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Xu H, Sheng S, Luo W, Xu X, Zhang Z. Acute respiratory distress syndrome heterogeneity and the septic ARDS subgroup. Front Immunol 2023; 14:1277161. [PMID: 38035100 PMCID: PMC10682474 DOI: 10.3389/fimmu.2023.1277161] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is an acute diffuse inflammatory lung injury characterized by the damage of alveolar epithelial cells and pulmonary capillary endothelial cells. It is mainly manifested by non-cardiogenic pulmonary edema, resulting from intrapulmonary and extrapulmonary risk factors. ARDS is often accompanied by immune system disturbance, both locally in the lungs and systemically. As a common heterogeneous disease in critical care medicine, researchers are often faced with the failure of clinical trials. Latent class analysis had been used to compensate for poor outcomes and found that targeted treatment after subgrouping contribute to ARDS therapy. The subphenotype of ARDS caused by sepsis has garnered attention due to its refractory nature and detrimental consequences. Sepsis stands as the most predominant extrapulmonary cause of ARDS, accounting for approximately 32% of ARDS cases. Studies indicate that sepsis-induced ARDS tends to be more severe than ARDS caused by other factors, leading to poorer prognosis and higher mortality rate. This comprehensive review delves into the immunological mechanisms of sepsis-ARDS, the heterogeneity of ARDS and existing research on targeted treatments, aiming to providing mechanism understanding and exploring ideas for accurate treatment of ARDS or sepsis-ARDS.
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Affiliation(s)
- Huikang Xu
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shiying Sheng
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Weiwei Luo
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaofang Xu
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhaocai Zhang
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of the Diagnosis and Treatment for Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
- Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China
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Early Identification and Diagnostic Approach in Acute Respiratory Distress Syndrome (ARDS). Diagnostics (Basel) 2021; 11:diagnostics11122307. [PMID: 34943543 PMCID: PMC8700413 DOI: 10.3390/diagnostics11122307] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 12/15/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening condition defined by the acute onset of severe hypoxemia with bilateral pulmonary infiltrates, in the absence of a predominant cardiac involvement. Whereas the current Berlin definition was proposed in 2012 and mainly focused on intubated patients under invasive mechanical ventilation, the recent COVID-19 pandemic has highlighted the need for a more comprehensive definition of ARDS including patients treated with noninvasive oxygenation strategies, especially high-flow nasal oxygen therapy, and fulfilling all other diagnostic criteria. Early identification of ARDS in patients breathing spontaneously may allow assessment of earlier initiation of pharmacological and non-pharmacological treatments. In the same way, accurate identification of the ARDS etiology is obviously of paramount importance for early initiation of adequate treatment. The precise underlying etiological diagnostic (bacterial, viral, fungal, immune, malignant, drug-induced, etc.) as well as the diagnostic approach have been understudied in the literature. To date, no clinical practice guidelines have recommended structured diagnostic work-up in ARDS patients. In addition to lung-protective ventilation with the aim of preventing worsening lung injury, specific treatment of the underlying cause has a central role to improve outcomes. In this review, we discuss early identification of ARDS in non-intubated patients breathing spontaneously and propose a structured diagnosis work-up.
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Ruan SY, Huang CT, Chang HT, Liu WL, Wang WJ, Tseng YT, Yang HC, Kuo LC, Chien JY, Wu HD. Construct Validity of PaO2/FiO2 Ratios in Defining Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2021; 205:364-366. [PMID: 34874819 DOI: 10.1164/rccm.202108-1924le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sheng-Yuan Ruan
- National Taiwan University Hospital, 38006, Department of Internal Medicine, Taipei, Taiwan;
| | - Chun-Ta Huang
- National Taiwan University Hospital, 38006, Internal Medicine, Taipei, Taiwan
| | - Hou-Tai Chang
- Far Eastern Memorial Hospital, 46608, New Taipei City, Taiwan
| | - Wei-Lun Liu
- Fu Jen Catholic University Hospital, 485856, New Taipei City, Taiwan
| | - Wei-Jhen Wang
- National Taiwan University Hospital, 38006, Taipei, Taiwan
| | - Yun-Ting Tseng
- National Taiwan University Hospital, 38006, Taipei, Taiwan
| | - Han-Ching Yang
- National Taiwan University Hospital Hsin-Chu Branch, 63423, Hsinchu, Taiwan
| | - Lu-Cheng Kuo
- National Taiwan University Hospital, 38006, Department of Internal Medicine, Taipei, Taiwan
| | - Jung-Yien Chien
- National Taiwan University Hospital, 38006, Internal Medicine, Taipei, Taiwan
| | - Huey-Dong Wu
- National Taiwan University Hospital, 38006, Internal Medicine, Taipei, Taiwan
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Ruan SY, Huang CT, Chien YC, Huang CK, Chien JY, Kuo LC, Kuo PH, Ku SC, Wu HD. Etiology-associated heterogeneity in acute respiratory distress syndrome: a retrospective cohort study. BMC Pulm Med 2021; 21:183. [PMID: 34059024 PMCID: PMC8168042 DOI: 10.1186/s12890-021-01557-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/26/2021] [Indexed: 12/16/2022] Open
Abstract
Background Heterogeneity in acute respiratory distress syndrome (ARDS) has led to many statistically negative clinical trials. Etiology is considered an important source of pathogenesis heterogeneity in ARDS but previous studies have usually adopted a dichotomous classification, such as pulmonary versus extrapulmonary ARDS, to evaluate it. Etiology-associated heterogeneity in ARDS remains poorly described. Methods In this retrospective cohort study, we described etiology-associated heterogeneity in gas exchange abnormality (PaO2/FiO2 [P/F] and ventilatory ratios), hemodynamic instability, non-pulmonary organ dysfunction as measured by the Sequential Organ Failure Assessment (SOFA) score, biomarkers of inflammation and coagulation, and 30-day mortality. Linear regression was used to model the trajectory of P/F ratios over time. Wilcoxon rank-sum tests, Kruskal–Wallis rank tests and Chi-squared tests were used to compare between-etiology differences. Results From 1725 mechanically ventilated patients in the ICU, we identified 258 (15%) with ARDS. Pneumonia (48.4%) and non-pulmonary sepsis (11.6%) were the two leading causes of ARDS. Compared with pneumonia associated ARDS, extra-pulmonary sepsis associated ARDS had a greater P/F ratio recovery rate (difference = 13 mmHg/day, p = 0.01), more shock (48% versus 73%, p = 0.01), higher non-pulmonary SOFA scores (6 versus 9 points, p < 0.001), higher d-dimer levels (4.2 versus 9.7 mg/L, p = 0.02) and higher mortality (43% versus 67%, p = 0.02). In pneumonia associated ARDS, there was significant difference in proportion of shock (p = 0.005) between bacterial and non-bacterial pneumonia. Conclusion This study showed that there was remarkable etiology-associated heterogeneity in ARDS. Heterogeneity was also observed within pneumonia associated ARDS when bacterial pneumonia was compared with other non-bacterial pneumonia. Future studies on ARDS should consider reporting etiology-specific data and exploring possible effect modification associated with etiology. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01557-9.
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Affiliation(s)
- Sheng-Yuan Ruan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan.
| | - Chun-Ta Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Ying-Chun Chien
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Chun-Kai Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Jung-Yien Chien
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Lu-Cheng Kuo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Ping-Hung Kuo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Shih-Chi Ku
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Huey-Dong Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
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Serdaroglu E, Kesici S, Bayrakci B, Kale G. Diffuse Alveolar Damage Correlation with Clinical Diagnosis of Pediatric Acute Respiratory Distress Syndrome. J Pediatr Intensive Care 2021; 10:52-57. [PMID: 33585062 PMCID: PMC7870331 DOI: 10.1055/s-0040-1714127] [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: 03/25/2020] [Accepted: 05/26/2020] [Indexed: 10/23/2022] Open
Abstract
Diffuse alveolar damage (DAD) is one of the pathological hallmarks of acute respiratory distress syndrome (ARDS). We aimed to compare pathological findings of DAD with clinical ARDS criteria. We re-evaluated 20 patients whose clinical autopsy revealed DAD. Total 11/20 patients with DAD (55%) met the 1994 American-European Consensus Conference and 7/17 (41%) met the 2012 Berlin clinical criteria. DAD showed only moderate correlation with current clinical ARDS definition. Oxygenation index (OI), seems to be the most valuable tool in predicting pulmonary damage severity, though OI is not listed in either of the previous definitions. We support the recommended use of OI by 2015 consensus conference.
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Affiliation(s)
- Esra Serdaroglu
- Department of Pediatric Critical Care, Hacettepe University Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Selman Kesici
- Department of Pediatric Critical Care, Hacettepe University Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Benan Bayrakci
- Department of Pediatric Critical Care, Hacettepe University Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Gulsev Kale
- Department of Pediatric Pathology, Hacettepe University Ihsan Dogramaci Children's Hospital, Ankara, Turkey
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Harrington JS, Schenck EJ, Oromendia C, Choi AMK, Siempos II. Acute respiratory distress syndrome without identifiable risk factors: A secondary analysis of the ARDS network trials. J Crit Care 2018; 47:49-54. [PMID: 29898428 DOI: 10.1016/j.jcrc.2018.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/30/2018] [Accepted: 06/01/2018] [Indexed: 02/01/2023]
Abstract
PURPOSE We examined whether patients with acute respiratory distress syndrome (ARDS) lacking risk factors are enrolled in therapeutic trials and assessed their clinical characteristics and outcomes. METHODS We performed a secondary analysis of patient-level data pooled from the ARMA, ALVEOLI, FACTT, ALTA and EDEN ARDSNet randomized controlled trials obtained from the Biologic Specimen and Data Repository Information Coordinating Center of the National Heart, Lung and Blood Institute. We compared baseline characteristics and clinical outcomes (before and after adjustment using Poisson regression model) of ARDS patients with versus without risk factors. RESULTS Of 3733 patients with ARDS, 81 (2.2%) did not have an identifiable risk factor. Patients without risk factors were younger, had lower baseline severity of illness, were more likely to have the ARDS resolve rapidly (i.e., within 24 h) (p < 0.001) and they had more ventilator-free days (median 21; p = 0.003), more intensive care unit-free days (18; p = 0.010), and more non-pulmonary organ failure-free days (24; p < 0.001) than comparators (17, 14 and 18, respectively). Differences persisted after adjustment for potential confounders. CONCLUSIONS Patients with ARDS without identifiable risk factors are enrolled in therapeutic trials and may have better outcomes, including a higher proportion of rapidly resolving ARDS, than those with risk factors.
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Affiliation(s)
- John S Harrington
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, United States
| | - Edward J Schenck
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, United States
| | - Clara Oromendia
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, United States
| | - Augustine M K Choi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, United States
| | - Ilias I Siempos
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, United States; First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, University of Athens Medical School, Athens, Greece.
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DesPrez K, McNeil JB, Wang C, Bastarache JA, Shaver CM, Ware LB. Oxygenation Saturation Index Predicts Clinical Outcomes in ARDS. Chest 2017; 152:1151-1158. [PMID: 28823812 PMCID: PMC5812755 DOI: 10.1016/j.chest.2017.08.002] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/02/2017] [Accepted: 08/01/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Traditional measures of ARDS severity such as Pao2/Fio2 may not reliably predict clinical outcomes. The oxygenation index (OI [Fio2 × mean airway pressure × 100)/Pao2]) may more accurately reflect ARDS severity but requires arterial blood gas measurement. We hypothesized that the oxygenation saturation index (OSI [Fio2 × mean airway pressure × 100)/oxygen saturation by pulse oximetry (Spo2)]) is a reliable noninvasive surrogate for the OI that is associated with hospital mortality and ventilator-free days (VFDs) in patients with ARDS. METHODS Critically ill patients enrolled in a prospective cohort study were eligible if they developed ARDS (Berlin criteria) during the first 4 ICU days and had mean airway pressure, Spo2/Fio2, and Pao2/Fio2 values recorded on the first day of ARDS (N = 329). The highest mean airway pressure and lowest Spo2/Fio2 and Pao2/Fio2 values were used to calculate OI and OSI. The association between OI or OSI and hospital mortality or VFD was analyzed by using logistic regression and linear regression, respectively. The area under the receiver-operating characteristic curve (AUC) for mortality was compared among OI, OSI, Spo2/Fio2, Pao2/Fio2, and Acute Physiology and Chronic Health Evaluation II scores. RESULTS OI and OSI were strongly correlated (rho = 0.862; P < .001). OSI was independently associated with hospital mortality (OR per 5-point increase in OSI, 1.228 [95% CI, 1.056-1.429]; P = .008). OI and OSI were each associated with a reduction in VFD (OI, P = .023; OSI, P = .005). The AUC for mortality prediction was greatest for Acute Physiology and Chronic Health Evaluation II scores (AUC, 0.695; P < .005) and OSI (AUC, 0.602; P = .007). The AUC for OSI was substantially better in patients aged < 40 years (AUC, 0.779; P < .001). CONCLUSIONS In patients with ARDS, the OSI was correlated with the OI. The OSI on the day of ARDS diagnosis was significantly associated with increased mortality and fewer VFDs. The findings suggest that OSI is a reliable surrogate for OI that can noninvasively provide prognostic information and assessment of ARDS severity.
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Affiliation(s)
- Katherine DesPrez
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - J. Brennan McNeil
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Chunxue Wang
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Julie A. Bastarache
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ciara M. Shaver
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN,CORRESPONDENCE TO: Lorraine B. Ware, MD, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, 1161 21st Ave S, T1218 Medical Center N, Nashville, TN 37232Division of AllergyPulmonary, and Critical Care MedicineVanderbilt University Medical Center1161 21st Ave S, T1218 Medical Center NNashvilleTN 37232
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8
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Balzer F, Menk M, Ziegler J, Pille C, Wernecke KD, Spies C, Schmidt M, Weber-Carstens S, Deja M. Predictors of survival in critically ill patients with acute respiratory distress syndrome (ARDS): an observational study. BMC Anesthesiol 2016; 16:108. [PMID: 27821065 PMCID: PMC5100178 DOI: 10.1186/s12871-016-0272-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 10/14/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Currently there is no ARDS definition or classification system that allows optimal prediction of mortality in ARDS patients. This study aimed to examine the predictive values of the AECC and Berlin definitions, as well as clinical and respiratory parameters obtained at onset of ARDS and in the course of the first seven consecutive days. METHODS The observational study was conducted at a 14-bed intensive care unit specialized on treatment of ARDS. Predictive validity of the AECC and Berlin definitions as well as PaO2/FiO2 and FiO2/PaO2*Pmean (oxygenation index) on mortality of ARDS patients was assessed and statistically compared. RESULTS Four hundred forty two critically-ill patients admitted for ARDS were analysed. Multivariate Cox regression indicated that the oxygenation index was the most accurate parameter for mortality prediction. The third day after ARDS criteria were met at our hospital was found to represent the best compromise between earliness and accuracy of prognosis of mortality regarding the time of assessment. An oxygenation index of 15 or greater was associated with higher mortality, longer length of stay in ICU and hospital and longer duration of mechanical ventilation. In addition, non-survivors had a significantly longer length of stay and duration of mechanical ventilation in referring hospitals before admitted to the national reference centre than survivors. CONCLUSIONS The oxygenation index is suggested to be the most suitable parameter to predict mortality in ARDS, preferably assessed on day 3 after admission to a specialized centre. Patients might benefit when transferred to specialized ICU centres as soon as possible for further treatment.
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Affiliation(s)
- Felix Balzer
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum / Campus Charité Mitte, Augustenburger Platz 1, D-13353, Berlin, Germany
| | - Mario Menk
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum / Campus Charité Mitte, Augustenburger Platz 1, D-13353, Berlin, Germany
| | - Jannis Ziegler
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Christian Pille
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum / Campus Charité Mitte, Augustenburger Platz 1, D-13353, Berlin, Germany
| | | | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum / Campus Charité Mitte, Augustenburger Platz 1, D-13353, Berlin, Germany
| | - Maren Schmidt
- Department of Anaesthesiology and Intensive Care Medicine, Werner Forßmann Krankenhaus, 16225, Eberswalde, Germany
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum / Campus Charité Mitte, Augustenburger Platz 1, D-13353, Berlin, Germany.
| | - Maria Deja
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum / Campus Charité Mitte, Augustenburger Platz 1, D-13353, Berlin, Germany. .,Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
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Cardinal-Fernández P, Correger E, Villanueva J, Rios F. Acute Respiratory Distress: From syndrome to disease. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.medine.2015.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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10
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Distrés respiratorio agudo: del síndrome a la enfermedad. Med Intensiva 2016; 40:169-75. [DOI: 10.1016/j.medin.2015.11.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 11/18/2015] [Accepted: 11/21/2015] [Indexed: 12/12/2022]
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Limiting acute respiratory distress syndrome in the emergency department: a survey of US academic emergency medicine physicians. Eur J Emerg Med 2015; 21:387-8. [PMID: 25159175 DOI: 10.1097/mej.0000000000000150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Kao KC, Hu HC, Chang CH, Hung CY, Chiu LC, Li SH, Lin SW, Chuang LP, Wang CW, Li LF, Chen NH, Yang CT, Huang CC, Tsai YH. Diffuse alveolar damage associated mortality in selected acute respiratory distress syndrome patients with open lung biopsy. Crit Care 2015; 19:228. [PMID: 25981598 PMCID: PMC4449559 DOI: 10.1186/s13054-015-0949-y] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Accepted: 05/11/2015] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Diffuse alveolar damage (DAD) is the pathological hallmark of acute respiratory distress syndrome (ARDS), however, the presence of DAD in the clinical criteria of ARDS patients by Berlin definition is little known. This study is designed to investigate the role of DAD in ARDS patients who underwent open lung biopsy. METHODS We retrospectively reviewed all ARDS patients who met the Berlin definition and underwent open lung biopsy from January 1999 to January 2014 in a referred medical center. DAD is characterized by hyaline membrane formation, lung edema, inflammation, hemorrhage and alveolar epithelial cell injury. Clinical data including baseline characteristics, severity of ARDS, clinical and pathological diagnoses, and survival outcomes were analyzed. RESULTS A total of 1838 patients with ARDS were identified and open lung biopsies were performed on 101 patients (5.5 %) during the study period. Of these 101 patients, the severity of ARDS on diagnosis was mild of 16.8 %, moderate of 56.5 % and severe of 26.7 %. The hospital mortality rate was not significant difference between the three groups (64.7 % vs 61.4 % vs 55.6 %, p = 0.81). Of the 101 clinical ARDS patients with open lung biopsies, 56.4 % (57/101) patients had DAD according to biopsy results. The proportion of DAD were 76.5 % (13/17) in mild, 56.1 % (32/57) in moderate and 44.4 % (12/27) in severe ARDS and there is no significant difference between the three groups (p = 0.113). Pathological findings of DAD patients had a higher hospital mortality rate than non-DAD patients (71.9 % vs 45.5 %, p = 0.007). Pathological findings of DAD (odds ratio: 3.554, 95 % CI, 1.385-9.12; p = 0.008) and Sequential Organ Failure Assessment score on the biopsy day (odds ratio: 1.424, 95 % CI, 1.187-1.707; p<0.001) were significantly and independently associated with hospital mortality. The baseline demographics and clinical characteristics were not significantly different between DAD and non-DAD patients. CONCLUSIONS The correlation of pathological findings of DAD and ARDS diagnosed by Berlin definition is modest. A pathological finding of DAD in ARDS patients is associated with hospital mortality and there are no clinical characteristics that could identify DAD patients before open lung biopsy.
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Affiliation(s)
- Kuo-Chin Kao
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St, Kwei-Shan, Taoyuan, 886, Taiwan.
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
- Department of Respiratory Therapy, Chang-Gung University College of Medicine, Taoyuan, Taiwan.
| | - Han-Chung Hu
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St, Kwei-Shan, Taoyuan, 886, Taiwan.
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
- Department of Respiratory Therapy, Chang-Gung University College of Medicine, Taoyuan, Taiwan.
| | - Chih-Hao Chang
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St, Kwei-Shan, Taoyuan, 886, Taiwan.
| | - Chen-Yiu Hung
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St, Kwei-Shan, Taoyuan, 886, Taiwan.
| | - Li-Chung Chiu
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St, Kwei-Shan, Taoyuan, 886, Taiwan.
| | - Shih-Hong Li
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St, Kwei-Shan, Taoyuan, 886, Taiwan.
| | - Shih-Wei Lin
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St, Kwei-Shan, Taoyuan, 886, Taiwan.
| | - Li-Pang Chuang
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St, Kwei-Shan, Taoyuan, 886, Taiwan.
| | - Chih-Wei Wang
- Department of Pathology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Li-Fu Li
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St, Kwei-Shan, Taoyuan, 886, Taiwan.
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
- Department of Respiratory Therapy, Chang-Gung University College of Medicine, Taoyuan, Taiwan.
| | - Ning-Hung Chen
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St, Kwei-Shan, Taoyuan, 886, Taiwan.
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Cheng-Ta Yang
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St, Kwei-Shan, Taoyuan, 886, Taiwan.
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Chung-Chi Huang
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St, Kwei-Shan, Taoyuan, 886, Taiwan.
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Ying-Huang Tsai
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Chiayi, Taiwan.
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Schmickl CN, Pannu S, Al-Qadi MO, Alsara A, Kashyap R, Dhokarh R, Herasevich V, Gajic O. Decision support tool for differential diagnosis of Acute Respiratory Distress Syndrome (ARDS) vs Cardiogenic Pulmonary Edema (CPE): a prospective validation and meta-analysis. Crit Care 2014; 18:659. [PMID: 25432274 PMCID: PMC4277656 DOI: 10.1186/s13054-014-0659-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 11/11/2014] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION We recently presented a prediction score providing decision support with the often-challenging early differential diagnosis of acute lung injury (ALI) vs cardiogenic pulmonary edema (CPE). To facilitate clinical adoption, our objective was to prospectively validate its performance in an independent cohort. METHODS Over 9 months, adult patients consecutively admitted to any intensive care unit of a tertiary-care center developing acute pulmonary edema were identified in real-time using validated electronic surveillance. For eligible patients, predictors were abstracted from medical records within 48 hours of the alert. Post-hoc expert review blinded to the prediction score established gold standard diagnosis. RESULTS Of 1,516 patients identified by electronic surveillance, data were abstracted for 249 patients (93% within 48 hours of disease onset), of which expert review (kappa 0.93) classified 72 as ALI, 73 as CPE and excluded 104 as "other". With an area under the curve (AUC) of 0.81 (95% confidence interval = 0.73 to 0.88) the prediction score showed similar discrimination as in prior cohorts (development AUC = 0.81, P = 0.91; retrospective validation AUC = 0.80, P = 0.92). Hosmer-Lemeshow test was significant (P = 0.01), but across eight previously defined score ranges probabilities of ALI vs CPE were the same as in the development cohort (P = 0.60). Results were the same when comparing acute respiratory distress syndrome (ARDS, Berlin definition) vs CPE. CONCLUSION The clinical prediction score reliably differentiates ARDS/ALI vs CPE. Pooled results provide precise estimates of the score's performance which can be used to screen patient populations or to assess the probability of ALI/ARDS vs CPE in specific patients. The score may thus facilitate early inclusion into research studies and expedite prompt treatment.
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Affiliation(s)
- Christopher N Schmickl
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- University Witten-Herdecke, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany.
- Harvard School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA.
| | - Sonal Pannu
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Mazen O Al-Qadi
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Anas Alsara
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Rahul Kashyap
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Rajanigandha Dhokarh
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Lahey Clinic, Pulmonary and Critical Care, 41 Burlington Mall Road, Burlington, MA, 01805, USA.
| | - Vitaly Herasevich
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Sweatt AJ, Levitt JE. Evolving epidemiology and definitions of the acute respiratory distress syndrome and early acute lung injury. Clin Chest Med 2014; 35:609-24. [PMID: 25453413 DOI: 10.1016/j.ccm.2014.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This article reviews the evolving definitions and epidemiology of the acute respiratory distress syndrome (ARDS) and highlights current efforts to improve identification of high-risk patients, thus to target prevention and early treatment before progression to ARDS. This information will be important for general practitioners and intensivists interested in improving the care of patients at risk for ARDS, and clinical researchers interested in designing clinical trials targeting the prevention and early treatment of acute lung injury.
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Affiliation(s)
- Andrew J Sweatt
- Division of Pulmonary and Critical Care Medicine, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Joseph E Levitt
- Division of Pulmonary and Critical Care Medicine, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA.
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15
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Fuller BM, Mohr NM, Graetz TJ, Lynch IP, Dettmer M, Cullison K, Coney T, Gogineni S, Gregory R. The impact of cardiac dysfunction on acute respiratory distress syndrome and mortality in mechanically ventilated patients with severe sepsis and septic shock: an observational study. J Crit Care 2014; 30:65-70. [PMID: 25179413 DOI: 10.1016/j.jcrc.2014.07.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 07/28/2014] [Accepted: 07/30/2014] [Indexed: 12/29/2022]
Abstract
PURPOSE Acute respiratory distress syndrome (ARDS) is associated with significant mortality and morbidity in survivors. Treatment is only supportive, therefore elucidating modifiable factors that could prevent ARDS could have a profound impact on outcome. The impact that sepsis-associated cardiac dysfunction has on ARDS is not known. MATERIALS AND METHODS In this retrospective observational cohort study of mechanically ventilated patients with severe sepsis and septic shock, 122 patients were assessed for the impact of sepsis-associated cardiac dysfunction on incidence of ARDS (primary outcome) and mortality. RESULTS Sepsis-associated cardiac dysfunction occurred in 44 patients (36.1%). There was no association of sepsis-associated cardiac dysfunction with ARDS incidence (p= 0.59) or mortality, and no association with outcomes in patients that did progress to ARDS after admission. Multivariable logistic regression demonstrated that higher BMI was associated with progression to ARDS (adjusted OR 11.84, 95% CI 1.24 to 113.0, p= 0.02). CONCLUSIONS Cardiac dysfunction in mechanically ventilated patients with sepsis did not impact ARDS incidence, clinical outcome in ARDS patients, or mortality. This contrasts against previous investigations demonstrating an influence of nonpulmonary organ dysfunction on outcome in ARDS. Given the frequency of ARDS as a sequela of sepsis, the impact of cardiac dysfunction on outcome should be further studied.
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Affiliation(s)
- Brian M Fuller
- Department of Anesthesiology, Division of Critical Care, Division of Emergency Medicine, Washington University School of Medicine, St Louis, MO.
| | - Nicholas M Mohr
- Department of Emergency Medicine, Department of Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Thomas J Graetz
- Department of Anesthesiology, Division of Critical Care, Division of Cardiothoracic Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Isaac P Lynch
- Department of Anesthesiology, Division of Critical Care, Division of Cardiothoracic Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Matthew Dettmer
- Division of Emergency Medicine, Washington University School of Medicine, St Louis, MO
| | - Kevin Cullison
- Division of Emergency Medicine, Washington University School of Medicine, St Louis, MO
| | - Talia Coney
- Saint Louis University School of Medicine, St Louis, MO
| | | | - Robert Gregory
- Southern Illinois University School of Medicine, Springfield, IL
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Bennett BC, Balick MJ. Does the name really matter? The importance of botanical nomenclature and plant taxonomy in biomedical research. JOURNAL OF ETHNOPHARMACOLOGY 2014; 152:387-392. [PMID: 24321863 DOI: 10.1016/j.jep.2013.11.042] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 10/18/2013] [Accepted: 11/23/2013] [Indexed: 06/03/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Medical research on plant-derived compounds requires a breadth of expertise from field to laboratory and clinical skills. Too often basic botanical skills are evidently lacking, especially with respect to plant taxonomy and botanical nomenclature. Binomial and familial names, synonyms and author citations are often misconstrued. The correct botanical name, linked to a vouchered specimen, is the sine qua non of phytomedical research. Without the unique identifier of a proper binomial, research cannot accurately be linked to the existing literature. Perhaps more significant, is the ambiguity of species determinations that ensues of from poor taxonomic practices. This uncertainty, not surprisingly, obstructs reproducibility of results-the cornerstone of science. MATERIALS AND METHODS Based on our combined six decades of experience with medicinal plants, we discuss the problems of inaccurate taxonomy and botanical nomenclature in biomedical research. This problems appear all too frequently in manuscripts and grant applications that we review and they extend to the published literature. We also review the literature on the importance of taxonomy in other disciplines that relate to medicinal plant research. RESULTS AND DISCUSSION In most cases, questions regarding orthography, synonymy, author citations, and current family designations of most plant binomials can be resolved using widely-available online databases and other electronic resources. Some complex problems require consultation with a professional plant taxonomist, which also is important for accurate identification of voucher specimens. Researchers should provide the currently accepted binomial and complete author citation, provide relevant synonyms, and employ the Angiosperm Phylogeny Group III family name. Taxonomy is a vital adjunct not only to plant-medicine research but to virtually every field of science. CONCLUSIONS Medicinal plant researchers can increase the precision and utility of their investigations by following sound practices with respect to botanical nomenclature. Correct spellings, accepted binomials, author citations, synonyms, and current family designations can readily be found on reliable online databases. When questions arise, researcher should consult plant taxonomists.
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Affiliation(s)
- Bradley C Bennett
- Department of Biological Sciences, Florida International University, Miami, FL 33199, USA.
| | - Michael J Balick
- Institute of Economic Botany, The New York Botanical Garden, 2900 Southern Blvd., Bronx, New York 10458, USA.
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Etiology and Outcomes of ARDS in a Rural-Urban Fringe Hospital of South India. Crit Care Res Pract 2014; 2014:181593. [PMID: 24660060 PMCID: PMC3934087 DOI: 10.1155/2014/181593] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 01/01/2014] [Accepted: 01/02/2014] [Indexed: 01/11/2023] Open
Abstract
Objectives. Etiology and outcomes of acute lung injury in tropical countries may be different from those of western nations. We describe the etiology and outcomes of illnesses causing acute lung injury in a rural populace. Study Design. A prospective observational study. Setting. Medical ICU of a teaching hospital in a rural-urban fringe location. Patients. Patients ≥13 years, admitted between December 2011 and May 2013, satisfying AECC criteria for ALI/ARDS. Results. Study had 61 patients; 46 had acute lung injury at admission. Scrub typhus was the commonest cause (7/61) and tropical infections contributed to 26% of total cases. Increasing ARDS severity was associated with older age, higher FiO2 and APACHE/SOFA scores, and longer duration of ventilation. Nonsurvivors were generally older, had shorter duration of illness, a nontropical infection, and higher total WBC counts, required longer duration of ventilation, and had other organ dysfunction and higher mean APACHE scores. The mortality rate of ARDS was 36.6% (22/61) in our study. Conclusion. Tropical infections form a major etiological component of acute lung injury in a developing country like India. Etiology and outcomes of ARDS may vary depending upon the geographic location and seasonal illnesses.
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Shen Y, Wang D, Wang X. Role of CCR2 and IL-8 in acute lung injury: a new mechanism and therapeutic target. Expert Rev Respir Med 2014; 5:107-14. [DOI: 10.1586/ers.10.80] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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19
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Influences of pleural effusion on respiratory mechanics, gas exchange, hemodynamics, and recruitment effects in acute respiratory distress syndrome. J Surg Res 2014; 186:346-53. [DOI: 10.1016/j.jss.2013.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 09/03/2013] [Accepted: 09/05/2013] [Indexed: 11/22/2022]
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20
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Early application of airway pressure release ventilation may reduce mortality in high-risk trauma patients: a systematic review of observational trauma ARDS literature. J Trauma Acute Care Surg 2013; 75:635-41. [PMID: 24064877 DOI: 10.1097/ta.0b013e31829d3504] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Adult respiratory distress syndrome is often refractory to treatment and develops after entering the health care system. This suggests an opportunity to prevent this syndrome before it develops. The objective of this study was to demonstrate that early application of airway pressure release ventilation in high-risk trauma patients reduces hospital mortality as compared with similarly injured patients on conventional ventilation. METHODS Systematic review of observational data in patients who received conventional ventilation in other trauma centers were compared with patients treated with early airway pressure release ventilation in our trauma center. Relevant studies were identified in a PubMed and MEDLINE search from 1995 to 2012 and included prospective and retrospective observational and cohort studies enrolling 100 or more adult trauma patients with reported adult respiratory distress syndrome incidence and mortality data. RESULTS Early airway pressure release ventilation as compared with the other trauma centers represented lower mean adult respiratory distress syndrome incidence (14.0% vs. 1.3%) and in-hospital mortality (14.1% vs. 3.9%). CONCLUSION These data suggest that early airway pressure release ventilation may prevent progression of acute lung injury in high-risk trauma patients, reducing trauma-related adult respiratory distress syndrome mortality. LEVEL OF EVIDENCE Systematic review, level IV.
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21
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Fioretto JR, Carvalho WB. Temporal evolution of acute respiratory distress syndrome definitions. J Pediatr (Rio J) 2013; 89:523-30. [PMID: 24035871 DOI: 10.1016/j.jped.2013.02.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 02/14/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE to review the evolution of acute respiratory distress syndrome (ARDS) definitions and present the current definition for the syndrome. DATA SOURCE a literature review and selection of the most relevant articles on ARDS definitions was performed using the MEDLINE®/PubMed® Resource Guide database (last ten years), in addition to including the most important articles (classic articles) that described the disease evolution. DATA SYNTHESIS the review included the following subjects: introduction; importance of definition; description of the first diagnostic criterion and subsequently used definitions, such as acute lung injury score; definition by the American-European Consensus Conference, and its limitations; description of the definition by Delphi, and its problems; accuracy of the aforementioned definitions; description of most recent definition (the Berlin definition), and its limitations; and practical importance of the new definition. CONCLUSIONS ARDS is a serious disease that remains an ongoing diagnostic and therapeutic challenge. The evolution of definitions used to describe the disease shows that studies are needed to validate the current definition, especially in pediatrics, where the data are very scarce.
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Affiliation(s)
- José R Fioretto
- Pediatrics Department, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, São Paulo, SP, Brazil; Sociedade Paulista de Terapia Intensiva, São Paulo, SP, Brazil.
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Temporal evolution of acute respiratory distress syndrome definitions. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2013. [DOI: 10.1016/j.jpedp.2013.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Abstract
OBJECTIVES Acute respiratory distress syndrome is characterized by diffuse alveolar damage and increased extravascular lung water levels. However, there is no threshold extravascular lung water level that can indicate diffuse alveolar damage in lungs. We aimed to determine the threshold extravascular lung water level that discriminates between normal lungs and lungs affected with diffuse alveolar damage. DESIGN A retrospective analysis of normal lungs and lungs affected with diffuse alveolar damage was performed. SETTING Normal lung cases were taken from published data. Lung cases with diffuse alveolar damage were taken from a nationwide autopsy database. All cases of autopsy followed hospital deaths in Japan from more than 800 hospitals between 2004 and 2009; complete autopsies with histopathologic examinations were performed by board-certified pathologists authorized by the Japanese Society of Pathology. PATIENTS Normal lungs: 534; lungs with diffuse alveolar damage: 1,688. INTERVENTIONS We compared the postmortem weights of both lungs between the two groups. These lung weights were converted to extravascular lung water values using a validated equation. Finally, the extravascular lung water value that indicated diffuse alveolar damage was estimated using receiver operating characteristic analysis. MEASUREMENTS AND MAIN RESULTS The extravascular lung water values of the lungs showing diffuse alveolar damage were approximately two-fold higher than those of normal lungs (normal group, 7.3±2.8 mL/kg vs diffuse alveolar damage group 13.7±4.5 mL/kg; p<0.001). An extravascular lung water level of 9.8 mL/kg allowed the diagnosis of diffuse alveolar damage to be established with a sensitivity of 81.3% and a specificity of 81.2% (area under the curve, 0.90; 95% CI, 0.88-0.91). An extravascular lung water level of 14.6 mL/kg represented a 99% positive predictive value. CONCLUSIONS This study may provide the first validated quantitative bedside diagnostic tool for diffuse alveolar damage. Extravascular lung water may allow the detection of diffuse alveolar damage and may support the clinical diagnosis of acute respiratory distress syndrome. The best extravascular lung water cut-off value to discriminate between normal lungs and lungs with diffuse alveolar damage is around 10 mL/kg.
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Bos LDJ, van Walree IC, Kolk AHJ, Janssen HG, Sterk PJ, Schultz MJ. Alterations in exhaled breath metabolite-mixtures in two rat models of lipopolysaccharide-induced lung injury. J Appl Physiol (1985) 2013; 115:1487-95. [PMID: 23908314 DOI: 10.1152/japplphysiol.00685.2013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Exhaled breath contains information on systemic and pulmonary metabolism, which may provide a monitoring tool for the development of lung injury. We aimed to determine the effect of intravenous (iv) and intratracheal (IT) lipopolysaccharide (LPS) challenge on the exhaled mixture of volatile metabolites and to assess the similarities between these two models. Male adult Sprague-Dawley rats were anesthetized, tracheotomized, and ventilated for 6 h. Lung injury was induced by iv or IT administration of LPS. Exhaled breath was monitored continuously using an electronic nose (eNose), and hourly using gas chromatography and mass spectrometry (GC-MS). GC-MS analysis identified 34 and 14 potential biological markers for lung injury in the iv and IT LPS models, respectively. These volatile biomarkers could be used to discriminate between LPS-challenged rats and control animals within 1 h after LPS administration. Electronic nose analysis resulted in a good separation 3 h after the LPS challenge. Hexanal, pentadecane and 6,10-dimethyl-5,9-undecadien-2-one concentrations decreased after both iv and IT LPS administration. Nonanoic acid was found in a higher concentration in exhaled breath after LPS inoculation into the trachea but in a lower concentration after iv infusion. LPS-induced lung injury rapidly changes exhaled breath metabolite mixtures in two animal models of lung injury. Changes partly overlap between an iv and an IT LPS challenge. This warrants testing the diagnostic accuracy of exhaled breath analysis for acute respiratory distress syndrome in clinical trials, possibly focusing on biological markers described in this study.
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Affiliation(s)
- Lieuwe D J Bos
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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25
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Kushimoto S, Endo T, Yamanouchi S, Sakamoto T, Ishikura H, Kitazawa Y, Taira Y, Okuchi K, Tagami T, Watanabe A, Yamaguchi J, Yoshikawa K, Sugita M, Kase Y, Kanemura T, Takahashi H, Kuroki Y, Izumino H, Rinka H, Seo R, Takatori M, Kaneko T, Nakamura T, Irahara T, Saito N. Relationship between extravascular lung water and severity categories of acute respiratory distress syndrome by the Berlin definition. Crit Care 2013; 17:R132. [PMID: 23844662 PMCID: PMC4056600 DOI: 10.1186/cc12811] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 04/06/2013] [Accepted: 06/20/2013] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The Berlin definition divides acute respiratory distress syndrome (ARDS) into three severity categories. The relationship between these categories and pulmonary microvascular permeability as well as extravascular lung water content, which is the hallmark of lung pathophysiology, remains to be elucidated. The aim of this study was to evaluate the relationship between extravascular lung water, pulmonary vascular permeability, and the severity categories as defined by the Berlin definition, and to confirm the associated predictive validity for severity. METHODS The extravascular lung water index (EVLWi) and pulmonary vascular permeability index (PVPI) were measured using a transpulmonary thermodilution method for three consecutive days in 195 patients with an EVLWi of ≥10 mL/kg and who fulfilled the Berlin definition of ARDS. Collectively, these patients were seen at 23 ICUs. Using the Berlin definition, patients were classified into three categories: mild, moderate, and severe. RESULTS Compared to patients with mild ARDS, patients with moderate and severe ARDS had higher acute physiology and chronic health evaluation II and sequential organ failure assessment scores on the day of enrollment. Patients with severe ARDS had higher EVLWi (mild, 16.1; moderate, 17.2; severe, 19.1; P <0.05) and PVPI (2.7; 3.0; 3.2; P <0.05). When categories were defined by the minimum PaO2/FIO2 ratio observed during the study period, the 28-day mortality rate increased with severity categories: moderate, odds ratio: 3.125 relative to mild; and severe, odds ratio: 4.167 relative to mild. On independent evaluation of 495 measurements from 195 patients over three days, negative and moderate correlations were observed between EVLWi and the PaO2/FIO2 ratio (r = -0.355, P<0.001) as well as between PVPI and the PaO2/FIO2 ratio (r = -0.345, P <0.001). ARDS severity was associated with an increase in EVLWi with the categories (mild, 14.7; moderate, 16.2; severe, 20.0; P <0.001) in all data sets. The value of PVPI followed the same pattern (2.6; 2.7; 3.5; P <0.001). CONCLUSIONS Severity categories of ARDS described by the Berlin definition have good predictive validity and may be associated with increased extravascular lung water and pulmonary vascular permeability. TRIAL REGISTRATION UMIN-CTR ID UMIN000003627.
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Affiliation(s)
- Shigeki Kushimoto
- Division of Emergency Medicine, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Tomoyuki Endo
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, 1-1 Seiryo-cho, Aoba-ku, Sendai, Miyagi 980-8574, Japan
| | - Satoshi Yamanouchi
- Division of Emergency Medicine, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Teruo Sakamoto
- Department of Emergency and Critical Care Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume-shi, Fukuoka 830-0011, Japan
| | - Hiroyasu Ishikura
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, 8-19-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
| | - Yasuhide Kitazawa
- Department of Emergency and Critical Care Medicine, Kansai Medical University, 10-15 Fumizonocho, Moriguchi, Osaka 573-1191, Japan
| | - Yasuhiko Taira
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa 216-8511, Japan
| | - Kazuo Okuchi
- Department of Emergency and Critical Care Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8521, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Akihiro Watanabe
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Junko Yamaguchi
- Department of Emergency and Critical Care Medicine, Nihon University School of Medicine Itabashi Hospital, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kazuhide Yoshikawa
- Shock Trauma and Emergency Medical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Manabu Sugita
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima-ku Tokyo 177-8521, Japan
| | - Yoichi Kase
- Critical Care Medicine, Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tochigi 105 8461, Japan
| | - Takashi Kanemura
- Emergency and Critical Care Medicine, National Hospital Organization Disaster Medical Center, 2-5-1, Higashigaoka, Meguro-ku, Tokyo 152-8902, Japan
| | - Hiroyuki Takahashi
- Department of Intensive Care Medicine, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa 230-8765, Japan
| | - Yuuichi Kuroki
- Department of Emergency and Critical Care Medicine, Social Insurance Chukyo Hospital, 1-1-10. Sanjyo, Minami-ku, Nagoya, Aichi 457-8510, Japan
| | - Hiroo Izumino
- Advanced Emergency and Critical Care Center, Kansai Medical University Takii Hospital, 10-15, Fumizono-cho, Moriguchi, Osaka 570-8507, Japan
| | - Hiroshi Rinka
- Emergency and Critical Care Medical Center, Osaka City General Hospital, 1-5-7 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Ryutarou Seo
- Intensive Care Unit, Kobe City Medical Center General Hospital, 4-6, Minatojimanakamachi, Chuo-ku, Kobe, Hyogo 650-0046, Japan
| | - Makoto Takatori
- Department of Anesthesia and Intensive Care, Hiroshima City Hospital, 7-33 Motomachi Naka-ku, Hiroshima-shi, Hiroshima 730-8518, Japan
| | - Tadashi Kaneko
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, 1-1-1, Minamikogushi, Ube-ku, Yamaguchi 755-8505, Japan
| | - Toshiaki Nakamura
- Intensive Care Unit, Nagasaki University Hospital, 1-14 Bunkyo-machi, Nagasaki-ku Nagasaki 852-8521, Japan
| | - Takayuki Irahara
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo 206-8512, Japan
| | - Nobuyuki Saito
- Department of Emergency and Critical Care Medicine, Nippon Medical School Chiba Hokusou Hospital, 1715 Kamagari, Inzai-shi, Chiba 270-1694, Japan
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Dong H, Li J, Lv Y, Zhou Y, Wang G, Hu S, He X, Yang P, Zhou Z, Xiang X, Wang CY. Comparative analysis of the alveolar macrophage proteome in ALI/ARDS patients between the exudative phase and recovery phase. BMC Immunol 2013; 14:25. [PMID: 23773529 PMCID: PMC3727986 DOI: 10.1186/1471-2172-14-25] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 06/11/2013] [Indexed: 11/21/2022] Open
Abstract
Background Despite decades of extensive studies, the morbidity and mortality for acute lung injury/acute respiratory distress syndrome (ALI/ARDS) remained high. Particularly, biomarkers essential for its early diagnosis and prognosis are lacking. Methods Recent studies suggest that alveolar macrophages (AMs) at the exudative phase of ALI/ARDS initiate, amplify and perpetuate inflammatory responses, while they resolve inflammation in the recovery phase to prevent further tissue injury and perpetuated inflammation in the lung. Therefore, proteins relevant to this functional switch could be valuable biomarkers for ALI/ARDS diagnosis and prognosis. We thus conducted comparative analysis of the AM proteome to assess its dynamic proteomic changes during ALI/ARDS progression and recovery. Results 135 proteins were characterized to be differentially expressed between AMs at the exudative and recovery phase. MALDI-TOF-MS and peptide mass fingerprint (PMF) analysis characterized 27 informative proteins, in which 17 proteins were found with a marked increase at the recovery phase, while the rest of 10 proteins were manifested by the significantly higher levels of expression at the exudative phase. Conclusions Given the role of above identified proteins played in the regulation of inflammatory responses, cell skeleton organization, oxidative stress, apoptosis and metabolism, they have the potential to serve as biomarkers for early diagnosis and prognosis in the setting of patients with ALI/ARDS.
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Affiliation(s)
- Haiyun Dong
- Intensive Care Unit, Diabetes Center, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
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Thille AW, Esteban A, Fernández-Segoviano P, Rodriguez JM, Aramburu JA, Peñuelas O, Cortés-Puch I, Cardinal-Fernández P, Lorente JA, Frutos-Vivar F. Comparison of the Berlin Definition for Acute Respiratory Distress Syndrome with Autopsy. Am J Respir Crit Care Med 2013; 187:761-7. [DOI: 10.1164/rccm.201211-1981oc] [Citation(s) in RCA: 277] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Rincon F, Ghosh S, Dey S, Maltenfort M, Vibbert M, Urtecho J, McBride W, Moussouttas M, Bell R, Ratliff JK, Jallo J. Impact of acute lung injury and acute respiratory distress syndrome after traumatic brain injury in the United States. Neurosurgery 2013; 71:795-803. [PMID: 22855028 DOI: 10.1227/neu.0b013e3182672ae5] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of disability, morbidity, and mortality. The effect of the acute respiratory distress syndrome and acute lung injury (ARDS/ALI) on in-hospital mortality after TBI remains controversial. OBJECTIVE To determine the epidemiology of ARDS/ALI, the prevalence of risk factors, and impact on in-hospital mortality after TBI in the United States. METHODS Retrospective cohort study of admissions of adult patients>18 years with a diagnosis of TBI and ARDS/ALI from 1988 to 2008 identified through the Nationwide Inpatient Sample. RESULTS During the 20-year study period, the prevalence of ARDS/ALI increased from 2% (95% confidence interval [CI], 2.1%-2.4%) in 1988 to 22% (95% CI, 21%-22%) in 2008 (P<.001). ARDS/ALI was more common in younger age; males; white race; later year of admission; in conjunction with comorbidities such as congestive heart failure, hypertension, chronic obstructive pulmonary disease, chronic renal and liver failure, sepsis, multiorgan dysfunction; and nonrural, medium/large hospitals, located in the Midwest, South, and West continental US location. Mortality after TBI decreased from 13% (95% CI, 12%-14%) in 1988 to 9% (95% CI, 9%-10%) in 2008 (P<.001). ARDS/ALI-related mortality after TBI decreased from 33% (95% CI, 33%-34%) in 1988 to 28% (95% CI, 28%-29%) in 2008 (P<.001). Predictors of in-hospital mortality after TBI were older age, male sex, white race, cancer, chronic kidney disease, hypertension, chronic liver disease, congestive heart failure, ARDS/ALI, and organ dysfunctions. CONCLUSION Our analysis demonstrates that ARDS/ALI is common after TBI. Despite an overall reduction of in-hospital mortality, ARDS/ALI carries a higher risk of in-hospital death after TBI.
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Affiliation(s)
- Fred Rincon
- Department of Neurology, Division of Critical Care, Thomas Jefferson University, Jefferson College of Medicine, Philadelphia, Pennsylvania 19107, USA.
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Extravascular lung water and the pulmonary vascular permeability index may improve the definition of ARDS. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:108. [PMID: 23347799 PMCID: PMC4057435 DOI: 10.1186/cc11918] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The recent Berlin definition has made some improvements in the older definition of acute respiratory distress syndrome (ARDS), although the concepts and components of the definition remained largely unchanged. In an effort to improve both predictive and face validity, the Berlin panel has examined a number of additional measures that may reflect increased pulmonary vascular permeability, including extravascular lung water. The panel concluded that although extravascular lung water has improved face validity and higher values are associated with mortality, it is infeasible to mandate on the basis of availability and the fact that it does not distinguish between hydrostatic and inflammatory pulmonary edema. However, the results of a multi-institutional study that appeared in the previous issue of Critical Care show that this latter reservation may not necessarily be true. By using extravascular lung water and the pulmonary vascular permeability index, both of which are derived from transpulmonary thermodilution, the authors could successfully differentiate between patients with ARDS and other patients in respiratory failure due to either cardiogenic edema or pleural effusion with atelectasis. This commentary discusses the merits and limitations of this study in view of the potential improvement that transpulmonary thermodilution may bring to the definition of ARDS.
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Fuller BM, Mohr NM, Drewry AM, Carpenter CR. Lower tidal volume at initiation of mechanical ventilation may reduce progression to acute respiratory distress syndrome: a systematic review. Crit Care 2013; 17:R11. [PMID: 23331507 PMCID: PMC3983656 DOI: 10.1186/cc11936] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 01/18/2013] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION The most appropriate tidal volume in patients without acute respiratory distress syndrome (ARDS) is controversial and has not been rigorously examined. Our objective was to determine whether a mechanical ventilation strategy using lower tidal volume is associated with a decreased incidence of progression to ARDS when compared with a higher tidal volume strategy. METHODS A systematic search of MEDLINE, EMBASE, CINAHL, the Cochrane Library, conference proceedings, and clinical trial registration was performed with a comprehensive strategy. Studies providing information on mechanically ventilated patients without ARDS at the time of initiation of mechanical ventilation, and in which tidal volume was independently studied as a predictor variable for outcome, were included. The primary outcome was progression to ARDS. RESULTS The search yielded 1,704 studies, of which 13 were included in the final analysis. One randomized controlled trial was found; the remaining 12 studies were observational. The patient cohorts were significantly heterogeneous in composition and baseline risk for developing ARDS; therefore, a meta-analysis of the data was not performed. The majority of the studies (n = 8) showed a decrease in progression to ARDS with a lower tidal volume strategy. ARDS developed early in the course of illness (5 hours to 3.7 days). The development of ARDS was associated with increased mortality, lengths of stay, mechanical ventilation duration, and nonpulmonary organ failure. CONCLUSIONS In mechanically ventilated patients without ARDS at the time of endotracheal intubation, the majority of data favors lower tidal volume to reduce progression to ARDS. However, due to significant heterogeneity in the data, no definitive recommendations can be made. Further randomized controlled trials examining the role of lower tidal volumes in patients without ARDS, controlling for ARDS risk, are needed.
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Affiliation(s)
- Brian M Fuller
- Department of Anesthesiology, Division of Critical Care, Division of Emergency Medicine, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, St. Louis, MO, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, Department of Anesthesia, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 375 Newton Road, Iowa City, IA, USA
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, St. Louis, MO, USA
| | - Christopher R Carpenter
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, St. Louis, MO, USA
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Affiliation(s)
- Je Hyeong Kim
- Division of Pulmonary, Sleep and Critical Care Medicine, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
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Kojicic M, Li G, Hanson AC, Lee KM, Thakur L, Vedre J, Ahmed A, Baddour LM, Ryu JH, Gajic O. Risk factors for the development of acute lung injury in patients with infectious pneumonia. Crit Care 2012; 16:R46. [PMID: 22417886 PMCID: PMC3568742 DOI: 10.1186/cc11247] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Revised: 02/12/2012] [Accepted: 03/14/2012] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Although pneumonia has been identified as the single most common risk factor for acute lung injury (ALI), we have a limited knowledge as to why ALI develops in some patients with pneumonia and not in others. The objective of this study was to determine frequency, risk factors, and outcome of ALI in patients with infectious pneumonia. METHODS A retrospective cohort study of adult patients with microbiologically positive pneumonia, hospitalized at two Mayo Clinic Rochester hospitals between January 1, 2005, and December 31, 2007. In a subsequent nested case-control analysis, we evaluated the differences in prehospital and intrahospital exposures between patients with and without ALI/acute respiratory distress syndrome (ARDS) matched by specific pathogen, isolation site, gender, and closest age in a 1:1 manner. RESULTS The study included 596 patients; 365 (61.2%) were men. The median age was 65 (IQR, 53 to 75) years. In total, 171 patients (28.7%) were diagnosed with ALI. The occurrence of ALI was less frequent in bacterial (n = 99 of 412, 24%) compared with viral (n = 19 of 55, 35%), fungal (n = 39 of 95, 41%), and mixed isolates pneumonias (n = 14 of 34, 41%; P = 0.002). After adjusting for baseline severity of illness and comorbidities, patients in whom ALI developed had a markedly increased risk of hospital death (ORadj 9.7; 95% CI, 6.0 to 15.9). In a nested case-control study, presence of shock (OR, 8.9; 95% CI, 2.8 to 45.9), inappropriate initial antimicrobial treatment (OR, 3.2; 95% CI, 1.3 to 8.5), and transfusions (OR, 4.8; 95% CI, 1.5 to 19.6) independently predicted ALI development. CONCLUSIONS The development of ALI among patients hospitalized with infectious pneumonia varied among pulmonary pathogens and was associated with increased mortality. Inappropriate initial antimicrobial treatment and transfusion predict the development of ALI independent of pathogen.
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Affiliation(s)
- Marija Kojicic
- The Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
- Urgent Pulmonology Department, The Institute for Pulmonary Diseases of Vojvodina, Institutski put 4, Sremska Kamenica 21204, Serbia
| | - Guangxi Li
- The Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
- Department of Pulmonary Medicine, Guang An Men Hospital, China Academy of Chinese Medical Science, 5 BeiXianGe Street, Beijing 100053, China
| | - Andrew C Hanson
- The Division of Biostatistics, Department of Health Sciences Research, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Kun-Moo Lee
- The Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
- Department of Anesthesiology, Paik Hospital, College of Medicine, InJe University, Gaegeum 2-dong, Busanjin-gu, Busan 614-735, South Korea
| | - Lokendra Thakur
- The Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Jayanth Vedre
- The Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Adil Ahmed
- The Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Larry M Baddour
- The Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Jay H Ryu
- The Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Ognjen Gajic
- The Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Kushimoto S, Taira Y, Kitazawa Y, Okuchi K, Sakamoto T, Ishikura H, Endo T, Yamanouchi S, Tagami T, Yamaguchi J, Yoshikawa K, Sugita M, Kase Y, Kanemura T, Takahashi H, Kuroki Y, Izumino H, Rinka H, Seo R, Takatori M, Kaneko T, Nakamura T, Irahara T, Saito N, Watanabe A. The clinical usefulness of extravascular lung water and pulmonary vascular permeability index to diagnose and characterize pulmonary edema: a prospective multicenter study on the quantitative differential diagnostic definition for acute lung injury/acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R232. [PMID: 23232188 PMCID: PMC3672621 DOI: 10.1186/cc11898] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Accepted: 12/06/2012] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is characterized by features other than increased pulmonary vascular permeability. Pulmonary vascular permeability combined with increased extravascular lung water content has been considered a quantitative diagnostic criterion of ALI/ARDS. This prospective, multi-institutional, observational study aimed to clarify the clinical pathophysiological features of ALI/ARDS and establish its quantitative diagnostic criteria. METHODS The extravascular lung water index (EVLWI) and the pulmonary vascular permeability index (PVPI) were measured using the transpulmonary thermodilution method in 266 patients with PaO2/FiO2 ratio ≤ 300 mmHg and bilateral infiltration on chest radiography, in 23 ICUs of academic tertiary referral hospitals. Pulmonary edema was defined as EVLWI ≥ 10 ml/kg. Three experts retrospectively determined the pathophysiological features of respiratory insufficiency by considering the patients' history, clinical presentation, chest computed tomography and radiography, echocardiography, EVLWI and brain natriuretic peptide level, and the time course of all preceding findings under systemic and respiratory therapy. RESULTS Patients were divided into the following three categories on the basis of the pathophysiological diagnostic differentiation of respiratory insufficiency: ALI/ARDS, cardiogenic edema, and pleural effusion with atelectasis, which were noted in 207 patients, 26 patients, and 33 patients, respectively. EVLWI was greater in ALI/ARDS and cardiogenic edema patients than in patients with pleural effusion with atelectasis (18.5 ± 6.8, 14.4 ± 4.0, and 8.3 ± 2.1, respectively; P < 0.01). PVPI was higher in ALI/ARDS patients than in cardiogenic edema or pleural effusion with atelectasis patients (3.2 ± 1.4, 2.0 ± 0.8, and 1.6 ± 0.5; P < 0.01). In ALI/ARDS patients, EVLWI increased with increasing pulmonary vascular permeability (r = 0.729, P < 0.01) and was weakly correlated with intrathoracic blood volume (r = 0.236, P < 0.01). EVLWI was weakly correlated with the PaO2/FiO2 ratio in the ALI/ARDS and cardiogenic edema patients. A PVPI value of 2.6 to 2.85 provided a definitive diagnosis of ALI/ARDS (specificity, 0.90 to 0.95), and a value < 1.7 ruled out an ALI/ARDS diagnosis (specificity, 0.95). CONCLUSION PVPI may be a useful quantitative diagnostic tool for ARDS in patients with hypoxemic respiratory failure and radiographic infiltrates. TRIAL REGISTRATION UMIN-CTR ID UMIN000003627.
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¿Somos capaces de optimizar la definición y el diagnóstico del síndrome de distrés respiratorio agudo severo? Med Intensiva 2012; 36:322-3. [DOI: 10.1016/j.medin.2012.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 02/01/2012] [Indexed: 11/19/2022]
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Lee EJ, Lim JY, Lee SY, Lee SH, In KH, Yoo SH, Sul D, Park S. The expression of HSPs, anti-oxidants, and cytokines in plasma and bronchoalveolar lavage fluid of patients with acute respiratory distress syndrome. Clin Biochem 2012; 45:493-8. [PMID: 22321564 PMCID: PMC8018908 DOI: 10.1016/j.clinbiochem.2012.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Revised: 11/22/2011] [Accepted: 01/21/2012] [Indexed: 01/11/2023]
Abstract
Objectives We studied several acute inflammatory materials (AIM) such as various inflammatory cytokines, oxidative stress, and heat shock proteins in ARDS patients by simultaneously measuring from bronchoalveolar lavage fluid (BALF) and plasma. Design and methods AIM were measured by using plasma and BALF sampling obtained from ARDS group (n = 12) and non-ARDS group (n = 12). Results In the BALF, only HSP 47 was significantly increased in ARDS group than non-ARDS group. In plasma, GRP 94, HSP 90, HSP 60, HSP 47, GPx-3, and IL-8 were increased significantly in ARDS group. In short, most of the AIM in BALF or plasma were not significantly different in ARDS group as compared with non-ARDS group. Ninety-day mortality was significantly related to HSP90, HSP 60 and GPx-3 in plasma but not in BALF. Conclusion Alteration of AIM levels in both BALF or plasma of ARDS group was not remarkable compared with the non-ARDS group. Our result suggests the need to reconsider ARDS pathophysiology and therapeutic strategy.
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Affiliation(s)
- Eun Joo Lee
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Korea University College of Medicine, Republic of Korea.
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Ronchi CF, dos Anjos Ferreira AL, Campos FJ, Kurokawa CS, Carpi MF, de Moraes MA, Bonatto RC, Defaveri J, Yeum KJ, Fioretto JR. High-frequency oscillatory ventilation attenuates oxidative lung injury in a rabbit model of acute lung injury. Exp Biol Med (Maywood) 2011; 236:1188-96. [DOI: 10.1258/ebm.2011.011085] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Mechanical ventilation (MV) can induce lung oxidative stress, which plays an important role in pulmonary injury. This study compared protective conventional mechanical ventilation (CMV) and high-frequency oscillatory ventilation (HFOV) for oxygenation, oxidative stress, inflammatory and histopathological lung injury in a rabbit model of acute lung injury (ALI). Rabbits ( n = 30) were ventilated at FiO2 1.0. Lung injury was induced by tracheal saline infusion (30 mL/kg, 38°C). Animals were randomly assigned to: (a) sham control (CG: tidal volume [ VT] 6 mL/kg, positive end expiratory pressure [PEEP] 5 cmH2O, respiratory rate [RR] 40 ipm); (b) ALI + CMV (CMVG: VT 6 mL/kg, PEEP 10 cmH2O, RR 40 ipm); or (c) ALI + HFOV (HFG: mean airway pressure [Paw] 14 cmH2O, RR 10 Hz) groups. Lung oxidative stress was assessed by total antioxidant performance assay, inflammatory response by the number of polymorphonuclear leukocytes/bronchoalveolar lavage fluid/lung and pulmonary histological damage was quantified by a score. Ventilatory and hemodynamic parameters were recorded every 30 min. Both ALI groups showed worse oxygenation after lung injury induction. After four hours of ventilation, HFG showed better oxygenation (partial pressure of oxygen [PaO2] – CG: 465.9 ± 30.5 = HFG: 399.1 ± 98.2 > CMVG: 232.7 ± 104 mmHg, P < 0.05) and inflammatory responses (CMVG: 4.27 ± 1.50 > HFG: 0.33 ± 0.20 = CG: 0.16 ± 0.15; polymorphonuclear cells/bronchoalveolar lavage fluid/lung, P < 0.05), less histopathological injury score (CMVG: 5 [1–16] > HFG: 1 [0–5] > CG: 0 [0–3]; P < 0.05), and lower lung oxidative stress than CMVG (CG: 59.4 ± 4.52 = HFG: 69.0 ± 4.99 > CMVG: 47.6 ± 2.58% protection/g protein, P < 0.05). This study showed that HFOV had an important protective role in ALI. It improved oxygenation, reduced inflammatory process and histopathological damage, and attenuated oxidative lung injury compared with protective CMV under these experimental conditions considering the study limitations.
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Affiliation(s)
- Carlos Fernando Ronchi
- Internal Medicine Department
- Jean Mayer USDA – Human Nutrition Research Center on Aging, Tufts University, Boston, MA 02111, USA
| | | | | | | | | | | | | | - Julio Defaveri
- Pathology Department, Sao Paulo State University (UNESP), Botucatu Medical School, 18618-970 Botucatu, SP, Brazil
| | - Kyung-Jin Yeum
- Jean Mayer USDA – Human Nutrition Research Center on Aging, Tufts University, Boston, MA 02111, USA
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Abstract
This article reviews the state of the art regarding biomarkers for prediction, diagnosis, and prognosis in acute lung injury. Biomarkers and the goals of biomarker research are defined. Progress along 4 general routes is examined. First, the results of wide-ranging existing protein biomarkers are reported. Second, newer biomarkers awaiting or with strong potential for validation are described. Third, progress in the fields of genomics and proteomics is reported. Finally, given the complexity and number of potential biomarkers, the results of combining clinical predictors with protein and other biomarkers to produce better prognostic and diagnostic indices are examined.
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Affiliation(s)
- Nicolas Barnett
- Research Fellow, Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Lorraine B. Ware
- Associate Professor of Medicine, Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee
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Abstract
Although acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are caused by different injuries and conditions, their similar clinical picture makes a compelling case for them to be studied as a single entity. An array of potential specific targets for pharmacologic intervention can be applied to ALI/ARDS as one disease. Although a working definition of ALI/ARDS that includes pulmonary and extrapulmonary causes can have benefit in standardizing supportive care, it can also complicate assessments of the efficacy of therapeutic interventions. In this article, definitions that have been recently used for ALI/ARDS in various clinical studies are discussed individually.
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Affiliation(s)
- K Raghavendran
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - LM Napolitano
- Department of Surgery, University of Michigan, Ann Arbor, MI
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Manejo de la falla respiratoria catastrófica en el adulto. REVISTA MÉDICA CLÍNICA LAS CONDES 2011. [DOI: 10.1016/s0716-8640(11)70427-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Chung F, Mueller D. Physical therapy management of ventilated patients with acute respiratory distress syndrome or severe acute lung injury. Physiother Can 2011; 63:191-8. [PMID: 22379259 DOI: 10.3138/ptc.2010-10] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Frank Chung
- Frank Chung, BSc(PT), MSc: Section Head, Physiotherapy Department, Burnaby Hospital, Burnaby, British Columbia
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Bone marrow-derived mononuclear cell therapy in experimental pulmonary and extrapulmonary acute lung injury. Crit Care Med 2010; 38:1733-41. [PMID: 20562701 DOI: 10.1097/ccm.0b013e3181e796d2] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To hypothesize that bone marrow-derived mononuclear cell (BMDMC) therapy might act differently on lung and distal organs in models of pulmonary or extrapulmonary acute lung injury with similar mechanical compromises. The pathophysiology of acute lung injury differs according to the type of primary insult. DESIGN Prospective, randomized, controlled, experimental study. SETTING University research laboratory. MEASUREMENTS AND MAIN RESULTS In control animals, sterile saline solution was intratracheally (0.05 mL) or intraperitoneally (0.5 mL) injected. Acute lung injury animals received Escherichia coli lipopolysaccharide intratracheally (40 microg, ALIp) or intraperitoneally (400 microg, ALIexp). Six hours after lipopolysaccharide administration, ALIp and ALIexp animals were further randomized into subgroups receiving saline (0.05 mL) or BMDMC (2 x 10) intravenously. On day 7, BMDMC led to the following: 1) increase in survival rate; 2) reduction in static lung elastance, alveolar collapse, and bronchoalveolar lavage fluid cellularity (higher in ALIexp than ALIp); 3) decrease in collagen fiber content, cell apoptosis in lung, kidney, and liver, levels of interleukin-6, KC (murine interleukin-8 homolog), and interleukin-10 in bronchoalveolar lavage fluid, and messenger RNA expression of insulin-like growth factor, platelet-derived growth factor, and transforming growth factor-beta in both groups, as well as repair of basement membrane, epithelium and endothelium, regardless of acute lung injury etiology; 4) increase in vascular endothelial growth factor levels in bronchoalveolar lavage fluid and messenger RNA expression in lung tissue in both acute lung injury groups; and 5) increase in number of green fluorescent protein-positive cells in lung, kidney, and liver in ALIexp. CONCLUSIONS BMDMC therapy was effective at modulating the inflammatory and fibrogenic processes in both acute lung injury models; however, survival and lung mechanics and histology improved more in ALIexp. These changes may be attributed to paracrine effects balancing pro- and anti-inflammatory cytokines and growth factors, because a small degree of pulmonary BMDMC engraftment was observed.
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Sheu CC, Gong MN, Zhai R, Chen F, Bajwa EK, Clardy PF, Gallagher DC, Thompson BT, Christiani DC. Clinical characteristics and outcomes of sepsis-related vs non-sepsis-related ARDS. Chest 2010; 138:559-67. [PMID: 20507948 DOI: 10.1378/chest.09-2933] [Citation(s) in RCA: 171] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND ARDS may occur after either septic or nonseptic injuries. Sepsis is the major cause of ARDS, but little is known about the differences between sepsis-related and non-sepsis-related ARDS. METHODS A total of 2,786 patients with ARDS-predisposing conditions were enrolled consecutively into a prospective cohort, of which 736 patients developed ARDS. We defined sepsis-related ARDS as ARDS developing in patients with sepsis and non-sepsis-related ARDS as ARDS developing after nonseptic injuries, such as trauma, aspiration, and multiple transfusions. Patients with both septic and nonseptic risks were excluded from analysis. RESULTS Compared with patients with non-sepsis-related ARDS (n = 62), patients with sepsis-related ARDS (n = 524) were more likely to be women and to have diabetes, less likely to have preceding surgery, and had longer pre-ICU hospital stays and higher APACHE III (Acute Physiology and Chronic Health Evaluation III) scores (median, 78 vs 65, P < .0001). There were no differences in lung injury score, blood pH, Pao(2)/Fio(2) ratio, and Paco(2) on ARDS diagnosis. However, patients with sepsis-related ARDS had significantly lower Pao(2)/Fio(2) ratios than patients with non-sepsis-related ARDS patients on ARDS day 3 (P = .018), day 7 (P = .004), and day 14 (P = .004) (repeated-measures analysis, P = .011). Compared with patients with non-sepsis-related ARDS, those with sepsis-related had a higher 60-day mortality (38.2% vs 22.6%; P = .016), a lower successful extubation rate (53.6% vs 72.6%; P = .005), and fewer ICU-free days (P = .0001) and ventilator-free days (P = .003). In multivariate analysis, age, APACHE III score, liver cirrhosis, metastatic cancer, admission serum bilirubin and glucose levels, and treatment with activated protein C were independently associated with 60-day ARDS mortality. After adjustment, sepsis-related ARDS was no longer associated with higher 60-day mortality (hazard ratio, 1.26; 95% CI, 0.71-2.22). CONCLUSION Sepsis-related ARDS has a higher overall disease severity, poorer recovery from lung injury, lower successful extubation rate, and higher mortality than non-sepsis-related ARDS. Worse clinical outcomes in sepsis-related ARDS appear to be driven by disease severity and comorbidities.
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Affiliation(s)
- Chau-Chyun Sheu
- Department of Environmental Health, Harvard School of Public Health, Boston, MA 02115, USA
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Comellas AP, Briva A. Role of endothelin-1 in acute lung injury. Transl Res 2009; 153:263-71. [PMID: 19446279 PMCID: PMC3046772 DOI: 10.1016/j.trsl.2009.02.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Revised: 02/19/2009] [Accepted: 02/20/2009] [Indexed: 01/11/2023]
Abstract
The alveolar-capillary membrane serves as a barrier that prevents the accumulation of fluid in the alveolar space and restricts the diffusion of large solutes while facilitating an efficient gas exchange. When this barrier becomes dysfunctional, patients develop acute lung injury (ALI), which is characterized by pulmonary edema and increased lung inflammation that leads to a life-threatening impairment of gas exchange. In addition to the increase of inflammatory cytokines, plasma levels of endothelin-1 (ET-1), which is a primarily endothelium-derived vasoconstrictor, are increased in patients with ALI. As patients recover, ET-1 levels decrease, which suggests that ET-1 may not only be a marker of endothelial dysfunction but may have a role in the pathogenesis of ALI. While pulmonary edema accumulates, alveolar fluid clearance (AFC) is of critical importance, as failure to return to normal clearance is associated with poor prognosis in patients with pulmonary edema. AFC involves active transport mechanisms where sodium (Na(+)) is actively transported from the alveolar airspaces, across the alveolar epithelium, and into the pulmonary circulation, which creates an osmotic gradient that is responsible for the clearance of lung edema. In this article, we review the relevance of ET-1 in the development of ALI, not only as a vasoconstrictor molecule but also by inhibiting AFC via the activation of endothelial ET-B receptors and generation. Furthermore, this review highlights the therapeutic role of drugs such as beta-adrenergic agonists and, in particular, of endothelin receptor antagonists in patients with ALI.
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Affiliation(s)
- Alejandro P Comellas
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa 52242, USA.
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Ozier Y, Mertes PM. Trali et Taco : diagnostic et prise en charge clinique des patients. Transfus Clin Biol 2009; 16:152-8. [DOI: 10.1016/j.tracli.2009.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Accepted: 03/18/2009] [Indexed: 12/28/2022]
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Abstract
Intramedullary fixation has advanced to the standard of care for fractures of the femoral shaft. Current controversies center on whether to prepare the intramedullary canal by reaming, particularly in certain subsets of patients. As understanding of the local and systemic effects of reaming deepens, there is a role for maximizing the benefits of intramedullary preparation before nail fixation, while attempting to minimize the major disadvantages of this technique. Several treatment strategies have emerged to address the downsides of intramedullary reaming. The purpose of this review is to discuss the history and current knowledge of intramedullary reaming with respect to problems associated with its use and the evolution of treatment modalities and their clinical applicability for orthopaedic trauma care.
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Crandall M, Shapiro MB, West MA. Does splenectomy protect against immune-mediated complications in blunt trauma patients? Mol Med 2009; 15:263-7. [PMID: 19593410 DOI: 10.2119/molmed.2009.00029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Accepted: 04/02/2009] [Indexed: 12/24/2022] Open
Abstract
Activation of the innate immune system results from severe trauma and the resultant systemic inflammatory response is thought to mediate remote organ injury. In animal models, vagal-mediated innate immune responses have been shown to modulate proinflammatory cytokine release in response to trauma or sepsis. In those models, vagal nerve transaction and splenectomy decreased cytokine release and protected against lung injury and mortality. We hypothesized that, if similar mechanisms are active in humans, patients who require splenectomy for trauma would have better outcomes than injured patients without splenectomy. We performed a retrospective cohort study on 46,858 patients who sustained blunt liver or spleen injury utilizing the 2002 National Trauma Data Bank (NTDB). Blunt trauma patients who underwent splenectomy were compared with all patients with splenic injuries. Demographic parameters and the following outcome variables were compared: mortality, hospital length of stay (LOS), ICU length of stay (ILOS), mean ventilator days (VENT), and incidence of acute respiratory distress syndrome (ARDS). Groups were compared controlling for age, gender, injury severity score (ISS), emergency department (ED) blood pressure, and ED base deficit (BD) using multiple regression analyses. Patients that underwent splenectomy had significantly shorter LOS than patients who were managed nonoperatively or with splenorrhaphy: LOS,15.1 versus 19.3 d, P = 0.002; ILOS, 7.8 versus 10.6 d, P < 0.001; and VENT, 7.1 versus 11.4 d, P < 0.001. Adjusted mortality rates (OR 1.02; 95% CI 0.98-1.05; P = 0.29) and the reported incidence of ARDS were not significantly different between the two groups (2.4% versus 3.6%; P = 0.213). Patients who underwent splenectomy demonstrated better secondary outcomes than patients who were managed nonoperatively or with splenorrhaphy, even when controlling for injury severity and physiologic derangements. It is possible that the improved outcomes seen in the group undergoing splenectomy were due to favorable modulation of the human innate immune inflammatory response after trauma.
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Affiliation(s)
- Marie Crandall
- Northwestern University Feinberg School of Medicine, Department of Surgery, Chicago, Illinois 60611, United States of America.
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Licker M, Diaper J, Villiger Y, Spiliopoulos A, Licker V, Robert J, Tschopp JM. Impact of intraoperative lung-protective interventions in patients undergoing lung cancer surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R41. [PMID: 19317902 PMCID: PMC2689485 DOI: 10.1186/cc7762] [Citation(s) in RCA: 157] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Revised: 03/02/2009] [Accepted: 03/24/2009] [Indexed: 11/29/2022]
Abstract
Introduction In lung cancer surgery, large tidal volume and elevated inspiratory pressure are known risk factors of acute lung (ALI). Mechanical ventilation with low tidal volume has been shown to attenuate lung injuries in critically ill patients. In the current study, we assessed the impact of a protective lung ventilation (PLV) protocol in patients undergoing lung cancer resection. Methods We performed a secondary analysis of an observational cohort. Demographic, surgical, clinical and outcome data were prospectively collected over a 10-year period. The PLV protocol consisted of small tidal volume, limiting maximal pressure ventilation and adding end-expiratory positive pressure along with recruitment maneuvers. Multivariate analysis with logistic regression was performed and data were compared before and after implementation of the PLV protocol: from 1998 to 2003 (historical group, n = 533) and from 2003 to 2008 (protocol group, n = 558). Results Baseline patient characteristics were similar in the two cohorts, except for a higher cardiovascular risk profile in the intervention group. During one-lung ventilation, protocol-managed patients had lower tidal volume (5.3 ± 1.1 vs. 7.1 ± 1.2 ml/kg in historical controls, P = 0.013) and higher dynamic compliance (45 ± 8 vs. 32 ± 7 ml/cmH2O, P = 0.011). After implementing PLV, there was a decreased incidence of acute lung injury (from 3.7% to 0.9%, P < 0.01) and atelectasis (from 8.8 to 5.0, P = 0.018), fewer admissions to the intensive care unit (from 9.4% vs. 2.5%, P < 0.001) and shorter hospital stay (from 14.5 ± 3.3 vs. 11.8 ± 4.1, P < 0.01). When adjusted for baseline characteristics, implementation of the open-lung protocol was associated with a reduced risk of acute lung injury (adjusted odds ratio of 0.34 with 95% confidence interval of 0.23 to 0.75; P = 0.002). Conclusions Implementing an intraoperative PLV protocol in patients undergoing lung cancer resection was associated with improved postoperative respiratory outcomes as evidence by significantly reduced incidences of acute lung injury and atelectasis along with reduced utilization of intensive care unit resources.
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Affiliation(s)
- Marc Licker
- Department of Anaesthesiology, Pharmacology and Intensive Care, Faculty of Medicine, University of Geneva, rue Micheli-du-Crest, CH-1211 Geneva, Switzerland.
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Belda FJ, Aguilar G, Ferrando C. Variation in Extravascular Lung Water in ALI/ARDS Patients using Open Lung Strategy. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Acute respiratory distress syndrome: time to entertain a change but not to make one. Crit Care Med 2008; 36:2926-8. [PMID: 18812792 DOI: 10.1097/ccm.0b013e31818afaf3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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