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Schenck EJ, Siempos II. Innovation in Enrichment: Is Persistence Enough? Crit Care Med 2024; 52:853-856. [PMID: 38619345 PMCID: PMC11027940 DOI: 10.1097/ccm.0000000000006239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Edward J Schenck
- NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, NY
- Division of Pulmonary & Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Ilias I Siempos
- Division of Pulmonary & Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, NY
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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Sathe NA, Zelnick LR, Morrell ED, Bhatraju PK, Kerchberger VE, Hough CL, Ware LB, Fohner AE, Wurfel MM. Development and External Validation of Models to Predict Persistent Hypoxemic Respiratory Failure for Clinical Trial Enrichment. Crit Care Med 2024; 52:764-774. [PMID: 38197736 PMCID: PMC11018468 DOI: 10.1097/ccm.0000000000006181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
OBJECTIVES Improving the efficiency of clinical trials in acute hypoxemic respiratory failure (HRF) depends on enrichment strategies that minimize enrollment of patients who quickly resolve with existing care and focus on patients at high risk for persistent HRF. We aimed to develop parsimonious models predicting risk of persistent HRF using routine data from ICU admission and select research immune biomarkers. DESIGN Prospective cohorts for derivation ( n = 630) and external validation ( n = 511). SETTING Medical and surgical ICUs at two U.S. medical centers. PATIENTS Adults with acute HRF defined as new invasive mechanical ventilation (IMV) and hypoxemia on the first calendar day after ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We evaluated discrimination, calibration, and practical utility of models predicting persistent HRF risk (defined as ongoing IMV and hypoxemia on the third calendar day after admission): 1) a clinical model with least absolute shrinkage and selection operator (LASSO) selecting Pa o2 /F io2 , vasopressors, mean arterial pressure, bicarbonate, and acute respiratory distress syndrome as predictors; 2) a model adding interleukin-6 (IL-6) to clinical predictors; and 3) a comparator model with Pa o2 /F io2 alone, representing an existing strategy for enrichment. Forty-nine percent and 69% of patients had persistent HRF in derivation and validation sets, respectively. In validation, both LASSO (area under the receiver operating characteristic curve, 0.68; 95% CI, 0.64-0.73) and LASSO + IL-6 (0.71; 95% CI, 0.66-0.76) models had better discrimination than Pa o2 /F io2 (0.64; 95% CI, 0.59-0.69). Both models underestimated risk in lower risk deciles, but exhibited better calibration at relevant risk thresholds. Evaluating practical utility, both LASSO and LASSO + IL-6 models exhibited greater net benefit in decision curve analysis, and greater sample size savings in enrichment analysis, compared with Pa o2 /F io2 . The added utility of LASSO + IL-6 model over LASSO was modest. CONCLUSIONS Parsimonious, interpretable models that predict persistent HRF may improve enrichment of trials testing HRF-targeted therapies and warrant future validation.
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Affiliation(s)
- Neha A. Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Leila R. Zelnick
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Eric D. Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence, University of Washington
| | - V. Eric Kerchberger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Catherine L. Hough
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Lorraine B, Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Alison E Fohner
- Department of Epidemiology, School of Public Health, University of Washington
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence, University of Washington
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Valda Toro PL, Willmore A, Wu NE, Delucchi KL, Jauregui A, Sinha P, Liu KD, Hendrickson CM, Sarma A, Neyton LPA, Leligdowicz A, Langelier CR, Zhuo H, Jones C, Kangelaris KN, Gomez AD, Matthay MA, Calfee CS. Rapidly improving ARDS differs clinically and biologically from persistent ARDS. Crit Care 2024; 28:132. [PMID: 38649920 PMCID: PMC11034037 DOI: 10.1186/s13054-024-04883-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/20/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Rapidly improving acute respiratory distress syndrome (RIARDS) is an increasingly appreciated subgroup of ARDS in which hypoxemia improves within 24 h after initiation of mechanical ventilation. Detailed clinical and biological features of RIARDS have not been clearly defined, and it is unknown whether RIARDS is associated with the hypoinflammatory or hyperinflammatory phenotype of ARDS. The purpose of this study was to define the clinical and biological features of RIARDS and its association with inflammatory subphenotypes. METHODS We analyzed data from 215 patients who met Berlin criteria for ARDS (endotracheally intubated) and were enrolled in a prospective observational cohort conducted at two sites, one tertiary care center and one urban safety net hospital. RIARDS was defined according to previous studies as improvement of hypoxemia defined as (i) PaO2:FiO2 > 300 or (ii) SpO2: FiO2 > 315 on the day following diagnosis of ARDS (day 2) or (iii) unassisted breathing by day 2 and for the next 48 h (defined as absence of endotracheal intubation on day 2 through day 4). Plasma biomarkers were measured on samples collected on the day of study enrollment, and ARDS phenotypes were allocated as previously described. RESULTS RIARDS accounted for 21% of all ARDS participants. Patients with RIARDS had better clinical outcomes compared to those with persistent ARDS, with lower hospital mortality (13% vs. 57%; p value < 0.001) and more ICU-free days (median 24 vs. 0; p value < 0.001). Plasma levels of interleukin-6, interleukin-8, and plasminogen activator inhibitor-1 were significantly lower among patients with RIARDS. The hypoinflammatory phenotype of ARDS was more common among patients with RIARDS (78% vs. 51% in persistent ARDS; p value = 0.001). CONCLUSIONS This study identifies a high prevalence of RIARDS in a multicenter observational cohort and confirms the more benign clinical course of these patients. We report the novel finding that RIARDS is characterized by lower concentrations of plasma biomarkers of inflammation compared to persistent ARDS, and that hypoinflammatory ARDS is more prevalent among patients with RIARDS. Identification and exclusion of RIARDS could potentially improve prognostic and predictive enrichment in clinical trials.
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Affiliation(s)
- Patricia L Valda Toro
- Department of Medicine, Division of Pulmonary and Critical Care, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Internal Medicine, University of California San Francisco, San Francisco, USA.
| | - Andrew Willmore
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Nelson E Wu
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Kevin L Delucchi
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Alejandra Jauregui
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Pratik Sinha
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kathleen D Liu
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Carolyn M Hendrickson
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Aartik Sarma
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Lucile P A Neyton
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Charles R Langelier
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Hanjing Zhuo
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Chayse Jones
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Kirsten N Kangelaris
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Antonio D Gomez
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Michael A Matthay
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
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4
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Andrianopoulos I, Giannakoulis VG, Papoutsi E, Papathanakos G, Koulouras V, Thompson BT, Siempos II. PROLONGED MECHANICAL VENTILATION IN ACUTE RESPIRATORY DISTRESS SYNDROME. Shock 2024; 61:240-245. [PMID: 38010051 DOI: 10.1097/shk.0000000000002248] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
ABSTRACT Purpose: Trajectory of acute respiratory distress syndrome (ARDS) spans from rapidly improving cases to cases receiving prolonged mechanical ventilation (PMV). We attempted to estimate temporal trends of prevalence and mortality of PMV and to identify risk factors associated with mortality of patients with ARDS receiving PMV. Methods: We performed a secondary analysis of individual patient data from six randomized controlled clinical trials conducted by the ARDS Network. Prolonged mechanical ventilation was defined as the need for mechanical ventilation for >21 consecutive days. Results: Of 4,216 patients with ARDS, 646 (15.3%) received PMV. Prevalence of PMV gradually declined from 18.4% in the ARDS Network: Low-Tidal-Volume Trial (published in 2000) trial to 10.9% in the SAILS (2014) trial ( R2 = 0.728, P = 0.031). Ninety-day mortality of patients receiving PMV did not change over time ( R2 = 0.271, P = 0.290) and remained as high as 36.8%. Ιn the three most recent trials, risk factors associated with mortality among the 250 patients with ARDS receiving PMV included age, malignancy, pneumonia as the cause of ARDS, coagulation dysfunction, and hepatic dysfunction during the first 21 days after trial enrollment. Conclusion: Although prevalence of PMV among patients enrolled in ARDS Network trials gradually declined, mortality did not change. Risk factors associated with mortality were mostly nonmodifiable.
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Affiliation(s)
- Ioannis Andrianopoulos
- Department of Intensive Care Medicine, University Hospital of Ioannina, Ioannina, Greece
| | - Vassilis G Giannakoulis
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Eleni Papoutsi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Georgios Papathanakos
- Department of Intensive Care Medicine, University Hospital of Ioannina, Ioannina, Greece
| | - Vasilios Koulouras
- Department of Intensive Care Medicine, University Hospital of Ioannina, Ioannina, Greece
| | - B Taylor Thompson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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5
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Matthay MA, Arabi Y, Arroliga AC, Bernard G, Bersten AD, Brochard LJ, Calfee CS, Combes A, Daniel BM, Ferguson ND, Gong MN, Gotts JE, Herridge MS, Laffey JG, Liu KD, Machado FR, Martin TR, McAuley DF, Mercat A, Moss M, Mularski RA, Pesenti A, Qiu H, Ramakrishnan N, Ranieri VM, Riviello ED, Rubin E, Slutsky AS, Thompson BT, Twagirumugabe T, Ware LB, Wick KD. A New Global Definition of Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:37-47. [PMID: 37487152 PMCID: PMC10870872 DOI: 10.1164/rccm.202303-0558ws] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/24/2023] [Indexed: 07/26/2023] Open
Abstract
Background: Since publication of the 2012 Berlin definition of acute respiratory distress syndrome (ARDS), several developments have supported the need for an expansion of the definition, including the use of high-flow nasal oxygen, the expansion of the use of pulse oximetry in place of arterial blood gases, the use of ultrasound for chest imaging, and the need for applicability in resource-limited settings. Methods: A consensus conference of 32 critical care ARDS experts was convened, had six virtual meetings (June 2021 to March 2022), and subsequently obtained input from members of several critical care societies. The goal was to develop a definition that would 1) identify patients with the currently accepted conceptual framework for ARDS, 2) facilitate rapid ARDS diagnosis for clinical care and research, 3) be applicable in resource-limited settings, 4) be useful for testing specific therapies, and 5) be practical for communication to patients and caregivers. Results: The committee made four main recommendations: 1) include high-flow nasal oxygen with a minimum flow rate of ⩾30 L/min; 2) use PaO2:FiO2 ⩽ 300 mm Hg or oxygen saturation as measured by pulse oximetry SpO2:FiO2 ⩽ 315 (if oxygen saturation as measured by pulse oximetry is ⩽97%) to identify hypoxemia; 3) retain bilateral opacities for imaging criteria but add ultrasound as an imaging modality, especially in resource-limited areas; and 4) in resource-limited settings, do not require positive end-expiratory pressure, oxygen flow rate, or specific respiratory support devices. Conclusions: We propose a new global definition of ARDS that builds on the Berlin definition. The recommendations also identify areas for future research, including the need for prospective assessments of the feasibility, reliability, and prognostic validity of the proposed global definition.
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Affiliation(s)
- Michael A. Matthay
- Department of Medicine
- Department of Anesthesia
- Cardiovascular Research Institute, and
| | - Yaseen Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Gordon Bernard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Lung Research, and
| | | | - Laurent J. Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Carolyn S. Calfee
- Department of Medicine
- Department of Anesthesia
- Cardiovascular Research Institute, and
| | - Alain Combes
- Médecine Intensive – Réanimation, Sorbonne Université, APHP Hôpital Pitié-Salpêtrière, Paris, France
| | - Brian M. Daniel
- Respiratory Therapy, University of California, San Francisco, San Francisco, California
| | - Niall D. Ferguson
- Interdepartmental Division of Critical Care Medicine and
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michelle N. Gong
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Jeffrey E. Gotts
- Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | | | - John G. Laffey
- Anesthesia, University Hospital Galway, University of Galway, Galway, Ireland
| | | | - Flavia R. Machado
- Intensive Care Department, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Thomas R. Martin
- Department of Medicine, University of Washington, Seattle, Washington
| | - Danny F. McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Alain Mercat
- Medical ICU, Angers University Hospital, Angers, France
| | - Marc Moss
- Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | | | - Antonio Pesenti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Haibo Qiu
- Critical Care Medicine, Zhongda Hospital, Nanjing, China
| | | | - V. Marco Ranieri
- Emergency and Intensive Care Medicine, Alma Mater Studorium University of Bologna, Bologna, Italy
| | - Elisabeth D. Riviello
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Arthur S. Slutsky
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Theogene Twagirumugabe
- Department of Anesthesia, Critical Care, and Emergency Medicine, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda; and
| | - Lorraine B. Ware
- Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Katherine D. Wick
- Department of Medicine, University of California, Davis, Davis, California
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6
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Papoutsi E, Kremmydas P, Tsolaki V, Kyriakoudi A, Routsi C, Kotanidou A, Siempos II. Racial and ethnic minority participants in clinical trials of acute respiratory distress syndrome. Intensive Care Med 2023; 49:1479-1488. [PMID: 37847403 PMCID: PMC10709247 DOI: 10.1007/s00134-023-07238-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 09/19/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE There is growing interest in improving the inclusiveness of racial and ethnic minority participants in trials of acute respiratory distress syndrome (ARDS). With our study we aimed to examine temporal trends of representation and mortality of racial and ethnic minority participants in randomized controlled trials of ARDS. METHODS We performed a secondary analysis of eight ARDS Network and PETAL Network therapeutic clinical trials, published between 2000 and 2019. We classified race/ethnicity into "White", "Black", "Hispanic", or "Other" (including Asian, American Indian or Alaskan Native, Native Hawaiian, or other Pacific Islander participants). RESULTS Of 5375 participants with ARDS, 1634 (30.4%) were Black, Hispanic, or Other race participants. Representation of racial and ethnic minority participants in trials did not change significantly over time (p = 0.257). However, among participants with moderate to severe ARDS (i.e., partial pressure of arterial oxygen to fraction of inspired oxygen ratio < 150), the difference in mortality between racial and ethnic minority participants and White participants decreased over time. In the five most recent trials, including 2923 participants with ARDS, there were no statistically significant differences in mortality between racial/ethnic groups, even after adjusting for potential confounders. In these five most recent trials, mortality was 31% for White, 31.9% for Black, 30.3% for Hispanic, and 37.1% for Other race participants (p = 0.633). CONCLUSION Representation of racial and ethnic minority participants in ARDS trials from North America, published between 2000 and 2019, did not change over time. Black and Hispanic participants with ARDS may have similar mortality as White participants within trials.
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Affiliation(s)
- Eleni Papoutsi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 45-47 Ipsilantou Street, 10676, Athens, Greece
| | - Panagiotis Kremmydas
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 45-47 Ipsilantou Street, 10676, Athens, Greece
| | - Vasiliki Tsolaki
- Critical Care Department, University Hospital of Larissa, University of Thessaly Faculty of Medicine, Larissa, Greece
| | - Anna Kyriakoudi
- First Department of Respiratory Medicine, Thoracic Diseases General Hospital Sotiria, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Christina Routsi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 45-47 Ipsilantou Street, 10676, Athens, Greece
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 45-47 Ipsilantou Street, 10676, Athens, Greece
| | - Ilias I Siempos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 45-47 Ipsilantou Street, 10676, Athens, Greece.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA.
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7
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Ferraz JFFM, Siuba MT, Krishnan S, Chatburn RL, Mireles-Cabodevila E, Duggal A. Physiologic Markers of Disease Severity in ARDS. Respir Care 2023; 68:1708-1718. [PMID: 37438051 PMCID: PMC10676265 DOI: 10.4187/respcare.11100] [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] [Received: 04/03/2023] [Accepted: 07/06/2023] [Indexed: 07/14/2023]
Abstract
Despite its significant limitations, the PaO2 /FIO2 remains the standard tool to classify disease severity in ARDS. Treatment decisions and research enrollment have depended on this parameter for over 50 years. In addition, several variables have been studied over the past few decades, incorporating other physiologic considerations such as ventilation efficiency, lung mechanics, and right-ventricular performance. This review describes the strengths and limitations of all relevant parameters, with the goal of helping us better understand disease severity and possible future treatment targets.
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Affiliation(s)
- Joao F F M Ferraz
- Department of Hospital Medicine, Community Care Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Sudhir Krishnan
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Robert L Chatburn
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Eduardo Mireles-Cabodevila
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio.
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8
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Villar J, Szakmany T, Grasselli G, Camporota L. Redefining ARDS: a paradigm shift. Crit Care 2023; 27:416. [PMID: 37907946 PMCID: PMC10619227 DOI: 10.1186/s13054-023-04699-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 11/02/2023] Open
Abstract
Although the defining elements of "acute respiratory distress syndrome" (ARDS) have been known for over a century, the syndrome was first described in 1967. Since then, despite several revisions of its conceptual definition, it remains a matter of debate whether ARDS is a discrete nosological entity. After almost 60 years, it is appropriate to examine how critical care has modeled this fascinating syndrome and affected patient's outcome. Given that the diagnostic criteria of ARDS (e.g., increased pulmonary vascular permeability and diffuse alveolar damage) are difficult to ascertain in clinical practice, we believe that a step forward would be to standardize the assessment of pulmonary and extrapulmonary involvement in ARDS to ensure that each patient can receive the most appropriate and effective treatment. The selection of treatments based on arbitrary ranges of PaO2/FiO2 lacks sufficient sensitivity to individualize patient care.
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Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029, Madrid, Spain.
- Research Unit, Hospital Universitario Dr. Negrin, Barranco de La Ballena S/N, 4Th Floor-South Wing, 35019, Las Palmas de Gran Canaria, Spain.
- Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada.
| | - Tamas Szakmany
- Department of Intensive Care Medicine & Anesthesia, Aneurin Bevan University Health Board, Newport, NP20 2UB, Wales, UK
- Honorary Professor in Intensive Care, Cardiff University, Cardiff, CF14 4XW, Wales, UK
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
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Giannakoulis VG, Papoutsi E, Kaldis V, Tsirogianni A, Kotanidou A, Siempos II. Postoperative acute respiratory distress syndrome in randomized controlled trials. Surgery 2023; 174:1050-1055. [PMID: 37481422 DOI: 10.1016/j.surg.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/05/2023] [Accepted: 06/18/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Acute respiratory distress syndrome is a potentially fatal postoperative complication. We aimed to estimate temporal trends of the representation of patients with postoperative acute respiratory distress syndrome in clinical trials, determine their distinct clinical features, and identify predictors of mortality. METHODS This is a secondary analysis of 7 randomized controlled clinical trials conducted by the Acute Respiratory Distress Syndrome Network and the Clinical Trials Network for the Prevention and Early Treatment of Acute Lung Injury. Patients with acute respiratory distress syndrome were classified into a postoperative acute respiratory distress syndrome group (ie, patients who had undergone elective surgery in the immediate period before trial enrollment) and a non-postoperative acute respiratory distress syndrome group. RESULTS Out of 5,316 patients with acute respiratory distress syndrome, 256 (4.8%) had postoperative acute respiratory distress syndrome. Representation of postoperative acute respiratory distress syndrome in trials gradually declined from 2000 to 2011, but it remained stable afterward at 2.7%. Postoperative acute respiratory distress syndrome was associated with lower 90-day mortality (24.6% vs 30.9%, P = .032) than non-postoperative acute respiratory distress syndrome, even after adjusting for age, acute respiratory distress syndrome severity, usage of vasopressors at baseline, and the study publication year (hazard ratio 0.63, 95% confidence interval 0.49-0.82). Age (odds ratio 1.07, 95% confidence interval 1.04-1.09), immunosuppression (odds ratio 4.12, 95% confidence interval 1.43-11.86), and positive fluid balance (odds ratio 1.09, 95% confidence interval 1.04-1.14) were associated with 90-day mortality among patients with postoperative acute respiratory distress syndrome. CONCLUSION Representation of postoperative acute respiratory distress syndrome in trials of the Acute Respiratory Distress Syndrome Network and the Clinical Trials Network for the Prevention and Early Treatment of Acute Lung Injury gradually declined from 2000 to 2011 but remained stable afterward. Postoperative acute respiratory distress syndrome was associated with lower mortality than non-postoperative acute respiratory distress syndrome. These findings may put both temporal trends and the prognosis of postoperative acute respiratory distress syndrome in perspective. Also, positive fluid balance was associated with the mortality of patients with postoperative acute respiratory distress syndrome.
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Affiliation(s)
- Vassilis G Giannakoulis
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Greece
| | - Eleni Papoutsi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Greece
| | - Vassileios Kaldis
- Department of Emergency Medicine, KAT General Hospital, Athens, Greece
| | | | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Greece
| | - Ilias I Siempos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Greece; Department of Medicine, Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY.
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10
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Grasselli G, Calfee CS, Camporota L, Poole D, Amato MBP, Antonelli M, Arabi YM, Baroncelli F, Beitler JR, Bellani G, Bellingan G, Blackwood B, Bos LDJ, Brochard L, Brodie D, Burns KEA, Combes A, D'Arrigo S, De Backer D, Demoule A, Einav S, Fan E, Ferguson ND, Frat JP, Gattinoni L, Guérin C, Herridge MS, Hodgson C, Hough CL, Jaber S, Juffermans NP, Karagiannidis C, Kesecioglu J, Kwizera A, Laffey JG, Mancebo J, Matthay MA, McAuley DF, Mercat A, Meyer NJ, Moss M, Munshi L, Myatra SN, Ng Gong M, Papazian L, Patel BK, Pellegrini M, Perner A, Pesenti A, Piquilloud L, Qiu H, Ranieri MV, Riviello E, Slutsky AS, Stapleton RD, Summers C, Thompson TB, Valente Barbas CS, Villar J, Ware LB, Weiss B, Zampieri FG, Azoulay E, Cecconi M. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med 2023; 49:727-759. [PMID: 37326646 PMCID: PMC10354163 DOI: 10.1007/s00134-023-07050-7] [Citation(s) in RCA: 97] [Impact Index Per Article: 97.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.
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Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | | | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Francesca Baroncelli
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Geoff Bellingan
- Intensive Care Medicine, University College London, NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurent Brochard
- Keenan Research Center, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Critical Care, Unity Health Toronto - Saint Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013, Paris, France
| | - Sonia D'Arrigo
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Sharon Einav
- Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology and Critical Care, Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Departments of Medicine and Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jean-Pierre Frat
- CHU De Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM, CIC-1402, IS-ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Claude Guérin
- University of Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7200, Créteil, France
| | - Margaret S Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Catherine L Hough
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi Teaching Hospital, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier, France
| | - Nicole P Juffermans
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken Der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arthur Kwizera
- Makerere University College of Health Sciences, School of Medicine, Department of Anesthesia and Intensive Care, Kampala, Uganda
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, College of Medicine Nursing and Health Sciences, University of Galway, Galway, Ireland
- Anesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospitals Groups, Galway, Ireland
| | - Jordi Mancebo
- Intensive Care Department, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Alain Mercat
- Département de Médecine Intensive Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - Nuala J Meyer
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Canada
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Michelle Ng Gong
- Division of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Laurent Papazian
- Bastia General Hospital Intensive Care Unit, Bastia, France
- Aix-Marseille University, Faculté de Médecine, Marseille, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mariangela Pellegrini
- Anesthesia and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Marco V Ranieri
- Alma Mater Studiorum - Università di Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Elisabeth Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charlotte Summers
- Department of Medicine, University of Cambridge Medical School, Cambridge, UK
| | - Taylor B Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Carmen S Valente Barbas
- University of São Paulo Medical School, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jesús Villar
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM CVK), Charitè - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Fernando G Zampieri
- Academic Research Organization, Albert Einstein Hospital, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris Cité University, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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11
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Jones TW, Almuntashiri S, Chase A, Alhumaid A, Somanath PR, Sikora A, Zhang D. Plasma matrix metalloproteinase-3 predicts mortality in acute respiratory distress syndrome: a biomarker analysis of a randomized controlled trial. Respir Res 2023; 24:166. [PMID: 37349704 PMCID: PMC10286483 DOI: 10.1186/s12931-023-02476-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/09/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Matrix metalloproteinase-3 (MMP-3) is a proteolytic enzyme involved in acute respiratory distress syndrome (ARDS) pathophysiology that may serve as a lung-specific biomarker in ARDS. METHODS This study was a secondary biomarker analysis of a subset of Albuterol for the Treatment of Acute Lung Injury (ALTA) trial patients to determine the prognostic value of MMP-3. Plasma sample MMP-3 was measured by enzyme-linked immunosorbent assay. The primary outcome was the area under the receiver operating characteristic (AUROC) of MMP-3 at day 3 for the prediction of 90-day mortality. RESULTS A total of 100 unique patient samples were evaluated and the AUROC analysis of day three MMP-3 showed an AUROC of 0.77 for the prediction of 90-day mortality (95% confidence interval: 0.67-0.87), corresponding to a sensitivity of 92% and specificity of 63% and an optimal cutoff value of 18.4 ng/mL. Patients in the high MMP-3 group (≥ 18.4 ng/mL) showed higher mortality compared to the non-elevated MMP-3 group (< 18.4 ng/mL) (47% vs. 4%, p < 0.001). A positive difference in day zero and day three MMP-3 concentration was predictive of mortality with an AUROC of 0.74 correlating to 73% sensitivity, 81% specificity, and an optimal cutoff value of + 9.5 ng/mL. CONCLUSIONS Day three MMP-3 concentration and difference in day zero and three MMP-3 concentrations demonstrated acceptable AUROCs for predicting 90-day mortality with a cut-point of 18.4 ng/mL and + 9.5 ng/mL, respectively. These results suggest a prognostic role of MMP-3 in ARDS.
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Affiliation(s)
- Timothy W. Jones
- Department of Pharmacy, Augusta University Medical Center, 1120 15th St., Augusta, GA 30912 USA
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 120 15th Street, HM-117, Augusta, GA 30912 USA
| | - Sultan Almuntashiri
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 120 15th Street, HM-117, Augusta, GA 30912 USA
| | - Aaron Chase
- Department of Pharmacy, Augusta University Medical Center, 1120 15th St., Augusta, GA 30912 USA
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 120 15th Street, HM-117, Augusta, GA 30912 USA
| | - Abdullah Alhumaid
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 120 15th Street, HM-117, Augusta, GA 30912 USA
| | - Payaningal R. Somanath
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 120 15th Street, HM-117, Augusta, GA 30912 USA
| | - Andrea Sikora
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 120 15th Street, HM-117, Augusta, GA 30912 USA
| | - Duo Zhang
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 120 15th Street, HM-117, Augusta, GA 30912 USA
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12
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Bos LDJ, de Grooth HJ, Tuinman PR. A structured diagnostic algorithm for patients with ARDS. Crit Care 2023; 27:94. [PMID: 36941668 PMCID: PMC10027589 DOI: 10.1186/s13054-023-04368-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2023 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Lieuwe Durk Jacobus Bos
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Harm Jan de Grooth
- Department of Intensive Care, Amsterdam UMC, Location VUMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care, Amsterdam UMC, Location VUMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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13
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Li H, Bihari S, Weister T, LeMahieu A, Kashyap R, Chalmers S, Lal A, Bersten A, Gajic O. Admission serum sodium and osmolarity are not associated with the occurrence or outcomes of acute respiratory distress syndrome in critically ill. J Crit Care 2023; 73:154179. [PMID: 36368178 PMCID: PMC9616514 DOI: 10.1016/j.jcrc.2022.154179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/03/2022] [Accepted: 10/07/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Previous studies suggested that hypernatremia or hyperosmolarity may have protective effects in lung injury. We hypothesized that hypernatremia and/or hyperosmolarity would prevent ARDS. DESIGN Retrospective cohort study of all admissions at medical, surgical, and multidisciplinary intensive care units in Mayo Clinic, Rochester from the year of 2009 to 2019. The occurrence of ARDS was identified using a validated computerized search strategy. The association between serum sodium/osmolarity and the occurrence of ARDS was analyzed using a multivariable logistic regression model. The relationship between serum sodium/osmolarity and outcomes of ARDS was analyzed using linear and logistic regression models. RESULTS Among 50,498 patients, the serum sodium level on admission did not have a significant association with the occurrence of ARDS, with an adjusted odds ratio of 0.95 [95% CI (0.86, 1.05)]. There was no significant association between calculated serum osmolarity and the occurrence of ARDS, with an adjusted odds ratio of 1.03 [95% CI (1.00, 1.07)]. 1560 patients developed ARDS during the ICU stay. Their serum sodium level and osmolarity level did not have a significant association with their outcomes. CONCLUSIONS Admission serum sodium or serum osmolarity were not associated with the occurrence or outcomes of ARDS in ICU.
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Affiliation(s)
- Heyi Li
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Shailesh Bihari
- Intensive Care Unit, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia 5042, Australia
| | - Timothy Weister
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN 55905, USA
| | - Allison LeMahieu
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Rochester, MN 55905, USA
| | - Rahul Kashyap
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Sarah Chalmers
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Amos Lal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Andrew Bersten
- Intensive Care Unit, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia 5042, Australia
| | - Ognjen Gajic
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
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14
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Villar J, González-Martin JM, Añón JM, Ferrando C, Soler JA, Mosteiro F, Mora-Ordoñez JM, Ambrós A, Fernández L, Montiel R, Vidal A, Muñoz T, Pérez-Méndez L, Rodríguez-Suárez P, Fernández C, Fernández RL, Szakmany T, Burns KEA, Steyerberg EW, Slutsky AS. Clinical relevance of timing of assessment of ICU mortality in patients with moderate-to-severe Acute Respiratory Distress Syndrome. Sci Rep 2023; 13:1543. [PMID: 36707634 PMCID: PMC9883467 DOI: 10.1038/s41598-023-28824-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/25/2023] [Indexed: 01/28/2023] Open
Abstract
Mortality is a frequently reported outcome in clinical studies of acute respiratory distress syndrome (ARDS). However, timing of mortality assessment has not been well characterized. We aimed to identify a crossing-point between cumulative survival and death in the intensive care unit (ICU) of patients with moderate-to-severe ARDS, beyond which the number of survivors would exceed the number of deaths. We hypothesized that this intersection would occur earlier in a successful clinical trial vs. observational studies of moderate/severe ARDS and predict treatment response. We conducted an ancillary study of 1580 patients with moderate-to-severe ARDS managed with lung-protective ventilation to assess the relevance and timing of measuring ICU mortality rates at different time-points during ICU stay. First, we analyzed 1303 patients from four multicenter, observational cohorts enrolling consecutive patients with moderate/severe ARDS. We assessed cumulative ICU survival from the time of moderate/severe ARDS diagnosis to ventilatory support discontinuation within 7-days, 28-days, 60-days, and at ICU discharge. Then, we compared these findings to those of a successful randomized trial of 277 moderate/severe ARDS patients. In the observational cohorts, ICU mortality (487/1303, 37.4%) and 28-day mortality (425/1102, 38.6%) were similar (p = 0.549). Cumulative proportion of ICU survivors and non-survivors crossed at day-7; after day-7, the number of ICU survivors was progressively higher compared to non-survivors. Measures of oxygenation, lung mechanics, and severity scores were different between survivors and non-survivors at each point-in-time (p < 0.001). In the trial cohort, the cumulative proportion of survivors and non-survivors in the treatment group crossed before day-3 after diagnosis of moderate/severe ARDS. In clinical ARDS studies, 28-day mortality closely approximates and may be used as a surrogate for ICU mortality. For patients with moderate-to-severe ARDS, ICU mortality assessment within the first week of a trial might be an early predictor of treatment response.
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Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029, Madrid, Spain. .,Research Unit, Hospital Universitario Dr. Negrín, Barranco de La Ballena S/N, 4th Floor - South wing, 35019, Las Palmas de Gran Canaria, Spain. .,Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada.
| | - Jesús M González-Martin
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029, Madrid, Spain.,Research Unit, Hospital Universitario Dr. Negrín, Barranco de La Ballena S/N, 4th Floor - South wing, 35019, Las Palmas de Gran Canaria, Spain
| | - José M Añón
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029, Madrid, Spain.,Intensive Care Unit, Hospital Universitario La Paz, IdiPaz, 28046, Madrid, Spain
| | - Carlos Ferrando
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029, Madrid, Spain.,Surgical Intensive Care Unit, Department of Anesthesia, Hospital Clinic, IDIBAPS, 08036, Barcelona, Spain
| | - Juan A Soler
- Intensive Care Unit, Hospital Universitario Virgen de Arrixaca, 30120, Murcia, Spain
| | - Fernando Mosteiro
- Intensive Care Unit, Hospital Universitario de A Coruña, 15006, La Coruña, Spain
| | - Juan M Mora-Ordoñez
- Intensive Care Unit, Hospital Universitario Regional Carlos Haya, 29010, Málaga, Spain
| | - Alfonso Ambrós
- Intensive Care Unit, Hospital General Universitario de Ciudad Real, 13005, Ciudad Real, Spain
| | - Lorena Fernández
- Intensive Care Unit, Hospital Universitario Río Hortega, 47012, Valladolid, Spain
| | - Raquel Montiel
- Intensive Care Unit, Hospital Universitario NS de Candelaria, 38010, Santa Cruz de Tenerife, Spain
| | - Anxela Vidal
- Intensive Care Unit, Hospital Universitario Fundación Jiménez Díaz, 28040, Madrid, Spain
| | - Tomás Muñoz
- Intensive Care Unit, Hospital Universitario de Cruces, 48903, Barakaldo, Vizcaya, Spain
| | - Lina Pérez-Méndez
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029, Madrid, Spain.,Research Unit, Hospital Universitario NS de Candelaria, 38010, Santa Cruz de Tenerife, Spain
| | - Pedro Rodríguez-Suárez
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029, Madrid, Spain.,Thoracic Surgery, Hospital Universitario Dr. Negrín, 35019, Las Palmas de Gran Canaria, Spain
| | - Cristina Fernández
- Research Unit, Hospital Universitario Dr. Negrín, Barranco de La Ballena S/N, 4th Floor - South wing, 35019, Las Palmas de Gran Canaria, Spain
| | - Rosa L Fernández
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029, Madrid, Spain.,Research Unit, Hospital Universitario Dr. Negrín, Barranco de La Ballena S/N, 4th Floor - South wing, 35019, Las Palmas de Gran Canaria, Spain
| | - Tamas Szakmany
- Department of Intensive Care Medicine and Anesthesia, Bevan University Health Board, Newport, NP20 2UB, UK.,Honorary Professor in Intensive Care, Cardiff University, Cardiff, CF14 4XW, Wales, UK
| | - Karen E A Burns
- Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada.,Critical Care Medicine, Unity Health Toronto-St. Michael's Hospital, Toronto, M5B 1W8, Canada.,Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ewout W Steyerberg
- Department Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Arthur S Slutsky
- Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada.,Division of Critical Care Medicine, University of Toronto, Toronto, ON, M5T 3A1, Canada
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15
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Ruan Z, Li D, Chen X, Qiu Z. Association of serum total bilirubin and potential predictors with mortality in acute respiratory failure: A retrospective cohort study. Heart Lung 2023; 57:12-18. [PMID: 35987112 DOI: 10.1016/j.hrtlng.2022.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/04/2022] [Accepted: 08/08/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Total serum bilirubin (TBIL) levels are a risk factor in critically ill patients. However, the relationship between the dynamics of TBIL and the prognosis of acute respiratory failure (ARF) patients is unclear. OBJECTIVES This study aimed to investigate the impact of different levels of TBIL during hospitalization on mortality in ARF patients. METHODS This study used a retrospective cohort study. We extracted information on ARF patients from the Medical Information Bank for Intensive Care (MIMIC)-III (version 1.4). We used propensity score matching (PSM) to adjust for the level of potential baseline-level differences between groups. Cox regression was used to analyze mortality risk factors in patients with ARF. Subgroup analysis was used to explore special populations. RESULTS 2673 patients were included in the study, and 19.7% developed hyperbilirubinemia (TBIL ≥ 2 mg/dL) during their hospitalization. After PSM, multivariate Cox regression showed a 50% and 135% increased risk of death for a maximum value of TBIL ≥ 5 mg/dL and minimum value of TBIL ≥ 2 mg/dL during hospitalization, respectively, compared to the control population. In addition, age ≥ 65 years, previous comorbid malignancies, respiratory rate ≥ 22 beats/min, SpO2 ≥ 95, BUN ≥ 20 mg/dL, lactate ≥ 5 mmol/L, platelet < 100 * 10 ^ 9/L were independent risk factors for 1-year mortality in ARF patients. Subgroup analysis showed that high bilirubin had a greater effect on patients aged less than 65 years (P for interaction < 0.05). CONCLUSIONS Hyper TBIL (TBIL max ≥ 5 mg/dL or TBIL min ≥ 2 mg/dL) was an independent risk factor for 1-year mortality in patients with ARF. This study suggests that clinicians should be aware of TBIL levels and intervene early in these patients.
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Affiliation(s)
- Zhishen Ruan
- Shandong Traditional Chinese Medicine University, Ji Nan, China
| | - Dan Li
- Shandong Traditional Chinese Medicine University, Ji Nan, China
| | - Xianhai Chen
- Shandong Traditional Chinese Medicine University, Ji Nan, China; Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Ji Nan, China.
| | - Zhanjun Qiu
- Shandong Traditional Chinese Medicine University, Ji Nan, China; Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Ji Nan, China.
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16
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Discriminating Acute Respiratory Distress Syndrome from other forms of respiratory failure via iterative machine learning. INTELLIGENCE-BASED MEDICINE 2023; 7:100087. [PMID: 36624822 PMCID: PMC9812471 DOI: 10.1016/j.ibmed.2023.100087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/22/2022] [Accepted: 01/04/2023] [Indexed: 01/06/2023]
Abstract
Acute Respiratory Distress Syndrome (ARDS) is associated with high morbidity and mortality. Identification of ARDS enables lung protective strategies, quality improvement interventions, and clinical trial enrolment, but remains challenging particularly in the first 24 hours of mechanical ventilation. To address this we built an algorithm capable of discriminating ARDS from other similarly presenting disorders immediately following mechanical ventilation. Specifically, a clinical team examined medical records from 1263 ICU-admitted, mechanically ventilated patients, retrospectively assigning each patient a diagnosis of "ARDS" or "non-ARDS" (e.g., pulmonary edema). Exploiting data readily available in the clinical setting, including patient demographics, laboratory test results from before the initiation of mechanical ventilation, and features extracted by natural language processing of radiology reports, we applied an iterative pre-processing and machine learning framework. The resulting model successfully discriminated ARDS from non-ARDS causes of respiratory failure (AUC = 0.85) among patients meeting Berlin criteria for severe hypoxia. This analysis also highlighted novel patient variables that were informative for identifying ARDS in ICU settings.
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17
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Martos-Benítez FD, Estévez-Muguercia R, Orama-Requejo V, Del Toro-Simoni T. Prognostic value of the novel P/FPE index to classify ARDS severity: A cohort study. Med Intensiva 2022:S2173-5727(22)00309-5. [PMID: 36344340 DOI: 10.1016/j.medine.2022.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/07/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To evaluate the impact of the novel P/FPE index to classify ARDS severity on mortality of patients with ARDS. DESIGN A retrospective cohort study. SETTING Twelve-bed medical and surgical intensive care unit from January 2018 to December 2020. PATIENTS A total of 217 ARDS patients managed with invasive mechanical ventilation >48h. INTERVENTIONS None. VARIABLES ARDS severity on day 1 and day 3 was measured based on PaO2/FiO2 ratio and P/FPE index [PaO2/(FiO2×PEEP)]. Primary outcome was the hospital mortality. RESULTS Hospital mortality rate was 59.9%. Relative to PaO2/FiO2 ratio, 31.8% of patients on day 1 and 77.0% on day 3 were reclassified into a different category of ARDS severity by P/FPE index. The level of PEEP was lower by P/FPE index-based ARDS severity classification than by using PaO2/FiO2 ratio. The performance for predicting mortality of P/FPE index was superior to PaO2/FiO2 ratio in term of AROC (day 1: 0.72 vs. 0.62; day 3: 0.87 vs. 0.68) and CORR (day 1: 0.370 vs. 0.213; day 3: 0.634 vs. 0.301). P/FPE index improved prediction of risk of death compared to PaO2/FiO2 ratio as showed by the qNRI (day 1: 72.0%, p<0.0001; day 3: 132.4%, p<0.0001) and IDI (day 1: 0.09, p<0.0001; day 3: 0.31, p<0.0001). CONCLUSIONS Assessment of ARDS severity based on P/FPE index seems better than PaO2/FiO2 ratio for predicting mortality. The value of P/FPE index for clinical decision-making requires confirmation by randomized controlled trials.
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Affiliation(s)
- F D Martos-Benítez
- Intensive Care Unit - 8, Hermanos Ameijeiras Hospital, Havana 10400, Cuba.
| | | | - V Orama-Requejo
- Intermediate Care Unit, Hospital of Palamos, Palamos 17230, Spain
| | - T Del Toro-Simoni
- Intensive Care Unit, Manuel Ascunce Domenech Hospital, Camagüey 70600, Cuba
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18
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Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome. Med Intensiva 2022; 46:609-618. [PMID: 36313965 PMCID: PMC9597521 DOI: 10.1016/j.medin.2022.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/25/2022] [Indexed: 01/05/2023]
Abstract
Objective Evidence only proves low surpasses high tidal volume (V T) for acute respiratory distress syndrome (ARDS). Intermediate V T is a common setting for ARDS patients and has been demonstrated as effective as low V T in non-ARDS patients. The effectiveness of intermediate V T in ARDS has not been studied and is the objective of this study. Design A retrospective cohort study. Setting Five ICUs with their totally 130 beds in Taiwan. Patients or participants ARDS patients under invasive ventilation. Interventions No. Main variables of interest 28-D mortality. Result Totally 382 patients, with 6958 ventilator settings eligible for lung protection, were classified into low (mean V T = 6.7 ml/kg), intermediate (mean V T = 8.9 ml/kg) and high (mean V T = 11.2 ml/kg) V T groups. With similar baseline ARDS and ICU severities, intermediate and low V T groups did not differ in 28-D mortality (47% vs. 63%, P = 0.06) or other outcomes such as 90-D mortality, ventilator-free days, ventilator-dependence rate. Multivariate analysis revealed high V T was independently associated with 28-D and 90-D mortality, but intermediate V T was not significantly associated with 28-D mortality (HR 1.34, CI 0.92-1.97, P = 0.13) or 90-D mortality. When the intermediate and low V T groups were matched in propensity scores (n = 66 for each group), their outcomes were also not significantly different. Conclusion Intermediate V T, with its outcomes similar to small V T, is an acceptable option for ventilated ARDS patients. This conclusion needs verification through clinical trials.
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19
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Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome. MEDICINA INTENSIVA (ENGLISH EDITION) 2022; 46:609-618. [PMCID: PMC9633924 DOI: 10.1016/j.medine.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/25/2022] [Indexed: 11/06/2022]
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20
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Grapsa E, Adamos G, Andrianopoulos I, Tsolaki V, Giannakoulis VG, Karavidas N, Giannopoulou V, Sarri K, Mizi E, Gavrielatou E, Papathanakos G, Mantzarlis KD, Mastora Z, Magira E, Koulouras V, Kotanidou A, Siempos II. Association Between Vaccination Status and Mortality Among Intubated Patients With COVID-19-Related Acute Respiratory Distress Syndrome. JAMA Netw Open 2022; 5:e2235219. [PMID: 36205996 PMCID: PMC9547321 DOI: 10.1001/jamanetworkopen.2022.35219] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
IMPORTANCE Although vaccination substantially reduces the risk of severe COVID-19, it is yet unknown whether vaccinated patients who develop COVID-19 and require invasive mechanical ventilation have lower mortality than controls. OBJECTIVE To examine the association between COVID-19 vaccination status and mortality among critically ill patients who require invasive mechanical ventilation owing to acute respiratory distress syndrome (ARDS) related to COVID-19. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study was performed between June 7, 2021, and February 1, 2022, among 265 consecutive adult patients with COVID-19 in academic intensive care units who underwent invasive mechanical ventilation owing to ARDS. EXPOSURES Patients in the full vaccination group had completed the primary COVID-19 vaccination series more than 14 days but less than 5 months prior to intubation. This time threshold was chosen because guidelines from the US Centers for Disease Control and Prevention recommend a booster dose beyond that time. The remaining patients (ie, those who were unvaccinated, partially vaccinated, or fully vaccinated <14 days or >5 months before intubation) comprised the control group. MAIN OUTCOMES AND MEASURES The primary outcome was time from intubation to all-cause intensive care unit mortality. A Cox proportional hazards regression model including vaccination status, age, comorbid conditions, and baseline Sequential Organ Failure Assessment score on the day of intubation was used. RESULTS A total of 265 intubated patients (170 men [64.2%]; median age, 66.0 years [IQR, 58.0-76.0 years]; 26 [9.8%] in the full vaccination group) were included in the study. A total of 20 patients (76.9%) in the full vaccination group received the BNT162b2 vaccine, and the remaining 6 (23.1%) received the ChAdOx1 nCoV-19 vaccine. Patients in the full vaccination group were older (median age, 72.5 years [IQR, 62.8-80.0 years] vs 66.0 years [IQR, 57.0-75.0 years]) and more likely to have comorbid conditions (24 of 26 [92.3%] vs 160 of 239 [66.9%]), including malignant neoplasm (6 of 26 [23.1%] vs 18 of 239 [7.5%]), than those in the control group. Full vaccination status was significantly associated with lower mortality compared with controls (16 of 26 patients [61.5%] died in the full vaccination group vs 163 of 239 [68.2%] in the control group; hazard ratio, 0.55 [95% CI, 0.32-0.94]; P = .03). CONCLUSIONS AND RELEVANCE In this cohort study, full vaccination status was associated with lower mortality compared with controls, which suggests that vaccination might be beneficial even among patients who were intubated owing to COVID-19-related ARDS. These results may inform discussions with families about prognosis.
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Affiliation(s)
- Eirini Grapsa
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Georgios Adamos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | | | - Vasiliki Tsolaki
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Vassilis G. Giannakoulis
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Nikitas Karavidas
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Vassiliki Giannopoulou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Katerina Sarri
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Eleftheria Mizi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Evdokia Gavrielatou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Georgios Papathanakos
- Department of Intensive Care Unit, University Hospital of Ioannina, Ioannina, Greece
| | - Konstantinos D. Mantzarlis
- Critical Care Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Zafeiria Mastora
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Eleni Magira
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Vasilios Koulouras
- Department of Intensive Care Unit, University Hospital of Ioannina, Ioannina, Greece
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ilias I. Siempos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, New York
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21
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Respiratory Subsets in Patients with Moderate to Severe Acute Respiratory Distress Syndrome for Early Prediction of Death. J Clin Med 2022; 11:jcm11195724. [PMID: 36233592 PMCID: PMC9570540 DOI: 10.3390/jcm11195724] [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: 08/10/2022] [Revised: 09/19/2022] [Accepted: 09/24/2022] [Indexed: 12/16/2022] Open
Abstract
Introduction: In patients with acute respiratory distress syndrome (ARDS), the PaO2/FiO2 ratio at the time of ARDS diagnosis is weakly associated with mortality. We hypothesized that setting a PaO2/FiO2 threshold in 150 mm Hg at 24 h from moderate/severe ARDS diagnosis would improve predictions of death in the intensive care unit (ICU). Methods: We conducted an ancillary study in 1303 patients with moderate to severe ARDS managed with lung-protective ventilation enrolled consecutively in four prospective multicenter cohorts in a network of ICUs. The first three cohorts were pooled (n = 1000) as a testing cohort; the fourth cohort (n = 303) served as a confirmatory cohort. Based on the thresholds for PaO2/FiO2 (150 mm Hg) and positive end-expiratory pressure (PEEP) (10 cm H2O), the patients were classified into four possible subsets at baseline and at 24 h using a standardized PEEP-FiO2 approach: (I) PaO2/FiO2 ≥ 150 at PEEP < 10, (II) PaO2/FiO2 ≥ 150 at PEEP ≥ 10, (III) PaO2/FiO2 < 150 at PEEP < 10, and (IV) PaO2/FiO2 < 150 at PEEP ≥ 10. Primary outcome was death in the ICU. Results: ICU mortalities were similar in the testing and confirmatory cohorts (375/1000, 37.5% vs. 112/303, 37.0%, respectively). At baseline, most patients from the testing cohort (n = 792/1000, 79.2%) had a PaO2/FiO2 < 150, with similar mortality among the four subsets (p = 0.23). When assessed at 24 h, ICU mortality increased with an advance in the subset: 17.9%, 22.8%, 40.0%, and 49.3% (p < 0.0001). The findings were replicated in the confirmatory cohort (p < 0.0001). However, independent of the PEEP levels, patients with PaO2/FiO2 < 150 at 24 h followed a distinct 30-day ICU survival compared with patients with PaO2/FiO2 ≥ 150 (hazard ratio 2.8, 95% CI 2.2−3.5, p < 0.0001). Conclusions: Subsets based on PaO2/FiO2 thresholds of 150 mm Hg assessed after 24 h of moderate/severe ARDS diagnosis are clinically relevant for establishing prognosis, and are helpful for selecting adjunctive therapies for hypoxemia and for enrolling patients into therapeutic trials.
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22
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Wick KD, Aggarwal NR, Curley MAQ, Fowler AA, Jaber S, Kostrubiec M, Lassau N, Laterre PF, Lebreton G, Levitt JE, Mebazaa A, Rubin E, Sinha P, Ware LB, Matthay MA. Opportunities for improved clinical trial designs in acute respiratory distress syndrome. THE LANCET. RESPIRATORY MEDICINE 2022; 10:916-924. [PMID: 36057279 DOI: 10.1016/s2213-2600(22)00294-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/02/2022] [Accepted: 07/19/2022] [Indexed: 02/08/2023]
Abstract
The acute respiratory distress syndrome (ARDS) is a common critical illness syndrome with high morbidity and mortality. There are no proven pharmacological therapies for ARDS. The current definition of ARDS is based on shared clinical characteristics but does not capture the heterogeneity in clinical risk factors, imaging characteristics, physiology, timing of onset and trajectory, and biology of the syndrome. There is increasing interest within the ARDS clinical trialist community to design clinical trials that reduce heterogeneity in the trial population. This effort must be balanced with ongoing work to craft an inclusive, global definition of ARDS, with important implications for trial design. Ultimately, the two aims-to design trials that are applicable to the diverse global ARDS population while also advancing opportunities to identify targetable traits-should coexist. In this Personal View, we recommend two primary strategies to improve future ARDS trials: the development of new methods to target treatable traits in clinical trial populations, and improvements in the representativeness of ARDS trials, with the inclusion of global populations. We emphasise that these two strategies are complementary. We also discuss how a proposed expansion of the definition of ARDS could affect the future of clinical trials.
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Affiliation(s)
- Katherine D Wick
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Neil R Aggarwal
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado, Aurora, CO, USA; National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Martha A Q Curley
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Alpha A Fowler
- Division of Pulmonary Disease and Critical Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Samir Jaber
- University Hospital, CHU de Montpellier Hôpital Saint Eloi, Intensive Care Unit and Transplantation, Department of Anesthesiology DAR B, Montpellier, France
| | - Maciej Kostrubiec
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Nathalie Lassau
- Department of Imaging, Gustave Roussy, Université Paris Saclay, Villejuif, France; Biomaps, UMR1281 INSERM, CEA, CNRS, Université Paris Saclay, Villejuif, France
| | - Pierre François Laterre
- Intensive Care Medicine, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Guillaume Lebreton
- Institute of Cardiometabolism and Nutrition, Inserm, UMRS 1166-ICAN, Sorbonne University, Paris, France; Cardiac Surgery Service, Institute of Cardiology, AP-HP, Sorbonne University, Paris, France
| | - Joseph E Levitt
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, Paris, France
| | | | - Pratik Sinha
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA; Departments of Medicine and Anesthesia, University of California, San Francisco, CA, USA.
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23
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Shih JA, Robertson HK, Issa MS, Grossestreuer AV, Donnino MW, Berg KM, Moskowitz A. Acute respiratory distress syndrome after in-hospital cardiac arrest. Resuscitation 2022; 177:78-84. [PMID: 35580706 PMCID: PMC9320405 DOI: 10.1016/j.resuscitation.2022.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Acute respiratory distress syndrome (ARDS) after out-of-hospital cardiac arrest is common and associated with worse outcomes. In the hospital setting, there are many potential risk factors for post-arrest ARDS, such as aspiration, sepsis, and shock. ARDS after in-hospital cardiac arrest (IHCA) has not been characterized. METHODS We performed a single-center retrospective study of adult patients admitted to the hospital between 2014-2018 who suffered an IHCA, achieved return of spontaneous circulation (ROSC), and were either already intubated at the time of arrest or within 2 hours of ROSC. Post-IHCA ARDS was defined as meeting the Berlin criteria in the first 3 days following ROSC. Outcomes included alive-and-ventilator free days across 28 days, hospital length-of-stay, hospital mortality, and hospital disposition. RESULTS Of 203 patients included, 146 (71.9%) developed ARDS. In unadjusted analysis, patients with ARDS had fewer alive-and-ventilator-free days over 28 days with a median of 1 (IQR: 0, 21) day, compared to 18 (IQR: 0, 25) days in patients without ARDS (p = 0.03). However, this association was not significant after multivariate adjustment. There was also a non-significant longer hospital length-of-stay (15 [IQR: 7, 26] vs 10 [IQR: 7, 22] days, p = 0.25; median adjusted increase in ARDS patients: 3 [95% CI: -2 to 8] days, p = 0.27) and higher hospital mortality (53% vs 44%, p = 0.26; aOR 1.6 [95% CI: 0.8-2.9], p = 0.17) in the ARDS group. CONCLUSION Among IHCA patients, almost three-quarters developed ARDS within 3 days of ROSC. As in out of hospital cardiac arrest, post-IHCA ARDS is common.
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Affiliation(s)
- Jenny A. Shih
- Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States,Corresponding author. (J.A. Shih)
| | - Hannah K. Robertson
- Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States
| | - Mahmoud S. Issa
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States
| | - Anne V. Grossestreuer
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States
| | - Michael W. Donnino
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States,Department of Pulmonology and Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States,Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States
| | - Katherine M. Berg
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States,Department of Pulmonology and Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States
| | - Ari Moskowitz
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States,Department of Pulmonology and Critical Care, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467-2401, United States
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24
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Xu Z, Mao C, Su C, Zhang H, Siempos I, Torres LK, Pan D, Luo Y, Schenck EJ, Wang F. Sepsis subphenotyping based on organ dysfunction trajectory. Crit Care 2022; 26:197. [PMID: 35786445 PMCID: PMC9250715 DOI: 10.1186/s13054-022-04071-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/25/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Sepsis is a heterogeneous syndrome, and the identification of clinical subphenotypes is essential. Although organ dysfunction is a defining element of sepsis, subphenotypes of differential trajectory are not well studied. We sought to identify distinct Sequential Organ Failure Assessment (SOFA) score trajectory-based subphenotypes in sepsis. METHODS We created 72-h SOFA score trajectories in patients with sepsis from four diverse intensive care unit (ICU) cohorts. We then used dynamic time warping (DTW) to compute heterogeneous SOFA trajectory similarities and hierarchical agglomerative clustering (HAC) to identify trajectory-based subphenotypes. Patient characteristics were compared between subphenotypes and a random forest model was developed to predict subphenotype membership at 6 and 24 h after being admitted to the ICU. The model was tested on three validation cohorts. Sensitivity analyses were performed with alternative clustering methodologies. RESULTS A total of 4678, 3665, 12,282, and 4804 unique sepsis patients were included in development and three validation cohorts, respectively. Four subphenotypes were identified in the development cohort: Rapidly Worsening (n = 612, 13.1%), Delayed Worsening (n = 960, 20.5%), Rapidly Improving (n = 1932, 41.3%), and Delayed Improving (n = 1174, 25.1%). Baseline characteristics, including the pattern of organ dysfunction, varied between subphenotypes. Rapidly Worsening was defined by a higher comorbidity burden, acidosis, and visceral organ dysfunction. Rapidly Improving was defined by vasopressor use without acidosis. Outcomes differed across the subphenotypes, Rapidly Worsening had the highest in-hospital mortality (28.3%, P-value < 0.001), despite a lower SOFA (mean: 4.5) at ICU admission compared to Rapidly Improving (mortality:5.5%, mean SOFA: 5.5). An overall prediction accuracy of 0.78 (95% CI, [0.77, 0.8]) was obtained at 6 h after ICU admission, which increased to 0.87 (95% CI, [0.86, 0.88]) at 24 h. Similar subphenotypes were replicated in three validation cohorts. The majority of patients with sepsis have an improving phenotype with a lower mortality risk; however, they make up over 20% of all deaths due to their larger numbers. CONCLUSIONS Four novel, clinically-defined, trajectory-based sepsis subphenotypes were identified and validated. Identifying trajectory-based subphenotypes has immediate implications for the powering and predictive enrichment of clinical trials. Understanding the pathophysiology of these differential trajectories may reveal unanticipated therapeutic targets and identify more precise populations and endpoints for clinical trials.
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Affiliation(s)
- Zhenxing Xu
- grid.5386.8000000041936877XDivision of Health Informatics, Department of Population Health Sciences, Weill Cornell Medicine, 425 E. 61st Street, 3rd Floor, Suite 301, New York, NY USA
| | - Chengsheng Mao
- grid.16753.360000 0001 2299 3507Division of Health and Biomedical Informatics, Department of Preventive Medicine Center for Health Information Partnerships, Feinberg School of Medicine, Northwestern University, Rubloff Building 11th Floor, 750 N Lake Shore, Chicago, IL USA
| | - Chang Su
- grid.264727.20000 0001 2248 3398Department of Health Service Administration and Policy, College of Public Health, Temple University, Philadelphia, PA USA
| | - Hao Zhang
- grid.5386.8000000041936877XDivision of Health Informatics, Department of Population Health Sciences, Weill Cornell Medicine, 425 E. 61st Street, 3rd Floor, Suite 301, New York, NY USA
| | - Ilias Siempos
- grid.413734.60000 0000 8499 1112Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, 425 E. 61st Street, 4th Floor, Suite 402, New York, NY USA ,grid.5386.8000000041936877XWeill Cornell Medicine, Weill Cornell Medical College, New York, NY USA
| | - Lisa K. Torres
- grid.413734.60000 0000 8499 1112Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, 425 E. 61st Street, 4th Floor, Suite 402, New York, NY USA ,grid.5386.8000000041936877XWeill Cornell Medicine, Weill Cornell Medical College, New York, NY USA
| | - Di Pan
- grid.413734.60000 0000 8499 1112Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, 425 E. 61st Street, 4th Floor, Suite 402, New York, NY USA ,grid.5386.8000000041936877XWeill Cornell Medicine, Weill Cornell Medical College, New York, NY USA
| | - Yuan Luo
- Division of Health and Biomedical Informatics, Department of Preventive Medicine Center for Health Information Partnerships, Feinberg School of Medicine, Northwestern University, Rubloff Building 11th Floor, 750 N Lake Shore, Chicago, IL, USA.
| | - Edward J. Schenck
- grid.413734.60000 0000 8499 1112Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, 425 E. 61st Street, 4th Floor, Suite 402, New York, NY USA ,grid.5386.8000000041936877XWeill Cornell Medicine, Weill Cornell Medical College, New York, NY USA
| | - Fei Wang
- Division of Health Informatics, Department of Population Health Sciences, Weill Cornell Medicine, 425 E. 61st Street, 3rd Floor, Suite 301, New York, NY, USA.
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Martos-Benítez F, Estévez-Muguercia R, Orama-Requejo V, del Toro-Simoni T. Prognostic value of the novel P/FPE index to classify ARDS severity: A cohort study. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Macrophage-Targeted Nanomedicines for ARDS/ALI: Promise and Potential. Inflammation 2022; 45:2124-2141. [PMID: 35641717 PMCID: PMC9154210 DOI: 10.1007/s10753-022-01692-3] [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: 02/08/2022] [Revised: 04/11/2022] [Accepted: 05/24/2022] [Indexed: 11/05/2022]
Abstract
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are characterized by progressive lung impairment typically triggered by inflammatory processes. The mortality toll for ARDS/ALI yet remains high because of the poor prognosis, lack of disease-specific inflammation management therapies, and prolonged hospitalizations. The urgency for the development of new effective therapeutic strategies has become acutely evident for patients with coronavirus disease 2019 (COVID-19) who are highly susceptible to ARDS/ALI. We propose that the lack of target specificity in ARDS/ALI of current treatments is one of the reasons for poor patient outcomes. Unlike traditional therapeutics, nanomedicine offers precise drug targeting to inflamed tissues, the capacity to surmount pulmonary barriers, enhanced interactions with lung epithelium, and the potential to reduce off-target and systemic adverse effects. In this article, we focus on the key cellular drivers of inflammation in ARDS/ALI: macrophages. We propose that as macrophages are involved in the etiology of ARDS/ALI and regulate inflammatory cascades, they are a promising target for new therapeutic development. In this review, we offer a survey of multiple nanomedicines that are currently being investigated with promising macrophage targeting potential and strategies for pulmonary delivery. Specifically, we will focus on nanomedicines that have shown engagement with proinflammatory macrophage targets and have the potential to reduce inflammation and reverse tissue damage in ARDS/ALI.
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Abstract
OBJECTIVE To describe, through a narrative review, the physiologic principles underlying electrical impedance tomography, and its potential applications in managing acute respiratory distress syndrome (ARDS). To address the current evidence supporting its use in different clinical scenarios along the ARDS management continuum. DATA SOURCES We performed an online search in Pubmed to review articles. We searched MEDLINE, Cochrane Central Register, and clinicaltrials.gov for controlled trials databases. STUDY SELECTION Selected publications included case series, pilot-physiologic studies, observational cohorts, and randomized controlled trials. To describe the rationale underlying physiologic principles, we included experimental studies. DATA EXTRACTION Data from relevant publications were reviewed, analyzed, and its content summarized. DATA SYNTHESIS Electrical impedance tomography is an imaging technique that has aided in understanding the mechanisms underlying multiple interventions used in ARDS management. It has the potential to monitor and predict the response to prone positioning, aid in the dosage of flow rate in high-flow nasal cannula, and guide the titration of positive-end expiratory pressure during invasive mechanical ventilation. The latter has been demonstrated to improve physiologic and mechanical parameters correlating with lung recruitment. Similarly, its use in detecting pneumothorax and harmful patient-ventilator interactions such as pendelluft has been proven effective. Nonetheless, its impact on clinically meaningful outcomes remains to be determined. CONCLUSIONS Electrical impedance tomography is a potential tool for the individualized management of ARDS throughout its different stages. Clinical trials should aim to determine whether a specific approach can improve clinical outcomes in ARDS management.
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Gavrielatou E, Vaporidi K, Tsolaki V, Tserlikakis N, Zakynthinos GE, Papoutsi E, Maragkuti A, Mantelou AG, Karayiannis D, Mastora Z, Georgopoulos D, Zakynthinos E, Routsi C, Zakynthinos SG, Schenck EJ, Kotanidou A, Siempos II. Rapidly improving acute respiratory distress syndrome in COVID-19: a multi-centre observational study. Respir Res 2022; 23:94. [PMID: 35422037 PMCID: PMC9008400 DOI: 10.1186/s12931-022-02015-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 04/02/2022] [Indexed: 11/23/2022] Open
Abstract
Background Before the pandemic of coronavirus disease (COVID-19), rapidly improving acute respiratory distress syndrome (ARDS), mostly defined by early extubation, had been recognized as an increasingly prevalent subphenotype (making up 15–24% of all ARDS cases), associated with good prognosis (10% mortality in ARDSNet trials). We attempted to determine the prevalence and prognosis of rapidly improving ARDS and of persistent severe ARDS related to COVID-19. Methods We included consecutive patients with COVID-19 receiving invasive mechanical ventilation in three intensive care units (ICU) during the second pandemic wave in Greece. We defined rapidly improving ARDS as extubation or a partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2:FiO2) greater than 300 on the first day following intubation. We defined persistent severe ARDS as PaO2:FiO2 of equal to or less than 100 on the second day following intubation. Results A total of 280 intubated patients met criteria of ARDS with a median PaO2:FiO2 of 125.0 (interquartile range 93.0–161.0) on day of intubation, and overall ICU-mortality of 52.5% (ranging from 24.3 to 66.9% across the three participating sites). Prevalence of rapidly improving ARDS was 3.9% (11 of 280 patients); no extubation occurred on the first day following intubation. ICU-mortality of patients with rapidly improving ARDS was 54.5%. This low prevalence and high mortality rate of rapidly improving ARDS were consistent across participating sites. Prevalence of persistent severe ARDS was 12.1% and corresponding mortality was 82.4%. Conclusions Rapidly improving ARDS was not prevalent and was not associated with good prognosis among patients with COVID-19. This is starkly different from what has been previously reported for patients with ARDS not related to COVID-19. Our results on both rapidly improving ARDS and persistent severe ARDS may contribute to our understanding of trajectory of ARDS and its association with prognosis in patients with COVID-19. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-02015-8.
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Gavrielatou E, Xourgia E, Xixi NA, Mantelou AG, Ischaki E, Kanavou A, Zervakis D, Routsi C, Kotanidou A, Siempos II. Effect of Vitamin C on Clinical Outcomes of Critically Ill Patients With COVID-19: An Observational Study and Subsequent Meta-Analysis. Front Med (Lausanne) 2022; 9:814587. [PMID: 35223911 PMCID: PMC8873176 DOI: 10.3389/fmed.2022.814587] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/19/2022] [Indexed: 12/15/2022] Open
Abstract
Background Whether vitamin C provides any benefit when administered in critically ill patients, including those with coronavirus disease (COVID-19), is controversial. We endeavored to estimate the effect of administration of vitamin C on clinical outcomes of critically ill patients with COVID-19 by performing an observational study and subsequent meta-analysis. Methods Firstly, we conducted an observational study of critically ill patients with laboratory-confirmed COVID-19 who consecutively underwent invasive mechanical ventilation in an academic intensive care unit (ICU) during the second pandemic wave. We compared all-cause mortality of patients receiving vitamin C (“vitamin C” group) or not (“control” group) on top of standard-of-care. Subsequently, we systematically searched PubMed and CENTRAL for relevant studies, which reported on all-cause mortality (primary outcome) and/or morbidity of critically ill patients with COVID-19 receiving vitamin C or not treatment. Pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using a random effects model. The meta-analysis was registered with PROSPERO. Results In the observational study, baseline characteristics were comparable between the two groups. Mortality was 20.0% (2/10) in the vitamin C group vs. 47.6% (49/103; p = 0.11) in the control group. Subsequently, the meta-analysis included 11 studies (6 observational; five randomized controlled trials) enrolling 1,807 critically ill patients with COVID-19. Mortality of patients receiving vitamin C on top of standard-of-care was not lower than patients receiving standard-of-care alone (25.8 vs. 34.7%; RR 0.85, 95% CI 0.57–1.26; p = 0.42). Conclusions After combining results of our observational cohort with those of relevant studies into a meta-analysis of data from 1,807 patients, we found that administration vitamin C as opposed to standard-of-care alone might not be associated with lower of mortality among critically ill patients with COVID-19. Additional evidence is anticipated from relevant large randomized controlled trials which are currently underway. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42021276655.
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Affiliation(s)
- Evdokia Gavrielatou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Xourgia
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikoleta A. Xixi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Athina G. Mantelou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Ischaki
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Aggeliki Kanavou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitris Zervakis
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Christina Routsi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ilias I. Siempos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York-Presbyterian Hospital, Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, United States
- *Correspondence: Ilias I. Siempos
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Alipanah N, Calfee CS. Phenotyping in acute respiratory distress syndrome: state of the art and clinical implications. Curr Opin Crit Care 2022; 28:1-8. [PMID: 34670998 PMCID: PMC8782441 DOI: 10.1097/mcc.0000000000000903] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Decades of research in acute respiratory distress syndrome (ARDS) have led to few interventions that impact clinical outcomes. The pandemic of patients with ARDS due to the novel SARS-CoV-2 infection has stressed the need for more effective therapies in ARDS. Phenotyping may enable successful trials and precision therapeutics in this patient population. RECENT FINDINGS Clinical phenotypes that group patients by shared cause, time-course or radiographic presentation are of prognostic value, but their use is limited by misclassification. Physiological phenotypes, including the P/F ratio, ventilatory ratio and dead space fraction, predict poor outcomes but can rapidly change, making them unstable over time. Biologic phenotypes have prognostic value with composite clinical and biomarker sub-phenotypes additionally impacting treatment response but are yet to be prospectively validated. SUMMARY Although much progress has been made in ARDS phenotyping, implementation of precision medicine practices will depend on conducting phenotype-aware trials using rapid point of care assays or machine learning algorithms. Omics studies will enhance our understanding of biologic determinants of clinical outcomes in ARDS sub-phenotypes. Whether biologic ARDS sub-phenotypes are specific to this syndrome or rather more broadly identify endotypes of critical illness remains to be determined.
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Affiliation(s)
- Narges Alipanah
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco
| | - Carolyn S. Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco
- Department of Anesthesia, University of California San Francisco
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Chalmers SJ, Lal A, Gajic O, Kashyap R. Timing of ARDS Resolution (TARU): A Pragmatic Clinical Assessment of ARDS Resolution in the ICU. Lung 2021; 199:439-445. [PMID: 34585258 PMCID: PMC8478608 DOI: 10.1007/s00408-021-00479-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 09/13/2021] [Indexed: 12/14/2022]
Abstract
Purpose Lack of a pragmatic outcome measures for acute respiratory distress syndrome (ARDS) resolution is a barrier to meaningful interventional trials of novel treatments. We evaluated a pragmatic, electronic health record (EHR)-based approach toward the clinical assessment of a novel outcome measure: ICU ARDS resolution. Methods We conducted a retrospective observational cohort study evaluating adult patients with moderate–severe ARDS admitted to the medical intensive care unit (ICU) at Mayo Clinic in Rochester, MN, from January 2001 through December 2010. We compared the association of ICU ARDS resolution vs non-resolution with mortality. ICU ARDS resolution was defined as improvement in P/F > 200 for at least 48 h or (if arterial blood gas unavailable) SpO2:FiO2 (S/F) > 235, or discharge prior to 48 h from first P/F > 200 without subsequent decline in P/F, as documented in EHR. Results Of the 254 patients included, ICU ARDS resolution was achieved in 179 (70%). Hospital mortality was lower in patients who met ICU ARDS resolution criteria as compared to those who did not (23% vs. 41%, p < 0.01). After adjusting for age, gender, and illness severity, the patients who met ICU ARDS resolution criteria had lower odds of hospital mortality [odds ratio 0.47, 95% CI 0.25–0.86; p = 0.015]. Conclusion The electronic health record-based pragmatic measure of ICU ARDS resolution is associated with patient outcomes and may serve as an intermediate outcome assessing novel mechanistic treatments.
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Affiliation(s)
- Sarah J Chalmers
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC-EPM), Mayo Clinic, Rochester, MN, USA. .,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA. .,Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Amos Lal
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC-EPM), Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC-EPM), Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rahul Kashyap
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC-EPM), Mayo Clinic, Rochester, MN, USA.,Department of Anesthesia, Mayo Clinic, Rochester, MN, USA
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Identification of persistent and resolving subphenotypes of acute hypoxemic respiratory failure in two independent cohorts. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:336. [PMID: 34526076 PMCID: PMC8442814 DOI: 10.1186/s13054-021-03755-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/31/2021] [Indexed: 01/02/2023]
Abstract
Background Acute hypoxemic respiratory failure (HRF) is associated with high morbidity and mortality, but its heterogeneity challenges the identification of effective therapies. Defining subphenotypes with distinct prognoses or biologic features can improve therapeutic trials, but prior work has focused on ARDS, which excludes many acute HRF patients. We aimed to characterize persistent and resolving subphenotypes in the broader HRF population.
Methods In this secondary analysis of 2 independent prospective ICU cohorts, we included adults with acute HRF, defined by invasive mechanical ventilation and PaO2-to-FIO2 ratio ≤ 300 on cohort enrollment (n = 768 in the discovery cohort and n = 1715 in the validation cohort). We classified patients as persistent HRF if still requiring mechanical ventilation with PaO2-to-FIO2 ratio ≤ 300 on day 3 following ICU admission, or resolving HRF if otherwise. We estimated relative risk of 28-day hospital mortality associated with persistent HRF, compared to resolving HRF, using generalized linear models. We also estimated fold difference in circulating biomarkers of inflammation and endothelial activation on cohort enrollment among persistent HRF compared to resolving HRF. Finally, we stratified our analyses by ARDS to understand whether this was driving differences between persistent and resolving HRF.
Results Over 50% developed persistent HRF in both the discovery (n = 386) and validation (n = 1032) cohorts. Persistent HRF was associated with higher risk of death relative to resolving HRF in both the discovery (1.68-fold, 95% CI 1.11, 2.54) and validation cohorts (1.93-fold, 95% CI 1.50, 2.47), after adjustment for age, sex, chronic respiratory illness, and acute illness severity on enrollment (APACHE-III in discovery, APACHE-II in validation). Patients with persistent HRF displayed higher biomarkers of inflammation (interleukin-6, interleukin-8) and endothelial dysfunction (angiopoietin-2) than resolving HRF after adjustment. Only half of persistent HRF patients had ARDS, yet exhibited higher mortality and biomarkers than resolving HRF regardless of whether they qualified for ARDS. Conclusion Patients with persistent HRF are common and have higher mortality and elevated circulating markers of lung injury compared to resolving HRF, and yet only a subset are captured by ARDS definitions. Persistent HRF may represent a clinically important, inclusive target for future therapeutic trials in HRF. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03755-7.
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Liu X, Jiang Y, Jia X, Ma X, Han C, Guo N, Peng Y, Liu H, Ju Y, Luo X, Li X, Bu Y, Zhang J, Liu Y, Gao Y, Zhao M, Wang H, Luo L, Yu K, Wang C. Identification of distinct clinical phenotypes of acute respiratory distress syndrome with differential responses to treatment. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:320. [PMID: 34461969 PMCID: PMC8404019 DOI: 10.1186/s13054-021-03734-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/18/2021] [Indexed: 02/05/2023]
Abstract
Background Acute respiratory distress syndrome (ARDS) is a heterogeneous syndrome, and the identification of homogeneous subgroups and phenotypes is the first step toward precision critical care. We aimed to explore whether ARDS phenotypes can be identified using clinical data, are reproducible and are associated with clinical outcomes and treatment response. Methods This study is based on a retrospective analysis of data from the telehealth intensive care unit (eICU) collaborative research database and three ARDS randomized controlled trials (RCTs) (ALVEOLI, FACTT and SAILS trials). We derived phenotypes in the eICU by cluster analysis based on clinical data and compared the clinical characteristics and outcomes of each phenotype. The reproducibility of the derived phenotypes was tested using the data from three RCTs, and treatment effects were evaluated. Results Three clinical phenotypes were identified in the training cohort of 3875 ARDS patients. Of the three phenotypes identified, phenotype I (n = 1565; 40%) was associated with fewer laboratory abnormalities, less organ dysfunction and the lowest in-hospital mortality rate (8%). Phenotype II (n = 1232; 32%) was correlated with more inflammation and shock and had a higher mortality rate (18%). Phenotype III (n = 1078; 28%) was strongly correlated with renal dysfunction and acidosis and had the highest mortality rate (22%). These results were validated using the data from the validation cohort (n = 3670) and three RCTs (n = 2289) and had reproducibility. Patients with these ARDS phenotypes had different treatment responses to randomized interventions. Specifically, in the ALVEOLI cohort, the effects of ventilation strategy (high PEEP vs low PEEP) on ventilator-free days differed by phenotype (p = 0.001); in the FACTT cohort, there was a significant interaction between phenotype and fluid-management strategy for 60-day mortality (p = 0.01). The fluid-conservative strategy was associated with improved mortality in phenotype II but had the opposite effect in phenotype III. Conclusion Three clinical phenotypes of ARDS were identified and had different clinical characteristics and outcomes. The analysis shows evidence of a phenotype-specific treatment benefit in the ALVEOLI and FACTT trials. These findings may improve the identification of distinct subsets of ARDS patients for exploration in future RCTs. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03734-y.
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Affiliation(s)
- Xiaowei Liu
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Yusheng Jiang
- LinkDoc AI Lab, LinkDoc Technology, Floor 11, Sinosteel Plaza, 8 Haidian Street, Haidian District, Beijing, 100080, China
| | - Xiaonan Jia
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Xiaohui Ma
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Ci Han
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Nana Guo
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, 150 Haping Road, Nangang District, Harbin, 150081, Heilongjiang, China
| | - Yahui Peng
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Haitao Liu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, 150 Haping Road, Nangang District, Harbin, 150081, Heilongjiang, China
| | - Yingnan Ju
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, 150 Haping Road, Nangang District, Harbin, 150081, Heilongjiang, China
| | - Xiangfeng Luo
- LinkDoc AI Lab, LinkDoc Technology, Floor 11, Sinosteel Plaza, 8 Haidian Street, Haidian District, Beijing, 100080, China
| | - Xueting Li
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, 150 Haping Road, Nangang District, Harbin, 150081, Heilongjiang, China
| | - Yue Bu
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Jin Zhang
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Yansong Liu
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Yan Gao
- Department of Critical Care Medicine, Forth Affiliated Hospital of Harbin Medical University, 37 Yiyuan Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Mingyan Zhao
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Hongliang Wang
- Department of Critical Care Medicine, Second Affiliated Hospital of Harbin Medical University, 246 Xuefu Road, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Ligang Luo
- LinkDoc AI Lab, LinkDoc Technology, Floor 11, Sinosteel Plaza, 8 Haidian Street, Haidian District, Beijing, 100080, China
| | - Kaijiang Yu
- Department of Critical Care Medicine, First Affiliated Hospital of Harbin Medical University, 23 Postal Street, Nangang District, Harbin, 150001, Heilongjiang, China.
| | - Changsong Wang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, 150 Haping Road, Nangang District, Harbin, 150081, Heilongjiang, China.
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Goligher EC, Costa ELV, Yarnell CJ, Brochard LJ, Stewart TE, Tomlinson G, Brower RG, Slutsky AS, Amato MPB. Effect of Lowering Vt on Mortality in Acute Respiratory Distress Syndrome Varies with Respiratory System Elastance. Am J Respir Crit Care Med 2021; 203:1378-1385. [PMID: 33439781 DOI: 10.1164/rccm.202009-3536oc] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Rationale: If the risk of ventilator-induced lung injury in acute respiratory distress syndrome (ARDS) is causally determined by driving pressure rather than by Vt, then the effect of ventilation with lower Vt on mortality would be predicted to vary according to respiratory system elastance (Ers). Objectives: To determine whether the mortality benefit of ventilation with lower Vt varies according to Ers. Methods: In a secondary analysis of patients from five randomized trials of lower- versus higher-Vt ventilation strategies in ARDS and acute hypoxemic respiratory failure, the posterior probability of an interaction between the randomized Vt strategy and Ers on 60-day mortality was computed using Bayesian multivariable logistic regression. Measurements and Main Results: Of 1,096 patients available for analysis, 416 (38%) died by Day 60. The posterior probability that the mortality benefit from lower-Vt ventilation strategies varied with Ers was 93% (posterior median interaction odds ratio, 0.80 per cm H2O/[ml/kg]; 90% credible interval, 0.63-1.02). Ers was classified as low (<2 cm H2O/[ml/kg], n = 321, 32%), intermediate (2-3 cm H2O/[ml/kg], n = 475, 46%), and high (>3 cm H2O/[ml/kg], n = 224, 22%). In these groups, the posterior probabilities of an absolute risk reduction in mortality ≥ 1% were 55%, 82%, and 92%, respectively. The posterior probabilities of an absolute risk reduction ≥ 5% were 29%, 58%, and 82%, respectively. Conclusions: The mortality benefit of ventilation with lower Vt in ARDS varies according to elastance, suggesting that lung-protective ventilation strategies should primarily target driving pressure rather than Vt.
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Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto General Hospital, Toronto, Ontario, Canada
| | - Eduardo L V Costa
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Brazil.,Research and Education Institute, Hospital Sírio-Libanes, São Paulo, Brazil
| | - Christopher J Yarnell
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - George Tomlinson
- Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Roy G Brower
- Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Marcelo P B Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Brazil
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35
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He H, Chi Y, Yang Y, Yuan S, Long Y, Zhao P, Frerichs I, Fu F, Möller K, Zhao Z. Early individualized positive end-expiratory pressure guided by electrical impedance tomography in acute respiratory distress syndrome: a randomized controlled clinical trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:230. [PMID: 34193224 PMCID: PMC8243615 DOI: 10.1186/s13054-021-03645-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/16/2021] [Indexed: 12/16/2022]
Abstract
Background Individualized positive end-expiratory pressure (PEEP) by electrical impedance tomography (EIT) has potential interest in the optimization of ventilation distribution in acute respiratory distress syndrome (ARDS). The aim of the study was to determine whether early individualized titration of PEEP with EIT improved outcomes in patients with ARDS. Methods A total of 117 ARDS patients receiving mechanical ventilation were randomly assigned to EIT group (n = 61, PEEP adjusted based on ventilation distribution) or control group (n = 56, low PEEP/FiO2 table). The primary outcome was 28-day mortality. Secondary and exploratory outcomes were ventilator-free days, length of ICU stay, incidence of pneumothorax and barotrauma, and difference in Sequential Organ Failure Assessment (SOFA) score at day 1 (ΔD1-SOFA) and day 2 (ΔD2-SOFA) compared with baseline. Measurements and main results There was no statistical difference in the value of PEEP between the EIT group and control group, but the combination of PEEP and FiO2 was different between groups. In the control group, a significantly positive correlation was found between the PEEP value and the corresponding FiO2 (r = 0.47, p < 0.00001) since a given matched table was used for PEEP settings. Diverse combinations of PEEP and FiO2 were found in the EIT group (r = 0.05, p = 0.68). There was no significant difference in mortality rate (21% vs. 27%, EIT vs. control, p = 0.63), ICU length of stay (13.0 (7.0, 25.0) vs 10.0 (7.0, 14.8), median (25th–75th percentile); p = 0.17), and ventilator-free days at day 28 (14.0 (2.0, 23.0) vs 19.0 (0.0, 24.0), p = 0.55) between the two groups. The incidence of new barotrauma was zero. Compared with control group, significantly lower ΔD1-SOFA and ΔD2-SOFA were found in the EIT group (p < 0.001) in a post hoc comparison. Moreover, the EIT group exhibited a significant decrease of SOFA at day 2 compared with baseline (paired t-test, difference by − 1 (− 3.5, 0), p = 0.001). However, the control group did show a similar decrease (difference by 1 (− 2, 2), p = 0.131). Conclusion Our study showed a 6% absolute decrease in mortality in the EIT group: a statistically non-significant, but clinically non-negligible result. This result along with the showed improvement in organ function might justify further reserach to validate the beneficial effect of individualized EIT-guided PEEP setting on clinical outcomes of patients with ARDS. Trial registration: ClinicalTrials, NCT02361398. Registered 11 February 2015—prospectively registered, https://clinicaltrials.gov/show/NCT02361398.
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Affiliation(s)
- Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Chi
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yingying Yang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Siyi Yuan
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
| | - Pengyu Zhao
- Department of Administration, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Inéz Frerichs
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center of Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Feng Fu
- Department of Biomedical Engineering, Fourth Military Medical University, 169 Changle Xi Rd, Xi'an, China
| | - Knut Möller
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Zhanqi Zhao
- Department of Biomedical Engineering, Fourth Military Medical University, 169 Changle Xi Rd, Xi'an, China. .,Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany.
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36
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Hensley MK, Sjoding MW, Prescott HC. COUNTERPOINT: Should Corticosteroids Be Routine Treatment in Early ARDS? No. Chest 2021; 159:29-33. [PMID: 33422201 DOI: 10.1016/j.chest.2020.07.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Matthew K Hensley
- Division of Pulmonary, Allergy, and Critical Care Medicine, Unstiversity of Pittsburgh, Pittsburgh, PA.
| | - Michael W Sjoding
- Department of Internal Medicine, Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI
| | - Hallie C Prescott
- Department of Internal Medicine, Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI
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37
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Rebuttal From Dr Hensley et al. Chest 2021; 159:34-35. [PMID: 33422203 DOI: 10.1016/j.chest.2020.07.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/19/2020] [Indexed: 11/21/2022] Open
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38
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Chiu LC, Lin SW, Liu PH, Chuang LP, Chang CH, Hung CY, Li SH, Lee CS, Wu HP, Huang CC, Li HH, Kao KC, Hu HC. Reclassifying severity after 48 hours could better predict mortality in acute respiratory distress syndrome. Ther Adv Respir Dis 2021; 14:1753466620936877. [PMID: 32631150 PMCID: PMC7343354 DOI: 10.1177/1753466620936877] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Disease severity may change in the first week after acute respiratory distress syndrome (ARDS) onset. The aim of this study was to evaluate whether the reclassification of disease severity after 48 h (i.e. day 3) of ARDS onset could help in predicting mortality and determine factors associated with ARDS persistence and mortality. METHODS We performed a secondary analysis of a 3-year prospective, observational cohort study of ARDS in a tertiary care referral center. Disease severity was reclassified after 48 h of enrollment, and cases that still fulfilled the Berlin criteria were regarded as nonresolving ARDS. RESULTS A total of 1034 ARDS patients were analyzed. Overall hospital mortality was 57.7% (56.7%, 57.5%, and 58.6% for patients with initial mild, moderate, and severe ARDS, respectively, p = 0.189). On day 3 reclassification, the hospital mortality rates were as follows: resolved (42.1%), mild (47.9%), moderate (62.4%), and severe ARDS (76.1%) (p < 0.001). Patients with improving severity on day 3 had lower mortality (48.8%), whereas patients with the same or worsening severity on day 3 had higher mortality (62.7% and 76.3%, respectively). Patients who were older, had lower PaO2/FiO2, or higher positive end-expiratory pressure on day 1 were significantly associated with nonresolving ARDS on day 3. A Cox regression model with ARDS severity as a time-dependent covariate and competing risk analysis demonstrated that ARDS severity was independently associated with hospital mortality, and nonresolving ARDS had significantly increased hazard of death than resolved ARDS (p < 0.0001). Cumulative mortality curve for ARDS severity comparisons demonstrated significantly different (overall comparison, p < 0.001). CONCLUSIONS Reclassification of disease severity after 48 h of ARDS onset could help to divide patients into subgroups with greater separation in terms of mortality. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Li-Chung Chiu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan.,Department of Thoracic Medicine, New Taipei Municipal TuCheng Hospital and Chang Gung University, Taoyuan
| | - Shih-Wei Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Pi-Hua Liu
- Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, Taoyuan.,Department of Internal Medicine, Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Taoyuan
| | - Li-Pang Chuang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Chih-Hao Chang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Department of Thoracic Medicine, New Taipei Municipal TuCheng Hospital and Chang Gung University, Taoyuan
| | - Chen-Yiu Hung
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Department of Thoracic Medicine, New Taipei Municipal TuCheng Hospital and Chang Gung University, Taoyuan
| | - Shih-Hong Li
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Chung-Shu Lee
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Huang-Pin Wu
- Division of Pulmonary, Critical Care and Sleep Medicine, Chang Gung Memorial Hospital, Keelung
| | - Chung-Chi Huang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan
| | - Hsin-Hsien Li
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan.,Department of Intensive Care, Xiamen Chang Gung Hospital, China
| | - Han-Chung Hu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., GuiShan, Taoyua 333.,Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.,Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan
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Torres LK, Hoffman KL, Oromendia C, Diaz I, Harrington JS, Schenck EJ, Price DR, Gomez-Escobar L, Higuera A, Vera MP, Baron RM, Fredenburgh LE, Huh JW, Choi AMK, Siempos II. Attributable mortality of acute respiratory distress syndrome: a systematic review, meta-analysis and survival analysis using targeted minimum loss-based estimation. Thorax 2021; 76:1176-1185. [PMID: 33863829 DOI: 10.1136/thoraxjnl-2020-215950] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 03/15/2021] [Accepted: 03/24/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although acute respiratory distress syndrome (ARDS) is associated with high mortality, its direct causal link with death is unclear. Clarifying this link is important to justify costly research on prevention of ARDS. OBJECTIVE To estimate the attributable mortality, if any, of ARDS. DESIGN First, we performed a systematic review and meta-analysis of observational studies reporting mortality of critically ill patients with and without ARDS matched for underlying risk factor. Next, we conducted a survival analysis of prospectively collected patient-level data from subjects enrolled in three intensive care unit (ICU) cohorts to estimate the attributable mortality of critically ill septic patients with and without ARDS using a novel causal inference method. RESULTS In the meta-analysis, 44 studies (47 cohorts) involving 56 081 critically ill patients were included. Mortality was higher in patients with versus without ARDS (risk ratio 2.48, 95% CI 1.86 to 3.30; p<0.001) with a numerically stronger association between ARDS and mortality in trauma than sepsis. In the survival analysis of three ICU cohorts enrolling 1203 critically ill patients, 658 septic patients were included. After controlling for confounders, ARDS was found to increase the mortality rate by 15% (95% CI 3% to 26%; p=0.015). Significant increases in mortality were seen for severe (23%, 95% CI 3% to 44%; p=0.028) and moderate (16%, 95% CI 2% to 31%; p=0.031), but not for mild ARDS. CONCLUSIONS ARDS has a direct causal link with mortality. Our findings provide information about the extent to which continued funding of ARDS prevention trials has potential to impart survival benefit. PROSPERO REGISTRATION NUMBER CRD42017078313.
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Affiliation(s)
- Lisa K Torres
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Katherine L Hoffman
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA
| | - Clara Oromendia
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA
| | - Ivan Diaz
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA
| | - John S Harrington
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Edward J Schenck
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - David R Price
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Luis Gomez-Escobar
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Angelica Higuera
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mayra Pinilla Vera
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rebecca M Baron
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Laura E Fredenburgh
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jin-Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center/University of Ulsan College of Medicine, Seoul, South Korea
| | - Augustine M K Choi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Ilias I Siempos
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA .,First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Athens General Hospital/National and Kapodistrian University of Athens Medical School, Athens, Greece
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40
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Zhan Z, Yang X, Du H, Zhang C, Song Y, Ran X, Zhang A, Yang M. Early Improvement of Acute Respiratory Distress Syndrome in Patients With COVID-19 in the Intensive Care Unit: Retrospective Analysis. JMIR Public Health Surveill 2021; 7:e24843. [PMID: 33630743 PMCID: PMC7945975 DOI: 10.2196/24843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Since the start of the COVID-19 pandemic, there have been over 2 million deaths globally. Acute respiratory distress syndrome (ARDS) may be the main cause of death. OBJECTIVE This study aimed to describe the clinical features, outcomes, and ARDS characteristics of patients with COVID-19 admitted to the intensive care unit (ICU) in Chongqing, China. METHODS The epidemiology of COVID-19 from January 21, 2020, to March 15, 2020, in Chongqing, China, was analyzed retrospectively, and 75 ICU patients from two hospitals were included in this study. On day 1, 56 patients with ARDS were selected for subgroup analysis, and a modified Poisson regression was performed to identify predictors for the early improvement of ARDS (eiARDS). RESULTS Chongqing reported a 5.3% case fatality rate for the 75 ICU patients. The median age of these patients was 57 (IQR 25-75) years, and no bias was present in the sex ratio. A total of 93% (n=70) of patients developed ARDS during ICU stay, and more than half had moderate ARDS. However, most patients (n=41, 55%) underwent high-flow nasal cannula oxygen therapy, but not mechanical ventilation. Nearly one-third of patients with ARDS improved (arterial blood oxygen partial pressure/oxygen concentration >300 mm Hg) in 1 week, which was defined as eiARDS. Patients with eiARDS had a higher survival rate and a shorter length of ICU stay than those without eiARDS. Age (<55 years) was the only variable independently associated with eiARDS, with a risk ratio of 2.67 (95% CI 1.17-6.08). CONCLUSIONS A new subphenotype of ARDS-eiARDS-in patients with COVID-19 was identified. As clinical outcomes differ, the stratified management of patients based on eiARDS or age is highly recommended.
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Affiliation(s)
- Zhu Zhan
- Department of Intensive Care Unit, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Ultrasound Molecular Imaging, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin Yang
- Department of Respiratory and Geriatrics, Chongqing Public Health Medical Center, Chongqing, China
| | - Hu Du
- Department of Intensive Care Unit, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chuanlai Zhang
- Department of Intensive Care Unit, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuyan Song
- Department of Intensive Care Unit, Chongqing Public Health Medical Center, Chongqing, China
| | - Xiaoyun Ran
- Department of Intensive Care Unit, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - An Zhang
- Department of Intensive Care Unit, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mei Yang
- Department of Intensive Care Unit, Chongqing Sixth People's Hospital, Chongqing, China
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41
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Price DR, Hoffman KL, Oromendia C, Torres LK, Schenck EJ, Choi ME, Choi AMK, Baron RM, Huh JW, Siempos II. Effect of Neutropenic Critical Illness on Development and Prognosis of Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2021; 203:504-508. [PMID: 32986956 DOI: 10.1164/rccm.202003-0753le] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ilias I Siempos
- Weill Cornell Medicine New York, New York.,National and Kapodistrian University of Athens Medical School Athens, Greece
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42
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Bos LDJ, Artigas A, Constantin JM, Hagens LA, Heijnen N, Laffey JG, Meyer N, Papazian L, Pisani L, Schultz MJ, Shankar-Hari M, Smit MR, Summers C, Ware LB, Scala R, Calfee CS. Precision medicine in acute respiratory distress syndrome: workshop report and recommendations for future research. Eur Respir Rev 2021; 30:30/159/200317. [PMID: 33536264 DOI: 10.1183/16000617.0317-2020] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/11/2020] [Indexed: 12/18/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a devastating critical illness that can be triggered by a wide range of insults and remains associated with a high mortality of around 40%. The search for targeted treatment for ARDS has been disappointing, possibly due to the enormous heterogeneity within the syndrome. In this perspective from the European Respiratory Society research seminar on "Precision medicine in ARDS", we will summarise the current evidence for heterogeneity, explore the evidence in favour of precision medicine and provide a roadmap for further research in ARDS. There is evident variation in the presentation of ARDS on three distinct levels: 1) aetiological; 2) physiological and 3) biological, which leads us to the conclusion that there is no typical ARDS. The lack of a common presentation implies that intervention studies in patients with ARDS need to be phenotype aware and apply a precision medicine approach in order to avoid the lack of success in therapeutic trials that we faced in recent decades. Deeper phenotyping and integrative analysis of the sources of variation might result in identification of additional treatable traits that represent specific pathobiological mechanisms, or so-called endotypes.
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Affiliation(s)
- Lieuwe D J Bos
- Intensive Care, Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands .,Laboratory of Intensive Care and Anesthesiology Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Dept of Respiratory Medicine, Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Antonio Artigas
- Critical Care Center, Corporació Sanitaria Universitaria Parc Tauli, CIBER Enfermedades Respiratorias, Autonomouus University of Barcelona, Sabadell, Spain
| | - Jean-Michel Constantin
- Dept of Anaesthesiology and Critical Care, Sorbonne University, GRC 29, AP-HP, DMU DREAM, Pitié-Salpêtrière Hospital, Paris, France
| | - Laura A Hagens
- Intensive Care, Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nanon Heijnen
- Intensive care, Maastricht UMC, University of Maastricht, Maastricht, The Netherlands
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.,Dept of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Galway, Ireland
| | - Nuala Meyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Laurent Papazian
- Intensive Care Medicine and regional ECMO center, North hospital - Aix-Marseille University, Marseille, France
| | - Lara Pisani
- Dipartimento Cardio-Toraco-Vascolare, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Marcus J Schultz
- Intensive Care, Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Intensive Care and Anesthesiology Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Dept of Respiratory Medicine, Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Manu Shankar-Hari
- School of Immunology & Microbial Sciences, Kings College London, London, UK
| | - Marry R Smit
- Intensive Care, Amsterdam UMC - location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Raffaele Scala
- Respiratory Division with Pulmonary Intensive Care Unit, S. Donato Hospital, Usl Toscana Sudest, Arezzo, Italy
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Dept of Medicine, University of California, San Francisco, CA, USA.,Dept of Anesthesia, University of California, San Francisco, CA, USA
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43
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Prone Ventilation for Patients with Mild or Moderate Acute Respiratory Distress Syndrome. Ann Am Thorac Soc 2021; 17:24-29. [PMID: 31532692 DOI: 10.1513/annalsats.201906-456ip] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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44
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Torbic H, Krishnan S, Harnegie MP, Duggal A. Neuromuscular Blocking Agents for ARDS: A Systematic Review and Meta-Analysis. Respir Care 2021; 66:120-128. [PMID: 32843506 PMCID: PMC9993827 DOI: 10.4187/respcare.07849] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Studies evaluating neuromuscular blocking agents (NMBAs) in the management of ARDS have produced inconsistent results in terms of their effect on mortality. The purpose of this systematic review and meta-analysis was to evaluate differences in mortality comparing subjects with ARDS who received NMBA to those who received placebo or usual care. METHODS We searched Ovid, MEDLINE, Embase, CINAHL, Cochrane, Scopus, and Web of Science for randomized controlled trials evaluating administration of NMBAs in subjects with ARDS. RESULTS We included 6 studies (N = 1,558 subjects) from 1,814 abstracts identified by our search strategy. The use of early, continuous-infusion NMBAs reduces the risk of short-term (ie, 21-28-d) mortality (relative risk 0.71 [95% CI 0.52-0.98], P = .030, I 2 = 60%) in subjects with ARDS but does not reduce the risk of long-term (ie, 90-d) mortality (relative risk 0.81 [95% CI 0.64-1.04], P = .10, I 2 = 54%). NMBAs decreased the risk of barotrauma (relative risk 0.55 [95% CI 0.35-0.85], P = .008, I 2 = 0%) and pneumothorax (relative risk 0.46 [95% CI 0.28-0.77], P = .003, I 2 = 0%) compared to control. CONCLUSIONS In subjects with ARDS, early use of NMBAs improves oxygenation, reduces the incidence of ventilator-induced lung injury, and decreases 21-28-d mortality, but it does not improve 90-d mortality. NMBAs should be considered for select patients with moderate-to-severe ARDS for short durations.
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Affiliation(s)
- Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio.
| | - Sudhir Krishnan
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
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45
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Price DR, Hoffman KL, Sanchez E, Choi AMK, Siempos II. Temporal trends of outcomes of neutropenic patients with ARDS enrolled in therapeutic clinical trials. Intensive Care Med 2021; 47:122-123. [PMID: 33034690 PMCID: PMC7545373 DOI: 10.1007/s00134-020-06263-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 11/30/2022]
Affiliation(s)
- David R Price
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, 1300 York Avenue, New York, NY, 10065, USA.,Department of Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Katherine L Hoffman
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Elizabeth Sanchez
- Department of Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Augustine M K Choi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, 1300 York Avenue, New York, NY, 10065, USA.,Department of Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Ilias I Siempos
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, 1300 York Avenue, New York, NY, 10065, USA. .,First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece.
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Major publications in the critical care pharmacotherapy literature: 2019. J Crit Care 2020; 62:197-205. [PMID: 33422810 DOI: 10.1016/j.jcrc.2020.12.018] [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] [Received: 07/22/2020] [Revised: 12/07/2020] [Accepted: 12/20/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE To summarize selected meta-analyses and trials related to critical care pharmacotherapy published in 2019. MATERIALS AND METHODS The Critical Care Pharmacotherapy Literature Update (CCPLU) Group screened 36 journals monthly for impactful articles and reviewed 113 articles during 2019 according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. RESULTS Articles with a 1A grade, including three clinical practice guidelines, six meta-analyses, and five original research trials are reviewed here from those included in the monthly CCPLU. Clinical practice guidelines on the use of polymyxins and antiarrhythmic drugs in cardiac arrest as well as meta-analyses on antipsychotic use in delirium, stress ulcer prophylaxis (SUP), and vasoactive medications in septic shock and cardiac arrest were summarized. Original research trials evaluated delirium, sedation, neuromuscular blockade, SUP, anticoagulation reversal, and hemostasis. CONCLUSION This clinical review and expert opinion provides summary and perspectives of clinical practice impact on influential critical care pharmacotherapy publications in 2019.
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Cloonan SM, Kim K, Esteves P, Trian T, Barnes PJ. Mitochondrial dysfunction in lung ageing and disease. Eur Respir Rev 2020; 29:29/157/200165. [PMID: 33060165 DOI: 10.1183/16000617.0165-2020] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/25/2020] [Indexed: 12/12/2022] Open
Abstract
Mitochondrial biology has seen a surge in popularity in the past 5 years, with the emergence of numerous new avenues of exciting mitochondria-related research including immunometabolism, mitochondrial transplantation and mitochondria-microbe biology. Since the early 1960s mitochondrial dysfunction has been observed in cells of the lung in individuals and in experimental models of chronic and acute respiratory diseases. However, it is only in the past decade with the emergence of more sophisticated tools and methodologies that we are beginning to understand how this enigmatic organelle regulates cellular homeostasis and contributes to disease processes in the lung. In this review, we highlight the diverse role of mitochondria in individual lung cell populations and what happens when these essential organelles become dysfunctional with ageing and in acute and chronic lung disease. Although much remains to be uncovered, we also discuss potential targeted therapeutics for mitochondrial dysfunction in the ageing and diseased lung.
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Affiliation(s)
- Suzanne M Cloonan
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Dept of Medicine, New York, NY, USA.,School of Medicine, Trinity College Dublin and Tallaght University Hospital, Dublin, Ireland
| | - Kihwan Kim
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Dept of Medicine, New York, NY, USA
| | - Pauline Esteves
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, Dépt de Pharmacologie, CIC 1401, Bordeaux, France.,INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France
| | - Thomas Trian
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, Dépt de Pharmacologie, CIC 1401, Bordeaux, France.,INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France
| | - Peter J Barnes
- National Heart and Lung Institute, Imperial College, London, UK
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Spadaro S, Capuzzo M, Volta CA. Fatigue of ICU Survivors, No Longer to Be Neglected. Chest 2020; 158:848-849. [DOI: 10.1016/j.chest.2020.05.521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 05/02/2020] [Indexed: 01/09/2023] Open
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49
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Subphenotypes in critical care: translation into clinical practice. THE LANCET RESPIRATORY MEDICINE 2020; 8:631-643. [PMID: 32526190 DOI: 10.1016/s2213-2600(20)30124-7] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/06/2020] [Accepted: 03/05/2020] [Indexed: 12/14/2022]
Abstract
Despite progress in the supportive care available for critically ill patients, few advances have been made in the search for effective disease-modifying therapeutic options. The fact that many trials in critical care medicine have not identified a treatment benefit is probably due, in part, to the underlying heterogeneity of critical care syndromes. Numerous approaches have been proposed to divide populations of critically ill patients into more meaningful subgroups (subphenotypes), some of which might be more useful than others. Subclassification systems driven by clinical features and biomarkers have been proposed for acute respiratory distress syndrome, sepsis, acute kidney injury, and pancreatitis. Identifying the systems that are most useful and biologically meaningful could lead to a better understanding of the pathophysiology of critical care syndromes and the discovery of new treatment targets, and allow recruitment in future therapeutic trials to focus on predicted responders. This Review discusses proposed subphenotypes of critical illness syndromes and highlights the issues that will need to be addressed to translate subphenotypes into clinical practice.
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50
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Supervised machine learning for the early prediction of acute respiratory distress syndrome (ARDS). J Crit Care 2020; 60:96-102. [PMID: 32777759 DOI: 10.1016/j.jcrc.2020.07.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 06/25/2020] [Accepted: 07/19/2020] [Indexed: 01/28/2023]
Abstract
PURPOSE Acute respiratory distress syndrome (ARDS) is a serious respiratory condition with high mortality and associated morbidity. The objective of this study is to develop and evaluate a novel application of gradient boosted tree models trained on patient health record data for the early prediction of ARDS. MATERIALS AND METHODS 9919 patient encounters were retrospectively analyzed from the Medical Information Mart for Intensive Care III (MIMIC-III) data base. XGBoost gradient boosted tree models for early ARDS prediction were created using routinely collected clinical variables and numerical representations of radiology reports as inputs. XGBoost models were iteratively trained and validated using 10-fold cross validation. RESULTS On a hold-out test set, algorithm classifiers attained area under the receiver operating characteristic curve (AUROC) values of 0.905 when tested for the detection of ARDS at onset and 0.827, 0.810, and 0.790 for the prediction of ARDS at 12-, 24-, and 48-h windows prior to onset, respectively. CONCLUSION Supervised machine learning predictions may help predict patients with ARDS up to 48 h prior to onset.
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