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Borsi SH, Shoushtari MH, Raji H, Nezhad HH, Mal-Amir MD. The Efficacy of Daily Administration of Nebulized Heparin on the Prevention of Endotracheal Tube Blockage in Patients With Pneumonia. Cureus 2024; 16:e53244. [PMID: 38425613 PMCID: PMC10903965 DOI: 10.7759/cureus.53244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVE Nosocomial infections pose a significant public health concern, impacting over 100 million people worldwide annually. Within this research, we investigated heparin nebulization through the endotracheal tube and its effect on preventing blockage due to clots and mucus plugs compared to normal saline. METHODS A double-blind clinical experiment was done on a cohort of 40 pneumonia patients who were intubated and hospitalized in the intensive care unit (ICU) at Imam Khomeini Hospital in Ahvaz, Iran. The individuals were randomly assigned to two groups of 20 patients using a random allocation technique. The initial cohort was administered 5000 IU of heparin diluted in 4 ccs of 0.9% normal saline every eight hours via a nebulizer through a tracheal tube. In contrast, the second cohort was given 5 ccs of normal saline as a nebulizer through a tracheal tube. The study compared the incidence of tracheal tube obstruction caused by mucus plug or clot, the occurrence of patient hypoxia resulting in emergency tracheal tube replacement, and the frequency of emergency tracheal tube suction due to partial obstruction caused by mucus plug in both the heparin and saline groups. RESULTS According to our data, the number of patients in the heparin group who could avoid the need for emergency tracheal tube replacement owing to blockage was more significant than in the ordinary saline group (P=0.013). Heparin was significantly correlated with the number of times emergency suction was required to remove a tracheal tube occlusion (P=0.01). Heparin had no significant effect on coagulation factors (international normalized ratio [INR], platelet [PLT], and partial thromboplastin time [PTT]), Acute Physiology and Chronic Health Evaluation (APACHE) score, pneumonia severity index (PSI), saturation of patients, or tracheal tube secretions. There was no statistically significant difference in total time spent in the intensive care unit (P=0.91). CONCLUSIONS Further studies are suggested to determine the effect of heparin nebulization on preventing endotracheal tube obstruction due to clots and mucus plugs in intubated ICU patients.
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Affiliation(s)
- Seyed Hamid Borsi
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
| | - Maryam Haddadzadeh Shoushtari
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
| | - Hanieh Raji
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
| | - Hooshmand Hosseini Nezhad
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
| | - Mehrdad Dargahi Mal-Amir
- Department of Internal Medicine, School of Medicine, Air Pollution and Respiratory Diseases Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IRN
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Anticoagulant Treatment in Severe ARDS COVID-19 Patients. J Clin Med 2022; 11:jcm11102695. [PMID: 35628822 PMCID: PMC9148112 DOI: 10.3390/jcm11102695] [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: 04/07/2022] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 02/08/2023] Open
Abstract
Patients with COVID-19 may complicate their evolution with thromboembolic events. Incidence of thromboembolic complications are high and also, patients with the critically-ill disease showed evidence of microthrombi and microangiopathy in the lung probably due to endothelial damage by directly and indirectly injured endothelial and epithelial cells. Pulmonary embolism, deep venous thrombosis and arterial embolism were reported in patients with COVID-19, and several analytical abnormal coagulation parameters have been described as well. D-dimer, longer coagulation times and lower platelet counts have been associated with poor outcomes. The use of anticoagulation or high doses of prophylactic heparin is controversial. Despite the use of anticoagulation or high prophylactic dose of heparin have been associated with better outcomes in observational studies, only in patients with non-critically ill disease benefits for anticoagulation was observed. In critically-ill patient, anticoagulation was not associated with better outcomes. Other measures such as antiplatelet therapy, fibrinolytic therapy or nebulized anticoagulants are being studied in ongoing clinical trials.
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Olapour A, Rashidi M, Javaher Foroush F, Akhoondzadeh R, Hosseini N. Effect of Nebulized Heparin on Weaning off Intubated Patients with Acute Respiratory Distress Syndrome (ARDS) Admitted to Intensive Care Unit (ICU): A Randomized Clinical Trial. Anesth Pain Med 2021; 11:e115938. [PMID: 35075409 PMCID: PMC8782059 DOI: 10.5812/aapm.115938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/25/2021] [Accepted: 10/04/2021] [Indexed: 02/07/2023] Open
Abstract
Background: Acute respiratory distress syndrome (ARDS) treatment is based on supportive care such as mechanical ventilation, prophylaxis of stress ulcer, prophylaxis of deep vein thrombosis (DVT), nutritional support, and treatment of underlying disease. Objectives: We aimed to investigate the effects of nebulized heparin on weaning off intubated ARDS patients admitted to the intensive care unit (ICU). Methods: In this double-blind clinical trial study, 60 patients with ARDS receiving routine care according to the ARDS protocol were randomly assigned into two groups: intervention group (receiving nebulized heparin 5000 u/BD for one week) and control group (receiving nebulized sterile water 2 cc/BD for one week). The respiratory index (PaO2/FiO2), pulmonary shunt percentage (measured by ABG), tidal volume, minute ventilation, admission duration in the ICU, and days of mechanical ventilation required were recorded for each patient for one week. Results: There was no significant difference in demographic data between the two groups. Inhaled heparin in patients with ARDS could significantly increase the respiratory index (PaO2/FiO2) and decrease pulmonary shunt percentage, minute ventilation, and tidal volume. It also significantly reduced the number of admission days in the ICU and the need for mechanical ventilation. Conclusions: The result of the present study showed that inhaled heparin in intubated ARDS patients admitted to the ICU improved respiratory and pulmonary status and reduced the need for mechanical ventilation and admission days in the ICU. Nebulizing heparin, as an anti-inflammatory and anti-coagulant agent, is an effective and safe medication for ARDS patients on mechanical ventilation.
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Affiliation(s)
- Alireza Olapour
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mahboobe Rashidi
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Corresponding Author: Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Fatemeh Javaher Foroush
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Reza Akhoondzadeh
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nastaran Hosseini
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Corresponding Author: Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
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Kipshidze N, Dangas G, White CJ, Kipshidze N, Siddiqui F, Lattimer CR, Carter CA, Fareed J. Viral Coagulopathy in Patients With COVID-19: Treatment and Care. Clin Appl Thromb Hemost 2020; 26:1076029620936776. [PMID: 32687449 PMCID: PMC7461127 DOI: 10.1177/1076029620936776] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
COVID-19 has proven to be particularly challenging given the complex
pathogenesis of SARS-CoV-2. Early data have demonstrated how the host
response to this novel coronavirus leads to the proliferation of
pro-inflammatory cytokines, massive endothelial damage, and
generalized vascular manifestations. While SARS-CoV-2 primarily
targets the upper and lower respiratory tract, other organ systems are
also affected. SARS-CoV-2 relies on 2 host cell receptors for
successful attachment: angiotensin-converting enzyme 2 and
transmembrane protease serine 2. Clinicopathologic reports have
demonstrated associations between severe COVID-19 and viral
coagulopathy, resulting in pulmonary embolism; venous, arterial, and
microvascular thrombosis; lung endothelial injury; and associated
thrombotic complications leading to acute respiratory distress
syndrome. Viral coagulopathy is not novel given similar observations
with SARS classic, including the consumption of platelets, generation
of thrombin, and increased fibrin degradation product exhibiting overt
disseminated intravascular coagulation–like syndrome. The specific
mechanism(s) behind the thrombotic complications in COVID-19 patients
has yet to be fully understood. Parenteral anticoagulants, such as
heparin and low-molecular-weights heparins, are widely used in the
management of COVID-19 patients. Beyond the primary (anticoagulant)
effects of these agents, they may exhibit antiviral,
anti-inflammatory, and cytoprotective effects. Direct oral
anticoagulants and antiplatelet agents are also useful in the
management of these patients. Tissue plasminogen activator and other
fibrinolytic modalities may also be helpful in the overall management.
Catheter-directed thrombolysis can be used in patients developing
pulmonary embolism. Further investigations are required to understand
the molecular and cellular mechanisms involved in the pathogenesis of
COVID-19-associated thrombotic complications.
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Affiliation(s)
| | - George Dangas
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher J White
- Ochsner Clinical School, University of Queensland, AU and Ochsner Medical Center, New Orleans, LA, USA
| | | | - Fakiha Siddiqui
- Department of Pathology, Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Christopher R Lattimer
- London Northwest University Health Care NHS Trust, London, United Kingdom.,Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Charles A Carter
- Department of Clinical Research, College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC, USA
| | - Jawed Fareed
- Department of Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA.,Department of Pharmacology and Neuroscience, Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
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Ashoor TM, Hasseb AM, Esmat IM. Nebulized heparin and salbutamol versus salbutamol alone in acute exacerbations of chronic obstructive pulmonary disease requiring mechanical ventilation: a double-blind randomized controlled trial. Korean J Anesthesiol 2020; 73:509-517. [PMID: 32106642 PMCID: PMC7714627 DOI: 10.4097/kja.19418] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/26/2020] [Indexed: 02/06/2023] Open
Abstract
Background Nebulized heparin has been effectively used in the management of many pulmonary diseases. However, its effect on mechanically ventilated patients with acute exacerbation chronic obstructive pulmonary disease (AECOPD) has never been studied. This study aimed to assess the efficacy of nebulized heparin and salbutamol to increase ventilator-free days (VFD) in mechanically ventilated AECOPD patients and the effect of nebulized heparin on respiratory and coagulation functions. Methods In this double-blind controlled study, 60 mechanically ventilated adult patients with AECOPD were randomly allocated into two groups; heparin and salbutamol (HS) group and salbutamol only (S) group. In the HS group, patients received nebulized heparin (25,000 IU) and salbutamol (5 mg) every 6 hours. Patients in the S group received nebulized salbutamol only (5 mg). The treatment was continued while patients remained ventilated for a maximum of 14 days. The primary outcome was VFDs at day 14. PaCO2, PaO2/FiO2 ratio, number of nebulizations withheld, C-reactive protein (CRP) titer and activated partial thromboplastin time (APTT) were secondary outcomes. Results Patients in the Group HS had significantly more VFDs 4.7 ± 3.3 compared with those in the Group S 2.4 ± 2.6, P = 0.007. PaCO2 levels, PaO2/FiO2, the decrease in the CRP level and the increase in the APTT from the baseline showed no evidence of difference in both groups. Conclusions The co-administration of nebulized heparin and salbutamol, compared with salbutamol alone, significantly increased (VFDs) among mechanically ventilated AECOPD patients without increasing bleeding risks.
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Affiliation(s)
- Tarek Mohamed Ashoor
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Ahmad Mahmoud Hasseb
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Ibrahim Mamdouh Esmat
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
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Camprubí-Rimblas M, Tantinyà N, Bringué J, Guillamat-Prats R, Artigas A. Anticoagulant therapy in acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:36. [PMID: 29430453 PMCID: PMC5799142 DOI: 10.21037/atm.2018.01.08] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 12/28/2017] [Indexed: 01/11/2023]
Abstract
Acute respiratory distress syndrome (ARDS) presents a complex pathophysiology characterized by pulmonary activated coagulation and reduced fibrinolysis. Despite advances in supportive care of this syndrome, morbidity and mortality remains high, leading to the need of novel therapies to combat this disease. Focus these therapies in the inhibition of ARDS development pathophysiology is essential. Beneficial effects of anticoagulants in ARDS have been proved in preclinical and clinical trials, thanks to its anticoagulant and anti-inflammatory properties. Moreover, local administration by nebulization in the alveolar compartment increases local efficacy and does not produce systemic bleeding. In this review the coagulation and fibrinolytic pathway and its pharmacological targets to treat ARDS are summarized.
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Affiliation(s)
- Marta Camprubí-Rimblas
- Institut d’Investigació i Innovació Parc Tauli (I3PT), Sabadell, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Neus Tantinyà
- Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Josep Bringué
- Institut d’Investigació i Innovació Parc Tauli (I3PT), Sabadell, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Spain
- Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Raquel Guillamat-Prats
- Institut d’Investigació i Innovació Parc Tauli (I3PT), Sabadell, Spain
- Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Antonio Artigas
- Institut d’Investigació i Innovació Parc Tauli (I3PT), Sabadell, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Spain
- Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Critical Care Center, Corporació Sanitària Universitaria Parc Taulí, Sabadell, Spain
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