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Dilawri A, Muir J, Brodie D, Abrams D, Agerstrand C, Madahar P, Dzierba AL. Practices surrounding antimicrobial use in patients managed with extracorporeal membrane oxygenation: An international survey. J Crit Care 2024; 81:154534. [PMID: 38367526 DOI: 10.1016/j.jcrc.2024.154534] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/23/2024] [Accepted: 02/04/2024] [Indexed: 02/19/2024]
Abstract
PURPOSE This study aimed to survey critical care clinicians and characterize their perception of antimicrobial dosing strategies in patients receiving extracorporeal membrane oxygenation (ECMO). METHODS International, cross-sectional survey distributed to members of the Society of Critical Care Medicine in October 2022. RESULTS Respondents were primarily physicians (45%), with 92% practicing in North America. Ninety-seven percent of respondents reported antimicrobial dosing in critically ill patients to be challenging, due to physiological derangements seen in the patient population. Eighty-seven percent reported consideration of physicochemical drug properties when dosing antimicrobials in ECMO-supported patients, with lipophilicity (83%) and degree of protein binding (74%) being the two most common. Respondents' approach to antimicrobial dosing strategies did not significantly differ in critically ill ECMO-supported patients, compared to patients with equal severity of illness not receiving ECMO support. CONCLUSION Approaches to antimicrobial dosing strategies do not significantly differ among respondents between critically ill patients on ECMO support, compared to patients with equal severity of illness not receiving ECMO support. These findings were unexpected considering the added physiologic complexity of the ECMO circuit to critically ill adult patients and the need for well designed and adequately powered studies to inform empiric dosing guidance for ECMO-supported patients.
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Affiliation(s)
- Atul Dilawri
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Justin Muir
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Daniel Brodie
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Darryl Abrams
- Division of Pulmonary and Critical Care Medicine, Columbia College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Cara Agerstrand
- Division of Pulmonary and Critical Care Medicine, Columbia College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Purnema Madahar
- Division of Pulmonary and Critical Care Medicine, Columbia College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Amy L Dzierba
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY, United States of America; Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons and NewYork-Presbyterian Hospital, New York, NY, United States of America.
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2
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Anderson MR, Madahar P, Baldwin MR. The authors reply. Crit Care Med 2024; 52:e206-e207. [PMID: 38483231 PMCID: PMC11052566 DOI: 10.1097/ccm.0000000000006197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Affiliation(s)
- Michaela R. Anderson
- University of Pennsylvania, Division of Pulmonary and Critical Care, Philadelphia, PA
| | - Purnema Madahar
- Columbia University, Division of Pulmonary, Allergy, and Critical Care, New York, NY
| | - Matthew R. Baldwin
- Columbia University, Division of Pulmonary, Allergy, and Critical Care, New York, NY
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3
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Fernando SM, MacLaren G, Barbaro RP, Mathew R, Munshi L, Madahar P, Fried JA, Ramanathan K, Lorusso R, Brodie D, McIsaac DI. Age and associated outcomes among patients receiving venoarterial extracorporeal membrane oxygenation-analysis of the Extracorporeal Life Support Organization registry. Intensive Care Med 2023; 49:1456-1466. [PMID: 37792052 DOI: 10.1007/s00134-023-07199-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 05/04/2023] [Accepted: 08/08/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE Venoarterial extracorporeal membrane oxygenation (V-A ECMO) can be used to support severely ill patients with cardiogenic shock. While age is commonly used in patient selection, little is known regarding its association with outcomes in this population. We sought to evaluate the association between increasing age and outcomes following V-A ECMO. METHODS We used individual-level patient data from 440 centers in the international Extracorporeal Life Support Organization registry. We included all adult patients receiving V-A ECMO from 2017 to 2019. The primary outcome was hospital mortality. Secondary outcomes included a composite of complications following initiation of V-A ECMO. We conducted Bayesian analyses of the relationship between increasing age and outcomes of interest. RESULTS We included 15,172 patients receiving V-A ECMO. Of these, 8172 (53.9%) died in hospital. For the analysis conducted using weakly informed priors, and as compared to the reference category of age 18-29, the age bracket of 30-39 (odds ratio [OR] 0.94, 95% credible interval [CrI] 0.79-1.10) was not associated with hospital mortality, but age brackets 40-49 (odds ratio [OR] 1.26, 95% CrI: 1.08-1.47), 50-59 (OR 1.78, 95% CrI: 1.55-2.06), 60-69 (OR 2.24, 95% CrI: 1.94-2.59), 70-79 (OR 2.90, 95% CrI: 2.49-3.39) and ≥ 80 (OR 4.02, 95% CrI: 3.13-5.20) were independently associated with increasing hospital mortality. Similar results were found in the analysis conducted with an informative prior, as well as between increasing age and post-ECMO complications. CONCLUSIONS Among patients receiving V-A ECMO for cardiogenic shock, increasing age is strongly associated with increasing odds of death and complications, and this association emerges as early as 40 years of age.
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Affiliation(s)
- Shannon M Fernando
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada.
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Ryan P Barbaro
- Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Rebecca Mathew
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Purnema Madahar
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Justin A Fried
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Roberto Lorusso
- Department of Cardio Thoracic Surgery, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Daniel Brodie
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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4
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Madahar P, Capaccione KM, Salvatore MM, Short B, Wahab R, Abrams D, Parekh M, Geleris JD, Furfaro D, Anderson MR, Zucker J, Brodie D, Cummings MJ, O’Donnell M, McGroder CF, Wei Y, Garcia CK, Baldwin MR. Fibrotic-Like Pulmonary Radiographic Patterns Are Not Associated With Adverse Outcomes in COVID-19 Chronic Critical Illness. Crit Care Med 2023; 51:e209-e220. [PMID: 37294143 PMCID: PMC10615871 DOI: 10.1097/ccm.0000000000005954] [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] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Pulmonary fibrosis is a feared complication of COVID-19. To characterize the risks and outcomes associated with fibrotic-like radiographic abnormalities in patients with COVID-19-related acute respiratory distress syndrome (ARDS) and chronic critical illness. DESIGN Single-center prospective cohort study. SETTING We examined chest CT scans performed between ICU discharge and 30 days after hospital discharge using established methods to quantify nonfibrotic and fibrotic-like patterns. PATIENTS Adults hospitalized with COVID-19-related ARDS and chronic critical illness (> 21 d of mechanical ventilation, tracheostomy, and survival to ICU discharge) between March 2020 and May 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We tested associations of fibrotic-like patterns with clinical characteristics and biomarkers, and with time to mechanical ventilator liberation and 6-month survival, controlling for demographics, comorbidities, and COVID-19 therapies. A total of 141 of 616 adults (23%) with COVID-19-related ARDS developed chronic critical illness, and 64 of 141 (46%) had a chest CT a median (interquartile range) 66 days (42-82 d) after intubation. Fifty-five percent had fibrotic-like patterns characterized by reticulations and/or traction bronchiectasis. In adjusted analyses, interleukin-6 level on the day of intubation was associated with fibrotic-like patterns (odds ratio, 4.40 per quartile change; 95% CI, 1.90-10.1 per quartile change). Other inflammatory biomarkers, Sequential Organ Failure Assessment score, age, tidal volume, driving pressure, and ventilator days were not. Fibrotic-like patterns were not associated with longer time to mechanical ventilator liberation or worse 6-month survival. CONCLUSIONS Approximately half of adults with COVID-19-associated chronic critical illness have fibrotic-like patterns that are associated with higher interleukin-6 levels at intubation. Fibrotic-like patterns are not associated with longer time to liberation from mechanical ventilation or worse 6-month survival.
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Affiliation(s)
- Purnema Madahar
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
| | - Kathleen M. Capaccione
- Division of Cardiothoracic Imaging, Department of Radiology, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
| | - Mary M. Salvatore
- Division of Cardiothoracic Imaging, Department of Radiology, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
| | - Briana Short
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
| | - Romina Wahab
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
| | - Darryl Abrams
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
| | - Madhavi Parekh
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
| | - Joshua D. Geleris
- Division of General Medicine, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
| | - David Furfaro
- Division of Pulmonary, Allergy, and Critical Care, Harvard Medical School/Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michaela R Anderson
- Division of Pulmonary and Critical Care, University of Pennsylvania Medical School, Philadelphia, PA, USA
| | - Jason Zucker
- Division of Infectious Diseases, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
| | - Matthew J. Cummings
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
| | - Max O’Donnell
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
| | - Claire F. McGroder
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
| | - Ying Wei
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Christine K. Garcia
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
| | - Matthew R. Baldwin
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian, New York, NY, USA
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5
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Hickey AJ, Cummings MJ, Short B, Brodie D, Panzer O, Madahar P, O'Donnell MR. Approach to the Physiologically Challenging Endotracheal Intubation in the Intensive Care Unit. Respir Care 2023; 68:1438-1448. [PMID: 37221087 PMCID: PMC10506638 DOI: 10.4187/respcare.10821] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Endotracheal intubation for airway management is a common procedure in the ICU. Intubation may be difficult due to anatomic airway abnormalities but also due to physiologic derangements that predispose patients to cardiovascular collapse during the procedure. Results of studies demonstrate a high incidence of morbidity and mortality associated with airway management in the ICU. To reduce the likelihood of complications, medical teams must be well versed in the general principles of intubation and be prepared to manage physiologic derangements while securing the airway. In this review, we present relevant literature on the approach to endotracheal intubation in the ICU and provide pragmatic recommendations relevant to medical teams performing intubations in patients who are physiologically unstable.
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Affiliation(s)
- Andrew J Hickey
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York
| | - Matthew J Cummings
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York
| | - Briana Short
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Oliver Panzer
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Purnema Madahar
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York
| | - Max R O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York.
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
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6
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Kim JS, Manichaikul AW, Hoffman EA, Balte P, Anderson MR, Bernstein EJ, Madahar P, Oelsner EC, Kawut SM, Wysoczanski A, Laine AF, Adegunsoye A, Ma JZ, Taub MA, Mathias RA, Rich SS, Rotter JI, Noth I, Garcia CK, Barr RG, Podolanczuk AJ. MUC5B, telomere length and longitudinal quantitative interstitial lung changes: the MESA Lung Study. Thorax 2023; 78:566-573. [PMID: 36690926 PMCID: PMC9899287 DOI: 10.1136/thorax-2021-218139] [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: 08/26/2021] [Accepted: 07/11/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND The MUC5B promoter variant (rs35705950) and telomere length are linked to pulmonary fibrosis and CT-based qualitative assessments of interstitial abnormalities, but their associations with longitudinal quantitative changes of the lung interstitium among community-dwelling adults are unknown. METHODS We used data from participants in the Multi-Ethnic Study of Atherosclerosis with high-attenuation areas (HAAs, Examinations 1-6 (2000-2018)) and MUC5B genotype (n=4552) and telomere length (n=4488) assessments. HAA was defined as the per cent of imaged lung with attenuation of -600 to -250 Hounsfield units. We used linear mixed-effects models to examine associations of MUC5B risk allele (T) and telomere length with longitudinal changes in HAAs. Joint models were used to examine associations of longitudinal changes in HAAs with death and interstitial lung disease (ILD). RESULTS The MUC5B risk allele (T) was associated with an absolute change in HAAs of 2.60% (95% CI 0.36% to 4.86%) per 10 years overall. This association was stronger among those with a telomere length below an age-adjusted percentile of 5% (p value for interaction=0.008). A 1% increase in HAAs per year was associated with 7% increase in mortality risk (rate ratio (RR)=1.07, 95% CI 1.02 to 1.12) for overall death and 34% increase in ILD (RR=1.34, 95% CI 1.20 to 1.50). Longer baseline telomere length was cross-sectionally associated with less HAAs from baseline scans, but not with longitudinal changes in HAAs. CONCLUSIONS Longitudinal increases in HAAs were associated with the MUC5B risk allele and a higher risk of death and ILD.
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Affiliation(s)
- John S Kim
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Ani W Manichaikul
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, USA
- Center for Public Health Genomics, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Eric A Hoffman
- Department of Radiology, University of Iowa, Iowa City, Iowa, USA
| | - Pallavi Balte
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Michaela R Anderson
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Elana J Bernstein
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Purnema Madahar
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Elizabeth C Oelsner
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Steven M Kawut
- Department of Medicine, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics and Epidemiology, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Artur Wysoczanski
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Andrew F Laine
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | | | - Jennie Z Ma
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Margaret A Taub
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rasika A Mathias
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stephen S Rich
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, USA
- Center for Public Health Genomics, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Jerome I Rotter
- Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California, USA
- The Institute for Translational Genomics and Population Sciences, The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Imre Noth
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Christine Kim Garcia
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - R Graham Barr
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Anna J Podolanczuk
- Division of Pulmonary and Critical Care, Weill Cornell Medical College, New York, New York, USA
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Abrams D, Agerstrand C, Beitler JR, Karagiannidis C, Madahar P, Yip NH, Pesenti A, Slutsky AS, Brochard L, Brodie D. Risks and Benefits of Ultra-Lung-Protective Invasive Mechanical Ventilation Strategies with a Focus on Extracorporeal Support. Am J Respir Crit Care Med 2022; 205:873-882. [PMID: 35044901 DOI: 10.1164/rccm.202110-2252cp] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Lung-protective ventilation strategies are the current standard of care for patients with acute respiratory distress syndrome (ARDS) in an effort to provide adequate ventilatory requirements while minimizing ventilator-induced lung injury. Some patients may benefit from ultra-lung-protective ventilation, a strategy that achieves lower airway pressures and tidal volumes than the current standard. Specific physiological parameters beyond severity of hypoxemia, such as driving pressure and respiratory system elastance, may be predictive of those most likely to benefit. Since application of ultra-lung-protective ventilation is often limited by respiratory acidosis, extracorporeal membrane oxygenation (ECMO) or extracorporeal carbon dioxide removal (ECCO2R), which remove carbon dioxide from blood, are attractive options. These strategies are associated with hematological complications, especially when applied at low blood flow rates with devices designed for higher blood flows, and a recent large randomized, controlled trial failed to show a benefit from an ECCO2R-facilitated ultra-lung-protective ventilation strategy. Only in patients with very severe forms of ARDS has the use of an ultra-lung-protective ventilation strategy - accomplished with ECMO - been suggested to have a favorable risk-to-benefit profile. In this Critical Care Perspective, we address key areas of controversy related to ultra-lung-protective ventilation, including the trade-offs between minimizing ventilator-induced lung injury and the risks from strategies to achieve this added protection. In addition, we suggest which patients might benefit most from an ultra-lung-protective strategy and propose areas of future research.
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Affiliation(s)
- Darryl Abrams
- Columbia University Medical Center, Medicine, Division of Pulmonary, Allergy, & Critical Care, New York, New York, United States
| | - Cara Agerstrand
- Columbia University Medical Center, Medicine, Division of Pulmonary, Allergy, & Critical Care, New York, New York, United States
| | - Jeremy R Beitler
- Columbia University College of Physicians and Surgeons, 12294, Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, New York, New York, United States.,NewYork-Presbyterian Hospital, 25065, New York, New York, United States
| | - Christian Karagiannidis
- Hospital Cologne-Merheim, 61060, Department of Pneumology and Critical Care Medicine, Koln, Germany.,Witten/Herdecke University, 12263, Cologne, Germany
| | - Purnema Madahar
- Columbia University Medical Center, Medicine, Division of Pulmonary, Allergy, & Critical Care, New York, New York, United States
| | - Natalie H Yip
- Columbia University Medical Center, Dept of Medicine Pulmonary, New York City, New York, United States
| | - Antonio Pesenti
- Universita degli Studi di Milano, 9304, Department of Pathophysiology and Transplantation, Milano, Italy
| | | | - Laurent Brochard
- St Michael's Hospital in Toronto, Li Ka Shing Knowledge Institute, Keenan Research Centre, Toronto, Ontario, Canada.,University of Toronto, 7938, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Daniel Brodie
- Columbia, Critical Care, New York, New York, United States;
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8
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Madahar P, Burkart KM, Brodie D. Standardizing the Approach to Liberation From Venovenous Extracorporeal Membrane Oxygenation. Chest 2021; 160:1583-1584. [PMID: 34743837 DOI: 10.1016/j.chest.2021.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 07/12/2021] [Indexed: 01/19/2023] Open
Affiliation(s)
- Purnema Madahar
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Kristin M Burkart
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA.
| | - Daniel Brodie
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
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9
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Madahar P, Talmor D, Beitler JR. Transpulmonary Pressure-guided Ventilation to Attenuate Atelectrauma and Hyperinflation in Acute Lung Injury. Am J Respir Crit Care Med 2021; 203:934-937. [PMID: 33227213 PMCID: PMC8048752 DOI: 10.1164/rccm.202011-4116ed] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Purnema Madahar
- Center for Acute Respiratory Failure.,Division of Pulmonary, Allergy, and Critical Care Medicine Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital New York, New York and
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine Harvard Medical School and Beth Israel Deaconess Medical Center Boston, Massachusetts
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure.,Division of Pulmonary, Allergy, and Critical Care Medicine Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital New York, New York and
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10
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Agerstrand C, Dubois R, Takeda K, Uriel N, Lemaitre P, Fried J, Masoumi A, Cheung EW, Kaku Y, Witer L, Liou P, Gerall C, Klein-Cloud R, Abrams D, Cunningham J, Madahar P, Parekh M, Short B, Yip NH, Serra A, Beck J, Brewer M, Fung K, Mullin D, Oommen R, Stanifer BP, Middlesworth W, Sonett J, Brodie D. Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019: Crisis Standards of Care. ASAIO J 2021; 67:245-249. [PMID: 33627596 DOI: 10.1097/mat.0000000000001376] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has placed extraordinary strain on global healthcare systems. Use of extracorporeal membrane oxygenation (ECMO) for patients with severe respiratory or cardiac failure attributed to COVID-19 has been debated due to uncertain survival benefit and the resources required to safely deliver ECMO support. We retrospectively investigated adult patients supported with ECMO for COVID-19 at our institution during the first 80 days following New York City's declaration of a state of emergency. The primary objective was to evaluate survival outcomes in patients supported with ECMO for COVID-19 and describe the programmatic adaptations made in response to pandemic-related crisis conditions. Twenty-two patients with COVID-19 were placed on ECMO during the study period. Median age was 52 years and 18 (81.8%) were male. Twenty-one patients (95.4%) had severe ARDS and seven (31.8%) had cardiac failure. Fifteen patients (68.1%) were managed with venovenous ECMO while 7 (31.8%) required arterial support. Twelve patients (54.5%) were transported on ECMO from external institutions. Twelve patients were discharged alive from the hospital (54.5%). Extracorporeal membrane oxygenation was used successfully in patients with respiratory and cardiac failure due to COVID-19. The continued use of ECMO, including ECMO transport, during crisis conditions was possible even at the height of the COVID-19 pandemic.
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Affiliation(s)
- Cara Agerstrand
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Richard Dubois
- Department of Surgery, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Philippe Lemaitre
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Justin Fried
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Amirali Masoumi
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Eva W Cheung
- Divisions of Pediatric Cardiology and Critical Care, Department of Pediatrics, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Yuji Kaku
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Lucas Witer
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Peter Liou
- Department of Surgery, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Claire Gerall
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Rafael Klein-Cloud
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Darryl Abrams
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Jennifer Cunningham
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Purnema Madahar
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Madhavi Parekh
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Briana Short
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Natalie H Yip
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Alexis Serra
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - James Beck
- Department of Clinical Perfusion and Anesthesia Support Services, NewYork-Presbyterian Hospital, New York, New York
| | - Michael Brewer
- Department of Clinical Perfusion and Anesthesia Support Services, NewYork-Presbyterian Hospital, New York, New York
| | - Kenmund Fung
- Department of Clinical Perfusion and Anesthesia Support Services, NewYork-Presbyterian Hospital, New York, New York
| | - Dana Mullin
- Department of Clinical Perfusion and Anesthesia Support Services, NewYork-Presbyterian Hospital, New York, New York
| | - Roy Oommen
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Bryan Payne Stanifer
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - William Middlesworth
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Joshua Sonett
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
| | - Daniel Brodie
- From the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York
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11
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Madahar P, Wunsch H, Jha P, Slutsky AS, Brodie D. Trends in COVID-19-related in-hospital mortality: lessons learned from nationwide samples. Lancet Respir Med 2021; 9:322-324. [PMID: 33600776 PMCID: PMC7906680 DOI: 10.1016/s2213-2600(21)00080-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Purnema Madahar
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY 10032, USA
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Prabhat Jha
- Center for Global Health Research, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Keenan Research Center, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY 10032, USA.
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12
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Hobbs BD, Putman RK, Araki T, Nishino M, Gudmundsson G, Gudnason V, Eiriksdottir G, Zilhao Nogueira NR, Dupuis J, Xu H, O'Connor GT, Manichaikul A, Nguyen J, Podolanczuk AJ, Madahar P, Rotter JI, Lederer DJ, Barr RG, Rich SS, Ampleford EJ, Ortega VE, Peters SP, O'Neal WK, Newell JD, Bleecker ER, Meyers DA, Allen RJ, Oldham JM, Ma SF, Noth I, Jenkins RG, Maher TM, Hubbard RB, Wain LV, Fingerlin TE, Schwartz DA, Washko GR, Rosas IO, Silverman EK, Hatabu H, Cho MH, Hunninghake GM. Overlap of Genetic Risk between Interstitial Lung Abnormalities and Idiopathic Pulmonary Fibrosis. Am J Respir Crit Care Med 2020; 200:1402-1413. [PMID: 31339356 DOI: 10.1164/rccm.201903-0511oc] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Rationale: Interstitial lung abnormalities (ILAs) are associated with the highest genetic risk locus for idiopathic pulmonary fibrosis (IPF); however, the extent to which there are unique associations among individuals with ILAs or additional overlap with IPF is not known.Objectives: To perform a genome-wide association study (GWAS) of ILAs.Methods: ILAs and a subpleural-predominant subtype were assessed on chest computed tomography (CT) scans in the AGES (Age Gene/Environment Susceptibility), COPDGene (Genetic Epidemiology of Chronic Obstructive Pulmonary Disease [COPD]), Framingham Heart, ECLIPSE (Evaluation of COPD Longitudinally to Identify Predictive Surrogate End-points), MESA (Multi-Ethnic Study of Atherosclerosis), and SPIROMICS (Subpopulations and Intermediate Outcome Measures in COPD Study) studies. We performed a GWAS of ILAs in each cohort and combined the results using a meta-analysis. We assessed for overlapping associations in independent GWASs of IPF.Measurements and Main Results: Genome-wide genotyping data were available for 1,699 individuals with ILAs and 10,274 control subjects. The MUC5B (mucin 5B) promoter variant rs35705950 was significantly associated with both ILAs (P = 2.6 × 10-27) and subpleural ILAs (P = 1.6 × 10-29). We discovered novel genome-wide associations near IPO11 (rs6886640, P = 3.8 × 10-8) and FCF1P3 (rs73199442, P = 4.8 × 10-8) with ILAs, and near HTRE1 (rs7744971, P = 4.2 × 10-8) with subpleural-predominant ILAs. These novel associations were not associated with IPF. Among 12 previously reported IPF GWAS loci, five (DPP9, DSP, FAM13A, IVD, and MUC5B) were significantly associated (P < 0.05/12) with ILAs.Conclusions: In a GWAS of ILAs in six studies, we confirmed the association with a MUC5B promoter variant and found strong evidence for an effect of previously described IPF loci; however, novel ILA associations were not associated with IPF. These findings highlight common genetically driven biologic pathways between ILAs and IPF, and also suggest distinct ones.
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Affiliation(s)
- Brian D Hobbs
- Channing Division of Network Medicine.,Division of Pulmonary and Critical Care Medicine
| | | | - Tetsuro Araki
- Department of Radiology, and.,Center for Pulmonary Functional Imaging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mizuki Nishino
- Department of Radiology, and.,Center for Pulmonary Functional Imaging, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Vilmundur Gudnason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Icelandic Heart Association, Kopavogur, Iceland
| | | | | | - Josée Dupuis
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts.,NHLBI Framingham Heart Study, Framingham, Massachusetts
| | - Hanfei Xu
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - George T O'Connor
- NHLBI Framingham Heart Study, Framingham, Massachusetts.,Pulmonary Center, Department of Medicine, Boston University, Boston, Massachusetts
| | - Ani Manichaikul
- Center for Public Health Genomics.,Department of Public Health Sciences, and
| | | | | | - Purnema Madahar
- Department of Medicine, College of Physicians and Surgeons, and
| | - Jerome I Rotter
- Institute for Translational Genomics and Population Sciences, Los Angeles Biomedical Research Institute, and.,Division of Genomic Outcomes, Department of Pediatrics and.,Department of Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - David J Lederer
- Department of Medicine, College of Physicians and Surgeons, and.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - R Graham Barr
- Department of Medicine, College of Physicians and Surgeons, and.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Stephen S Rich
- Center for Public Health Genomics.,Department of Public Health Sciences, and
| | - Elizabeth J Ampleford
- Department of Internal Medicine, Center for Precision Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Victor E Ortega
- Department of Internal Medicine, Center for Precision Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Stephen P Peters
- Department of Internal Medicine, Center for Precision Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Wanda K O'Neal
- Marsico Lung Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - John D Newell
- Division of Cardiovascular and Pulmonary Imaging, Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, Iowa.,Department of Radiology, University of Washington, Seattle, Washington
| | - Eugene R Bleecker
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona
| | - Deborah A Meyers
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona
| | - Richard J Allen
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Justin M Oldham
- Department of Internal Medicine, University of California Davis, Davis, California
| | - Shwu-Fan Ma
- Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, Virginia
| | - Imre Noth
- Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, Virginia
| | - R Gisli Jenkins
- National Institute for Health Research, Biomedical Research Centre, Respiratory Research Unit, School of Medicine, and
| | - Toby M Maher
- National Institute for Health Research, Respiratory Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom.,Fibrosis Research Group, Inflammation, Repair and Development Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Richard B Hubbard
- National Institute for Health Research, Biomedical Research Centre, Respiratory Research Unit, School of Medicine, and.,Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom
| | - Louise V Wain
- National Institute for Health Research, Leicester Respiratory Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Tasha E Fingerlin
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado; and.,Department of Biostatistics and Informatics
| | - David A Schwartz
- Department of Biostatistics and Informatics.,Department of Medicine, School of Medicine, and.,Department of Immunology, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - George R Washko
- Division of Pulmonary and Critical Care Medicine.,Center for Pulmonary Functional Imaging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ivan O Rosas
- Division of Pulmonary and Critical Care Medicine
| | - Edwin K Silverman
- Channing Division of Network Medicine.,Division of Pulmonary and Critical Care Medicine
| | - Hiroto Hatabu
- Department of Radiology, and.,Center for Pulmonary Functional Imaging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael H Cho
- Channing Division of Network Medicine.,Division of Pulmonary and Critical Care Medicine
| | - Gary M Hunninghake
- Division of Pulmonary and Critical Care Medicine.,Center for Pulmonary Functional Imaging, Brigham and Women's Hospital, Boston, Massachusetts
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13
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Abstract
Ventilation-induced lung injury results from mechanical stress and strain that occur during tidal ventilation in the susceptible lung. Classical descriptions of ventilation-induced lung injury have focused on harm from positive pressure ventilation. However, injurious forces also can be generated by patient effort and patient–ventilator interactions. While the role of global mechanics has long been recognized, regional mechanical heterogeneity within the lungs also appears to be an important factor propagating clinically significant lung injury. The resulting clinical phenotype includes worsening lung injury and a systemic inflammatory response that drives extrapulmonary organ failures. Bedside recognition of ventilation-induced lung injury requires a high degree of clinical acuity given its indistinct presentation and lack of definitive diagnostics. Yet the clinical importance of ventilation-induced lung injury is clear. Preventing such biophysical injury remains the most effective management strategy to decrease morbidity and mortality in patients with acute respiratory distress syndrome and likely benefits others at risk.
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Affiliation(s)
- Purnema Madahar
- Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons, New York City, NY, USA.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York City, NY, USA.,Department of Medicine, New York-Presbyterian Hospital, New York City, NY, USA
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons, New York City, NY, USA.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York City, NY, USA.,Department of Medicine, New York-Presbyterian Hospital, New York City, NY, USA
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14
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Choi B, Kawut SM, Raghu G, Hoffman E, Tracy R, Madahar P, Bernstein EJ, Barr RG, Lederer DJ, Podolanczuk A. Regional distribution of high-attenuation areas on chest computed tomography in the Multi-Ethnic Study of Atherosclerosis. ERJ Open Res 2020; 6:00115-2019. [PMID: 32154292 PMCID: PMC7049731 DOI: 10.1183/23120541.00115-2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 12/04/2019] [Indexed: 11/16/2022] Open
Abstract
High-attenuation areas (HAA) are a computed tomography-based quantitative measure of subclinical interstitial lung disease (ILD). We aimed to validate HAA in lung regions that are less subject to artefacts, such as extravascular lung water or dependent atelectasis. We examined the associations of HAA within six lung regions (basilar, non-basilar, peel, core, basilar peel, basilar core) with serum biomarkers of lung remodelling, forced vital capacity (FVC), visually-assessed interstitial lung abnormalities (ILA), and all-cause and ILD-specific mortality. We performed cross-sectional and longitudinal analyses of participants in the Multi-Ethnic Study of Atherosclerosis, a prospective cohort of 6814 adults aged 45–84 years without known cardiovascular disease who underwent cardiac computed tomography. Median regional HAA ranged from 3.8% in the peel to 4.8% in the basilar core. Doubling of regional HAA was associated with greater serum matrix metalloproteinase-7 (range 3.8% to 10.3%; p≤0.01), higher odds of ILA (OR 1.42 to 2.20; p≤0.03), and a higher risk of all-cause mortality (hazard ratio 1.20 to 1.47; p≤0.001). Doubling of regional HAA was associated with greater serum interleukin-6 (4.9% to 10.3%; p≤0.005) and higher risk of ILD-specific mortality (hazard ratio 3.30 to 3.98; p<0.001), except in the basilar core. Doubling of regional HAA was associated with lower FVC in the non-basilar, core and basilar core (113 mL to 186 mL; p<0.001). Associations of HAA with lung remodelling biomarkers, ILA risk and all-cause mortality were consistent across all regions of the lung, including dependent areas where atelectasis may be present. These findings support the validity of HAA as a measure of pathologic subclinical ILD. Evenwhen found in small regions of the lungs, high-attenuation areas, a CT-based quantitative measure of subclinical ILD, are associated with biomarkers of lung remodelling, risk of interstitial lung abnormalities and all-cause mortalityhttp://bit.ly/36psfin
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Affiliation(s)
- Bina Choi
- Columbia University Medical Center, New York, NY, USA
| | - Steven M Kawut
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Ganesh Raghu
- University of Washington Medical Center, Seattle, WA, USA
| | - Eric Hoffman
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | | | | | | | - R Graham Barr
- Columbia University Medical Center, New York, NY, USA
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15
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Rosenzweig EB, Gannon WD, Madahar P, Agerstrand C, Abrams D, Liou P, Brodie D, Bacchetta M. Extracorporeal life support bridge for pulmonary hypertension: A high-volume single-center experience. J Heart Lung Transplant 2019; 38:1275-1285. [DOI: 10.1016/j.healun.2019.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/29/2019] [Accepted: 09/03/2019] [Indexed: 11/15/2022] Open
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16
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Dzierba AL, Abrams D, Madahar P, Muir J, Agerstrand C, Brodie D. Current practice and perceptions regarding pain, agitation and delirium management in patients receiving venovenous extracorporeal membrane oxygenation. J Crit Care 2019; 53:98-106. [DOI: 10.1016/j.jcrc.2019.05.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/09/2019] [Accepted: 05/27/2019] [Indexed: 11/15/2022]
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17
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Madahar P, Duprez DA, Podolanczuk AJ, Bernstein EJ, Kawut SM, Raghu G, Barr RG, Gross MD, Jacobs DR, Lederer DJ. Collagen biomarkers and subclinical interstitial lung disease: The Multi-Ethnic Study of Atherosclerosis. Respir Med 2018; 140:108-114. [PMID: 29957270 DOI: 10.1016/j.rmed.2018.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 04/02/2018] [Accepted: 06/01/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Lung fibrosis is attributed to derangements in extracellular matrix remodeling, a process driven by collagen turnover. We examined the association of two collagen biomarkers, carboxy-terminal telopeptide of collagen type I (ICTP) and amino-terminal propeptide of type III procollagen (PIIINP), with subclinical interstitial lung disease (ILD) in adults. METHODS We performed a cross-sectional analysis of 3244 participants age 45-84 years in the Multi-Ethnic Study of Atherosclerosis. Serum ICTP and PIIINP levels were measured at baseline by radioimmunoassay. Subclinical ILD was defined as high attenuation areas (HAA) in the lung fields on baseline cardiac CT scans. Interstitial lung abnormalities (ILA) were measured in 1082 full-lung CT scans at 9.5 years median follow-up. We used generalized linear models to examine the associations of collagen biomarkers with HAA and ILA. RESULTS Median (IQR) for ICTP was 3.2 μg/L (2.6-3.9 μg/L) and for PIIINP was 5.3 μg/L (4.5-6.2 μg/L). In fully adjusted models, each SD increment in ICTP was associated with a 1.3% increment in HAA (95% CI 0.2-2.4%, p = 0.02) and each SD increment in PIIINP was associated with a 0.96% increment in HAA (95% CI 0.06-1.9%, p = 0.04). There was no association between ICTP or PIIINP and ILA. There was no evidence of effect modification by gender, race, smoking status or eGFR. CONCLUSIONS Higher levels of collagen biomarkers are associated with greater HAA independent of gender, race and smoking status. This suggests that extracellular matrix remodeling may accompany subclinical ILD prior to the onset of clinically evident disease.
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Affiliation(s)
- Purnema Madahar
- Department of Medicine, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Daniel A Duprez
- Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Anna J Podolanczuk
- Department of Medicine, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Elana J Bernstein
- Department of Medicine, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Steven M Kawut
- Department of Medicine and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Ganesh Raghu
- Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - R Graham Barr
- Department of Medicine, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA; Department of Epidemiology, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Myron D Gross
- Department of Laboratory Medicine and Pathology, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - David R Jacobs
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - David J Lederer
- Department of Medicine, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA; Department of Epidemiology, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA.
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18
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Abstract
OBJECTIVES To measure the prevalence and incidence of delirium in older adults as they transition from the emergency department (ED) to the inpatient ward, and to determine the association between delirium during early hospitalisation and subsequent clinical deterioration. DESIGN Prospective cohort study. SETTING Urban tertiary care hospital in Bronx, New York. PARTICIPANTS Adults aged 65 years or older admitted to the inpatient ward from the ED (n=260). MEASUREMENTS Beginning in the ED, delirium was assessed daily for 3 days, using the Confusion Assessment Method for the Intensive Care Unit. OUTCOMES (1) Clinical deterioration, defined as unanticipated intensive care unit (ICU) admission or in-hospital death (primary outcome); (2) decline in discharge status, defined as discharge to higher level of care, hospice or in-hospital death. RESULTS 38 of 260 participants (15%) were delirious at least once during the first 3 days of hospitalisation. Of the 29 (11%) patients with delirium in the ED (ie, hospital day 1), delirium persisted into hospital day 2 in 72% (n=21), and persisted for all 3 days in 52% (n=15). In multivariate analyses, as little as 1 episode of delirium during the first 3 days was associated with increased odds of unanticipated ICU admission or in-hospital death (adjusted OR 8.07 (95% CI 1.91 to 34.14); p=0.005). Delirium that persisted for all 3 days was associated with a decline in discharge status, even after adjusting for factors such as severity of illness and baseline cognitive impairment (adjusted OR 4.70 (95% CI 1.41 to 15.63); p=0.012). CONCLUSIONS Delirium during the first few days of hospitalisation was associated with poor outcomes in older adults admitted from the ED to the inpatient ward. These findings suggest the need for serial delirium monitoring that begins in the ED to identify a high-risk population that may benefit from closer follow-up and intervention.
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Affiliation(s)
- S Jean Hsieh
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Purnema Madahar
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Aluko A Hope
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jennifer Zapata
- Department of Emergency Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Michelle N Gong
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
- Albert Einstein College of Medicine, Bronx, New York, USA
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19
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Venegas-Borsellino C, Dym A, Madahar P, Mejia E, Bangar M, Colvin M, Keene A, Eisen L. An Evaluation of Leadership and Teamwork Skills by Internal Medicine Residents During In-Hospital Cardiac Arrest and Rapid Response Scenarios After Simulation Training. Chest 2014. [DOI: 10.1378/chest.1991432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Kort S, Mamidipally S, Madahar P, Dave S, Brown DL. Real time three-dimensional stress echocardiography: a new approach for assessing diastolic function. Echocardiography 2011; 28:676-83. [PMID: 21718353 DOI: 10.1111/j.1540-8175.2011.01399.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the feasibility of utilizing real time three-dimensional echocardiography (RT3DE) for assessment of diastolic function during stress. METHODS Rest and stress volumes were acquired in 24 patients and parameters of diastolic function-peak ventricular filling rate (PFR) and time to peak filling rate (TPFR)-were calculated. RESULTS Calculation of diastolic parameters was feasible in all patients. Resting PFR correlated with end-diastolic (EDV) and stroke volumes and inversely with TPFR (r = 0.53, 0.66, -0.5). With stress, PFR increased by 93% and TPFR decreased by 23% (P < 0.001). Stress PFR correlated with stress heart rate, EDV and stroke volume (r = 0.52, 0.50, 0.62) while TPFR correlated inversely with heart rate (r =-0.71). The change in PFR with stress correlated with the change in stroke volume (r = 0.42), while the change in TPFR correlated with the change in end-systolic volume (ESV) (r = 0.43) and inversely with the change in diastolic blood pressure (r =-0.41). Rest and stress PFR and TPFR are independent of age, gender and blood pressure and the change in PFR is independent of stress heart rate or blood pressure. E/E' correlated with stress TPFR (r = 0.72) and change in TPFR (r = 0.67) and inversely with change in PFR (r =-0.67). CONCLUSIONS RT3DE can assess diastolic function during stress by detecting changes in PFR and TPFR, independent of gender, age, and blood pressure. The changes in these parameters with stress are influenced by baseline filling pressures. Larger studies are required to validate the clinical significance of these observations.
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Affiliation(s)
- Smadar Kort
- Division of Cardiovascular Medicine, Stony Brook University Medical Center, Stony Brook, New York 11794, USA.
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Kort S, Madahar P, Ajmera A, Brown DL. Mitral Annular Velocities Generated by Speckle Tracking Imaging: Reproducibility and Correlation with Tissue Doppler Velocities. Echocardiography 2010; 27:637-43. [DOI: 10.1111/j.1540-8175.2009.01104.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Kort S, Mamidipally S, Madahar P, Buzzanca L, Blizzard B, Gamboa J, Brown DL. Segmental Contribution to Left Ventricular Systolic Function at Rest and Stress: A Quantitative Real Time Three-Dimensional Echocardiographic Study. Echocardiography 2010; 27:167-73. [DOI: 10.1111/j.1540-8175.2009.00992.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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