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Ware LR, Kim CS, Szumita PM, DeGrado JR. A Narrative Review on the Administration of Inhaled Prostaglandins in Critically Ill Adult Patients With Acute Respiratory Distress Syndrome. Ann Pharmacother 2024; 58:533-548. [PMID: 37589097 DOI: 10.1177/10600280231194539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVE To describe the effect of inhaled prostaglandins on both oxygenation and mortality in critically ill patients with acute respiratory distress syndrome (ARDS), with a focus on safety and efficacy in coronavirus disease 2019 (COVID-19)-associated ARDS and non-COVID-19 ARDS. DATA SOURCES A literature search of MEDLINE was performed using the following search terms: inhaled prostaglandins, inhaled epoprostenol, inhaled nitric oxide, ARDS, critically ill. All abstracts were reviewed. STUDY SELECTION AND DATA EXTRACTION Relevant English-language reports and studies conducted in humans between 1980 and June 2023 were considered. DATA SYNTHESIS Data regarding inhaled prostaglandins and their effect on oxygenation are limited but show a benefit in patients who respond to therapy, and data pertaining to their effect on mortality is scarce. Concerns exist regarding the formulation of inhaled epoprostenol (iEPO) utilized in addition to modes of medication delivery; however, the limited data surrounding their use have shown a reasonable safety profile. Other avenues and beneficial effects may exist with inhaled prostaglandins, such as use in COVID-19-associated ARDS or non-COVID-19 ARDS patients undergoing noninvasive mechanical ventilation or during patient transport. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The use of inhaled prostaglandins can be considered in critically ill patients with COVID-19-associated ARDS or non-COVID-19 ARDS who are experiencing difficulties with oxygenation refractory to nonpharmacologic strategies. CONCLUSIONS The use of iEPO and other inhaled prostaglandins requires further investigation to fully elucidate their effects on clinical outcomes, but it appears these medications may have a potential benefit in COVID-19-associated ARDS and non-COVID-19 ARDS patients with refractory hypoxemia but with little effect on mortality.
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Affiliation(s)
- Lydia R Ware
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Christine S Kim
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Paul M Szumita
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Jeremy R DeGrado
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
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Torbic H, Saini A, Harnegie MP, Sadana D, Duggal A. Inhaled Prostacyclins for Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. Crit Care Explor 2023; 5:e0931. [PMID: 37303944 PMCID: PMC10256381 DOI: 10.1097/cce.0000000000000931] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023] Open
Abstract
Studies evaluating inhaled prostacyclins for the management of acute respiratory distress syndrome (ARDS) have produced inconsistent results regarding their effect on oxygenation. The purpose of this systematic review and meta-analysis was to evaluate the change in the Pao2/Fio2 ratio after administration of an inhaled prostacyclin in patients with ARDS. DATA SOURCES We searched Ovid Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane, Scopus, and Web of Science. STUDY SELECTION We included abstracts and trials evaluating administration of inhaled prostacyclins in patients with ARDS. DATA EXTRACTION Change in the Pao2/Fio2 ratio, Pao2, and mean pulmonary artery pressure (mPAP) were extracted from included studies. Evidence certainty and risk of bias were evaluated using Grading of Recommendations Assessment, Development, and Evaluation and the Cochrane Risk of Bias tool. DATA SYNTHESIS We included 23 studies (1,658 patients) from 6,339 abstracts identified by our search strategy. The use of inhaled prostacyclins improved oxygenation by increasing the Pao2/Fio2 ratio from baseline (mean difference [MD], 40.35; 95% CI, 26.14-54.56; p < 0.00001; I2 = 95%; very low quality evidence). Of the eight studies to evaluate change in Pao2, inhaled prostacyclins also increased Pao2 from baseline (MD, 12.68; 95% CI, 2.89-22.48 mm Hg; p = 0.01; I2 = 96%; very low quality evidence). Only three studies evaluated change in mPAP, but inhaled prostacyclins were found to improve mPAP from baseline (MD, -3.67; 95% CI, -5.04 to -2.31 mm Hg; p < 0.00001; I2 = 68%; very low quality evidence). CONCLUSIONS In patients with ARDS, use of inhaled prostacyclins improves oxygenation and reduces pulmonary artery pressures. Overall data are limited and there was high risk of bias and heterogeneity among included studies. Future studies evaluating inhaled prostacyclins for ARDS should evaluate their role in ARDS subphenotypes, including cardiopulmonary ARDS.
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Affiliation(s)
| | - Aftabh Saini
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, MA
| | | | - Divyajot Sadana
- Department of Critical Care, Cleveland Clinic, Cleveland, OH
| | - Abhijit Duggal
- Department of Critical Care, Cleveland Clinic, Cleveland, OH
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Buckley MS, Mendez A, Radosevich JJ, Agarwal SK, MacLaren R. Comparison of 2 different inhaled epoprostenol dosing strategies for acute respiratory distress syndrome in critically ill adults: Weight-based vs fixed-dose administration. Am J Health Syst Pharm 2023; 80:S11-S22. [PMID: 35877207 DOI: 10.1093/ajhp/zxac192] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Inhaled epoprostenol (iEPO) is a viable, temporizing option for acute respiratory distress syndrome (ARDS), although the optimal iEPO dosing strategy remains inconclusive. The purpose of this study was to evaluate oxygenation and ventilation parameters in a comparison of weight-based and fixed-dose iEPO in adult patients with moderate-to-severe ARDS. METHODS A retrospective cohort study was conducted at 2 academic medical centers in adult intensive care unit (ICU) patients administered either fixed-dose or weight-based iEPO for moderate-to-severe ARDS. The primary endpoint was the highest recorded change in the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) within 4 hours of baseline. Secondary analyses compared responder rates within 4 hours of initiation, oxygenation and ventilation parameters, in-hospital mortality rates, mechanical ventilation duration, length of stay (ICU and hospital), and tracheostomy rates between the study groups. RESULTS A total of 294 patients were included, n = 194 with 100 (34.0%) and 194 (66.0%) in the weight-based and fixed-dose iEPO groups, respectively. The mean (SD) change in the highest recorded PaO2/FiO2 value from baseline up to 4 hours after initiation in the fixed-dose and weight-based groups was 81.1 (106.0) and 41.0 (72.5) mm Hg, respectively (P = 0.0015). The responder rate at 4 hours after iEPO initiation was significantly higher in the fixed-dose group (69.9%) than in the weight-based group (30.1%) (P = 0.02). The only predictor of response was fixed-dose administration (odds ratio, 3.28; 95% confidence interval, 1.6-6.7; P = 0.0012). Clinical outcomes were comparable between the groups. CONCLUSION Fixed-dose iEPO was associated with significantly higher response rates then weight-based iEPO during the first 4 hours of therapy. Fixed-dose iEPO is a more convenient strategy than weight-based approaches.
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Affiliation(s)
- Mitchell S Buckley
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, AZ, USA
| | - Angel Mendez
- Department of Pharmacy, Banner Desert Medical Center, Mesa, AZ, USA
| | - John J Radosevich
- Department of Pharmacy, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Sumit K Agarwal
- Department of Medicine, University of Arizona-College of Medicine Phoenix, Phoenix, AZ, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Nasrullah A, Virk S, Shah A, Jacobs M, Hamza A, Sheikh AB, Javed A, Butt MA, Sangli S. Acute Respiratory Distress Syndrome and the Use of Inhaled Pulmonary Vasodilators in the COVID-19 Era: A Narrative Review. Life (Basel) 2022; 12:1766. [PMID: 36362921 PMCID: PMC9695622 DOI: 10.3390/life12111766] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 10/25/2022] [Accepted: 10/31/2022] [Indexed: 09/03/2023] Open
Abstract
The Coronavirus disease (COVID-19) pandemic of 2019 has resulted in significant morbidity and mortality, especially from severe acute respiratory distress syndrome (ARDS). As of September 2022, more than 6.5 million patients have died globally, and up to 5% required intensive care unit treatment. COVID-19-associated ARDS (CARDS) differs from the typical ARDS due to distinct pathology involving the pulmonary vasculature endothelium, resulting in diffuse thrombi in the pulmonary circulation and impaired gas exchange. The National Institute of Health and the Society of Critical Care Medicine recommend lung-protective ventilation, prone ventilation, and neuromuscular blockade as needed. Further, a trial of pulmonary vasodilators is suggested for those who develop refractory hypoxemia. A review of the prior literature on inhaled pulmonary vasodilators in ARDS suggests only a transient improvement in oxygenation, with no mortality benefit. This narrative review aims to highlight the fundamental principles in ARDS management, delineate the fundamental differences between CARDS and ARDS, and describe the comprehensive use of inhaled pulmonary vasodilators. In addition, with the differing pathophysiology of CARDS from the typical ARDS, we sought to evaluate the current evidence regarding the use of inhaled pulmonary vasodilators in CARDS.
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Affiliation(s)
- Adeel Nasrullah
- Division of Pulmonology and Critical Care, Allegheny Health Network, Pittsburgh, PA 15212, USA
| | - Shiza Virk
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15512, USA
| | - Aaisha Shah
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15512, USA
| | - Max Jacobs
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15512, USA
| | - Amina Hamza
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15512, USA
| | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM 87106, USA
| | - Anam Javed
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15512, USA
| | - Muhammad Ali Butt
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15512, USA
| | - Swathi Sangli
- Division of Pulmonology and Critical Care, Allegheny Health Network, Pittsburgh, PA 15212, USA
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Woyke S, Mair N, Haller T, Ronzani M, Plunser D, Oberacher H, Gatterer H, Rugg C, Ströhle M. The impact of nebulized epoprostenol and iloprost on hemoglobin oxygen affinity: an ex vivo experiment. Am J Physiol Lung Cell Mol Physiol 2022; 322:L898-L903. [PMID: 35503651 PMCID: PMC9169818 DOI: 10.1152/ajplung.00084.2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/25/2022] [Accepted: 04/25/2022] [Indexed: 11/22/2022] Open
Abstract
Inhalational prostacyclins act as strong vasodilators, potentially improving oxygenation by reducing shunt fraction and ventilation-perfusion mismatch. As prostacyclin receptors are known to be present on human erythrocytes, possible direct effects on hemoglobin oxygen transport were further explored by examining the sole in vitro influence of prostacyclins on hemoglobin oxygen (Hb-O2) affinity. Venous blood samples from 20 healthy volunteers were exposed in vitro to supramaximal doses of epoprostenol, iloprost, and compared with control. By high-throughput measurements, hemoglobin oxygen dissociation curves (ODCs) were derived. Hb-O2 affinity, expressed by P50 and Hill coefficient, was determined and analyzed for three subgroups: males (n = 10), females not taking oral contraceptives (n = 4), and females taking oral contraceptives (n = 6). Epoprostenol significantly decreased P50 in all (males, females without contraceptives, and females taking oral contraceptives) [27.5 (26.4-28.6) mmHg (control) vs. 24.2 (22.7-25.3) mmHg; P < 0.001. median (interquartile range, IQR)] thereby increasing Hb-O2 affinity. Inversely, iloprost only showed significant effects in females taking oral contraceptives where P50 was markedly increased and therefore Hb-O2 affinity decreased [28.4 (27.9-28.9) mmHg (control) vs. 34.4 (32.2-36.0) mmHg; P < 0.001]. Prostacyclin-receptor stimulation and subsequent cAMP-mediated ATP release from erythrocytes are discussed as a possible underlying mechanism for the effect of epoprostenol on Hb-O2 affinity. The reason for the sex hormone-modified iloprost effect remains unclear. Being aware of potentially differing effects on Hb-O2 affinity might help select the right prostacyclin (epoprostenol vs. iloprost) depending on the patient and the underlying disease (e.g., acute respiratory distress syndrome vs. peripheral arterial disease).
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Affiliation(s)
- Simon Woyke
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Norbert Mair
- Institute of Physiology and Medical Physics, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Haller
- Institute of Physiology and Medical Physics, Medical University of Innsbruck, Innsbruck, Austria
| | - Marco Ronzani
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - David Plunser
- Institute of Legal Medicine and Core Facility Metabolomics, Medical University of Innsbruck, Innsbruck, Austria
| | - Herbert Oberacher
- Institute of Legal Medicine and Core Facility Metabolomics, Medical University of Innsbruck, Innsbruck, Austria
| | - Hannes Gatterer
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Christopher Rugg
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Mathias Ströhle
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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McPeck M, Smaldone GC. Continuous infusion aerosol delivery of prostacyclins during mechanical ventilation: challenges, limitations, and recent advances. Expert Opin Drug Deliv 2022; 19:465-474. [PMID: 35382661 DOI: 10.1080/17425247.2022.2061460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Critically ill mechanically ventilated patients routinely receive aerosol delivery of epoprostenol by continuous infusion of the nebulizer by syringe pump. This procedure is 'off-label' as no FDA approved drug presently exists. Without standardized protocols, therapy is based on prior experience with bronchodilators, limited studies of delivery systems and anecdotal clinical trials. Current protocols based upon patient body weight and drug concentration determines the infusion rate of drug dose delivered to the nebulizer , which is only distantly related to dose delivered to the lung and may be altered by many factors. AREAS COVERED This paper reviews the background of this technique as well as current methods of managing drug delivery, technical challenges, and limitations. A recent advance in aerosol laboratory bench testing, using radiolabeled aerosols, is presented to reveal important factors defining delivery. EXPERT OPINION Off-label use of continuously nebulized prostacyclin in the ICU lacks the support of large clinical trials needed for FDA clearance. However, comprehensive bench studies afford the potential for clinicians to better understand and manage therapy at a level above simple dosing of the nebulizer by body weight. New research techniques are enhancing our basic comprehension of the interaction between aerosol devices and the mechanical ventilator.
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Affiliation(s)
- Michael McPeck
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Gerald C Smaldone
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
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Lubinsky AS, Brosnahan SB, Lehr A, Elnadoury O, Hagedorn J, Garimella B, Bender MT, Amoroso N, Artigas A, Bos LDJ, Kaufman D. Inhaled pulmonary vasodilators are not associated with improved gas exchange in mechanically ventilated patients with COVID-19: A retrospective cohort study. J Crit Care 2022; 69:153990. [PMID: 35180636 PMCID: PMC8847100 DOI: 10.1016/j.jcrc.2022.153990] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/23/2021] [Accepted: 07/24/2021] [Indexed: 01/19/2023]
Abstract
Purpose Measure the effect of inhaled pulmonary vasodilators on gas exchange in mechanically ventilated patients with COVID-19. Methods A retrospective observational cohort study at three New York University Hospitals was performed including eighty-four mechanically ventilated SARS Cov-2 nasopharyngeal PCR positive patients, sixty nine treated with inhaled nitric oxide (iNO) and fifteen with inhaled epoprostenol (iEPO). The primary outcomes were change in PAO2:FIO2 ratio, oxygenation Index (OI), and ventilatory ratio (VR) after initiation of inhaled pulmonary vasodilators. Results There was no significant change in PAO2:FIO2ratio after initiation of iNO (mean − 4.1, 95% CI -17.3-9.0, P = 0.54) or iEPO (mean − 3.4, 95% CI -19.7-12.9, P = 0.66), in OI after initiation of iNO (mean 2.1, 95% CI-0.04-4.2, P = 0.054) or iEPO (mean − 3.4, 95% CI -19.7-12.9, P = 0.75), or in VR after initiation of iNO (mean 0.17, 95% CI -0.03-0.36, P = 0.25) or iEPO (mean 0.33, 95% CI -0.0847-0.74, P = 0.11). PAO2:FIO2, OI and VR did not significantly change over a five day period starting the day prior to drug initiation in patients who received either iNO or iEPO assessed with a fixed effects model. Conclusion Inhaled pulmonary vasodilators were not associated with significant improvement in gas exchange in mechanically ventilated patients with COVID-19.
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Affiliation(s)
- Anthony Steven Lubinsky
- New York University Langone Health, 550 1(st) Ave, New York, NY 10016, United States of America.
| | - Shari B Brosnahan
- New York University Langone Health, 550 1(st) Ave, New York, NY 10016, United States of America
| | - Andrew Lehr
- New York University Langone Health, 550 1(st) Ave, New York, NY 10016, United States of America
| | - Ola Elnadoury
- New York University Langone Brooklyn Hospital, 150 55(th) Street, Brooklyn, NY 11220, United States of America
| | - Jacklyn Hagedorn
- New York University Langone Health, 550 1(st) Ave, New York, NY 10016, United States of America
| | - Bhaskara Garimella
- New York University Langone Brooklyn Hospital, 150 55(th) Street, Brooklyn, NY 11220, United States of America
| | - Michael T Bender
- New York University, Long Island School of Medicine, 259 1(st) Street, Mineola, NY 11501, United States of America
| | - Nancy Amoroso
- New York University Langone Health, 550 1(st) Ave, New York, NY 10016, United States of America
| | - Antonio Artigas
- Critical Care Center, Corporacion Sanitaria Universitaria Parc Tauli, CIBER Enfermedades Respiratorias, Autonomus University of Barcelona, Parc Tauli 1, 08208 Sabadell, Spain
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, location AMC, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands
| | - David Kaufman
- New York University Langone Health, 550 1(st) Ave, New York, NY 10016, United States of America
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The Use of Inhaled Epoprostenol for Acute Respiratory Distress Syndrome Secondary due to COVID-19: A Case Series. J Crit Care Med (Targu Mures) 2021; 8:33-40. [PMID: 35274053 PMCID: PMC8852286 DOI: 10.2478/jccm-2021-0037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 09/27/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction Inhaled epoprostenol (iEpo) is a pulmonary vasodilator used to treat refractory respiratory failure, including that caused by Coronavirus 2019 (COVID-19) pneumonia. Aim of Study To describe the experience at three teaching hospitals using iEpo for severe respiratory failure due to COVID-19 and evaluate its efficacy in improving oxygenation. Methods Fifteen patients were included who received iEpo, had confirmed COVID-19 and had an arterial blood gas measurement in the 12 hours before and 24 hours after iEpo initiation. Results Eleven patients received prone ventilation before iEpo (73.3%), and six (40%) were paralyzed. The partial pressure of arterial oxygen to fraction of inspired oxygen (P/F ratio) improved from 95.7 mmHg to 118.9 mmHg (p=0.279) following iEpo initiation. In the nine patients with severe ARDS, the mean P/F ratio improved from 66.1 mmHg to 95.7 mmHg (p=0.317). Ultimately, four patients (26.7%) were extubated after an average of 9.9 days post-initiation. Conclusions The findings demonstrated a trend towards improvement in oxygenation in critically ill COVID-19 patients. Although limited by the small sample size, the results of this case series portend further investigation into the role of iEpo for severe respiratory failure associated with COVID-19.
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Unexpected Interruptions in the Inhaled Epoprostenol Delivery System: Incidence of Adverse Sequelae and Therapeutic Consequences in Critically Ill Patients. Crit Care Explor 2021; 3:e0548. [PMID: 34671745 PMCID: PMC8522871 DOI: 10.1097/cce.0000000000000548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Inhaled epoprostenol is a continuously delivered selective pulmonary vasodilator that is used in patients with refractory hypoxemia, right heart failure, and postcardiac surgery pulmonary hypertension. Published data suggest that inhaled epoprostenol administration via vibrating mesh nebulizer systems may lead to unexpected interruptions in drug delivery. The frequency of these events is unknown. The objective of this study was to describe the incidence and clinical consequences of unexpected interruption in critically ill patients. DESIGN Retrospective review and analysis. SETTING Stanford University Hospital, a 605-bed tertiary care center. PATIENTS Patients receiving inhaled epoprostenol in 2019. INTERVENTIONS No interventions. MEASUREMENTS AND MAIN RESULTS Clinical indication, duration of inhaled epoprostenol delivery, mode of respiratory support, and documented unexpected interruption. In 2019, there were 493 administrations of inhaled epoprostenol in 433 unique patients. Primary indications for inhaled epoprostenol were right heart dysfunction (n = 394; 79.9%) and hypoxemia (n = 92; 18.7%). Unexpected delivery interruptions occurred in 31 administrations (6.3%). Median duration of therapy prior to unexpected interruption was 2 days (interquartile range, 2-5 d). Respiratory support at the time of unexpected interruption was mechanical ventilation (61.3%), high-flow nasal cannula (35.5%), and noninvasive positive pressure ventilation (3.2%). Adverse sequelae of unexpected interruption included elevated pulmonary artery pressures (n = 12), systemic hypotension (n = 8), hypoxemia (n = 8), elevated central venous pressure (n = 4), and cardiac arrest (n = 1). Therapeutic interventions following unexpected interruption included initiation of inhaled nitric oxide (n = 21), increase in vasoactive medication (n = 2), and increase in respiratory support (n = 2). Most of the adverse events were Common Terminology Criteria for Adverse Events grade 3 and 4 (93.5%). CONCLUSIONS A retrospective review of patients receiving inhaled epoprostenol via vibrating mesh nebulizer in 2019 revealed interruptions in 6.3% of administrations with most of these interruptions requiring therapeutic intervention. The true incidence of unexpected interruption and subsequent rate of unexpected interruption's requiring intervention is unknown due to the reliance on unexpected interruption identification and subsequent documentation in the electronic medical record. Sudden interruption in inhaled epoprostenol delivery can result in severe cardiopulmonary compromise, and on rare occasion, death.
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Keshavamurthy S, Bazan V, Tribble TA, Baz MA, Zwischenberger JB. Ambulatory extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation. Indian J Thorac Cardiovasc Surg 2021; 37:366-379. [PMID: 34483506 PMCID: PMC8408364 DOI: 10.1007/s12055-021-01210-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/29/2021] [Accepted: 05/02/2021] [Indexed: 11/25/2022] Open
Abstract
Ambulatory extracorporeal membrane oxygenation (ECMO) has shown promise as a bridge to lung transplantation. The primary goal of ambulatory ECMO is to provide enough gas exchange to allow patients to participate in preoperative physical therapy. Various strategies of ambulatory ECMO are utilized depending upon patients’ need. A wide spectrum of ECMO configurations is available to tackle this situation. We discuss those configurations in this article.
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Affiliation(s)
- Suresh Keshavamurthy
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, 740 S. Limestone, A-301, Lexington, KY 40536 USA
| | - Vanessa Bazan
- University of Kentucky College of Medicine, William R. Willard Medical Education Building, MN 150, Lexington, KY 40536 USA
| | - Thomas Andrew Tribble
- Mechanical Circulatory Support Coordinator, MCS Department, Gill Heart & Vascular Institute, 1000 S. Limestone Pav A.08.273, Lexington, KY 40536 USA
| | - Maher Afif Baz
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, 740 S. Limestone, A-301, Lexington, KY 40536 USA
| | - Joseph Bertram Zwischenberger
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, 740 S. Limestone, A-301, Lexington, KY 40536 USA
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Liu K, Wang H, Yu SJ, Tu GW, Luo Z. Inhaled pulmonary vasodilators: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:597. [PMID: 33987295 PMCID: PMC8105872 DOI: 10.21037/atm-20-4895] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/30/2020] [Indexed: 02/05/2023]
Abstract
Pulmonary hypertension (PH) is a severe disease that affects people of all ages. It can occur as an idiopathic disorder at birth or as part of a variety of cardiovascular and pulmonary disorders. Inhaled pulmonary vasodilators (IPV) can reduce pulmonary vascular resistance (PVR) and improve RV function with minimal systemic effects. IPV includes inhaled nitric oxide (iNO), inhaled aerosolized prostacyclin, or analogs, including epoprostenol, iloprost, treprostinil, and other vasodilators. In addition to pulmonary vasodilating effects, IPV can also be used to improve oxygenation, reduce inflammation, and protect cell. Off-label use of IPV is common in daily clinical practice. However, evidence supporting the inhalational administration of these medications is limited, inconclusive, and controversial regarding their safety and efficacy. We conducted a search for relevant papers published up to May 2020 in four databases: PubMed, Google Scholar, EMBASE and Web of Science. This review demonstrates that the clinical using and updated evidence of IPV. iNO is widely used in neonates, pediatrics, and adults with different cardiopulmonary diseases. The limitations of iNO include high cost, flat dose-response, risk of significant rebound PH after withdrawal, and the requirement of complex technology for monitoring. The literature suggests that inhaled aerosolized epoprostenol, iloprost, treprostinil and others such as milrinone and levosimendan may be similar to iNO. More research of IPV is needed to determine acceptable inclusion criteria, long-term outcomes, and management strategies including time, dose, and duration.
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Affiliation(s)
- Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Med, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
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Kotsiou OS, Gourgoulianis KI, Zarogiannis SG. The role of nitric oxide in pleural disease. Respir Med 2021; 179:106350. [PMID: 33662805 DOI: 10.1016/j.rmed.2021.106350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 11/25/2022]
Abstract
Nitric oxide (NO) regulates various physiological and pathophysiological functions in the lungs. However, there is much less information about the effects of NO in the pleura. The present review aimed to explore the available evidence regarding the role of NO in pleural disease. NO, has a double-edged role in the pleural cavity. It is an essential signaling molecule mediating various physiological cell functions such as lymphatic drainage of the serous cavities, the immune response to intracellular multiplication of pathogens, and downregulation of neutrophil migration, but also induces genocytotoxic and mutagenic effects when present in excess. NO is implicated in the pathogenesis of asbestos-related or exudative pleural disease and mesothelioma. From a clinical point of view, the fraction of exhaled NO has been suggested as a potential non-invasive tool for the diagnosis of benign asbestos-related disorders. Under experimental conditions, NO-mimetics were found to attenuate hypoxia-induced therapy resistance in mesothelioma. Similarly, hybrid agents consisting of an NO donor coupled with a parent anti-inflammatory drug showed an enhancement of the anti-inflammatory activity of anti-inflammatory drugs. However, given the paucity of research work performed over the last years in this area, further research should be undertaken to establish reliable conclusions with respect to the feasibility of determining or targeting the NO signaling pathway for pleural disease diagnosis and therapeutic management.
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Affiliation(s)
- Ourania S Kotsiou
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, BIOPOLIS, 41110, Larissa, Greece; Department of Physiology, Faculty of Medicine, University of Thessaly, BIOPOLIS, 41500, Larissa, Greece.
| | - Konstantinos I Gourgoulianis
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, BIOPOLIS, 41110, Larissa, Greece
| | - Sotirios G Zarogiannis
- Department of Physiology, Faculty of Medicine, University of Thessaly, BIOPOLIS, 41500, Larissa, Greece
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13
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Hajjar LA, Costa IBSDS, Rizk SI, Biselli B, Gomes BR, Bittar CS, de Oliveira GQ, de Almeida JP, de Oliveira Bello MV, Garzillo C, Leme AC, Elena M, Val F, de Almeida Lopes M, Lacerda MVG, Ramires JAF, Kalil Filho R, Teboul JL, Landoni G. Intensive care management of patients with COVID-19: a practical approach. Ann Intensive Care 2021; 11:36. [PMID: 33604873 PMCID: PMC7891474 DOI: 10.1186/s13613-021-00820-w] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 01/29/2021] [Indexed: 02/06/2023] Open
Abstract
SARS-CoV-2, the causative agent of coronavirus disease 2019 (COVID-19), is responsible for the largest pandemic facing humanity since the Spanish flu pandemic in the early twentieth century. Since there is no specific antiviral treatment, optimized support is the most relevant factor in the patient's prognosis. In the hospital setting, the identification of high-risk patients for clinical deterioration is essential to ensure access to intensive treatment of severe conditions in a timely manner. The initial management of hypoxemia includes conventional oxygen therapy, high-flow nasal canula oxygen, and non-invasive ventilation. For patients requiring invasive mechanical ventilation, lung-protective ventilation with low tidal volumes and plateau pressure is recommended. Cardiovascular complications are frequent and include myocardial injury, thrombotic events, myocarditis, and cardiogenic shock. Acute renal failure is a common complication and is a marker of poor prognosis, with significant impact in costs and resources allocation. Regarding promising therapies for COVID-19, the most promising drugs until now are remdesivir and corticosteroids although further studies may be needed to confirm their effectiveness. Other therapies such as, tocilizumab, anakinra, other anti-cytokine drugs, and heparin are being tested in clinical trials. Thousands of physicians are living a scenario that none of us have ever seen: demand for hospital exceed capacity in most countries. Until now, the certainty we have is that we should try to decrease the number of infected patients and that an optimized critical care support is the best strategy to improve patient's survival.
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Affiliation(s)
- Ludhmila Abrahão Hajjar
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil.
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil.
| | | | - Stephanie Itala Rizk
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
- Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Bruno Biselli
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Brenno Rizerio Gomes
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Cristina Salvadori Bittar
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
| | | | - Juliano Pinheiro de Almeida
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | | | - Cibele Garzillo
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Alcino Costa Leme
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Moizo Elena
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fernando Val
- Instituto Leônidas & Maria Deane, Fiocruz, Manaus, Brazil
| | | | | | - José Antonio Franchini Ramires
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Roberto Kalil Filho
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
- Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Sud University Hospitals, Le Kremlin Bicêtre, France
| | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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14
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DeGrado JR, Szumita PM, Schuler BR, Dube KM, Lenox J, Kim EY, Weinhouse GL, Massaro AF. Evaluation of the Efficacy and Safety of Inhaled Epoprostenol and Inhaled Nitric Oxide for Refractory Hypoxemia in Patients With Coronavirus Disease 2019. Crit Care Explor 2020; 2:e0259. [PMID: 33134949 PMCID: PMC7581066 DOI: 10.1097/cce.0000000000000259] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The objectives of this study were to evaluate the efficacy and safety of inhaled epoprostenol and inhaled nitric oxide in patients with refractory hypoxemia secondary to coronavirus disease 2019. DESIGN Retrospective single-center study. SETTING ICUs at a large academic medical center in the United States. PATIENTS Thirty-eight adult critically ill patients with coronavirus disease 2019 and refractory hypoxemia treated with either inhaled epoprostenol or inhaled nitric oxide for at least 1 hour between March 1, 2020, and June 30, 2020. INTERVENTIONS Electronic chart review. MEASUREMENTS AND MAIN RESULTS Of 93 patients screened, 38 were included in the analysis, with mild (4, 10.5%), moderate (24, 63.2%), or severe (10, 26.3%), with acute respiratory distress syndrome. All patients were initiated on inhaled epoprostenol as the initial pulmonary vasodilator and the median time from intubation to initiation was 137 hours (68-228 h). The median change in Pao2/Fio2 was 0 (-12.8 to 31.6) immediately following administration of inhaled epoprostenol. Sixteen patients were classified as responders (increase Pao2/Fio2 > 10%) to inhaled epoprostenol, with a median increase in Pao2/Fio2 of 34.1 (24.3-53.9). The mean change in Pao2 and Spo2 was -0.55 ± 41.8 and -0.6 ± 4.7, respectively. Eleven patients transitioned to inhaled nitric oxide with a median change of 11 (3.6-24.8) in Pao2/Fio2. A logistic regression analysis did not identify any differences in outcomes or characteristics between the responders and the nonresponders. Minimal adverse events were seen in patients who received either inhaled epoprostenol or inhaled nitric oxide. CONCLUSIONS We found that the initiation of inhaled epoprostenol and inhaled nitric oxide in patients with refractory hypoxemia secondary to coronavirus disease 2019, on average, did not produce significant increases in oxygenation metrics. However, a group of patients had significant improvement with inhaled epoprostenol and inhaled nitric oxide. Administration of inhaled epoprostenol or inhaled nitric oxide may be considered in patients with severe respiratory failure secondary to coronavirus disease 2019.
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Affiliation(s)
| | - Paul M. Szumita
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA
| | - Brian R. Schuler
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA
| | - Kevin M. Dube
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA
| | - Jesslyn Lenox
- Department of Respiratory Therapy, Brigham and Women’s Hospital, Boston, MA
| | - Edy Y. Kim
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Gerald L. Weinhouse
- Department of Respiratory Therapy, Brigham and Women’s Hospital, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Anthony F. Massaro
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Elnadoury O, Beattie J, Lubinsky AS. Uninterrupted Continuous and Intermittent Nebulizer Therapy in a COVID-19 Patient Using Sequential Vibratory Mesh Nebulizers: A Case Report. J Aerosol Med Pulm Drug Deliv 2020; 33:357-360. [PMID: 32852238 DOI: 10.1089/jamp.2020.1636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Interruptions in continuous nebulized pulmonary vasodilators, such as epoprostenol, can potentially result in clinical deterioration in respiratory status. Coadministration of other intermittent nebulized therapies may require opening the ventilator circuit to facilitate administration. However, in patients with SARS-CoV2 infection, it is preferred to avoid opening the circuit whenever feasible to prevent aerosolization of the virus and exposure of health care workers. In this study, we describe a unique method of administering continuous epoprostenol nebulization and intermittent nebulized antibiotics, mucolytics, and bronchodilators, using Aerogen vibrating mesh nebulizers without interruptions in epoprostenol or opening the ventilator circuit. This technique set up consisted of stacking two Aerogen nebulizer cups, each with its own controller. This approach was successful in allowing concomitant delivery of intermittent and continuous nebulized therapy without interruptions. To our knowledge, this method has not been previously described in the literature and may be helpful to bedside clinicians facing a similar clinical scenario.
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Affiliation(s)
- Ola Elnadoury
- Department of Pharmacy, NYU Langone Hospital-Brooklyn, Brooklyn, New York, USA
| | - Jason Beattie
- Department of Medicine-Pulmonary, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anthony S Lubinsky
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, NYU Langone Health, New York, New York, USA
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16
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Neethling E, Moreno Garijo J, Mangalam TK, Badiwala MV, Billia P, Wasowicz M, Van Rensburg A, Slinger P. Intraoperative and Early Postoperative Management of Heart Transplantation: Anesthetic Implications. J Cardiothorac Vasc Anesth 2020; 34:2189-2206. [DOI: 10.1053/j.jvca.2019.09.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 09/07/2019] [Accepted: 09/24/2019] [Indexed: 12/16/2022]
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17
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Buckley MS, Agarwal SK, Garcia-Orr R, Saggar R, MacLaren R. Comparison of Fixed-Dose Inhaled Epoprostenol and Inhaled Nitric Oxide for Acute Respiratory Distress Syndrome in Critically Ill Adults. J Intensive Care Med 2020; 36:466-476. [PMID: 32133901 DOI: 10.1177/0885066620906800] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Several reports have demonstrated similar effects on oxygenation between inhaled epoprostenol (iEPO) compared to inhaled nitric oxide (iNO) for acute respiratory distress syndrome (ARDS). Previous studies directly comparing oxygenation and clinical outcomes between iEPO and iNO exclusively in an adult ARDS patient population utilized a weight-based dosing strategy. The purpose of this study was to compare the clinical and economic impact between iNO and fixed-dosed iEPO for ARDS in adult intensive care unit (ICU) patients. METHODS This retrospective cohort study was conducted at a major academic medical center between January 1, 2014, and October 31, 2018. Patients ≥18 years of age with moderate-to-severe ARDS were included. The primary end point was to compare the mean change in partial arterial oxygen pressure to fraction of inspired oxygen (Pao 2: Fio 2) at 4 hours from baseline between iEPO and iNO. Other secondary aims were total acquisition drug costs, in-hospital mortality, ICU and hospital length of stay, and duration of mechanical ventilation. RESULTS A total of 239 patients were included with 139 (58.2%) and 100 (41.8%) in the iEPO and iNO groups, respectively. The mean change in Pao 2: Fio 2 at 4 hours from baseline in the iEPO and iNO groups were 31.4 ± 54.6 and 32.4 ± 42.7 mm Hg, respectively (P = .88). The responder rate at 4 hours was similar between iEPO and iNO groups (64.7% and 66.0%, respectively, P = .84). Clinical outcomes including mortality, overall hospital and ICU length of stay, and mechanical ventilation duration were similar between iEPO and iNO groups. Estimated annual cost-savings realized with iEPO was USD1 074 433. CONCLUSION Fixed-dose iEPO was comparable to iNO in patients with moderate-to-severe ARDS for oxygenation and ventilation parameters as well as clinical outcomes. Significant cost-savings were realized with iEPO use.
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Affiliation(s)
- Mitchell S Buckley
- 22386Banner-University Medical Center Phoenix, Department of Pharmacy, Phoenix, AZ, USA
| | - Sumit K Agarwal
- 22386Banner-University Medical Center Phoenix, Care Transformation, Phoenix, AZ, USA
| | - Roxanne Garcia-Orr
- 22386Banner-University Medical Center Phoenix, Department of Critical Care, Phoenix, AZ, USA
| | - Rajeev Saggar
- 22386Banner-University Medical Center Phoenix, Department of Critical Care, Phoenix, AZ, USA
| | - Robert MacLaren
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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18
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Xin R, Pan YL, Wang Y, Wang SY, Wang R, Xia B, Qin RN, Fu Y, Wu YH. Nickel-refining fumes induce NLRP3 activation dependent on mitochondrial damage and ROS production in Beas-2B cells. Arch Biochem Biophys 2019; 676:108148. [DOI: 10.1016/j.abb.2019.108148] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/29/2019] [Accepted: 10/09/2019] [Indexed: 12/23/2022]
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19
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Collier TE, Kataria V, Modrykamien A. Inhaled epoprostenol utilization pattern after implementation of an administration policy. Proc (Bayl Univ Med Cent) 2019; 33:10-14. [PMID: 32063756 DOI: 10.1080/08998280.2019.1668668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/31/2019] [Accepted: 09/09/2019] [Indexed: 10/25/2022] Open
Abstract
Epoprostenol, a pulmonary vasodilator, is used to reduce pulmonary artery pressure. Its inhaled administration results in ventilation and perfusion matching with oxygenation improvement. Epoprostenol is used as treatment for various conditions, particularly acute respiratory distress syndrome (ARDS) and pulmonary arterial hypertension. In 2018, Baylor University Medical Center implemented a policy for inhaled epoprostenol utilization aimed at standardizing clinical practice. This study analyzed epoprostenol utilization patterns in patients with ARDS after implementation of this administration policy. Drug responders and nonresponders were compared for clinical outcomes and physiologic changes before and after use, and policy compliance was evaluated. Of 79 eligible patients, 30 fulfilled inclusion criteria: 14 (47%) had ARDS and 16 (53%) had non-ARDS. In all patients with ARDS, epoprostenol was a second rescue agent after neuromuscular blockade, prone positioning, corticosteroids, and extracorporeal membrane oxygenation. Epoprostenol was associated with statistically significant improvement of oxygenation before and after utilization in patients with ARDS (ratio of arterial oxygen partial pressure to fractional inspired oxygen 70 vs 140, respectively; P = 0.04). Overall, 10 (71%) ARDS patients were epoprostenol responders; 9 (56%) were deemed responders among subjects with non-ARDS. Comparison of outcomes between responders and nonresponders showed no statistically significant variations. Policy compliance was obtained in 24 (80%) patients.
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Affiliation(s)
- Tia E Collier
- Department of Pharmacy, Baylor University Medical CenterDallasTexas
| | - Vivek Kataria
- Department of Pharmacy, Baylor University Medical CenterDallasTexas
| | - Ariel Modrykamien
- Medical Intensive Care Unit, Department of Critical Care, Baylor University Medical CenterDallasTexas.,Pulmonary and Critical Care Specialists of DallasDallasTexas
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20
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Abstract
OBJECTIVES To describe the current state of the art regarding management of the critically ill trauma patient with an emphasis on initial management in the ICU. DATA SOURCES AND STUDY SELECTION A PubMed literature review was performed for relevant articles in English related to the management of adult humans with severe trauma. Specific topics included airway management, hemorrhagic shock, resuscitation, and specific injuries to the chest, abdomen, brain, and spinal cord. DATA EXTRACTION AND DATA SYNTHESIS The basic principles of initial management of the critically ill trauma patients include rapid identification and management of life-threatening injuries with the goal of restoring tissue oxygenation and controlling hemorrhage as rapidly as possible. The initial assessment of the patient is often truncated for procedures to manage life-threatening injuries. Major, open surgical procedures have often been replaced by nonoperative or less-invasive approaches, even for critically ill patients. Consequently, much of the early management has been shifted to the ICU, where the goal is to continue resuscitation to restore homeostasis while completing the initial assessment of the patient and watching closely for failure of nonoperative management, complications of procedures, and missed injuries. CONCLUSIONS The initial management of critically ill trauma patients is complex. Multiple, sometimes competing, priorities need to be considered. Close collaboration between the intensivist and the surgical teams is critical for optimizing patient outcomes.
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21
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Schraufnagel DP, Elgharably H, Siddiqi S, Hakim AH, Sale S, Mehta A, Skubas NJ, Gordon SM, Bakaeen F, Gillinov AM, Svensson LG, Navia JL. Value of perioperative inhaled epoprostenol with low tidal volume ventilation for complex endocarditis surgery. J Card Surg 2019; 34:676-683. [DOI: 10.1111/jocs.14095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 05/17/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Dean P. Schraufnagel
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Shirin Siddiqi
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Ali H. Hakim
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Shiva Sale
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Anand Mehta
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Nikolaos J. Skubas
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Steven M. Gordon
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Faisal Bakaeen
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - A. Marc Gillinov
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Lars G. Svensson
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Jose L. Navia
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
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22
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Abstract
Patients with pulmonary arterial hypertension (PAH) who are admitted to the intensive care unit (ICU) pose a challenge to the multidisciplinary health-care team due to the complexity of the pathophysiology of their disease state and the medication considerations that must be made to appropriately manage them. PAH is a progressive disease with the majority of patients ultimately dying as a result of right ventricular (RV) failure. During an acute decompensation, patients must be appropriately managed to optimize volume status, RV function, cardiac output, and systemic perfusion, while treating the underlying cause of the exacerbation. During times of critical illness, the ability to administer medications approved for use in PAH can be impacted by end-organ damage, hemodynamic instability, new drug interactions, or available dosage forms. Balancing the multimodal treatment approach needed to manage an acute exacerbation and the pharmacokinetic and administration concerns impacting baseline PAH therapy as a result of critical illness requires an expert multiprofessional PAH team. The purpose of this review is to evaluate specific management considerations for critically ill patients with PAH in the ICU.
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Affiliation(s)
- Heather Torbic
- 1 Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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23
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Buckley MS, Dzierba AL, Muir J, Gonzales JP. Moderate to Severe Acute Respiratory Distress Syndrome Management Strategies: A Narrative Review. J Pharm Pract 2019; 32:347-360. [PMID: 30791860 DOI: 10.1177/0897190019830504] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) remains a common complication associated with significant negative outcomes in critically ill patients. Lung-protective mechanical ventilation strategies remain the cornerstone in the management of ARDS. Several therapeutic options are currently available including fluid management, neuromuscular blocking agents, prone positioning, extracorporeal membrane oxygenation, corticosteroids, and inhaled pulmonary vasodilating agents (prostacyclins and nitric oxide). Unfortunately, an evidence-based, standard-of-care approach in managing ARDS beyond lung-protective ventilation remains elusive, contributing to significant variability in clinical practice. Although the optimal therapeutic strategy for managing moderate to severe ARDS remains extremely controversial, therapies supported with more robust clinical evidence should be considered first. The purpose of this narrative review is to discuss the published clinical evidence for both pharmacologic and nonpharmacologic management strategies in adult patients with moderate to severe ARDS as well as to discuss practical considerations for implementation.
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Affiliation(s)
- Mitchell S Buckley
- 1 Department of Pharmacy, Banner University Medical Center, Phoenix, AZ, USA
| | - Amy L Dzierba
- 2 Department of Pharmacy, New York-Presbyterian Hospital, NY, USA
| | - Justin Muir
- 2 Department of Pharmacy, New York-Presbyterian Hospital, NY, USA
| | - Jeffrey P Gonzales
- 3 Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
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24
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Cortes-Puentes GA, Oeckler RA, Marini JJ. Physiology-guided management of hemodynamics in acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:353. [PMID: 30370280 DOI: 10.21037/atm.2018.04.40] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Skillfully implemented mechanical ventilation (MV) may prove of immense benefit in restoring physiologic homeostasis. However, since hemodynamic instability is a primary factor influencing mortality in acute respiratory distress syndrome (ARDS), clinicians should be vigilant regarding the potentially deleterious effects of MV on right ventricular (RV) function and pulmonary vascular mechanics (PVM). During both spontaneous and positive pressure MV (PPMV), tidal changes in pleural pressure (PPL), transpulmonary pressure (PTP, the difference between alveolar pressure and PPL), and lung volume influence key components of hemodynamics: preload, afterload, heart rate, and myocardial contractility. Acute cor pulmonale (ACP), which occurs in 20-25% of ARDS cases, emerges from negative effects of lung pathology and inappropriate changes in PPL and PTP on the pulmonary microcirculation during PPMV. Functional, minimally invasive hemodynamic monitoring for tracking cardiac performance and output adequacy is integral to effective care. In this review we describe a physiology-based approach to the management of hemodynamics in the setting of ARDS: avoiding excessive cardiac demand, regulating fluid balance, optimizing heart rate, and keeping focus on the pulmonary circuit as cornerstones of effective hemodynamic management for patients in all forms of respiratory failure.
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Affiliation(s)
| | - Richard A Oeckler
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Regions Hospital, St Paul, MN, USA
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25
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Ammar MA, Sasidhar M, Lam SW. Inhaled Epoprostenol Through Noninvasive Routes of Ventilator Support Systems. Ann Pharmacother 2018; 52:1173-1181. [PMID: 29890848 DOI: 10.1177/1060028018782209] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The administration of inhaled epoprostenol (iEPO) through noninvasive routes of ventilator support systems has never been previously evaluated. OBJECTIVE Describe the use of iEPO when administered through noninvasive routes of ventilator support systems. METHODS Critically ill patients admitted to the intensive care unit who received iEPO through noninvasive routes were analyzed. Improvements in respiratory status and hemodynamic parameters were evaluated. Safety end points assessed included hypotension, rebound hypoxemia, significant bleeding, and thrombocytopenia. RESULTS A total of 36 patients received iEPO through noninvasive routes: high-flow oxygen therapy through nasal cannula, n = 29 (81%) and noninvasive positive-pressure ventilation, n = 7 (19%). Sixteen patients had improvement in their respiratory status: mean decrease in fraction of inspired oxygen (FiO2), 20% ± 13%; mean increase in partial pressure of arterial oxygen to FiO2 (PaO2/FiO2) ratio, 60 ± 50 mm Hg; and mean decrease in HFNC oxygen flow rate, 6 ± 3 liters per minute (LPM). Eight patients had declines in their respiratory status (mean increase in FiO2, 30% ± 20%; mean decrease in PaO2/FiO2 ratio, 38 ± 20 mm Hg; and mean increase in HFNC oxygen flow rate, 15 ± 10 LPM), and 12 patients had no change in their respiratory status. Conclusion and Relevance: This represents the first evaluation of the administration of iEPO through noninvasive routes of ventilator support systems and demonstrates that in critically ill patients, iEPO could be administered through a noninvasive route. Further evaluation is needed to determine the extent of benefit with this route of administration.
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Affiliation(s)
- Mahmoud A Ammar
- 1 Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT, USA
| | - Madhu Sasidhar
- 2 Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Simon W Lam
- 3 Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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26
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Tan Z, Wang H, Sun J, Li M. Effects of propofol pretreatment on lung morphology and heme oxygenase-1 expression in oleic acid-induced acute lung injury in rats. Acta Cir Bras 2018; 33:250-258. [PMID: 29668779 DOI: 10.1590/s0102-865020180030000007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/28/2018] [Indexed: 03/16/2023] Open
Abstract
PURPOSE To investigate the effects of propofol pretreatment on lung morphology and heme oxygenase-1 expression in oleic acid -induced acute lung injury in rats. METHODS A total of 32 male Sprague-Dawley rats (250-300g) were randomly divided into the following four groups (n=8/group): group C, group OA, group OA+PR, and group OA+IX to compare related parameter changes. RESULTS PaO2, PCO2, and PaO2/FiO2 were significantly different among the four treatment groups (P<0.05 or P<0.01). Lung wet/dry weight ratio and HO-1 protein expression also significantly differed among the groups (P<0.01). Immunohistochemistry showed that the expression of HO-1 in group OA+PR was stronger than those in groups OA, OA+IX, and C. Light microscopy revealed that pathological changes in lung tissues in group OA+PR were milder than those in group OA and group OA+IX. Electron microscopy showed that alveolar type II epithelial cell ultrastructure in group OA was relatively irregular with cell degeneration and disintegration and cytoplasmic lamellar bodies were vacuolized. Changes in group OA+PR were milder than those in group OA; however, they were more severe in group OA+IX than in group OA. CONCLUSION Propofol significantly increases the expression of HO-1 in the lung tissueand prevents changes in lung morphology due to ALI in rats.
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Affiliation(s)
- Zelong Tan
- Department of Anesthesiology, Tai'an Central Hospital, Tai'an, Shandong, China
| | - Huaizhou Wang
- Department of Anesthesiology, Yantai Stomatological Hospital, Yantai, Shandong, China
| | - Jing Sun
- Tai'an Maternal and Child Health Hospital, Tai'an, Shandong, China
| | - Mingsheng Li
- Department of Anesthesiology, Tai'an Central Hospital, Tai'an, Shandong, China
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Chen X, Wang H, Jia K, Wang H, Ren T. Anti-Semaphorin-7A single chain antibody demonstrates beneficial effects on pulmonary inflammation during acute lung injury. Exp Ther Med 2018; 15:2356-2364. [PMID: 29456642 PMCID: PMC5795465 DOI: 10.3892/etm.2018.5724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 03/07/2017] [Indexed: 12/31/2022] Open
Abstract
Pulmonary inflammation is a primary characteristic of lung injury initiated by the accession of immune cells into the alveolar space. Neutrophil migration serves an important role in pulmonary inflammation mediated by the migration of neutrophils into hypoxic tissue sites. The elimination of pulmonary inflammation is directly associated with rehabilitation in patients with lung injury. Anti-inflammatory treatment is essential following lung injury and ultimately determines patient outcomes. Semaphorin-7A (SEMA-7A) is a member of the Semaphorin family that influences the migration of neutrophils into hypoxic tissue sites, thus promoting inflammation. However, understanding of the role of SEMA-7A serves during lung injury is limited and the immunological function of SEMA-7A during the migration of neutrophils into acute injury sites remains unknown. The present study investigated SEMA-7A expression and constructed a single chain antibody for SEMA-7A (Anti-SEMA-7A) to study its therapeutic efficacy against pulmonary inflammation in a mouse model of acute injury sites. The data indicated that the expression of SEMA-7A was upregulated due to induction by pro-inflammatory cytokines and demonstrated that Anti-SEMA-7A inhibited SEMA-7A expression in vitro and in vivo. The current study also indicated that the production of pro-inflammatory cytokines induced by SEMA-7A in endothelial and epithelial cells enhanced pulmonary inflammation. Anti-SEMA-7A suppressed the transendothelial migration of neutrophils mediated by SEMA-7A. Anti-SEMA-7A treatment neutralized SEMA-7A expression and reduced signs of pulmonary inflammation, leading to the elimination of pulmonary inflammation in rat with acute lung injury. The current study identified Anti-SEMA-7A as a potential agent to interfere with the inflammatory pathway during acute lung injury, which may be the basis for anti-inflammatory strategies to treat lung injuries in the future.
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Affiliation(s)
- Xiao Chen
- Department of ICU, The First Affiliated Hospital, Nanyang Medicine College, Nanyang, Henan 473058, P.R. China
| | - Hailing Wang
- Department of ICU, The First Affiliated Hospital, Nanyang Medicine College, Nanyang, Henan 473058, P.R. China
| | - Kui Jia
- Department of ICU, The First Affiliated Hospital, Nanyang Medicine College, Nanyang, Henan 473058, P.R. China
| | - Hao Wang
- Department of ICU, The First Affiliated Hospital, Nanyang Medicine College, Nanyang, Henan 473058, P.R. China
| | - Tao Ren
- Department of ICU, The First Affiliated Hospital, Nanyang Medicine College, Nanyang, Henan 473058, P.R. China
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Coz Yataco A, Aguinaga Meza M, Buch KP, Disselkamp MA. Hospital and intensive care unit management of decompensated pulmonary hypertension and right ventricular failure. Heart Fail Rev 2018; 21:323-46. [PMID: 26486799 PMCID: PMC7102249 DOI: 10.1007/s10741-015-9514-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pulmonary hypertension and concomitant right ventricular failure present a diagnostic and therapeutic challenge in the intensive care unit and have been associated with a high mortality. Significant co-morbidities and hemodynamic instability are often present, and routine critical care unit resuscitation may worsen hemodynamics and limit the chances of survival in patients with an already underlying poor prognosis. Right ventricular failure results from structural or functional processes that limit the right ventricle’s ability to maintain adequate cardiac output. It is commonly seen as the result of left heart failure, acute pulmonary embolism, progression or decompensation of pulmonary hypertension, sepsis, acute lung injury, or in the perioperative setting. Prompt recognition of the underlying cause and institution of treatment with a thorough understanding of the elements necessary to optimize preload, cardiac contractility, enhance systemic arterial perfusion, and reduce right ventricular afterload are of paramount importance. Moreover, the emergence of previously uncommon entities in patients with pulmonary hypertension (pregnancy, sepsis, liver disease, etc.) and the availability of modern devices to provide support pose additional challenges that must be addressed with an in-depth knowledge of this disease.
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Affiliation(s)
- Angel Coz Yataco
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, 740 S. Limestone, KY Clinic L543, Lexington, KY, 40536, USA.
| | - Melina Aguinaga Meza
- Department of Internal Medicine, Division of Cardiovascular Medicine - Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Ketan P Buch
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, 740 S. Limestone, KY Clinic L543, Lexington, KY, 40536, USA
| | - Margaret A Disselkamp
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, 740 S. Limestone, KY Clinic L543, Lexington, KY, 40536, USA
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29
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Clinical Complications with the Delivery of Inhaled Epoprostenol in the Operating Room. Anesthesiology 2018; 127:383. [PMID: 28323647 DOI: 10.1097/aln.0000000000001611] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Deshpande SP, Mazzeffi MA, Strauss E, Hollis A, Tanaka KA. Prostacyclins in Cardiac Surgery: Coming of Age. Semin Cardiothorac Vasc Anesth 2017; 22:306-323. [DOI: 10.1177/1089253217749298] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Prostacyclin (prostaglandin I2 [PGI2]) is an eicosanoid lipid mediator produced by the endothelial cells. It plays pivotal roles in vascular homeostasis by virtue of its potent vasodilatory and antithrombotic effects. Stable pharmacological analogues of PGI2 are used for treatment of pulmonary hypertension and right ventricular failure. PGI2 dose dependently inhibits platelet activation induced by adenosine-5′-diphosphate, arachidonic acid, collagen, and low-dose thrombin. This property has led to its use as an alternative to direct thrombin inhibitors in patients with type II heparin-induced thrombocytopenia (HIT) undergoing cardiac surgery. The aims of this review are the following: (1) to review the pharmacology of PGI2 and its derivatives, (2) to present the evidence for their use in pulmonary hypertension and right heart failure, and (3) to discuss their utility in the management of HIT in cardiac surgery.
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Affiliation(s)
| | | | - Erik Strauss
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Allison Hollis
- University of Maryland School of Medicine, Baltimore, MD, USA
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32
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Sethi GS, Dharwal V, Naura AS. Poly(ADP-Ribose)Polymerase-1 in Lung Inflammatory Disorders: A Review. Front Immunol 2017; 8:1172. [PMID: 28974953 PMCID: PMC5610677 DOI: 10.3389/fimmu.2017.01172] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/04/2017] [Indexed: 12/19/2022] Open
Abstract
Asthma, acute lung injury (ALI), and chronic obstructive pulmonary disease (COPD) are lung inflammatory disorders with a common outcome, that is, difficulty in breathing. Corticosteroids, a class of potent anti-inflammatory drugs, have shown less success in the treatment/management of these disorders, particularly ALI and COPD; thus, alternative therapies are needed. Poly(ADP-ribose)polymerases (PARPs) are the post-translational modifying enzymes with a primary role in DNA repair. During the last two decades, several studies have reported the critical role played by PARPs in a good of inflammatory disorders. In the current review, the studies that address the role of PARPs in asthma, ALI, and COPD have been discussed. Among the different members of the family, PARP-1 emerges as a key player in the orchestration of lung inflammation in asthma and ALI. In addition, PARP activation seems to be associated with the progression of COPD. Furthermore, PARP-14 seems to play a crucial role in asthma. STAT-6 and GATA-3 are reported to be central players in PARP-1-mediated eosinophilic inflammation in asthma. Interestingly, oxidative stress-PARP-1-NF-κB axis appears to be tightly linked with inflammatory response in all three-lung diseases despite their distinct pathophysiologies. The present review sheds light on PARP-1-regulated factors, which may be common or differential players in asthma/ALI/COPD and put forward our prospective for future studies.
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Affiliation(s)
| | - Vivek Dharwal
- Department of Biochemistry, Panjab University, Chandigarh, India
| | - Amarjit S Naura
- Department of Biochemistry, Panjab University, Chandigarh, India
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Report of the ISHLT Working Group on Primary Lung Graft Dysfunction, part I: Definition and grading-A 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2017; 36:1097-1103. [PMID: 28942784 DOI: 10.1016/j.healun.2017.07.021] [Citation(s) in RCA: 349] [Impact Index Per Article: 49.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/19/2017] [Indexed: 12/27/2022] Open
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Sabato LA, Salerno DM, Moretz JD, Jennings DL. Inhaled Pulmonary Vasodilator Therapy for Management of Right Ventricular Dysfunction after Left Ventricular Assist Device Placement and Cardiac Transplantation. Pharmacotherapy 2017; 37:944-955. [DOI: 10.1002/phar.1959] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Leah A. Sabato
- Heart Failure and Cardiac Transplantation; Department of Pharmacy; UC Health-University of Cincinnati Medical Center; Cincinnati Ohio
| | - David M. Salerno
- Solid Organ Transplantation; Department of Pharmacy; NewYork-Presbyterian Hospital - Weill Cornell Medical Center; New York New York
| | - Jeremy D. Moretz
- Ventricular Assist Devices; Department of Pharmacy; Vanderbilt University Medical Center; Nashville Tennessee
| | - Douglas L. Jennings
- Heart Transplant and Mechanical Circulatory Support; Department of Pharmacy; New York-Presbyterian Hospital - Columbia University Medical Center; New York NY
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35
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Wilcox SR, Ries M, Bouthiller TA, Berry ED, Dowdy TL, DeGrace S. The Importance of Ground Critical Care Transport. J Intensive Care Med 2016; 32:163-169. [PMID: 27625421 DOI: 10.1177/0885066616668484] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Critical care transport (CCT) teams are specialized transport services, comprised of highly trained paramedics, nurses, and occasionally respiratory therapists, offering an expanded scope of practice beyond advanced life support (ALS) emergency medical service teams. We report 4 cases of patients with severe acute respiratory distress syndrome from influenza in need of extracorporeal membrane oxygenation evaluation at a tertiary care center, transported by ground. Our medical center did not previously have a ground CCT service, and therefore, in these cases, a physician and/or a respiratory therapist was sent with the paramedic team. In all 4 cases, the ground transport team enhanced the intensive care provided to these patients prior to arrival at the tertiary care center. In 2 of the cases, although limited by the profound hypoxemia, the team decreased the pressures and tidal volumes in an effort to approach evidence-based ventilator goals. In 3 cases, they stopped bicarbonate drips being used to treat mixed metabolic and respiratory acidosis, and in 1 case, they administered furosemide. In 1 case, they started cisatracurium, and in 3 others, they initiated inhaled epoprostenol. Existing literature supports the use of CCT teams over ALS teams for transport of the most critically ill patients, and helicopter CCT is not always available or practical. Therefore, offering comparable air and ground options, with similar staffing and resources, is a hallmark of a mature medical system with an integrated approach to CCT.
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Affiliation(s)
- Susan R Wilcox
- 1 Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Division of Emergency Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Michael Ries
- 2 Meducare Ground Transport, Medical University of South Carolina, Charleston, SC, USA
| | - Ted A Bouthiller
- 2 Meducare Ground Transport, Medical University of South Carolina, Charleston, SC, USA
| | - E Dean Berry
- 2 Meducare Ground Transport, Medical University of South Carolina, Charleston, SC, USA
| | - Travis L Dowdy
- 2 Meducare Ground Transport, Medical University of South Carolina, Charleston, SC, USA
| | - Sharon DeGrace
- 2 Meducare Ground Transport, Medical University of South Carolina, Charleston, SC, USA
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36
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Dube KM, Ditch KL, Hills L. Use of Nebulized Heparin, Nebulized N-Acetylcysteine, and Nebulized Epoprostenol in a Patient With Smoke Inhalational Injury and Acute Respiratory Distress Syndrome. J Pharm Pract 2016; 30:663-667. [PMID: 27535955 DOI: 10.1177/0897190016663071] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Smoke inhalation injury (SIJ) is associated with an increase in morbidity and mortality in patients with burns. SIJ causes airway damage, inflammation, and bronchial obstruction, resulting in decreased oxygenation and perfusion status in these patients. Retrospective studies have compared the use of nebulized heparin (NH) plus nebulized N-acetylcysteine (NAC) and albuterol in patients with SIJ to those who received standard ventilator support with bronchodilator therapy. These studies are associated with a decrease in mortality when NH and nebulized NAC are administered to patients with SIJ. Approximately 20% of patients who develop SIJ will also develop acute respiratory distress syndrome (ARDS). Epoprostenol, a selective pulmonary vasodilator, has been utilized in the treatment of ARDS with mixed results for improving gas exchange. To our knowledge, this is the first case report of the concomitant administration of NH, nebulized NAC, and nebulized epoprostenol following SIJ in a burn patient with ARDS.
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Affiliation(s)
- Kevin M Dube
- 1 Department of Pharmacy, PGY-2 Critical Care Pharmacy Resident, Brigham and Women's Hospital, Boston, MA, USA
| | - Kristen L Ditch
- 2 Department of Pharmacy, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Luanne Hills
- 3 Respiratory Department, University of Massachusetts Medical Center, Worcester, MA, USA
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37
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Akter F, Coghlan G, de Mel A. Nitric oxide in paediatric respiratory disorders: novel interventions to address associated vascular phenomena? Ther Adv Cardiovasc Dis 2016; 10:256-70. [PMID: 27215618 DOI: 10.1177/1753944716649893] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Nitric oxide (NO) has a significant role in modulating the respiratory system and is being exploited therapeutically. Neonatal respiratory failure can affect around 2% of all live births and is responsible for over one third of all neonatal mortality. Current treatment method with inhaled NO (iNO) has demonstrated great benefits to patients with persistent pulmonary hypertension, bronchopulmonary dysplasia and neonatal respiratory distress syndrome. However, it is not without its drawbacks, which include the need for patients to be attached to mechanical ventilators. Notably, there is also a lack of identification of subgroups amongst abovementioned patients, and homogeneity in powered studies associated with iNO, which is one of the limitations. There are significant developments in drug delivery methods and there is a need to look at alternative or supplementary methods of NO delivery that could reduce current concerns. The addition of NO-independent activators and stimulators, or drugs such as prostaglandins to work in synergy with NO donors might be beneficial. It is of interest to consider such delivery methods within the respiratory system, where controlled release of NO can be introduced whilst minimizing the production of harmful byproducts. This article reviews current therapeutic application of iNO and the state-of-the-art technology methods for sustained delivery of NO that may be adapted and developed to address respiratory disorders. We envisage this perspective would prompt active investigation of such systems for their potential clinical benefit.
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Affiliation(s)
- Farhana Akter
- UCL Centre for Nanotechnology and Regenerative Medicine; Division of Surgery and Interventional Science, UCL, UK
| | - Gerry Coghlan
- Pulmonary Hypertension Unit, Royal Free London NHS Foundation Trust, UK
| | - Achala de Mel
- Lecturer in Regenerative Medicine, UCL Centre for Nanotechnology and Regenerative Medicine, Division of Surgery and Interventional Science, University College London, Royal Free NHS Trust Hospital, 9th Floor, Room 355, Pond Street, London NW3 2QG, UK
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38
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Levy SD, Alladina JW, Hibbert KA, Harris RS, Bajwa EK, Hess DR. High-flow oxygen therapy and other inhaled therapies in intensive care units. Lancet 2016; 387:1867-78. [PMID: 27203510 DOI: 10.1016/s0140-6736(16)30245-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In this Series paper, we review the current evidence for the use of high-flow oxygen therapy, inhaled gases, and aerosols in the care of critically ill patients. The available evidence supports the use of high-flow nasal cannulae for selected patients with acute hypoxaemic respiratory failure. Heliox might prevent intubation or improve gas flow in mechanically ventilated patients with severe asthma. Additionally, it might improve the delivery of aerosolised bronchodilators in obstructive lung disease in general. Inhaled nitric oxide might improve outcomes in a subset of patients with postoperative pulmonary hypertension who had cardiac surgery; however, it has not been shown to provide long-term benefit in patients with acute respiratory distress syndrome (ARDS). Inhaled prostacyclins, similar to inhaled nitric oxide, are not recommended for routine use in patients with ARDS, but can be used to improve oxygenation in patients who are not adequately stabilised with traditional therapies. Aerosolised bronchodilators are useful in mechanically ventilated patients with asthma and chronic obstructive pulmonary disease, but are not recommended for those with ARDS. Use of aerosolised antibiotics for ventilator-associated pneumonia and ventilator-associated tracheobronchitis shows promise, but the delivered dose can be highly variable if proper attention is not paid to the delivery method.
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Affiliation(s)
- Sean D Levy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jehan W Alladina
- Division of Pulmonary, Critical Care, and Sleep Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathryn A Hibbert
- Division of Pulmonary, Critical Care, and Sleep Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - R Scott Harris
- Division of Pulmonary, Critical Care, and Sleep Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ednan K Bajwa
- Division of Pulmonary, Critical Care, and Sleep Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dean R Hess
- Respiratory Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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39
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Thunberg CA, Morozowich ST, Ramakrishna H. Inhaled therapy for the management of perioperative pulmonary hypertension. Ann Card Anaesth 2016; 18:394-402. [PMID: 26139748 PMCID: PMC4881725 DOI: 10.4103/0971-9784.159811] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Patients with pulmonary hypertension (PH) are at high risk for complications in the perioperative setting and often receive vasodilators to control elevated pulmonary artery pressure (PAP). Administration of vasodilators via inhalation is an effective strategy for reducing PAP while avoiding systemic side effects, chiefly hypotension. The prototypical inhaled pulmonary-specific vasodilator, nitric oxide (NO), has a proven track record but is expensive and cumbersome to implement. Alternatives to NO, including prostanoids (such as epoprostenol, iloprost, and treprostinil), NO-donating drugs (sodium nitroprusside, nitroglycerin, and nitrite), and phosphodiesterase inhibitors (milrinone, sildenafil) may be given via inhalation for the purpose of treating elevated PAP. This review will focus on the perioperative therapy of PH using inhaled vasodilators.
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Affiliation(s)
| | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Phoenix, Arizona, USA
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Vieillard-Baron A, Matthay M, Teboul JL, Bein T, Schultz M, Magder S, Marini JJ. Experts' opinion on management of hemodynamics in ARDS patients: focus on the effects of mechanical ventilation. Intensive Care Med 2016; 42:739-749. [PMID: 27038480 DOI: 10.1007/s00134-016-4326-3] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 03/11/2016] [Indexed: 02/06/2023]
Abstract
RATIONALE Acute respiratory distress syndrome (ARDS) is frequently associated with hemodynamic instability which appears as the main factor associated with mortality. Shock is driven by pulmonary hypertension, deleterious effects of mechanical ventilation (MV) on right ventricular (RV) function, and associated-sepsis. Hemodynamic effects of ventilation are due to changes in pleural pressure (Ppl) and changes in transpulmonary pressure (TP). TP affects RV afterload, whereas changes in Ppl affect venous return. Tidal forces and positive end-expiratory pressure (PEEP) increase pulmonary vascular resistance (PVR) in direct proportion to their effects on mean airway pressure (mPaw). The acutely injured lung has a reduced capacity to accommodate flowing blood and increases of blood flow accentuate fluid filtration. The dynamics of vascular pressure may contribute to ventilator-induced injury (VILI). In order to optimize perfusion, improve gas exchange, and minimize VILI risk, monitoring hemodynamics is important. RESULTS During passive ventilation pulse pressure variations are a predictor of fluid responsiveness when conditions to ensure its validity are observed, but may also reflect afterload effects of MV. Central venous pressure can be helpful to monitor the response of RV function to treatment. Echocardiography is suitable to visualize the RV and to detect acute cor pulmonale (ACP), which occurs in 20-25 % of cases. Inserting a pulmonary artery catheter may be useful to measure/calculate pulmonary artery pressure, pulmonary and systemic vascular resistance, and cardiac output. These last two indexes may be misleading, however, in cases of West zones 2 or 1 and tricuspid regurgitation associated with RV dilatation. Transpulmonary thermodilution may be useful to evaluate extravascular lung water and the pulmonary vascular permeability index. To ensure adequate intravascular volume is the first goal of hemodynamic support in patients with shock. The benefit and risk balance of fluid expansion has to be carefully evaluated since it may improve systemic perfusion but also may decrease ventilator-free days, increase pulmonary edema, and promote RV failure. ACP can be prevented or treated by applying RV protective MV (low driving pressure, limited hypercapnia, PEEP adapted to lung recruitability) and by prone positioning. In cases of shock that do not respond to intravascular fluid administration, norepinephrine infusion and vasodilators inhalation may improve RV function. Extracorporeal membrane oxygenation (ECMO) has the potential to be the cause of, as well as a remedy for, hemodynamic problems. Continuous thermodilution-based and pulse contour analysis-based cardiac output monitoring are not recommended in patients treated with ECMO, since the results are frequently inaccurate. Extracorporeal CO2 removal, which could have the capability to reduce hypercapnia/acidosis-induced ACP, cannot currently be recommended because of the lack of sufficient data.
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Affiliation(s)
- A Vieillard-Baron
- Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, Service de Réanimation, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 9, avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France. .,University of Versailles Saint-Quentin en Yvelines, Faculty of Medicine Paris Ile-de-France Ouest, 78280, Saint-Quentin en Yvelines, France. .,INSERM U-1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), UVSQ, 94807, Villejuif, France.
| | - M Matthay
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, USA
| | - J L Teboul
- Assistance Publique-Hôpitaux de Paris, Hôpitaux universitaires Paris-Sud, Hôpital de Bicêtre, service de réanimation médicale, Le Kremlin-Bicêtre, France.,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, France
| | - T Bein
- Department of Anesthesia, Operative Intensive Care, University Hospital Regensburg, 93042, Regensburg, Germany
| | - M Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology, Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - S Magder
- Department of Critical Care, McGill University Health Centre (Glen Site Campus), Montreal, Canada
| | - J J Marini
- Departments of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, Minneapolis/St. Paul, MN, USA
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41
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Matsuura T, Yoshimaru K, Yanagi Y, Esumi G, Hayashida M, Taguchi T. Massive pulmonary hemorrhage before living donor liver transplantation in infants. Pediatr Transplant 2016; 20:89-95. [PMID: 26691206 DOI: 10.1111/petr.12650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2015] [Indexed: 01/30/2023]
Abstract
A massive pulmonary hemorrhage in patients with liver cirrhosis is a life-threatening complication that may result in a contraindication of a liver transplantation because of its high mortality rate. Herein, we present two infant biliary atresia cases that successfully underwent an LDLT that was followed by intensive respiratory care for the pretransplant massive pulmonary hemorrhage. Both cases exhibited severe respiratory failure (minimum PaO2/FiO2; 46 mmHg and 39 mmHg, respectively). To arrest the bleeding, we applied a very high positive pressure ventilation treatment (maximum PIP/PEEP; 38/14 cmH2O and 55/15 cmH2O, respectively), plasma exchange, several FFP transfusions, and recombinant factor VIIa via intrapulmonary administration. In addition, we used CHDF treatment, applied HFOV transiently, and treated the patient with inhalation of nitric oxide. Although we prepared ECMO for intra-operative use, both cases were successfully managed with conventional mechanical ventilation without using ECMO, which may have worsened the pulmonary hemorrhage due to the use of an anticoagulant. Use of an excessive positive pressure management, although it poses a risk for barotrauma, could be acceptable to arrest the pulmonary bleeding in selected cases of liver failure patients who have no time remaining before LDLT.
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Affiliation(s)
- Toshiharu Matsuura
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koichiro Yoshimaru
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yusuke Yanagi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Genshiro Esumi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Makoto Hayashida
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Combination therapy with nitric oxide and molecular hydrogen in a murine model of acute lung injury. Shock 2016; 43:504-11. [PMID: 25643010 DOI: 10.1097/shk.0000000000000316] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute lung injury (ALI) is still a leading cause of morbidity and mortality in critically ill patients. Inhaled nitric oxide (NO) has been reported to ameliorate ALI. However, reactive nitrogen species produced by NO can cause lung injury. Because hydrogen gas (H2) is reported to eliminate peroxynitrite, it is expected to reduce the adverse effects of NO. Moreover, we have found that H2 inhalation can attenuate lung injury. Therefore, we hypothesized that combination therapy with NO and H2 might afford more potent therapeutic strategies for ALI. In the present study, a mouse model of ALI was induced by intratracheal administration of lipopolysaccharide (LPS). The animals were treated with inhaled NO (20 ppm), H2 (2%), or NO + H2, starting 5 min after LPS administration for 3 h. We found that LPS-challenged mice exhibited significant lung injury characterized by the deterioration of histopathology and histologic scores, wet-to-dry weight ratio, and oxygenation index (ratio of oxygen tension to inspired oxygen fraction [Pao2/Fio2]), as well as total protein in the bronchoalveolar lavage fluid (BALF), which was attenuated by NO or H2 treatment alone. Combination therapy with NO and H2 had a more beneficial effect with significant interaction between the two. While the nitrotyrosine level in lung tissue was prominent after NO inhalation alone, it was significantly eliminated after breathing a mixture of NO with H2. Furthermore, NO or H2 treatment alone markedly attenuated LPS-induced lung neutrophil recruitment and inflammation, as evidenced by downregulation of lung myeloperoxidase activity, total cells, and polymorphonuclear neutrophils in BALF, as well as proinflammatory cytokines (tumor necrosis factor α, interleukins 1β and 6, and high-mobility group box 1) and chemokines (keratinocyte-derived chemokine, macrophage inflammatory proteins 1α and 2, and monocyte chemoattractant protein 1) in BALF. Combination therapy with NO and H2 had a more beneficial effect against lung inflammatory response. Moreover, combination therapy with NO and H2 could more effectively inhibit LPS-induced pulmonary early and late nuclear factor κB activation as well as pulmonary cell apoptosis. In addition, combination treatment with inhaled NO and H2 could also significantly attenuate lung injury in polymicrobial sepsis. Combination therapy with subthreshold concentrations of NO and H2 still had a significantly beneficial effect against lung injury induced by LPS and polymicrobial sepsis. Collectively, these results demonstrate that combination therapy with NO and H2 provides enhanced therapeutic efficacy for ALI.
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Torbic H, Szumita PM, Anger KE, Nuccio P, Lagambina S, Weinhouse G. Clinical and Economic Impact of Formulary Conversion From Inhaled Flolan to Inhaled Veletri for Refractory Hypoxemia in Critically Ill Patients. Ann Pharmacother 2015; 50:106-12. [PMID: 26668204 DOI: 10.1177/1060028015621308] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Flolan (iFLO) and Veletri (iVEL) are 2 inhaled epoprostenol formulations. There is no published literature comparing these formulations in critically ill patients with refractory hypoxemia. OBJECTIVE To compare efficacy, safety, and cost outcomes in patients who received either iFLO or iVEL for hypoxic respiratory failure. METHODS This was a retrospective, single-center analysis of adult, mechanically ventilated patients receiving iFLO or iVEL for improvement in oxygenation. The primary end point was the change in the PaO2/FiO2 ratio after 1 hour of pulmonary vasodilator therapy. Secondary end points assessed were intensive care unit (ICU) length of stay (LOS), hospital LOS, duration of study therapy, duration of mechanical ventilation, mortality, incidence of adverse events, and cost. RESULTS A total of 104 patients were included (iFLO = 52; iVEL = 52). More iFLO patients had acute respiratory distress syndrome compared with the iVEL group (61.5 vs 34.6%; P = 0.01). There was no difference in the change in the PaO2/FiO2 ratio after 1 hour of therapy (33.04 ± 36.9 vs 31.47 ± 19.92; P = 0.54) in the iFLO and iVEL groups, respectively. Patients who received iVEL had a shorter duration of mechanical ventilation (P < 0.001) and ICU LOS (P < 0.001) but not hospital LOS (P = 0.86) and duration of therapy (P = 0.36). No adverse events were attributed to pulmonary vasodilator therapy, and there was no difference in cost. CONCLUSIONS We found no difference between iFLO and iVEL when comparing the change in the PaO2/FiO2 ratio, safety, and cost in hypoxic, critically ill patients. There were differences in secondary outcomes, likely a result of differences in underlying indication for inhaled epoprostenol.
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Affiliation(s)
| | | | | | - Paul Nuccio
- Brigham and Women's Hospital, Boston, MA, USA
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44
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McGinn K, Reichert M. A Comparison of Inhaled Nitric Oxide Versus Inhaled Epoprostenol for Acute Pulmonary Hypertension Following Cardiac Surgery. Ann Pharmacother 2015; 50:22-6. [PMID: 26438636 DOI: 10.1177/1060028015608865] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Direct comparisons of inhaled nitric oxide (iNO) to inhaled epoprostenol (iEPO) in patients with acute pulmonary hypertension (PHT) following cardiac surgery are lacking. OBJECTIVE To compare the relative efficacy, safety, and cost of iNO versus iEPO in patients with acute PHT following cardiac surgery. METHODS This is a single-center, retrospective, observational, cohort study comparing iNO to iEPO for acute postoperative PHT following cardiac surgery. The primary outcome was reduction of mean pulmonary artery pressure (mPAP) to < 30 mm Hg, 6 hours after ICU admission from the operating room. Secondary outcomes, included ICU and hospital length of stay, duration of mechanical ventilation, bleeding complications, hypotension, in-hospital mortality, and cost. RESULTS A total of 98 patients met inclusion criteria (iNO, n = 49; iEPO, n = 49). There was no difference in the primary outcome of reduction of mPAP to < 30 mm Hg 6 hours after ICU admission (iNO, 33 [67%] vs iEPO, 35 [71%]; P = 0.83) or in the incidence of adverse events collected (iNO, 10 [20%] vs iEPO, 11 [22%]; P = 1.00). Based on cost estimates, the median cost of iEPO per patient was $363.53 ($226-$864.60) versus $2562.50 ($1875-$8625) for iNO (P < 0.01). CONCLUSIONS The relative efficacy of iEPO appeared to be similar to that of iNO in reducing mPAP following cardiac surgery, in this retrospective review. Significant cost savings were associated with the use of iEPO.
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Affiliation(s)
- Kaitlin McGinn
- Auburn University, Harrison School of Pharmacy, Mobile, AL, USA University of South Alabama Medical Center, Mobile, AL, USA
| | - Marc Reichert
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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45
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Cardio-Pulmonary-Renal Interactions: A Multidisciplinary Approach. J Am Coll Cardiol 2015; 65:2433-48. [PMID: 26046738 DOI: 10.1016/j.jacc.2015.04.024] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 04/18/2015] [Accepted: 04/20/2015] [Indexed: 12/16/2022]
Abstract
Over the past decade, science has greatly advanced our understanding of interdependent feedback mechanisms involving the heart, lung, and kidney. Organ injury is the consequence of maladaptive neurohormonal activation, oxidative stress, abnormal immune cell signaling, and a host of other mechanisms that precipitate adverse functional and structural changes. The presentation of interorgan crosstalk may include an acute, chronic, or acute on chronic timeframe. We review the current, state-of-the-art understanding of cardio-pulmonary-renal interactions and their related pathophysiology, perpetuating nature, and cycles of increased susceptibility and reciprocal progression. To this end, we present a multidisciplinary approach to frame the diverse spectrum of published observations on the topic. Assessment of organ functional reserve and use of biomarkers are valuable clinical strategies to screen and detect disease, assist in diagnosis, assess prognosis, and predict recovery or progression to chronic disease.
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46
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Ammar MA, Bauer SR, Bass SN, Sasidhar M, Mullin R, Lam SW. Noninferiority of Inhaled Epoprostenol to Inhaled Nitric Oxide for the Treatment of ARDS. Ann Pharmacother 2015; 49:1105-12. [DOI: 10.1177/1060028015595642] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Inhaled nitric oxide and inhaled epoprostenol have been evaluated for the management of hypoxemia in acute respiratory distress syndrome, with clinical trials demonstrating comparable improvements in oxygenation. However, these trials have several limitations, making it difficult to draw definitive conclusions regarding clinical outcomes. Objective: The aim of this study was to evaluate the noninferiority and safety of inhaled epoprostenol compared with inhaled nitric oxide in mechanically ventilated acute respiratory distress syndrome (ARDS) patients with a primary outcome of ventilator-free days from day 1 to day 28. Methods: This was a retrospective, noninterventional, propensity-matched, noninferiority cohort study. Propensity score for receipt of inhaled nitric oxide was developed and patients were matched accordingly using a prespecified algorithm. Secondary objectives included evaluating day 28 intensive care unit–free days, changes in PaO2/FiO2 ratio after inhalation therapy initiation, and hospital mortality. Safety endpoints assessed included hypotension, methemoglobinemia, renal dysfunction, rebound hypoxemia, significant bleeding, and thrombocytopenia. Results: Ninety-four patients were included, with 47 patients in each group. Patients were well-matched with similar baseline characteristics, except patients in inhaled nitric oxide group had lower PaO2/FiO2 ratio. Management of ARDS was similar between groups. Mean difference in ventilator-free days between inhaled epoprostenol and inhaled nitric oxide was 2.16 days (95% confidence interval = −0.61 to 4.9), with lower limit of 95% confidence interval greater than the prespecified margin, hence satisfying noninferiority. There were no differences in any secondary or safety outcomes. Conclusions: Inhaled epoprostenol was noninferior to inhaled nitric oxide with regard to ventilator-free days from day 1 to day 28 in ARDS patients.
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47
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Chudow M, Carter M, Rumbak M. Pharmacological Treatments for Acute Respiratory Distress Syndrome. AACN Adv Crit Care 2015. [DOI: 10.4037/nci.0000000000000092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Melissa Chudow
- Melissa Chudow is PGY-2 Critical Care Pharmacy Resident, Department of Pharmacy Services, Tampa General Hospital, PO Box #1289, Tampa, FL 33601 ., Michelle Carter is Clinical Pharmacist, Department of Pharmacy Services, Tampa General Hospital, Tampa, Florida., Mark Rumbak is Division Director, Pulmonary, Critical Care, and Sleep Medicine, Morsani College of Medicine, University of South Florida, Tampa
| | - Michelle Carter
- Melissa Chudow is PGY-2 Critical Care Pharmacy Resident, Department of Pharmacy Services, Tampa General Hospital, PO Box #1289, Tampa, FL 33601 ., Michelle Carter is Clinical Pharmacist, Department of Pharmacy Services, Tampa General Hospital, Tampa, Florida., Mark Rumbak is Division Director, Pulmonary, Critical Care, and Sleep Medicine, Morsani College of Medicine, University of South Florida, Tampa
| | - Mark Rumbak
- Melissa Chudow is PGY-2 Critical Care Pharmacy Resident, Department of Pharmacy Services, Tampa General Hospital, PO Box #1289, Tampa, FL 33601 ., Michelle Carter is Clinical Pharmacist, Department of Pharmacy Services, Tampa General Hospital, Tampa, Florida., Mark Rumbak is Division Director, Pulmonary, Critical Care, and Sleep Medicine, Morsani College of Medicine, University of South Florida, Tampa
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48
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Dixit D, Bridgeman MB, Andrews LB, Narayanan N, Radbel J, Parikh A, Sunderram J. Acute Exacerbations of Chronic Obstructive Pulmonary Disease: Diagnosis, Management, and Prevention in Critically Ill Patients. Pharmacotherapy 2015; 35:631-48. [DOI: 10.1002/phar.1599] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Deepali Dixit
- Ernest Mario School of Pharmacy; Rutgers, The State University of New Jersey; Piscataway New Jersey
- Critical Care; Robert Wood Johnson University Hospital; New Brunswick New Jersey
| | - Mary Barna Bridgeman
- Ernest Mario School of Pharmacy; Rutgers, The State University of New Jersey; Piscataway New Jersey
- Internal Medicine; Robert Wood Johnson University Hospital; New Brunswick New Jersey
| | - Liza Barbarello Andrews
- Ernest Mario School of Pharmacy; Rutgers, The State University of New Jersey; Piscataway New Jersey
- Critical Care; Robert Wood Johnson University Hospital Hamilton; Hamilton New Jersey
| | - Navaneeth Narayanan
- Ernest Mario School of Pharmacy; Rutgers, The State University of New Jersey; Piscataway New Jersey
- Infectious Disease; Robert Wood Johnson University Hospital; New Brunswick New Jersey
| | - Jared Radbel
- Division of Pulmonary and Critical Care Medicine; Department of Medicine; Rutgers Robert Wood Johnson Medical School; New Brunswick New Jersey
| | - Amay Parikh
- Division of Pulmonary and Critical Care Medicine; Department of Medicine; Rutgers Robert Wood Johnson Medical School; New Brunswick New Jersey
| | - Jag Sunderram
- Division of Pulmonary and Critical Care Medicine; Department of Medicine; Rutgers Robert Wood Johnson Medical School; New Brunswick New Jersey
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49
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Mosier JM, Hypes C, Joshi R, Whitmore S, Parthasarathy S, Cairns CB. Ventilator Strategies and Rescue Therapies for Management of Acute Respiratory Failure in the Emergency Department. Ann Emerg Med 2015; 66:529-41. [PMID: 26014437 DOI: 10.1016/j.annemergmed.2015.04.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 04/08/2015] [Accepted: 04/20/2015] [Indexed: 01/19/2023]
Abstract
Acute respiratory failure is commonly encountered in the emergency department (ED), and early treatment can have effects on long-term outcome. Noninvasive ventilation is commonly used for patients with respiratory failure and has been demonstrated to improve outcomes in acute exacerbations of chronic obstructive lung disease and congestive heart failure, but should be used carefully, if at all, in the management of asthma, pneumonia, and acute respiratory distress syndrome. Lung-protective tidal volumes should be used for all patients receiving mechanical ventilation, and FiO2 should be reduced after intubation to achieve a goal of less than 60%. For refractory hypoxemia, new rescue therapies have emerged to help improve the oxygenation, and in some cases mortality, and should be considered in ED patients when necessary, as deferring until ICU admission may be deleterious. This review article summarizes the pathophysiology of acute respiratory failure, management options, and rescue therapies including airway pressure release ventilation, continuous neuromuscular blockade, inhaled nitric oxide, and extracorporeal membrane oxygenation.
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Affiliation(s)
- Jarrod M Mosier
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine, University of Arizona, Tucson, AZ.
| | - Cameron Hypes
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine, University of Arizona, Tucson, AZ
| | - Raj Joshi
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine, University of Arizona, Tucson, AZ
| | - Sage Whitmore
- Division of Emergency Critical Care, Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Sairam Parthasarathy
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, AZ
| | - Charles B Cairns
- Department of Emergency Medicine, University of Arizona, Tucson, AZ
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50
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Bauer SR, Tonelli AR. Beyond the evidence: treating pulmonary hypertension in the intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:524. [PMID: 25673475 PMCID: PMC4330936 DOI: 10.1186/s13054-014-0524-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Most patients with pulmonary arterial hypertension succumb to their disease in the ICU; however, limited evidence-based information exists to guide treatment in those that present with advanced right ventricular failure. Critical care physicians should be aware of the complexities of the treatment of patients with pulmonary arterial hypertension and should develop a strategy for their care. Current management is based on the pathophysiology of the disease and involves a multidisciplinary team supported by institutional polices directed at optimizing patient safety.
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