Club cell protein (CC)16 as potential lung injury marker in a porcine 72 h polytrauma model

BACKGROUND

Polytrauma and respiratory tract damage after thoracic trauma cause about 25% of mortality among severely injured patients. Thoracic trauma can lead to the development of severe lung complications such as acute respiratory distress syndrome, and is, therefore, of great interest for monitoring in intensive care units (ICU). In recent years, club cell protein (CC)16 with its antioxidant properties has proven to be a potential outcome-related marker. In this study, we evaluated whether CC16 constitutes as a marker of lung damage in a porcine polytrauma model.

METHODS

In a 72 h ICU polytrauma pig model (thoracic trauma, tibial fracture, hemorrhagic shock, liver laceration), blood plasma samples (0, 3, 9, 24, 48, 72 h), BAL samples (72 h) and lung tissue (72 h) were collected. The trauma group (PT) was compared to a sham group. CC16 as a possible biomarker for lung injury in this model, and IL-8 concentrations as known indicator for ongoing inflammation during trauma were determined by ELISA. Histological analysis of ZO-1 and determination of total protein content were used to show barrier disruption and edema formation in lung tissue from the trauma group.

RESULTS

Systemic CC16 levels were significantly increased early after polytrauma compared vs. sham. After 72 h, CC16 concentration was significantly increased in lung tissue as well as in BAL in PT vs. sham. Similarly, IL-8 and total protein content in BAL were significantly increased in PT vs. sham. Evaluation of ZO-1 staining showed significantly lower signal intensity for polytrauma.

CONCLUSION

The data confirm for the first time in a larger animal polytrauma model that lung damage was indicated by systemic and/or local CC16 response. Thus, early plasma and late BAL CC16 levels might be suitable to be used as markers of lung injury in this polytrauma model.

Lung Transplantation for Acute Respiratory Distress Syndrome

In this review, we discuss the outcomes of patients with severe acute respiratory distress syndrome (ARDS). We discuss evidence that suggests that a significant proportion of patients with ARDS develop end-stage lung disease and die of pulmonary complications. In carefully selected patients with permanent lung damage, lung transplant can be a life-saving treatment.

Lung failure after polytrauma with concomitant thoracic trauma in the elderly: an analysis from the TraumaRegister DGU®

Background

In developed countries worldwide, the number of older patients is increasing. Pulmonary complications are common in multiple injured patients with chest injuries. We assessed whether geriatric patients develop lung failure following multiple trauma with concomitant thoracic trauma more often than younger patients.

Methods

A retrospective analysis of severely injured patients with concomitant blunt thoracic trauma registered in the TraumaRegister DGU® (TR-DGU) between 2009 and 2018 was performed. Patients were categorized into four age groups: 55–64 y, 65–74 y, 75–84 y, and ≥ 85 y. Adult patients aged 18–54 years served as a reference group. Lung failure was defined as PaO2/FIO2 ≤ 200 mm Hg, if mechanical ventilation was performed.

Results

A total of 43,289 patients were included, of whom 9238 (21.3%) developed lung failure during their clinical stay. The rate of posttraumatic lung failure was seen to increase with age. While lung failure markedly increased the length of hospital stay, duration of mechanical ventilation, and length of ICU stay independent of the patient’s age, differences between younger and older patients with lung failure in regard to these parameters were clinically comparable. In addition, the development of respiratory failure showed a distinct increase in mortality with higher age, from 16.9% (18–54 y) to 67.2% (≥ 85 y).

Conclusion

Development of lung failure in severely injured patients with thoracic trauma markedly increases hospital length of stay, length of ICU stay, and duration of mechanical ventilation in patients, regardless of age. The development of respiratory failure appears to be related to the severity of the chest trauma rather than to increasing patient age. However, the greatest effects of lung failure, particularly in terms of mortality, were observed in the oldest patients.

[Acute respiratory distress syndrome]

Das „acute respiratory distress syndrome“ (ARDS) ist ein intensivmedizinisches Syndrom, das bei gleichbleibend erhöhter Prävalenz weiterhin eine hohe Mortalität und Morbidität bedingt. Seit der initialen Beschreibung im Jahr 1968 sind inzwischen die Pathophysiologie mit Inflammation nach potenziellen Triggern, die Diagnostik zugrunde liegender Krankheitsentitäten, die Wertigkeit von differenzierter invasiver Beatmung und intensivmedizinischen Prozeduren und die Prognose deutlich besser erforscht und verstanden. Die Berliner ARDS-Definition aus dem Jahr 2012 mit dem Ziel der bettseitigen Identifikation von Patienten mit ARDS trägt diesen Tatsachen Rechnung. Vermeidung von invasiver Beatmung, wenn möglich, lungenprotektive Beatmung, wenn invasive Beatmung notwendig ist mit adäquatem PEEP (positiver endexspiratorischer Druck), und Reduktion von Baro- und Atelektrauma sowie Volumenmanagement und Lagerungstherapie bleiben die wichtigsten apparativen Therapien. Kausale Therapien sind weiterhin, abgesehen von der Behandlung zugrunde liegender Infektionen, nicht vorhanden. Für die Überlebenden eines ARDS ergeben sich sehr häufig relevante Langzeitfolgen.

Possible advantages of early stabilization of spinal fractures in multiply injured patients with leading thoracic trauma - analysis based on the TraumaRegister DGU®

Background

Major trauma often comprises fractures of the thoracolumbar spine and these are often accompanied by relevant thoracic trauma. Major complications can be ascribed to substantial simultaneous trauma to the chest and concomitant immobilization due to spinal instability, pain or neurological dysfunction, impairing the respiratory system individually and together. Thus, we proposed that an early stabilization of thoracolumbar spine fractures will result in significant benefits regarding respiratory organ function, multiple organ failure and length of ICU / hospital stay.

Methods

Patients documented in the TraumaRegister DGU®, aged ≥16 years, ISS ≥ 16, AIS_Thorax ≥ 3 with a concomitant thoracic and / or lumbar spine injury severity (AIS_Spine) ≥ 3 were analyzed. Penetrating injuries and severe injuries to head, abdomen or extremities (AIS ≥ 3) led to patient exclusion. Groups with fractures of the lumbar (LS) or thoracic spine (TS) were formed according to the severity of spinal trauma (AIS_spine): AIS_LS = 3, AIS_LS = 4–5, AIS_TS = 3 and AIS_TS = 4–5, respectively.

Results

1740 patients remained for analysis, with 1338 (76.9%) undergoing spinal surgery within their hospital stay. 976 (72.9%) had spine surgery within the first 72 h, 362 (27.1%) later on. Patients with injuries to the thoracic spine (AIS_TS = 3) or lumbar spine (AIS_LS = 3) significantly benefit from early surgical intervention concerning ventilation time (AIS_LS = 3 only), ARDS, multiple organ failure, sepsis rate (AIS_TS = 3 only), length of stay in the intensive care unit and length of hospital stay. In multiple injured patients with at least severe thoracic spine trauma (AIS_TS ≥ 4) early surgery showed a significantly shorter ventilation time, decreased sepsis rate as well as shorter time spend in the ICU and in hospital.

Conclusions

Multiply injured patients with at least serious thoracic trauma (AIS_Thorax ≥ 3) and accompanying spine trauma can significantly benefit from early spine stabilization within the first 72 h after hospital admission. Based on the presented data, primary spine surgery within 72 h for fracture stabilization in multiply injured patients with leading thoracic trauma, especially in patients suffering from fractures of the thoracic spine, seems to be beneficial.

Weaning from prolonged veno-venous extracorporeal membrane oxygenation (ECMO) after transfer to a specialized center: a retrospective study

Veno-venous extracorporeal membrane oxygenation (vvECMO) is increasingly used as rescue therapy in severe respiratory failure. In patients with pre-existent lung diseases or persistent lung injury weaning from vvECMO can be challenging. This study sought to investigate outcomes of patients transferred to a specialized ECMO center after prolonged ECMO therapy. We performed a retrospective analysis of all patients admitted to our medical intensive care unit (ICU) between 01/2013 and 12/2016 who were transferred from an external ICU after > 8 days on vvECMO. 12 patients on ECMO for > 8 days were identified. Prior to transfer, patients underwent ECMO therapy for 18 ± 9.5 days. Total time on ECMO was 60 ± 46.6 days. 11/12 patients could be successfully weaned from ECMO, 7/12 in the first 28 days after transfer (8 ± 8.8 ECMO-free days at day 28). In 7 patients, ECMO could be terminated after at least partial lung recovery, in 4 patients after salvage lung transplant. No patient died or needed re-initiation of ECMO therapy at day 28. In summary, weaning from vvECMO was feasible even after prolonged ECMO courses and salvage lung transplant could be avoided in most cases. Patients may benefit from transfer to a specialized ECMO center.

Leukotriene B4 indicates lung injury and on-going inflammatory changes after severe trauma in a porcine long-term model

BACKGROUND

Recognizing patients at risk for pulmonary complications (PC) is of high clinical relevance. Migration of polymorphonuclear leukocytes (PMN) to inflammatory sites plays an important role in PC, and is tightly regulated by specific chemokines including interleukin (IL)-8 and other mediators such as leukotriene (LT)B4. Previously, we have reported that LTB4 indicated early patients at risk for PC after trauma. Here, the relevance of LTB4 to indicating lung integrity in a newly established long-term porcine severe trauma model (polytrauma, PT) was explored.

METHODS

Twelve pigs (3 months old, 30 ± 5kg) underwent PT including standardized femur fracture, lung contusion, liver laceration, hemorrhagic shock, subsequent resuscitation and surgical fracture fixation. Six animals served as controls (sham). After 72h lung damage and inflammatory changes were assessed. LTB4 was determined in plasma before the experiment, immediately after trauma, and after 2, 4, 24 or 72h. Bronchoalveolar lavage (BAL)-fluid was collected prior and after the experiment.

RESULTS

Lung injury, local gene expression of IL-8, IL-1β, IL-10, IL-18 and PMN-infiltration into lungs increased significantly in PT compared with sham. Systemic LTB4 increased markedly in both groups 4h after trauma. Compared with declined plasma LTB4 levels in sham, LTB4 increased further in PT after 72h. Similar increase was observed in BAL-fluid after PT.

CONCLUSIONS

In a severe trauma model, sustained changes in terms of lung injury and inflammation are determined at day 3 post-trauma. Specifically, increased LTB4 in this porcine long-term model indicated a rapid inflammatory alteration both locally and systemically. The results support the concept of LTB4 as a biomarker for PC after severe trauma and lung contusion.

Necrotizing fasciitis resulting in fatal lung aspergillosis: Uncommon pathogenesis. A case report

We present a fatal case of Aspergillus-associated lung failure in a patient with necrotizing fasciitis. The cause of the fasciitis was a retroperitoneal perforation of a colon carcinoma. Being already a rare condition, the fasciitis did not manifest as Fournier's gangrene like similar described cases illustrate, but instead travelled along the fasciae and subcutaneous fat tissue cranially into the thoracic cavity, ultimately leading to a disseminated infection of the lungs. The lethal outcome was thus caused by respiratory failure at a time when the primary focus was already successfully treated, contrary to typical cases of necrotizing fasciitis. This case report depicts the importance of acknowledging opportunistic fungal infections in the practice of emergency surgery. Contributing factors, pathogenesis and possible prevention measures are discussed.

[Extracorporeal lung support-news and future developments]

Technical developments as well as the experiences during the 2009 influenza pandemia have led to an increased and safer use of extracorporeal gas exchange. Indications are expanding as new systems with the main goal of CO₂ elimination have entered the market, thus, broadening the range of systems in addition to classic "high flow" extracorporeal membrane oxygenation (ECMO), although evidence for many suggested indications is sparse or lacking. However, recent research has shed light into the pathophysiology and interaction between the organism and the extracorporeal systems. Upcoming indications like avoiding intubation and mechanical ventilation or reducing invasiveness of ventilation are being evaluated. Novel data and technical advances will keep perspectives of extracorporeal gas exchange dynamic and exciting.