitaire de Montpellier, Department of Anesthesia and Intensive Care, 191 Av. du Doyen Gaston Giraud, 34295 Montpellier, France
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11
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Louis G, Belveyre T, Jacquot A, Hochard H, Aissa N, Kimmoun A, Goetz C, Levy B, Novy E. Infection related catheter complications in patients undergoing prone positioning for acute respiratory distress syndrome: an exposed/unexposed study. BMC Infect Dis 2021; 21:534. [PMID: 34098888 PMCID: PMC8182343 DOI: 10.1186/s12879-021-06197-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/04/2021] [Indexed: 12/15/2022] Open
Abstract
Background Prone positioning (PP) is a standard of care for patients with moderate–severe acute respiratory distress syndrome (ARDS). While adverse events associated with PP are well-documented in the literature, research examining the effect of PP on the risk of infectious complications of intravascular catheters is lacking. Method All consecutive ARDS patients treated with PP were recruited retrospectively over a two-year period and formed the exposed group. Intensive care unit (ICU) patients during the same period without ARDS for whom PP was not conducted but who had an equivalent disease severity were matched 1:1 to the exposed group based on age, sex, centre, length of ICU stay and SAPS II (unexposed group). Infection-related catheter complications were defined by a composite criterion, including catheter tip colonization or intravascular catheter-related infection. Results A total of 101 exposed patients were included in the study. Most had direct ARDS (pneumonia). The median [Q1–Q3] PP session number was 2 [1–4]. These patients were matched with 101 unexposed patients. The mortality rates of the exposed and unexposed groups were 31 and 30%, respectively. The incidence of the composite criterion was 14.2/1000 in the exposed group compared with 8.2/1000 days in the control group (p = 0.09). Multivariate analysis identified PP as a factor related to catheter colonization or infection (p = 0.04). Conclusion Our data suggest that PP is associated with a higher risk of CVC infectious complications.
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Affiliation(s)
- Guillaume Louis
- Intensive Care Unit, Metz-Thionville Regional Hospital, Mercy Hospital, 1 allée de Château, 57085, Metz, France.
| | - Thibaut Belveyre
- Intensive Care Unit, Metz-Thionville Regional Hospital, Mercy Hospital, 1 allée de Château, 57085, Metz, France
| | - Audrey Jacquot
- Medical intensive Care Unit, University Hospital of Nancy, Brabois, France
| | - Hélène Hochard
- Department of Bacteriology, Metz-Thionville Regional Hospital, Mercy Hospital, Metz, France
| | - Nejla Aissa
- Department of Bacteriology, University Hospital of Nancy, Nancy, France
| | - Antoine Kimmoun
- Medical intensive Care Unit, University Hospital of Nancy, Brabois, France
| | - Christophe Goetz
- Clinical Research Support Unit, Metz-Thionville Regional Hospital, Metz, France
| | - Bruno Levy
- Medical intensive Care Unit, University Hospital of Nancy, Brabois, France
| | - Emmanuel Novy
- Intensive Care Unit, Metz-Thionville Regional Hospital, Mercy Hospital, 1 allée de Château, 57085, Metz, France
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12
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Lee PH, Kuo CT, Hsu CY, Lin SP, Fu PK. Prognostic Factors to Predict ICU Mortality in Patients with Severe ARDS Who Received Early and Prolonged Prone Positioning Therapy. J Clin Med 2021; 10:jcm10112323. [PMID: 34073532 PMCID: PMC8198972 DOI: 10.3390/jcm10112323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 12/29/2022] Open
Abstract
Early and prolonged prone positioning (PP) therapy improve survival in advanced ARDS; however, the predictors of mortality remain unclear. The study aims to identify predictive factors correlated with mortality and build-up the prognostic score in patients with severe ARDS who received early and prolonged PP therapy. A total of 116 patients were enrolled in this retrospective cohort study. Univariate and multivariate regression models were used to estimate the odds ratio (OR) of mortality. Factors associated with mortality were assessed by Cox regression analysis and presented as the hazard ratio (HR) and 95% CI. In the multivariate regression model, renal replacement therapy (RRT; OR: 4.05, 1.54–10.67), malignant comorbidity (OR: 8.86, 2.22–35.41), and non-influenza-related ARDS (OR: 5.17, 1.16–23.16) were significantly associated with ICU mortality. Age, RRT, non-influenza-related ARDS, malignant comorbidity, and APACHE II score were included in a composite prone score, which demonstrated an area under the curve of 0.816 for predicting mortality risk. In multivariable Cox proportional hazard model, prone score more than 3 points was significantly associated with ICU mortality (HR: 2.13, 1.12–4.07, p = 0.021). We suggest prone score ≥3 points could be a good predictor for mortality in severe ARDS received PP therapy.
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Affiliation(s)
- Po-Hsin Lee
- Division of Chest, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan;
| | - Chen-Tsung Kuo
- Computer & Communications Center, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
| | - Chiann-Yi Hsu
- Biostatistics Task Force of Taichung Veterans General Hospital, Taichung 407219, Taiwan;
| | - Shih-Pin Lin
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan;
| | - Pin-Kuei Fu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan;
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402010, Taiwan
- College of Human Science and Social Innovation, Hungkuang University, Taichung 433304, Taiwan
- Department of Computer Science, Tunghai University, Taichung 407224, Taiwan
- Correspondence: ; Tel.: +886-937-701-592
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13
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Touchon F, Trigui Y, Prud'homme E, Lefebvre L, Giraud A, Dols AM, Martinez S, Bernardi M, Begne C, Granier P, Chanez P, Forel JM, Papazian L, Elharrar X. Awake prone positioning for hypoxaemic respiratory failure: past, COVID-19 and perspectives. Eur Respir Rev 2021; 30:30/160/210022. [PMID: 33952601 PMCID: PMC8112009 DOI: 10.1183/16000617.0022-2021] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/04/2021] [Indexed: 01/26/2023] Open
Abstract
Prone positioning reduces mortality in the management of intubated patients with moderate-to-severe acute respiratory distress syndrome. It allows improvement in oxygenation by improving ventilation/perfusion ratio mismatching. Because of its positive physiological effects, prone positioning has also been tested in non-intubated, spontaneously breathing patients, or “awake” prone positioning. This review provides an update on awake prone positioning for hypoxaemic respiratory failure, in both coronavirus disease 2019 (COVID-19) and non-COVID-19 patients. In non-COVID-19 acute respiratory failure, studies are limited to a few small nonrandomised studies and involved patients with different diseases. However, results have been appealing with regard to oxygenation improvement, especially when combined with noninvasive ventilation or high-flow nasal cannula. The recent COVID-19 pandemic has led to a major increase in hospitalisations for acute respiratory failure. Awake prone positioning has been used with the aim to prevent intensive care unit admission and mechanical ventilation. Prone positioning in conscious, non-intubated COVID-19 patients is used in emergency departments, medical wards and intensive care units. Several trials reported an improvement in oxygenation and respiratory rate during prone positioning, but impacts on clinical outcomes, particularly on intubation rates and survival, remain unclear. Tolerance of prolonged prone positioning is an issue. Larger controlled, randomised studies are underway to provide results concerning clinical benefit and define optimised prone positioning regimens. In intubated ARDS patients, prone positioning reduces mortality. On spontaneously breathing patients, oxygenation improved during awake prone positioning. Relevant data on clinical outcomes are expected, especially on COVID-19 patients.https://bit.ly/2PU3B6v
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Affiliation(s)
- François Touchon
- Service des Maladies Respiratoires, CH Aix-en-Provence, Aix-en-Provence, France
| | - Youssef Trigui
- Service des Maladies Respiratoires, CH Aix-en-Provence, Aix-en-Provence, France
| | - Eloi Prud'homme
- Médecine Intensive Réanimation, Assistance Publique Hôpitaux de Marseille, Marseille, France.,EA 3279, CEReSS - Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie, Aix-Marseille Université, Faculté de Médecine, Marseille, France
| | - Laurent Lefebvre
- Service de Réanimation Polyvalente, CH Aix-en-Provence, Aix-en-Provence, France
| | - Alais Giraud
- Unité de Recherche Clinique, CH Aix-en-Provence, Aix-en-Provence, France
| | | | - Stéphanie Martinez
- Service des Maladies Respiratoires, CH Aix-en-Provence, Aix-en-Provence, France
| | - Marie Bernardi
- Service des Maladies Respiratoires, CH Aix-en-Provence, Aix-en-Provence, France
| | - Camille Begne
- Service des Maladies Respiratoires, CH Aix-en-Provence, Aix-en-Provence, France
| | - Pascal Granier
- Médecine Physique et de Réadaptation, CH Aix-en-Provence, Aix-en-Provence, France
| | - Pascal Chanez
- Clinique des bronches, de l'allergie et du sommeil, AP-HM, Hôpital Nord, Marseille, France
| | - Jean-Marie Forel
- Médecine Intensive Réanimation, Assistance Publique Hôpitaux de Marseille, Marseille, France.,EA 3279, CEReSS - Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie, Aix-Marseille Université, Faculté de Médecine, Marseille, France
| | - Laurent Papazian
- Médecine Intensive Réanimation, Assistance Publique Hôpitaux de Marseille, Marseille, France.,EA 3279, CEReSS - Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie, Aix-Marseille Université, Faculté de Médecine, Marseille, France
| | - Xavier Elharrar
- Service des Maladies Respiratoires, CH Aix-en-Provence, Aix-en-Provence, France
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14
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Tan W, Xu DY, Xu MJ, Wang ZF, Dai B, Li LL, Zhao HW, Wang W, Kang J. The efficacy and tolerance of prone positioning in non-intubation patients with acute hypoxemic respiratory failure and ARDS: a meta-analysis. Ther Adv Respir Dis 2021; 15:17534666211009407. [PMID: 33888007 PMCID: PMC8071979 DOI: 10.1177/17534666211009407] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background and aims: The application of prone positioning with acute hypoxemic respiratory failure (AHRF) or acute respiratory distress syndrome (ARDS) in non-intubation patients is increasing gradually, applying prone positioning for more high-flow nasal oxygen therapy (HFNC) and non-invasive ventilation (NIV) patients. This meta-analysis evaluates the efficacy and tolerance of prone positioning combined with non-invasive respiratory support in patients with AHRF or ARDS. Methods: We searched randomized controlled trials (RCTs) (prospective or retrospective cohort studies, RCTs and case series) published in PubMed, EMBASE and the Cochrane Central Register of Controlled Trials from 1 January 2000 to 1 July 2020. We included studies that compared prone and supine positioning with non-invasive respiratory support in awake patients with AHRF or ARDS. The meta-analyses used random effects models. The methodological quality of the RCTs was evaluated using the Newcastle–Ottawa quality assessment scale. Results: A total of 16 studies fulfilled selection criteria and included 243 patients. The aggregated intubation rate and mortality rate were 33% [95% confidence interval (CI): 0.26–0.42, I2 = 25%], 4% (95% CI: 0.01–0.07, I2 = 0%), respectively, and the intolerance rate was 7% (95% CI: 0.01–0.12, I2 = 5%). Prone positioning increased PaO2/FiO2 [mean difference (MD) = 47.89, 95% CI: 28.12–67.66; p < 0.00001, I2 = 67%] and SpO2 (MD = 4.58, 95% CI: 1.35–7.80, p = 0.005, I2 = 97%), whereas it reduced respiratory rate (MD = −5.01, 95% CI: −8.49 to −1.52, p = 0.005, I2 = 85%). Subgroup analyses demonstrated that the intubation rate of shorter duration prone (⩽5 h/day) and longer duration prone (>5 h/day) were 34% and 21%, respectively; and the mortality rate of shorter duration prone (⩽5 h/day) and longer duration prone (>5 h/day) were 6% and 0%, respectively. PaO2/FiO2 and SpO2 were significantly improved in COVID-19 patients and non-COVID-19 patients. Conclusion: Prone positioning could improve the oxygenation and reduce respiratory rate in both COVID-19 patients and non-COVID-19 patients with non-intubated AHRF or ARDS. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Wei Tan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Dong-Yang Xu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Meng-Jiao Xu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Zan-Feng Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Bing Dai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, Liaoning 110001, China
| | - Li-Li Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, Liaoning 110001, China
| | - Hong-Wen Zhao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Wei Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Jian Kang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
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15
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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16
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Anand RK, Baidya DK, Maitra S, Ray BR. A Proposal for Dedicated "Prone Team" and "Prone Bundle of Care" in COVID-19 ICU. Indian J Crit Care Med 2021; 25:349-350. [PMID: 33790522 PMCID: PMC7991755 DOI: 10.5005/jp-journals-10071-23754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
How to cite this article: Anand RK, Baidya DK, Maitra S, Ray BR. A Proposal for Dedicated “Prone Team” and “Prone Bundle of Care” in COVID-19 ICU. Indian J Crit Care Med 2021;25(3):349–350.
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Affiliation(s)
- Rahul K Anand
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Dalim K Baidya
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Souvik Maitra
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Bikash R Ray
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Khullar R, Shah S, Singh G, Bae J, Gattu R, Jain S, Green J, Anandarangam T, Cohen M, Madan N, Prasanna P. Effects of Prone Ventilation on Oxygenation, Inflammation, and Lung Infiltrates in COVID-19 Related Acute Respiratory Distress Syndrome: A Retrospective Cohort Study. J Clin Med 2020; 9:E4129. [PMID: 33371426 PMCID: PMC7767429 DOI: 10.3390/jcm9124129] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/13/2020] [Accepted: 12/15/2020] [Indexed: 12/22/2022] Open
Abstract
Patients receiving mechanical ventilation for coronavirus disease 2019 (COVID-19) related, moderate-to-severe acute respiratory distress syndrome (CARDS) have mortality rates between 76-98%. The objective of this retrospective cohort study was to identify differences in prone ventilation effects on oxygenation, pulmonary infiltrates (as observed on chest X-ray (CXR)), and systemic inflammation in CARDS patients by survivorship and to identify baseline characteristics associated with survival after prone ventilation. The study cohort included 23 patients with moderate-to-severe CARDS who received prone ventilation for ≥16 h/day and was segmented by living status: living (n = 6) and deceased (n = 17). Immediately after prone ventilation, PaO2/FiO2 improved by 108% (p < 0.03) for the living and 150% (p < 3 × 10-4) for the deceased. However, the 48 h change in lung infiltrate severity in gravity-dependent lung zones was significantly better for the living than for the deceased (p < 0.02). In CXRs of the lower lungs before prone ventilation, we observed 5 patients with confluent infiltrates bilaterally, 12 patients with ground-glass opacities (GGOs) bilaterally, and 6 patients with mixed infiltrate patterns; 80% of patients with confluent infiltrates were alive vs. 8% of patients with GGOs. In conclusion, our small study indicates that CXRs may offer clinical utility in selecting patients with moderate-to-severe CARDS who will benefit from prone ventilation. Additionally, our study suggests that lung infiltrate severity may be a better indicator of patient disposition after prone ventilation than PaO2/FiO2.
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Affiliation(s)
- Rohit Khullar
- Renaissance School of Medicine and Department of Biomedical Informatics, Stony Brook University, Stony Brook, NY 11794, USA;
| | - Shrey Shah
- Division of Pulmonary Critical Care, Department of Internal Medicine, Newark Beth Israel Medical Center, Newark, NJ 07112, USA; (S.S.); (T.A.); (N.M.)
| | - Gagandeep Singh
- Department of Radiology, Newark Beth Israel Medical Center, Newark, NJ 07112, USA; (G.S.); (R.G.); (J.G.)
| | - Joseph Bae
- Renaissance School of Medicine and Department of Biomedical Informatics, Stony Brook University, Stony Brook, NY 11794, USA;
| | - Rishabh Gattu
- Department of Radiology, Newark Beth Israel Medical Center, Newark, NJ 07112, USA; (G.S.); (R.G.); (J.G.)
| | - Shubham Jain
- Department of Computer Science, Stony Brook University, Stony Brook, NY 11794, USA;
| | - Jeremy Green
- Department of Radiology, Newark Beth Israel Medical Center, Newark, NJ 07112, USA; (G.S.); (R.G.); (J.G.)
| | - Thiruvengadam Anandarangam
- Division of Pulmonary Critical Care, Department of Internal Medicine, Newark Beth Israel Medical Center, Newark, NJ 07112, USA; (S.S.); (T.A.); (N.M.)
| | - Marc Cohen
- Division of Cardiology, Department of Internal Medicine, Newark Beth Israel Medical Center, Newark, NJ 07112, USA;
| | - Nikhil Madan
- Division of Pulmonary Critical Care, Department of Internal Medicine, Newark Beth Israel Medical Center, Newark, NJ 07112, USA; (S.S.); (T.A.); (N.M.)
| | - Prateek Prasanna
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, NY 11794, USA
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Wiggermann N, Zhou J, Kumpar D. Proning Patients With COVID-19: A Review of Equipment and Methods. HUMAN FACTORS 2020; 62:1069-1076. [PMID: 32845730 PMCID: PMC7586000 DOI: 10.1177/0018720820950532] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/20/2020] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To identify and critically evaluate methods for proning patients with COVID-19 in the intensive care unit (ICU). BACKGROUND Acute respiratory distress syndrome (ARDS) is common in hospitalized patients with COVID-19. Proning improves blood oxygenation and survival rates in these patients but is not commonly performed due to the difficulty of the procedure. METHODS An academic literature review, internet video search, and consultation with five subject-matter experts was performed to identify known methods for proning. Evaluation of each method considered the number of healthcare workers required, physical stresses on staff, risk of adverse events to patients, and equipment cost and availability. RESULTS Several variations of manual techniques and-lift assisted techniques were identified in addition to a specialized proning bed. Manual methods require more healthcare workers, higher physical stresses, and greater risk of adverse events than lift-assisted methods or the proning bed. CONCLUSION Both the specialized proning bed and a lift-assisted method using straps largely eliminated manual forces required for proning while allowing for a controlled lowering and positioning of the patient. APPLICATION This review will guide practitioners to the most suitable methods for proning patients in the ICU.
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Affiliation(s)
| | - Jie Zhou
- Hillrom, Batesville, Indiana, USA
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Li M, Fang XZ, Liu XT, Zheng YF, Xie YB, Ma XD, Xia Y, Shao DH. Inhibition of calcineurin/NFATc4 signaling attenuates ventilator‑induced lung injury. Mol Med Rep 2019; 21:607-614. [PMID: 31789412 PMCID: PMC6947850 DOI: 10.3892/mmr.2019.10851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 10/10/2019] [Indexed: 12/15/2022] Open
Abstract
Ventilator-induced lung injury (VILI) is a life-threatening condition caused by the inappropriate use of mechanical ventilation (MV). However, the precise molecular mechanism inducing the development of VILI remains to be elucidated. In the present study, it was revealed that the calcineurin/NFATc4 signaling pathway mediates the expression of adhesion molecules and proinflammatory cytokines essential for the development of VILI. The present results revealed that a high tidal volume ventilation (HV) caused lung inflammation and edema in the alveolar walls and the infiltration of inflammatory cells. The calcineurin activity and protein expression in the lungs were increased in animals with VILI, and NFATc4 translocated into the nucleus following calcineurin activation. Furthermore, the translocation of NFATc4 and lung injury were prevented by a calcineurin inhibitor (CsA). Thus, the present results highlighted the critical role of the calcineurin/NFATc4 signaling pathway in VILI and suggest that this pathway coincides with the release of ICAM-1, VCAM-1, TNF-α and IL-1β.
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Affiliation(s)
- Min Li
- Department of Anesthesiology, Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu 212002, P.R. China
| | - Xiang-Zhi Fang
- Department of Anesthesiology, Clinical Medical School of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou, Jiangsu 225001, P.R. China
| | - Xiao-Tian Liu
- Department of Anesthesiology, Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu 212002, P.R. China
| | - Yong-Feng Zheng
- Department of Anesthesiology, Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu 212002, P.R. China
| | - Yun-Bin Xie
- Department of Anesthesiology, Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu 212002, P.R. China
| | - Xiao-Dong Ma
- Department of Anesthesiology, Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu 212002, P.R. China
| | - Yan Xia
- Department of Anesthesiology, Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu 212002, P.R. China
| | - Dong-Hua Shao
- Department of Anesthesiology, Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu 212002, P.R. China
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20
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Griffiths MJD, McAuley DF, Perkins GD, Barrett N, Blackwood B, Boyle A, Chee N, Connolly B, Dark P, Finney S, Salam A, Silversides J, Tarmey N, Wise MP, Baudouin SV. Guidelines on the management of acute respiratory distress syndrome. BMJ Open Respir Res 2019; 6:e000420. [PMID: 31258917 PMCID: PMC6561387 DOI: 10.1136/bmjresp-2019-000420] [Citation(s) in RCA: 257] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/01/2019] [Indexed: 12/16/2022] Open
Abstract
The Faculty of Intensive Care Medicine and Intensive Care Society Guideline Development Group have used GRADE methodology to make the following recommendations for the management of adult patients with acute respiratory distress syndrome (ARDS). The British Thoracic Society supports the recommendations in this guideline. Where mechanical ventilation is required, the use of low tidal volumes (<6 ml/kg ideal body weight) and airway pressures (plateau pressure <30 cmH2O) was recommended. For patients with moderate/severe ARDS (PF ratio<20 kPa), prone positioning was recommended for at least 12 hours per day. By contrast, high frequency oscillation was not recommended and it was suggested that inhaled nitric oxide is not used. The use of a conservative fluid management strategy was suggested for all patients, whereas mechanical ventilation with high positive end-expiratory pressure and the use of the neuromuscular blocking agent cisatracurium for 48 hours was suggested for patients with ARDS with ratio of arterial oxygen partial pressure to fractional inspired oxygen (PF) ratios less than or equal to 27 and 20 kPa, respectively. Extracorporeal membrane oxygenation was suggested as an adjunct to protective mechanical ventilation for patients with very severe ARDS. In the absence of adequate evidence, research recommendations were made for the use of corticosteroids and extracorporeal carbon dioxide removal.
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Affiliation(s)
| | - Danny Francis McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, West Midlands, UK
| | | | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Andrew Boyle
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Nigel Chee
- Academic Department of Critical Care, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, NIHR Biomedical Research Centre, University of Manchester, Manchester, Greater Manchester, UK
| | - Simon Finney
- Peri-Operative Medicine, Barts Health NHS Trust, London, UK
| | - Aemun Salam
- Peri-Operative Medicine, Barts Health NHS Trust, London, UK
| | - Jonathan Silversides
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Nick Tarmey
- Academic Department of Critical Care, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - Simon V Baudouin
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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21
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Yan X, Li Y, Choi YH, Wang C, Piao Y, Ye J, Jiang J, Li L, Xu H, Cui Q, Yan G, Jin M. Protective Effect and Mechanism of Alprostadil in Acute Respiratory Distress Syndrome Induced by Oleic Acid in Rats. Med Sci Monit 2018; 24:7186-7198. [PMID: 30296789 PMCID: PMC6190919 DOI: 10.12659/msm.909678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND This study investigated the role and mechanism of alprostadil in acute respiratory distress syndrome (ARDS) induced by oleic acid (OA) in rats. MATERIAL AND METHODS Sprague-Dawley rats were randomly divided into control, OA model, and OA + Alprostadil (2.5, 5, and 10 μg/kg, respectively) groups. The ARDS model was induced by femoral vein injection of OA, and alprostadil was administrated immediately. Lung injury was evaluated by lung wet-dry weight ratio (W/D) and histological analyses. Expressions of ACE, inflammatory mediators, apoptotic-related proteins, and proteins in the MAPKs and NF-κB signaling pathways were determined by Western blot or immunohistochemical staining. RESULTS Compared with the control group, the OA model group had significantly increased W/D, lung injury score, and collagen deposition at 3 h after OA injection. However, alprostadil (10 μg/kg) treatment significantly reduced OA-induced elevation of these indicators. Additionally, OA-induced expression of TNF-α and IL-1β were suppressed by alprostadil. The OA-induced activation of nuclear factor (NF) κB p65 was also reduced by alprostadil. Furthermore, we found that Alprostadil had an inhibitory effect on the phosphorylation of JNK, ERK1/2, and p38 MAPKs. Alprostadil inhibited Bax but increased Bcl-2, indicating a suppressive role in apoptosis. Remarkably increased expression of ACE in the OA model group was observed, which was decreased by alprostadil. CONCLUSIONS Alprostadil has a protective effect on ARDS induced by OA in rats, possibly through inhibiting apoptosis, suppressing the activation of MAPKs and NF-κB signaling pathways, and decreasing ACE protein expression. Therefore, the use of alprostadil in clinical ARDS treatment is promising.
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Affiliation(s)
- Xiujuan Yan
- Intensive Care Unit, Yanbian University Hospital, Yanji, Jilin, China (mainland)
| | - Yingxiu Li
- College of Marine Science, Shandong University (Weihai), Weihai, Shandong, China (mainland)
| | - Yun Ho Choi
- Department of Anatomy, Medical School, Institute for Medical Sciences, Chonbuk National University, Jeonju, Jeonbuk, South Korea
| | - Chongyang Wang
- Department of Anatomy, Histology, and Embryology, Yanbian University Medical College, Yanji, Jilin, China (mainland)
| | - Yihua Piao
- Intensive Care Unit, Yanbian University Hospital, Yanji, Jilin, China (mainland)
| | - Jing Ye
- Department of Anatomy, Histology, and Embryology, Yanbian University Medical College, Yanji, Jilin, China (mainland)
| | - Jingzhi Jiang
- Department of Anatomy, Histology, and Embryology, Yanbian University Medical College, Yanji, Jilin, China (mainland)
| | - Liangchang Li
- Department of Anatomy, Medical School, Institute for Medical Sciences, Chonbuk National University, Jeonju, Jeonbuk, South Korea
| | - Huixian Xu
- Intensive Care Unit, Yanbian University Hospital, Yanji, Jilin, China (mainland)
| | - Qingsong Cui
- Intensive Care Unit, Yanbian University Hospital, Yanji, Jilin, China (mainland)
| | - Guanghai Yan
- Department of Anatomy, Histology, and Embryology, Yanbian University Medical College, Yanji, Jilin, China (mainland)
| | - Minggen Jin
- Intensive Care Unit, Yanbian University Hospital, Yanji, Jilin, China (mainland)
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22
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Oliveira VM, Piekala DM, Deponti GN, Batista DCR, Minossi SD, Chisté M, Bairros PMN, Naue WDS, Welter DI, Vieira SRR. Safe prone checklist: construction and implementation of a tool for performing the prone maneuver. Rev Bras Ter Intensiva 2018; 29:131-141. [PMID: 28977254 PMCID: PMC5496747 DOI: 10.5935/0103-507x.20170023] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 10/08/2016] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To construct and implement an instrument (checklist) to improve safety when performing the prone maneuver. METHODS This was an applied, qualitative and descriptive study. The instrument was developed based on a broad review of the literature pertaining to the construction of a care protocol using the main electronic databases (MEDLINE, LILACS and Cochrane). RESULTS We describe the construction of a patient safety tool with numerous modifications and adaptations based on the observations of the multidisciplinary team regarding its use in daily practice. CONCLUSION The use of the checklist when performing the prone maneuver increased the safety and reliability of the procedure. The team's understanding of the tool's importance to patient safety and training in its use are necessary for its success.
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Affiliation(s)
| | - Daniele Martins Piekala
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
| | | | | | - Sílvia Daniela Minossi
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
| | - Marcele Chisté
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
| | | | - Wagner da Silva Naue
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
| | - Dulce Inês Welter
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
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23
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Dodoo-Schittko F, Brandstetter S, Brandl M, Blecha S, Quintel M, Weber-Carstens S, Kluge S, Kirschning T, Muders T, Bercker S, Ellger B, Arndt C, Meybohm P, Adamzik M, Goldmann A, Karagiannidis C, Bein T, Apfelbacher C. German-wide prospective DACAPO cohort of survivors of the acute respiratory distress syndrome (ARDS): a cohort profile. BMJ Open 2018; 8:e019342. [PMID: 29622574 PMCID: PMC5892755 DOI: 10.1136/bmjopen-2017-019342] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE While most research focuses on the association between medical characteristics and residual morbidity of survivors of the acute respiratory distress syndrome (ARDS), little is known about the relation between potentially modifiable intensive care unit (ICU) features and the course of health-related quality of life (HRQoL). Accordingly, the DACAPO study was set up to elucidate the influence of quality of intensive care on HRQoL and return to work (RtW) in survivors of ARDS. The continued follow-up of these former ICU patients leads to the establishment of the DACAPO (survivor) cohort. PARTICIPANTS Sixty-one ICUs all over Germany recruited patients with ARDS between September 2014 and April 2016. Inclusion criteria were: (1) age older than 18 years and (2) ARDS diagnosis according to the 'Berlin definition'. No further inclusion or exclusion criteria were applied. 1225 patients with ARDS could be included in the DACAPO ICU sample. Subsequently, the 876 survivors at ICU discharge form the actual DACAPO cohort. FINDINGS TO DATE The recruitment of the participants of the DACAPO cohort and the baseline data collection has been completed. The care-related data of the DACAPO cohort reveal a high proportion of adverse events (in particular, hypoglycaemia and reintubation). However, evidence-based supportive measures were applied frequently. FUTURE PLANS Three months, 6 months and 1 year after ICU admission a follow-up assessment is conducted. The instruments of the follow-up questionnaires comprise the domains: (A) HRQoL, (B) RtW, (C) general disability, (D) psychiatric symptoms and (E) social support. Additionally, an annual follow-up of the DACAPO cohort focusing on HRQoL, psychiatric symptoms and healthcare utilisation will be conducted. Furthermore, several add-on projects affecting medical issues are envisaged. TRIAL REGISTRATION NUMBER NCT02637011.
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Affiliation(s)
- Frank Dodoo-Schittko
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Susanne Brandstetter
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Magdalena Brandl
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Sebastian Blecha
- Department of Anesthesia, Operative Intensive Care, University Hospital Regensburg, Regensburg, Germany
| | - Michael Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medicine, Georg-August-Universität Göttingen, Göttingen, Germany
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
| | - Thomas Kirschning
- Department of Anesthesiology and Surgical Intensive Care, Medicine University Medical Center, Mannheim, Germany
| | - Thomas Muders
- Department of Anesthesiology and Operative Intensive Care, University Hospital Bonn, Bonn, Germany
| | - Sven Bercker
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Medical Faculty, Leipzig, Germany
| | - Björn Ellger
- Department of Anesthesiology and Operative Intensive Care, University Hospital Münster, Münster, Germany
| | - Christian Arndt
- Department of Anesthesiology and Operative Intensive Care, University Hospital Marburg, Marburg, Germany
| | - Patrick Meybohm
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Michael Adamzik
- Department of Anaesthesiology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Anton Goldmann
- Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Cologne, Germany
| | - Thomas Bein
- Department of Anesthesia, Operative Intensive Care, University Hospital Regensburg, Regensburg, Germany
| | - Christian Apfelbacher
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
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24
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Dodoo-Schittko F, Brandstetter S, Brandl M, Blecha S, Quintel M, Weber-Carstens S, Kluge S, Meybohm P, Rolfes C, Ellger B, Bach F, Welte T, Muders T, Thomann-Hackner K, Bein T, Apfelbacher C. Characteristics and provision of care of patients with the acute respiratory distress syndrome: descriptive findings from the DACAPO cohort baseline and comparison with international findings. J Thorac Dis 2017; 9:818-830. [PMID: 28449491 DOI: 10.21037/jtd.2017.03.120] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Little is known about the characteristics and real world life circumstances of ARDS (acute respiratory distress syndrome) patient populations. This knowledge is essential for transferring evidence-based therapy into routine healthcare. The aim of this study was to report socio-demographic and clinical characteristics in an unselected population of ARDS patients and to compare these results to findings from other large ARDS cohorts. METHODS A German based cross-sectional observational study was carried out. A total of 700 ARDS patients were recruited in 59 study sites between September 2014 and January 2016. Socio-demographic, disease and care related variables were recorded. Additionally, characteristics of other large ARDS cohorts identified by a systematic literature search were extracted into evidence tables. RESULTS Median age of ARDS patients was 58 years, 69% were male. Sixty percent had no employment, predominantly due to retirement. Seventy-one percent lived with a partner. The main cause of ARDS was a pulmonary 'direct' origin (79%). The distribution of severity was as follows: mild (14%), moderate (48%), severe (38%). Overall ICU mortality was calculated to be 34%. The observed prevalence of critical events (hypoxemia, hypoglycemia, re-intubation) was 47%. Supportive measures during ICU-treatment were applied to 60% of the patients. Other ARDS cohorts revealed a high heterogeneity in reported concomitant diseases, but sepsis and pneumonia were most frequently reported. Mean age ranged from 54 to 71 years and most patients were male. Other socio-demographic factors have been almost neglected. CONCLUSIONS The proportion of patients suffering of mild ARDS was lower compared to the only study identified, which also applied the Berlin definition. The frequency of critical events during ICU treatment was high and the implementation of evidence-based therapy (prone positioning, neuro-muscular blockers) was limited. More evidence on socio-demographic characteristics and further studies applying the current diagnostic criteria are desirable.
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Affiliation(s)
- Frank Dodoo-Schittko
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Susanne Brandstetter
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Magdalena Brandl
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Sebastian Blecha
- Department of Anesthesia, Operative Intensive Care, University Hospital Regensburg, Regensburg, Germany
| | - Michael Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medicine, Georg-August-Universität Göttingen, Göttingen, Germany
| | - Steffen Weber-Carstens
- Department of Anesthesia and Operative Intensive Care, Charitè Universitätsmedizin Berlin, Campus Virchow Klinikum and Campus Charitè Mitte, Berlin, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
| | - Patrick Meybohm
- Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Caroline Rolfes
- Department of Anesthesiology and Operative Intensive Care, University Hospital Marburg, Marburg, Germany
| | - Björn Ellger
- Department of Anesthesiology and Operative Intensive Care, University Hospital Münster, Münster, Germany
| | - Friedhelm Bach
- Department of Anesthesiology and Intensive Care, Evangelisches Krankenhaus, Bielefeld, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Medizinische Hochschule Hannover, Hannover, Germany
| | - Thomas Muders
- Department of Anesthesiology and Operative Intensive Care, University Hospital Bonn, Bonn, Germany
| | - Kathrin Thomann-Hackner
- Department of Anesthesia, Operative Intensive Care, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Bein
- Department of Anesthesia, Operative Intensive Care, University Hospital Regensburg, Regensburg, Germany
| | - Christian Apfelbacher
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
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25
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Kiasari AZ. Preventing Refractory Hypoxemia after Lung Transplantation by Prone Positioning: A New Agenda for Research. Indian J Crit Care Med 2017; 21:617-618. [PMID: 28970667 PMCID: PMC5613619 DOI: 10.4103/ijccm.ijccm_215_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Alieh Zamani Kiasari
- Department of Anesthesiology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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26
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Zhang Z, Gu WJ, Chen K, Ni H. Mechanical Ventilation during Extracorporeal Membrane Oxygenation in Patients with Acute Severe Respiratory Failure. Can Respir J 2017; 2017:1783857. [PMID: 28127231 PMCID: PMC5239989 DOI: 10.1155/2017/1783857] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/28/2016] [Accepted: 12/18/2016] [Indexed: 02/07/2023] Open
Abstract
Conventionally, a substantial number of patients with acute respiratory failure require mechanical ventilation (MV) to avert catastrophe of hypoxemia and hypercapnia. However, mechanical ventilation per se can cause lung injury, accelerating the disease progression. Extracorporeal membrane oxygenation (ECMO) provides an alternative to rescue patients with severe respiratory failure that conventional mechanical ventilation fails to maintain adequate gas exchange. The physiology behind ECMO and its interaction with MV were reviewed. Next, we discussed the timing of ECMO initiation based on the risks and benefits of ECMO. During the running of ECMO, the protective ventilation strategy can be employed without worrying about catastrophic hypoxemia and carbon dioxide retention. There is a large body of evidence showing that protective ventilation with low tidal volume, high positive end-expiratory pressure, and prone positioning can provide benefits on mortality outcome. More recently, there is an increasing popularity on the use of awake and spontaneous breathing for patients undergoing ECMO, which is thought to be beneficial in terms of rehabilitation.
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Affiliation(s)
- Zhongheng Zhang
- 1Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
- *Zhongheng Zhang:
| | - Wan-Jie Gu
- 2Department of Anesthesiology, Nanjing Drum Tower Hospital, Medical College of Nanjing University, Nanjing 210008, China
| | - Kun Chen
- 3Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Zhejiang, China
| | - Hongying Ni
- 3Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Zhejiang, China
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27
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Chertoff J. Why is prone positioning so unpopular? J Intensive Care 2016; 4:70. [PMID: 27933169 PMCID: PMC5124227 DOI: 10.1186/s40560-016-0194-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 11/19/2016] [Indexed: 12/02/2022] Open
Abstract
Recent studies have shown acute respiratory distress syndrome (ARDS) to be underdiagnosed and inadequately treated, as evidenced by underutilization of low-tidal volume ventilation. Despite a proven survival benefit in patients with severe ARDS, studies have also shown underutilization of prone positioning. Many questions persist as to the reasons for prone positioning's unpopularity. Additional studies are required to uncover the causes of this prone positioning underutilization phenomenon.
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Affiliation(s)
- Jason Chertoff
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32608 USA
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28
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Meralgia Paresthetica after Prone Positioning Ventilation in the Intensive Care Unit. Case Rep Crit Care 2016; 2016:7263201. [PMID: 27752369 PMCID: PMC5056243 DOI: 10.1155/2016/7263201] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/05/2016] [Indexed: 11/17/2022] Open
Abstract
Meralgia paresthetica (MP) is a mononeuropathy of the lateral femoral cutaneous nerve (LFCN) caused by external compression of the nerve during its course close to the anterior superior iliac spine. We present a case of a patient with acute respiratory distress induced by Legionella pneumonia who was admitted to the intensive care unit (ICU) for mechanical ventilation. In the ICU, the patient received one session of prone position ventilation for 8.5 consecutive hours. At evaluation six months later, the patient reported persistent bilateral numbness of the anterolateral thigh, which he complained had begun right after he woke up at the ICU. He was referred for further neurological and neurophysiological examination and was diagnosed with bilateral MP, a condition never previously described as a complication to mechanical ventilation in prone position in the ICU.
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29
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Koulouras V, Papathanakos G, Papathanasiou A, Nakos G. Efficacy of prone position in acute respiratory distress syndrome patients: A pathophysiology-based review. World J Crit Care Med 2016; 5:121-36. [PMID: 27152255 PMCID: PMC4848155 DOI: 10.5492/wjccm.v5.i2.121] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 01/11/2016] [Accepted: 03/07/2016] [Indexed: 02/06/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a syndrome with heterogeneous underlying pathological processes. It represents a common clinical problem in intensive care unit patients and it is characterized by high mortality. The mainstay of treatment for ARDS is lung protective ventilation with low tidal volumes and positive end-expiratory pressure sufficient for alveolar recruitment. Prone positioning is a supplementary strategy available in managing patients with ARDS. It was first described 40 years ago and it proves to be in alignment with two major ARDS pathophysiological lung models; the "sponge lung" - and the "shape matching" -model. Current evidence strongly supports that prone positioning has beneficial effects on gas exchange, respiratory mechanics, lung protection and hemodynamics as it redistributes transpulmonary pressure, stress and strain throughout the lung and unloads the right ventricle. The factors that individually influence the time course of alveolar recruitment and the improvement in oxygenation during prone positioning have not been well characterized. Although patients' response to prone positioning is quite variable and hard to predict, large randomized trials and recent meta-analyses show that prone position in conjunction with a lung-protective strategy, when performed early and in sufficient duration, may improve survival in patients with ARDS. This pathophysiology-based review and recent clinical evidence strongly support the use of prone positioning in the early management of severe ARDS systematically and not as a rescue maneuver or a last-ditch effort.
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30
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Cho CC, Lin MH, Chuang CY, Hsu CH. Macro Domain from Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Is an Efficient ADP-ribose Binding Module: CRYSTAL STRUCTURE AND BIOCHEMICAL STUDIES. J Biol Chem 2016; 291:4894-902. [PMID: 26740631 PMCID: PMC4777827 DOI: 10.1074/jbc.m115.700542] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Indexed: 01/12/2023] Open
Abstract
The newly emerging Middle East respiratory syndrome coronavirus (MERS-CoV)
encodes the conserved macro domain within non-structural protein 3. However, the
precise biochemical function and structure of the macro domain is unclear. Using
differential scanning fluorimetry and isothermal titration calorimetry, we
characterized the MERS-CoV macro domain as a more efficient adenosine
diphosphate (ADP)-ribose binding module than macro domains from other CoVs.
Furthermore, the crystal structure of the MERS-CoV macro domain was determined
at 1.43-Å resolution in complex with ADP-ribose. Comparison of macro
domains from MERS-CoV and other human CoVs revealed structural differences in
the α1 helix alters how the conserved Asp-20 interacts with ADP-ribose and
may explain the efficient binding of the MERS-CoV macro domain to ADP-ribose.
This study provides structural and biophysical bases to further evaluate the
role of the MERS-CoV macro domain in the host response via ADP-ribose binding
but also as a potential target for drug design.
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Affiliation(s)
- Chao-Cheng Cho
- From the Genome and Systems Biology Degree Program, National Taiwan University and Academia Sinica, Taipei 10617
| | - Meng-Hsuan Lin
- From the Genome and Systems Biology Degree Program, National Taiwan University and Academia Sinica, Taipei 10617
| | - Chien-Ying Chuang
- the Department of Agricultural Chemistry, National Taiwan University, Taipei 10617, and the Center for Systems Biology, National Taiwan University, Taipei 10617, Taiwan
| | - Chun-Hua Hsu
- From the Genome and Systems Biology Degree Program, National Taiwan University and Academia Sinica, Taipei 10617, the Department of Agricultural Chemistry, National Taiwan University, Taipei 10617, and the Center for Systems Biology, National Taiwan University, Taipei 10617, Taiwan
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31
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Abstract
BACKGROUND Acute hypoxaemia de novo or on a background of chronic hypoxaemia is a common reason for admission to intensive care and for provision of mechanical ventilation. Various refinements of mechanical ventilation or adjuncts are employed to improve patient outcomes. Mortality from acute respiratory distress syndrome, one of the main contributors to the need for mechanical ventilation for hypoxaemia, remains approximately 40%. Ventilation in the prone position may improve lung mechanics and gas exchange and could improve outcomes. OBJECTIVES The objectives of this review are (1) to ascertain whether prone ventilation offers a mortality advantage when compared with traditional supine or semi recumbent ventilation in patients with severe acute respiratory failure requiring conventional invasive artificial ventilation, and (2) to supplement previous systematic reviews on prone ventilation for hypoxaemic respiratory failure in an adult population. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 1), Ovid MEDLINE (1950 to 31 January 2014), EMBASE (1980 to 31 January 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 31 January 2014) and Latin American Caribbean Health Sciences Literature (LILACS) (1992 to 31 January 2014) in Ovid MEDLINE for eligible randomized controlled trials. We also searched for studies by handsearching reference lists of relevant articles, by contacting colleagues and by handsearching published proceedings of relevant journals. We applied no language constraints, and we reran the searches in CENTRAL, MEDLINE, EMBASE, CINAHL and LILACS in June 2015. We added five new studies of potential interest to the list of "Studies awaiting classification" and will incorporate them into formal review findings during the review update. SELECTION CRITERIA We included randomized controlled trials (RCTs) that examined the effects of prone position versus supine/semi recumbent position during conventional mechanical ventilation in adult participants with acute hypoxaemia. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed all trials identified by the search and assessed them for suitability, methods and quality. Two review authors extracted data, and three review authors reviewed the data extracted. We analysed data using Review Manager software and pooled included studies to determine the risk ratio (RR) for mortality and the risk ratio or mean difference (MD) for secondary outcomes; we also performed subgroup analyses and sensitivity analyses. MAIN RESULTS We identified nine relevant RCTs, which enrolled a total of 2165 participants (10 publications). All recruited participants suffered from disorders of lung function causing moderate to severe hypoxaemia and requiring mechanical ventilation, so they were fairly comparable, given the heterogeneity of specific disease diagnoses in intensive care. Risk of bias, although acceptable in the view of the review authors, was inevitable: Blinding of participants and carers to treatment allocation was not possible (face-up vs face-down).Primary analyses of short- and longer-term mortality pooled from six trials demonstrated an RR of 0.84 to 0.86 in favour of the prone position (PP), but findings were not statistically significant: In the short term, mortality for those ventilated prone was 33.4% (363/1086) and supine 38.3% (395/1031). This resulted in an RR of 0.84 (95% confidence interval (CI) 0.69 to 1.02) marginally in favour of PP. For longer-term mortality, results showed 41.7% (462/1107) for prone and 47.1% (490/1041) for supine positions, with an RR of 0.86 (95% CI 0.72 to 1.03). The quality of the evidence for both outcomes was rated as low as a result of important potential bias and serious inconsistency.Subgroup analyses for mortality identified three groups consistently favouring PP: those recruited within 48 hours of meeting entry criteria (five trials; 1024 participants showed an RR of 0.75 (95% CI 0.59 to 94)); those treated in the PP for 16 or more hours per day (five trials; 1005 participants showed an RR of 0.77 (95% CI 0.61 to 0.99)); and participants with more severe hypoxaemia at trial entry (six trials; 1108 participants showed an RR of 0.77 (95% CI 0.65 to 0.92)). The quality of the evidence for these outcomes was rated as moderate as a result of potentially important bias.Prone positioning appeared to influence adverse effects: Pressure sores (three trials; 366 participants) with an RR of 1.37 (95% CI 1.05 to 1.79) and tracheal tube obstruction with an RR of 1.78 (95% CI 1.22 to 2.60) were increased with prone ventilation. Reporting of arrhythmias was reduced with PP, with an RR of 0.64 (95% CI 0.47 to 0.87). AUTHORS' CONCLUSIONS We found no convincing evidence of benefit nor harm from universal application of PP in adults with hypoxaemia mechanically ventilated in intensive care units (ICUs). Three subgroups (early implementation of PP, prolonged adoption of PP and severe hypoxaemia at study entry) suggested that prone positioning may confer a statistically significant mortality advantage. Additional adequately powered studies would be required to confirm or refute these possibilities of subgroup benefit but are unlikely, given results of the most recent study and recommendations derived from several published subgroup analyses. Meta-analysis of individual patient data could be useful for further data exploration in this regard. Complications such as tracheal obstruction are increased with use of prone ventilation. Long-term mortality data (12 months and beyond), as well as functional, neuro-psychological and quality of life data, are required if future studies are to better inform the role of PP in the management of hypoxaemic respiratory failure in the ICU.
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Affiliation(s)
- Roxanna Bloomfield
- Intensive Care Unit and Department of Anaesthesia, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZN
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