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Zhang S, Boers LS, de Brabander J, van den Heuvel LB, Blok SG, Kullberg RFJ, Smids-Dierdorp BS, Dekker T, Aberson HL, Meijboom LJ, Vlaar APJ, Heunks L, Nossent EJ, van der Poll T, Bos LDJ, Duitman J. The alveolar fibroproliferative response in moderate to severe COVID-19-related acute respiratory distress syndrome and 1-yr follow-up. Am J Physiol Lung Cell Mol Physiol 2024; 326:L7-L18. [PMID: 37933449 DOI: 10.1152/ajplung.00156.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/27/2023] [Accepted: 10/30/2023] [Indexed: 11/08/2023] Open
Abstract
COVID-19-related acute respiratory distress syndrome (ARDS) can lead to long-term pulmonary fibrotic lesions. Alveolar fibroproliferative response (FPR) is a key factor in the development of pulmonary fibrosis. N-terminal peptide of procollagen III (NT-PCP-III) is a validated biomarker for activated FPR in ARDS. This study aimed to assess the association between dynamic changes in alveolar FPR and long-term outcomes, as well as mortality in COVID-19 ARDS patients. We conducted a prospective cohort study of 154 COVID-19 ARDS patients. We collected bronchoalveolar lavage (BAL) and blood samples for measurement of 17 pulmonary fibrosis biomarkers, including NT-PCP-III. We assessed pulmonary function and chest computed tomography (CT) at 3 and 12 mo after hospital discharge. We performed joint modeling to assess the association between longitudinal changes in biomarker levels and mortality at day 90 after starting mechanical ventilation. 154 patients with 284 BAL samples were analyzed. Of all patients, 40% survived to day 90, of whom 54 completed the follow-up procedure. A longitudinal increase in NT-PCP-III was associated with increased mortality (HR 2.89, 95% CI: 2.55-3.28; P < 0.001). Forced vital capacity and diffusion for carbon monoxide were impaired at 3 mo but improved significantly at one year after hospital discharge (P = 0.03 and P = 0.004, respectively). There was no strong evidence linking alveolar FPR during hospitalization and signs of pulmonary fibrosis in pulmonary function or chest CT images during 1-yr follow-up. In COVID-19 ARDS patients, alveolar FPR during hospitalization was associated with higher mortality but not with the presence of long-term fibrotic lung sequelae within survivors.NEW & NOTEWORTHY This is the first prospective study on the longitudinal alveolar fibroproliferative response in COVID-19 ARDS and its relationship with mortality and long-term follow-up. We used the largest cohort of COVID-19 ARDS patients who had consecutive bronchoalveolar lavages and measured 17 pulmonary fibroproliferative biomarkers. We found that a higher fibroproliferative response during admission was associated with increased mortality, but not correlated with long-term fibrotic lung sequelae in survivors.
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Affiliation(s)
- Shiqi Zhang
- Intensive Care Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Leonoor S Boers
- Intensive Care Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Justin de Brabander
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Laura B van den Heuvel
- Intensive Care Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Siebe G Blok
- Intensive Care Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Robert F J Kullberg
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Barbara S Smids-Dierdorp
- Pulmonary Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Experimental Immunology (EXIM), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Tamara Dekker
- Pulmonary Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Experimental Immunology (EXIM), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Hella L Aberson
- Experimental Immunology (EXIM), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Lilian J Meijboom
- Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Intensive Care Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Leo Heunks
- Intensive Care Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Esther J Nossent
- Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Division of Infectious Diseases, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Lieuwe D J Bos
- Intensive Care Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - JanWillem Duitman
- Pulmonary Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Experimental Immunology (EXIM), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Infection & Immunity, Inflammatory Diseases, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
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de Brabander J, Boers LS, Kullberg RFJ, Zhang S, Nossent EJ, Heunks LMA, Vlaar APJ, Bonta PI, Schultz MJ, van der Poll T, Duitman J, Bos LDJ. Persistent alveolar inflammatory response in critically ill patients with COVID-19 is associated with mortality. Thorax 2023; 78:912-921. [PMID: 37142421 DOI: 10.1136/thorax-2023-219989] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/29/2023] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Patients with COVID-19-related acute respiratory distress syndrome (ARDS) show limited systemic hyperinflammation, but immunomodulatory treatments are effective. Little is known about the inflammatory response in the lungs and if this could be targeted using high-dose steroids (HDS). We aimed to characterise the alveolar immune response in patients with COVID-19-related ARDS, to determine its association with mortality, and to explore the association between HDS treatment and the alveolar immune response. METHODS In this observational cohort study, a comprehensive panel of 63 biomarkers was measured in repeated bronchoalveolar lavage (BAL) fluid and plasma samples of patients with COVID-19 ARDS. Differences in alveolar-plasma concentrations were determined to characterise the alveolar inflammatory response. Joint modelling was performed to assess the longitudinal changes in alveolar biomarker concentrations, and the association between changes in alveolar biomarker concentrations and mortality. Changes in alveolar biomarker concentrations were compared between HDS-treated and matched untreated patients. RESULTS 284 BAL fluid and paired plasma samples of 154 patients with COVID-19 were analysed. 13 biomarkers indicative of innate immune activation showed alveolar rather than systemic inflammation. A longitudinal increase in the alveolar concentration of several innate immune markers, including CC motif ligand (CCL)20 and CXC motif ligand (CXCL)1, was associated with increased mortality. Treatment with HDS was associated with a subsequent decrease in alveolar CCL20 and CXCL1 levels. CONCLUSIONS Patients with COVID-19-related ARDS showed an alveolar inflammatory state related to the innate host response, which was associated with a higher mortality. HDS treatment was associated with decreasing alveolar concentrations of CCL20 and CXCL1.
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Affiliation(s)
- Justin de Brabander
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Leonoor S Boers
- Intensive Care Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Robert F J Kullberg
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Shiqi Zhang
- Intensive Care Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Esther J Nossent
- Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Leo M A Heunks
- Intensive Care Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Alexander P J Vlaar
- Intensive Care Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Peter I Bonta
- Pulmonary Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Intensive Care Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Infection & Immunity, Inflammatory Diseases, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - JanWillem Duitman
- Pulmonary Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Infection & Immunity, Inflammatory Diseases, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Experimental Immunology (EXIM), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Lieuwe D J Bos
- Intensive Care Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
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Philippot Q, Fekkar A, Gervais A, Le Voyer T, Boers LS, Conil C, Bizien L, de Brabander J, Duitman JW, Romano A, Rosain J, Blaize M, Migaud M, Jeljeli M, Hammadi B, Desmons A, Marchal A, Mayaux J, Zhang Q, Jouanguy E, Borie R, Crestani B, Luyt CE, Adle-Biassette H, Sene D, Megarbane B, Cobat A, Bastard P, Bos LDJ, Casanova JL, Puel A. Autoantibodies Neutralizing Type I IFNs in the Bronchoalveolar Lavage of at Least 10% of Patients During Life-Threatening COVID-19 Pneumonia. J Clin Immunol 2023; 43:1093-1103. [PMID: 37209324 PMCID: PMC10199445 DOI: 10.1007/s10875-023-01512-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/03/2023] [Indexed: 05/22/2023]
Abstract
Autoantibodies (auto-Abs) neutralizing type I interferons (IFNs) are found in the blood of at least 15% of unvaccinated patients with life-threatening COVID-19 pneumonia. We report here the presence of auto-Abs neutralizing type I IFNs in the bronchoalveolar lavage (BAL) of 54 of the 415 unvaccinated patients (13%) with life-threatening COVID-19 pneumonia tested. The 54 individuals with neutralizing auto-Abs in the BAL included 45 (11%) with auto-Abs against IFN-α2, 37 (9%) with auto-Abs against IFN-ω, 54 (13%) with auto-Abs against IFN-α2 and/or ω, and five (1%) with auto-Abs against IFN-β, including three (0.7%) with auto-Abs neutralizing IFN-α2, IFN-ω, and IFN-β, and two (0.5%) with auto-Abs neutralizing IFN-α2 and IFN-β. Auto-Abs against IFN-α2 also neutralize the other 12 subtypes of IFN-α. Paired plasma samples were available for 95 patients. All seven patients with paired samples who had detectable auto-Abs in BAL also had detectable auto-Abs in plasma, and one patient had auto-Abs detectable only in blood. Auto-Abs neutralizing type I IFNs are, therefore, present in the alveolar space of at least 10% of patients with life-threatening COVID-19 pneumonia. These findings suggest that these auto-Abs impair type I IFN immunity in the lower respiratory tract, thereby contributing to hypoxemic COVID-19 pneumonia.
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Affiliation(s)
- Quentin Philippot
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France.
- Imagine Institute, Université Paris Cité, Paris, EU, France.
| | - Arnaud Fekkar
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
- AP-HP, Groupe Hospitalier La Pitié-Salpêtrière, Service de Parasitologie Mycologie, Paris, EU, France
| | - Adrian Gervais
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
| | - Tom Le Voyer
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
| | - Leonoor S Boers
- Amsterdam UMC, University of Amsterdam, Intensive Care Medicine, Meibergdreef 9, Amsterdam, EU, The Netherlands
| | - Clément Conil
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
| | - Lucy Bizien
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
| | - Justin de Brabander
- Center for Experimental Molecular Medicine, Amsterdam UMC, Amsterdam, EU, Netherlands
| | - Jan Willem Duitman
- Amsterdam UMC, Location AMC, Department of Pulmonary Medicine, University of Amsterdam, 1105 AZ, Amsterdam, EU, The Netherlands
- Amsterdam UMC, Department of Experimental Immunology, Location University of Amsterdam, 1105 AZ, Amsterdam, EU, The Netherlands
- Amsterdam Infection & Immunity, Inflammatory Diseases, 1105 AZ, Amsterdam, EU, The Netherlands
| | - Alessia Romano
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
| | - Jérémie Rosain
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
| | - Marion Blaize
- AP-HP, Groupe Hospitalier La Pitié-Salpêtrière, Service de Parasitologie Mycologie, Paris, EU, France
| | - Mélanie Migaud
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
| | - Maxime Jeljeli
- Département 3I « Infection, Immunité Et Inflammation », Institut Cochin, INSERM U1016, Université Paris Cité, Paris, EU, France
- Faculté de Médecine, AP-HP-Centre Université de Paris, Hôpital Cochin, Service d'Immunologie Biologique, Université Paris Cité, Paris, EU, France
| | - Boualem Hammadi
- General Chemistry Laboratory, Department of Clinical Chemistry, APHP, Necker Hospital for Sick Children, Paris, EU, France
| | - Aurore Desmons
- Clinical Metabolomic Department, Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Saint Antoine Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP Sorbonne Université), Paris, France
| | - Astrid Marchal
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
| | - Julien Mayaux
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, EU, France
- Site Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, Hôpital Pitié-Salpêtrière, AP-HP, Sorbonne Université, Paris, EU, France
| | - Qian Zhang
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, NY, USA
| | - Emmanuelle Jouanguy
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, NY, USA
| | - Raphael Borie
- Service de Pneumologie A Hôpital Bichat, APHP, Paris, EU, France
- Inserm, PHERE, Université Paris Cité, 75018, Paris, EU, France
| | - Bruno Crestani
- Service de Pneumologie A Hôpital Bichat, APHP, Paris, EU, France
- Inserm, PHERE, Université Paris Cité, 75018, Paris, EU, France
| | - Charles Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, AP-HP, Hôpital Pitié-Salpêtrière, Paris, EU, France
- Inserm, Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, Paris, EU, France
| | - Homa Adle-Biassette
- AP-HP, Hôpital Lariboisière, Service Anatomie Pathologique and Université de Paris, Paris, EU, France
- Inserm, NeuroDiderot, Paris, EU, France
| | - Damien Sene
- Internal Medicine Department, AP-HP, Lariboisière Hospital, Paris, EU, France
- Université Paris Cité, Paris, EU, France
| | - Bruno Megarbane
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris, EU, France
- INSERM UMRS-1144, Paris-University, Paris, EU, France
| | - Aurélie Cobat
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, NY, USA
| | - Paul Bastard
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, NY, USA
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Hospital for Sick Children, AP-HP, Paris, France
| | - Lieuwe D J Bos
- Amsterdam UMC, University of Amsterdam, Intensive Care Medicine, Meibergdreef 9, Amsterdam, EU, The Netherlands
| | - Jean-Laurent Casanova
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, NY, USA
- Department of Pediatrics, Necker Hospital for Sick Children, Paris, EU, France
- Howard Hughes Medical Institute, New York, NY, USA
| | - Anne Puel
- Laboratory of Human Genetics of Infectious Diseases, Imagine Institute for Genetic Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 24 Boulevard du Montparnasse 75015, EU, Paris, France
- Imagine Institute, Université Paris Cité, Paris, EU, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, NY, USA
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Kullberg RFJ, de Brabander J, Boers LS, Bos LDJ, Wiersinga WJ. Reply to: Microbial Burden-associated Cytokine Storm May Explain Non-Resolving ARDS in COVID-19 Patients. Am J Respir Crit Care Med 2022; 206:1183-1184. [PMID: 35867884 PMCID: PMC9704841 DOI: 10.1164/rccm.202207-1346le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Kullberg RFJ, de Brabander J, Boers LS, Biemond JJ, Nossent EJ, Heunks LMA, Vlaar APJ, Bonta PI, van der Poll T, Duitman J, Bos LDJ, Wiersinga WJ. Lung Microbiota of Critically Ill Patients with COVID-19 Are Associated with Nonresolving Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2022; 206:846-856. [PMID: 35616585 PMCID: PMC9799265 DOI: 10.1164/rccm.202202-0274oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Rationale: Bacterial lung microbiota are correlated with lung inflammation and acute respiratory distress syndrome (ARDS) and altered in severe coronavirus disease (COVID-19). However, the association between lung microbiota (including fungi) and resolution of ARDS in COVID-19 remains unclear. We hypothesized that increased lung bacterial and fungal burdens are related to nonresolving ARDS and mortality in COVID-19. Objectives: To determine the relation between lung microbiota and clinical outcomes of COVID-19-related ARDS. Methods: This observational cohort study enrolled mechanically ventilated patients with COVID-19. All patients had ARDS and underwent bronchoscopy with BAL. Lung microbiota were profiled using 16S rRNA gene sequencing and quantitative PCR targeting the 16S and 18S rRNA genes. Key features of lung microbiota (bacterial and fungal burden, α-diversity, and community composition) served as predictors. Our primary outcome was successful extubation adjudicated 60 days after intubation, analyzed using a competing risk regression model with mortality as competing risk. Measurements and Main Results: BAL samples of 114 unique patients with COVID-19 were analyzed. Patients with increased lung bacterial and fungal burden were less likely to be extubated (subdistribution hazard ratio, 0.64 [95% confidence interval, 0.42-0.97]; P = 0.034 and 0.59 [95% confidence interval, 0.42-0.83]; P = 0.0027 per log10 increase in bacterial and fungal burden, respectively) and had higher mortality (bacterial burden, P = 0.012; fungal burden, P = 0.0498). Lung microbiota composition was associated with successful extubation (P = 0.0045). Proinflammatory cytokines (e.g., tumor necrosis factor-α) were associated with the microbial burdens. Conclusions: Bacterial and fungal lung microbiota are related to nonresolving ARDS in COVID-19 and represent an important contributor to heterogeneity in COVID-19-related ARDS.
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Affiliation(s)
| | | | - Leonoor S. Boers
- Department of Intensive Care Medicine,,Laboratory of Experimental Intensive Care and Anesthesiology
| | | | | | | | - Alexander P. J. Vlaar
- Department of Intensive Care Medicine,,Laboratory of Experimental Intensive Care and Anesthesiology
| | | | - Tom van der Poll
- Center for Experimental and Molecular Medicine,,Division of Infectious Diseases, and
| | - JanWillem Duitman
- Department of Pulmonary Medicine,,Department of Experimental Immunology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care Medicine,,Laboratory of Experimental Intensive Care and Anesthesiology,,Department of Pulmonary Medicine
| | - W. Joost Wiersinga
- Center for Experimental and Molecular Medicine,,Division of Infectious Diseases, and
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de Brabander J, Boers LS, Kullberg RFJ, Duitman JW, Bos LDJ. Time-dependent bias when analysing COVID-19-associated pulmonary aspergillosis. The Lancet Respiratory Medicine 2022; 10:e25-e26. [PMID: 35122732 PMCID: PMC8809898 DOI: 10.1016/s2213-2600(21)00582-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/17/2021] [Indexed: 11/26/2022]
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Valk CMA, Swart P, Boers LS, Botta M, Bos LDJ, de Abreu MG, Hol L, Hollmann MW, Horn J, Martin-Loeches I, Mazzinari G, Myatra SN, Nijbroek SG, Rosenberg NM, Stilma W, Tsonas AM, van der Ven WH, Neto AS, Schultz MJ, Paulus F. Practice of adjunctive treatments in critically ill COVID-19 patients-rational for the multicenter observational PRoAcT-COVID study in The Netherlands. Ann Transl Med 2021; 9:813. [PMID: 34268426 PMCID: PMC8246237 DOI: 10.21037/atm-21-764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/21/2021] [Indexed: 12/15/2022]
Abstract
Background Patients with coronavirus disease 2019 (COVID-19) may need hospitalization for supplemental oxygen, and some need intensive care unit (ICU) admission for escalation of care. Practice of adjunctive and supportive treatments remain uncertain and may vary widely between countries, within countries between hospitals, and possibly even within ICUs. We aim to investigate practice of adjunctive and supportive treatments, and their associations with outcome, in critically ill COVID-19 patients. Methods The ‘PRactice of Adjunctive Treatments in Intensive Care Unit Patients with Coronavirus Disease 2019’ (PRoAcT-COVID) study is a national, observational study to be undertaken in a large set of ICUs in The Netherlands. The PRoAcT-COVID includes consecutive ICU patients, admitted because of COVID-19 to one of the participating ICUs during a 3-month period. Daily follow-up lasts 28 days. The primary endpoint is a combination of adjunctive treatments, including types of oxygen support, ventilation, rescue therapies for hypoxemia refractory to supplementary oxygen or during invasive ventilation, other adjunctive and supportive treatments, and experimental therapies. We will also collect tracheostomy rate, duration of invasive ventilation and ventilator-free days and alive at day 28 (VFD-28), ICU and hospital length of stay, and the mortality rates in the ICU, hospital and at day 90. Discussion The PRoAcT-COVID study is an observational study combining high density treatment data with relevant clinical outcomes. Information on treatment practices, and their associations with outcomes in COVID-19 patients in highly and urgently needed. The results of the PRoAcT-COVID study will be rapidly available, and circulated through online presentations, such as webinars and electronic conferences, and publications in peer-reviewed journals—findings will also be presented at a dedicated website. At request, and after agreement of the PRoAcT-COVID steering committee, source data will be made available through local, regional and national anonymized datasets. Trial registration The PRoAcT-COVID study is registered at clinicaltrials.gov (study identifier NCT04719182).
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Affiliation(s)
- Christel M A Valk
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Pien Swart
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Leonoor S Boers
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Michela Botta
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Liselotte Hol
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands.,Department of Anesthesiology, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Janneke Horn
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | | | - Guido Mazzinari
- Department of Anaesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Sheila N Myatra
- Department of Intensive Care, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Sunny G Nijbroek
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands.,Department of Anesthesiology, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Neeltje M Rosenberg
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Willemke Stilma
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Anissa M Tsonas
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Ward H van der Ven
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands.,Data Analytics Research and Evaluation (DARE) Center, Austin Hospital, University of Melbourne, Melbourne, Australia
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands.,ACHIEVE, Centre of Applied Research, Amsterdam University of Applied Sciences, Faculty of Health, Amsterdam, The Netherlands
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8
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Botta M, Tsonas AM, Pillay J, Boers LS, Algera AG, Bos LDJ, Dongelmans DA, Hollmann MW, Horn J, Vlaar APJ, Schultz MJ, Neto AS, Paulus F. Ventilation management and clinical outcomes in invasively ventilated patients with COVID-19 (PRoVENT-COVID): a national, multicentre, observational cohort study. Lancet Respir Med 2021. [PMID: 33169671 DOI: 10.1016/s2213-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
BACKGROUND Little is known about the practice of ventilation management in patients with COVID-19. We aimed to describe the practice of ventilation management and to establish outcomes in invasively ventilated patients with COVID-19 in a single country during the first month of the outbreak. METHODS PRoVENT-COVID is a national, multicentre, retrospective observational study done at 18 intensive care units (ICUs) in the Netherlands. Consecutive patients aged at least 18 years were eligible for participation if they had received invasive ventilation for COVID-19 at a participating ICU during the first month of the national outbreak in the Netherlands. The primary outcome was a combination of ventilator variables and parameters over the first 4 calendar days of ventilation: tidal volume, positive end-expiratory pressure (PEEP), respiratory system compliance, and driving pressure. Secondary outcomes included the use of adjunctive treatments for refractory hypoxaemia and ICU complications. Patient-centred outcomes were ventilator-free days at day 28, duration of ventilation, duration of ICU and hospital stay, and mortality. PRoVENT-COVID is registered at ClinicalTrials.gov (NCT04346342). FINDINGS Between March 1 and April 1, 2020, 553 patients were included in the study. Median tidal volume was 6·3 mL/kg predicted bodyweight (IQR 5·7-7·1), PEEP was 14·0 cm H2O (IQR 11·0-15·0), and driving pressure was 14·0 cm H2O (11·2-16·0). Median respiratory system compliance was 31·9 mL/cm H2O (26·0-39·9). Of the adjunctive treatments for refractory hypoxaemia, prone positioning was most often used in the first 4 days of ventilation (283 [53%] of 530 patients). The median number of ventilator-free days at day 28 was 0 (IQR 0-15); 186 (35%) of 530 patients had died by day 28. Predictors of 28-day mortality were gender, age, tidal volume, respiratory system compliance, arterial pH, and heart rate on the first day of invasive ventilation. INTERPRETATION In patients with COVID-19 who were invasively ventilated during the first month of the outbreak in the Netherlands, lung-protective ventilation with low tidal volume and low driving pressure was broadly applied and prone positioning was often used. The applied PEEP varied widely, despite an invariably low respiratory system compliance. The findings of this national study provide a basis for new hypotheses and sample size calculations for future trials of invasive ventilation for COVID-19. These data could also help in the interpretation of findings from other studies of ventilation practice and outcomes in invasively ventilated patients with COVID-19. FUNDING Amsterdam University Medical Centers, location Academic Medical Center.
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Affiliation(s)
- Michela Botta
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Anissa M Tsonas
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Janesh Pillay
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands; University Medical Center Groningen, Groningen, The Netherlands
| | - Leonoor S Boers
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Anna Geke Algera
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Dave A Dongelmans
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Marcus W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Janneke Horn
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands; Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Austin Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands; ACHIEVE, Centre of Applied Research, Amsterdam University of Applied Sciences, Faculty of Health, Amsterdam, Netherlands
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9
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Botta M, Tsonas AM, Pillay J, Boers LS, Algera AG, Bos LDJ, Dongelmans DA, Hollmann MW, Horn J, Vlaar APJ, Schultz MJ, Neto AS, Paulus F. Ventilation management and clinical outcomes in invasively ventilated patients with COVID-19 (PRoVENT-COVID): a national, multicentre, observational cohort study. Lancet Respir Med 2020; 9:139-148. [PMID: 33169671 PMCID: PMC7584441 DOI: 10.1016/s2213-2600(20)30459-8] [Citation(s) in RCA: 168] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 08/29/2020] [Accepted: 09/07/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Little is known about the practice of ventilation management in patients with COVID-19. We aimed to describe the practice of ventilation management and to establish outcomes in invasively ventilated patients with COVID-19 in a single country during the first month of the outbreak. METHODS PRoVENT-COVID is a national, multicentre, retrospective observational study done at 18 intensive care units (ICUs) in the Netherlands. Consecutive patients aged at least 18 years were eligible for participation if they had received invasive ventilation for COVID-19 at a participating ICU during the first month of the national outbreak in the Netherlands. The primary outcome was a combination of ventilator variables and parameters over the first 4 calendar days of ventilation: tidal volume, positive end-expiratory pressure (PEEP), respiratory system compliance, and driving pressure. Secondary outcomes included the use of adjunctive treatments for refractory hypoxaemia and ICU complications. Patient-centred outcomes were ventilator-free days at day 28, duration of ventilation, duration of ICU and hospital stay, and mortality. PRoVENT-COVID is registered at ClinicalTrials.gov (NCT04346342). FINDINGS Between March 1 and April 1, 2020, 553 patients were included in the study. Median tidal volume was 6·3 mL/kg predicted bodyweight (IQR 5·7-7·1), PEEP was 14·0 cm H2O (IQR 11·0-15·0), and driving pressure was 14·0 cm H2O (11·2-16·0). Median respiratory system compliance was 31·9 mL/cm H2O (26·0-39·9). Of the adjunctive treatments for refractory hypoxaemia, prone positioning was most often used in the first 4 days of ventilation (283 [53%] of 530 patients). The median number of ventilator-free days at day 28 was 0 (IQR 0-15); 186 (35%) of 530 patients had died by day 28. Predictors of 28-day mortality were gender, age, tidal volume, respiratory system compliance, arterial pH, and heart rate on the first day of invasive ventilation. INTERPRETATION In patients with COVID-19 who were invasively ventilated during the first month of the outbreak in the Netherlands, lung-protective ventilation with low tidal volume and low driving pressure was broadly applied and prone positioning was often used. The applied PEEP varied widely, despite an invariably low respiratory system compliance. The findings of this national study provide a basis for new hypotheses and sample size calculations for future trials of invasive ventilation for COVID-19. These data could also help in the interpretation of findings from other studies of ventilation practice and outcomes in invasively ventilated patients with COVID-19. FUNDING Amsterdam University Medical Centers, location Academic Medical Center.
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Affiliation(s)
- Michela Botta
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Anissa M Tsonas
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Janesh Pillay
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands; University Medical Center Groningen, Groningen, The Netherlands
| | - Leonoor S Boers
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Anna Geke Algera
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Dave A Dongelmans
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Marcus W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Janneke Horn
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands; Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Austin Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, Netherlands; ACHIEVE, Centre of Applied Research, Amsterdam University of Applied Sciences, Faculty of Health, Amsterdam, Netherlands
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