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Levy E, Reilly JP. Pharmacologic Treatments in Acute Respiratory Failure. Crit Care Clin 2024; 40:275-289. [PMID: 38432696 DOI: 10.1016/j.ccc.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Acute respiratory failure relies on supportive care using non-invasive and invasive oxygen and ventilatory support. Pharmacologic therapies for the most severe form of respiratory failure, acute respiratory distress syndrome (ARDS), are limited. This review focuses on the most promising therapies for ARDS, targeting different mechanisms that contribute to dysregulated inflammation and resultant hypoxemia. Significant heterogeneity exists within the ARDS population. Treatment requires prompt recognition of ARDS and an understanding of which patients may benefit most from specific pharmacologic interventions. The key to finding effective pharmacotherapies for ARDS may rely on deeper understanding of pathophysiology and bedside identification of ARDS subphenotypes.
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Affiliation(s)
- Elizabeth Levy
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19146, USA
| | - John P Reilly
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19146, USA.
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2
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Di Fenza R, Shetty NS, Gianni S, Parcha V, Giammatteo V, Safaee Fakhr B, Tornberg D, Wall O, Harbut P, Lai PS, Li JZ, Paganoni S, Cenci S, Mueller AL, Houle TT, Akeju O, Bittner EA, Bose S, Scott LK, Carroll RW, Ichinose F, Hedenstierna M, Arora P, Berra L. High-Dose Inhaled Nitric Oxide in Acute Hypoxemic Respiratory Failure Due to COVID-19: A Multicenter Phase II Trial. Am J Respir Crit Care Med 2023; 208:1293-1304. [PMID: 37774011 PMCID: PMC10765403 DOI: 10.1164/rccm.202304-0637oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/28/2023] [Indexed: 10/01/2023] Open
Abstract
Rationale: The effects of high-dose inhaled nitric oxide on hypoxemia in coronavirus disease (COVID-19) acute respiratory failure are unknown. Objectives: The primary outcome was the change in arterial oxygenation (PaO2/FiO2) at 48 hours. The secondary outcomes included: time to reach a PaO2/FiO2.300mmHg for at least 24 hours, the proportion of participants with a PaO2/FiO2.300mmHg at 28 days, and survival at 28 and at 90 days. Methods: Mechanically ventilated adults with COVID-19 pneumonia were enrolled in a phase II, multicenter, single-blind, randomized controlled parallel-arm trial. Participants in the intervention arm received inhaled nitric oxide at 80 ppm for 48 hours, compared with the control group receiving usual care (without placebo). Measurements and Main Results: A total of 193 participants were included in the modified intention-to-treat analysis. The mean change in PaO2/FiO2 ratio at 48 hours was 28.3mmHg in the intervention group and 21.4mmHg in the control group (mean difference, 39.1mmHg; 95% credible interval [CrI], 18.1 to 60.3). The mean time to reach a PaO2/FiO2.300mmHg in the interventional group was 8.7 days, compared with 8.4 days for the control group (mean difference, 0.44; 95% CrI, 23.63 to 4.53). At 28 days, the proportion of participants attaining a PaO2/FiO2.300mmHg was 27.7% in the inhaled nitric oxide group and 17.2% in the control subjects (risk ratio, 2.03; 95% CrI, 1.11 to 3.86). Duration of ventilation and mortality at 28 and 90 days did not differ. No serious adverse events were reported. Conclusions: The use of high-dose inhaled nitric oxide resulted in an improvement of PaO2/FiO2 at 48 hours compared with usual care in adults with acute hypoxemic respiratory failure due to COVID-19.
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Affiliation(s)
- Raffaele Di Fenza
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Naman S. Shetty
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stefano Gianni
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Vibhu Parcha
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Valentina Giammatteo
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Bijan Safaee Fakhr
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Daniel Tornberg
- Department of Clinical Sciences and
- Department of Anesthesia and Intensive Care and
| | - Olof Wall
- Department of Clinical Sciences and
- Department of Clinical Science and Education, Sodersxjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Piotr Harbut
- Department of Clinical Sciences and
- Department of Anesthesia and Intensive Care and
| | - Peggy S. Lai
- Pulmonary and Critical Care Medicine, Department of Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Jonathan Z. Li
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Sabrina Paganoni
- Sean M. Healey and AMG Center for ALS
- Neurological Clinical Research Institute
- Harvard Medical School, Boston, Massachusetts
| | - Stefano Cenci
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Ariel L. Mueller
- Department of Anesthesia, Critical Care, and Pain Medicine
- Anesthesia Research Center
- Harvard Medical School, Boston, Massachusetts
| | - Timothy T. Houle
- Department of Anesthesia, Critical Care, and Pain Medicine
- Anesthesia Research Center
- Harvard Medical School, Boston, Massachusetts
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Edward A. Bittner
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Somnath Bose
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
| | - Louie K. Scott
- Critical Care Medicine, Department of Medicine, Louisiana State University Health Shreveport, Shreveport, Louisiana
| | - Ryan W. Carroll
- Division of Pediatric Critical Care Medicine, Department of Pediatrics
- Harvard Medical School, Boston, Massachusetts
| | - Fumito Ichinose
- Department of Anesthesia, Critical Care, and Pain Medicine
- Anesthesia Critical Care Center for Research, and
- Harvard Medical School, Boston, Massachusetts
| | | | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care, and Pain Medicine
- Anesthesia Critical Care Center for Research, and
- Respiratory Care Services, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Redaelli S, Pozzi M, Giani M, Magliocca A, Fumagalli R, Foti G, Berra L, Rezoagli E. Inhaled Nitric Oxide in Acute Respiratory Distress Syndrome Subsets: Rationale and Clinical Applications. J Aerosol Med Pulm Drug Deliv 2023. [PMID: 37083488 PMCID: PMC10402704 DOI: 10.1089/jamp.2022.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening condition, characterized by diffuse inflammatory lung injury. Since the coronavirus disease 2019 (COVID-19) pandemic spread worldwide, the most common cause of ARDS has been the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Both the COVID-19-associated ARDS and the ARDS related to other causes-also defined as classical ARDS-are burdened by high mortality and morbidity. For these reasons, effective therapeutic interventions are urgently needed. Among them, inhaled nitric oxide (iNO) has been studied in patients with ARDS since 1993 and it is currently under investigation. In this review, we aim at describing the biological and pharmacological rationale of iNO treatment in ARDS by elucidating similarities and differences between classical and COVID-19 ARDS. Thereafter, we present the available evidence on the use of iNO in clinical practice in both types of respiratory failure. Overall, iNO seems a promising agent as it could improve the ventilation/perfusion mismatch, gas exchange impairment, and right ventricular failure, which are reported in ARDS. In addition, iNO may act as a viricidal agent and prevent lung hyperinflammation and thrombosis of the pulmonary vasculature in the specific setting of COVID-19 ARDS. However, the current evidence on the effects of iNO on outcomes is limited and clinical studies are yet to demonstrate any survival benefit by administering iNO in ARDS.
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Affiliation(s)
- Simone Redaelli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Matteo Pozzi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Marco Giani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Aurora Magliocca
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Lorenzo Berra
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Respiratory Care Department, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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4
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Battaglini D, Fazzini B, Silva PL, Cruz FF, Ball L, Robba C, Rocco PRM, Pelosi P. Challenges in ARDS Definition, Management, and Identification of Effective Personalized Therapies. J Clin Med 2023; 12:jcm12041381. [PMID: 36835919 PMCID: PMC9967510 DOI: 10.3390/jcm12041381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023] Open
Abstract
Over the last decade, the management of acute respiratory distress syndrome (ARDS) has made considerable progress both regarding supportive and pharmacologic therapies. Lung protective mechanical ventilation is the cornerstone of ARDS management. Current recommendations on mechanical ventilation in ARDS include the use of low tidal volume (VT) 4-6 mL/kg of predicted body weight, plateau pressure (PPLAT) < 30 cmH2O, and driving pressure (∆P) < 14 cmH2O. Moreover, positive end-expiratory pressure should be individualized. Recently, variables such as mechanical power and transpulmonary pressure seem promising for limiting ventilator-induced lung injury and optimizing ventilator settings. Rescue therapies such as recruitment maneuvers, vasodilators, prone positioning, extracorporeal membrane oxygenation, and extracorporeal carbon dioxide removal have been considered for patients with severe ARDS. Regarding pharmacotherapies, despite more than 50 years of research, no effective treatment has yet been found. However, the identification of ARDS sub-phenotypes has revealed that some pharmacologic therapies that have failed to provide benefits when considering all patients with ARDS can show beneficial effects when these patients were stratified into specific sub-populations; for example, those with hyperinflammation/hypoinflammation. The aim of this narrative review is to provide an overview on current advances in the management of ARDS from mechanical ventilation to pharmacological treatments, including personalized therapy.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy
- Correspondence:
| | - Brigitta Fazzini
- Adult Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, Whitechapel, London E1 1BB, UK
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Fernanda Ferreira Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, 15145 Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, 15145 Genoa, Italy
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, 15145 Genoa, Italy
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5
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Palikova YA, Palikov VA, Novikova NI, Slashcheva GA, Rasskazova EA, Tukhovskaya EA, Danilkovich AV, Dyachenko IA, Belogurov Jr. AA, Kudriaeva AA, Bugrimov DY, Krasnorutskaya ON, Murashev AN. Derinat ® has an immunomodulatory and anti-inflammatory effect on the model of acute lung injury in male SD rats. Front Pharmacol 2022; 13:1111340. [PMID: 36642990 PMCID: PMC9837527 DOI: 10.3389/fphar.2022.1111340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/16/2022] [Indexed: 12/31/2022] Open
Abstract
To simulate acute lung injury (ALI) in SD male rats they we administered intratracheally with lipopolysaccharide (LPS) followed by hyperventilation of the lungs (HVL), which lead to functional changes in the respiratory system and an increase in the blood serum concentration of inflammatory cytokines. LPS + HVL after 4 h lead to pronounced histological signs of lung damage. We have studied the effectiveness of Derinat® when administered intramuscularly at dose of 7.5 mg/kg for 8 days in the ALI model. Derinat® administration lead to an increase in the concentration of most of the studied cytokines in a day. In the ALI model the administration of Derinat® returned the concentration of cytokines to its original values already 48 h after LPS + HVL, and also normalized the parameters of pulmonary respiration in comparison with animals without treatment. By the eighth day after LPS + HVL, respiratory parameters and cytokine levels, as well as biochemical and hematological parameters did not differ between groups, while histological signs of residual effects of lung damage were found in all animals, and were more pronounced in Derinat® group, which may indicate stimulation of the local immune response. Thus, the administration of Derinat® stimulates the immune response, has a pronounced protective effect against cytokinemia and respiratory failure caused by ALI, has immunomodulatory effect, and also stimulates a local immune response in lung tissues. Thus, Derinat® is a promising treatment for ALI.
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Affiliation(s)
- Yulia A. Palikova
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia
| | - Victor A. Palikov
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia
| | - Nadezhda I. Novikova
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia
| | - Gulsara A. Slashcheva
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia
| | - Ekaterina A. Rasskazova
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia
| | - Elena A. Tukhovskaya
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia,*Correspondence: Elena A. Tukhovskaya,
| | - Alexey V. Danilkovich
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia
| | - Igor A. Dyachenko
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia
| | - Alexey A. Belogurov Jr.
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (IBCh RAS), 16/10 Miklukho-Maklay Str, Moscow, Russia,Department of Biological Chemistry, Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Anna A. Kudriaeva
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (IBCh RAS), 16/10 Miklukho-Maklay Str, Moscow, Russia
| | - Daniil Y Bugrimov
- Voronezh State Medical University Named After N. N. Burdenko, 10 Studencheskaya Str, Voronezh, Russia
| | - Olga N. Krasnorutskaya
- Voronezh State Medical University Named After N. N. Burdenko, 10 Studencheskaya Str, Voronezh, Russia
| | - Arkady N. Murashev
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences (BIBCh RAS), 6 Prospekt Nauki, Pushchino, Russia,*Correspondence: Elena A. Tukhovskaya,
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6
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Meng L, Liao X, Wang Y, Chen L, Gao W, Wang M, Dai H, Yan N, Gao Y, Wu X, Wang K, Liu Q. Pharmacologic therapies of ARDS: From natural herb to nanomedicine. Front Pharmacol 2022; 13:930593. [PMID: 36386221 PMCID: PMC9651133 DOI: 10.3389/fphar.2022.930593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/03/2022] [Indexed: 12/15/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a common critical illness in respiratory care units with a huge public health burden. Despite tremendous advances in the prevention and treatment of ARDS, it remains the main cause of intensive care unit (ICU) management, and the mortality rate of ARDS remains unacceptably high. The poor performance of ARDS is closely related to its heterogeneous clinical syndrome caused by complicated pathophysiology. Based on the different pathophysiology phases, drugs, protective mechanical ventilation, conservative fluid therapy, and other treatment have been developed to serve as the ARDS therapeutic methods. In recent years, there has been a rapid development in nanomedicine, in which nanoparticles as drug delivery vehicles have been extensively studied in the treatment of ARDS. This study provides an overview of pharmacologic therapies for ARDS, including conventional drugs, natural medicine therapy, and nanomedicine. Particularly, we discuss the unique mechanism and strength of nanomedicine which may provide great promises in treating ARDS in the future.
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Affiliation(s)
- Linlin Meng
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Ximing Liao
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Yuanyuan Wang
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Liangzhi Chen
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Wei Gao
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Muyun Wang
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Huiling Dai
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
| | - Na Yan
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Yixuan Gao
- Department of Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xu Wu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Kun Wang
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
- *Correspondence: Kun Wang, ; Qinghua Liu,
| | - Qinghua Liu
- Department of Critical Care Medicine, Shanghai East Hospital, School of medicine, Tongji University, China
- *Correspondence: Kun Wang, ; Qinghua Liu,
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7
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Battaglini D, Robba C, Pelosi P, Rocco PRM. Treatment for acute respiratory distress syndrome in adults: A narrative review of phase 2 and 3 trials. Expert Opin Emerg Drugs 2022; 27:187-209. [PMID: 35868654 DOI: 10.1080/14728214.2022.2105833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Ventilatory management and general supportive care of acute respiratory distress syndrome (ARDS) in the adult population have led to significant clinical improvements, but morbidity and mortality remain high. Pharmacologic strategies acting on the coagulation cascade, inflammation, oxidative stress, and endothelial cell injury have been targeted in the last decade for patients with ARDS, but only a few of these have shown potential benefits with a meaningful clinical response and improved patient outcomes. The lack of availability of specific pharmacologic treatments for ARDS can be attributed to its complex pathophysiology, different risk factors, huge heterogeneity, and difficult classification into specific biological phenotypes and genotypes. AREAS COVERED In this narrative review, we briefly discuss the relevance and current advances in pharmacologic treatments for ARDS in adults and the need for the development of new pharmacological strategies. EXPERT OPINION Identification of ARDS phenotypes, risk factors, heterogeneity, and pathophysiology may help to design clinical trials personalized according to ARDS-specific features, thus hopefully decreasing the rate of failed clinical pharmacologic trials. This concept is still under clinical investigation and needs further development.
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Affiliation(s)
- Denise Battaglini
- Dipartimento di Anestesia e Rianimazione, Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - Chiara Robba
- Dipartimento di Anestesia e Rianimazione, Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Largo Rosanna Benzi, 10, 16132, Genoa, Italy.,Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - Paolo Pelosi
- Dipartimento di Anestesia e Rianimazione, Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Largo Rosanna Benzi, 10, 16132, Genoa, Italy.,Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, RJ 21941-902, Brazil.,COVID-19 Virus Network from Ministry of Science, Technology, and Innovation, Brazilian Council for Scientific and Technological Development, and Foundation Carlos Chagas Filho Research Support of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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8
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Tasaka S, Ohshimo S, Takeuchi M, Yasuda H, Ichikado K, Tsushima K, Egi M, Hashimoto S, Shime N, Saito O, Matsumoto S, Nango E, Okada Y, Hayashi K, Sakuraya M, Nakajima M, Okamori S, Miura S, Fukuda T, Ishihara T, Kamo T, Yatabe T, Norisue Y, Aoki Y, Iizuka Y, Kondo Y, Narita C, Kawakami D, Okano H, Takeshita J, Anan K, Okazaki SR, Taito S, Hayashi T, Mayumi T, Terayama T, Kubota Y, Abe Y, Iwasaki Y, Kishihara Y, Kataoka J, Nishimura T, Yonekura H, Ando K, Yoshida T, Masuyama T, Sanui M. ARDS Clinical Practice Guideline 2021. J Intensive Care 2022; 10:32. [PMID: 35799288 PMCID: PMC9263056 DOI: 10.1186/s40560-022-00615-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/10/2022] [Indexed: 12/16/2022] Open
Abstract
Background The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. Methods The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. Results Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4–8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). Conclusions This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00615-6.
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Affiliation(s)
- Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan.
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kazuya Ichikado
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kenji Tsushima
- International University of Health and Welfare, Tokyo, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Hyogo, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Osamu Saito
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Eishu Nango
- Department of Family Medicine, Seibo International Catholic Hospital, Tokyo, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichiro Hayashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mikio Nakajima
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Satoshi Okamori
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinya Miura
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Urayasu Hospital, Juntendo University, Chiba, Japan
| | - Tetsuro Kamo
- Department of Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology, Nishichita General Hospital, Tokai, Japan
| | | | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Daisuke Kawakami
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Hiromu Okano
- Department of Critical Care and Emergency Medicine, National Hospital Organization Yokohama Medical Center, Kanagawa, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kyoto, Japan
| | | | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Takuya Hayashi
- Pediatric Emergency and Critical Care Center, Saitama Children's Medical Center, Saitama, Japan
| | - Takuya Mayumi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Saitama, Japan
| | - Yoshifumi Kubota
- Kameda Medical Center Department of Infectious Diseases, Chiba, Japan
| | - Yoshinobu Abe
- Division of Emergency and Disaster Medicine Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yuki Kishihara
- Department of Emergency Medicine, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Jun Kataoka
- Department of Critical Care Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Aichi, Japan
| | - Koichi Ando
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Tomoyuki Masuyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
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Signori D, Magliocca A, Hayashida K, Graw JA, Malhotra R, Bellani G, Berra L, Rezoagli E. Inhaled nitric oxide: role in the pathophysiology of cardio-cerebrovascular and respiratory diseases. Intensive Care Med Exp 2022; 10:28. [PMID: 35754072 PMCID: PMC9234017 DOI: 10.1186/s40635-022-00455-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 06/08/2022] [Indexed: 11/23/2022] Open
Abstract
Nitric oxide (NO) is a key molecule in the biology of human life. NO is involved in the physiology of organ viability and in the pathophysiology of organ dysfunction, respectively. In this narrative review, we aimed at elucidating the mechanisms behind the role of NO in the respiratory and cardio-cerebrovascular systems, in the presence of a healthy or dysfunctional endothelium. NO is a key player in maintaining multiorgan viability with adequate organ blood perfusion. We report on its physiological endogenous production and effects in the circulation and within the lungs, as well as the pathophysiological implication of its disturbances related to NO depletion and excess. The review covers from preclinical information about endogenous NO produced by nitric oxide synthase (NOS) to the potential therapeutic role of exogenous NO (inhaled nitric oxide, iNO). Moreover, the importance of NO in several clinical conditions in critically ill patients such as hypoxemia, pulmonary hypertension, hemolysis, cerebrovascular events and ischemia-reperfusion syndrome is evaluated in preclinical and clinical settings. Accordingly, the mechanism behind the beneficial iNO treatment in hypoxemia and pulmonary hypertension is investigated. Furthermore, investigating the pathophysiology of brain injury, cardiopulmonary bypass, and red blood cell and artificial hemoglobin transfusion provides a focus on the potential role of NO as a protective molecule in multiorgan dysfunction. Finally, the preclinical toxicology of iNO and the antimicrobial role of NO-including its recent investigation on its role against the Sars-CoV2 infection during the COVID-19 pandemic-are described.
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Affiliation(s)
- Davide Signori
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Aurora Magliocca
- Department of Medical Physiopathology and Transplants, University of Milan, Milan, Italy
| | - Kei Hayashida
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY, USA
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, USA
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Jan A Graw
- Department of Anesthesiology and Operative Intensive Care Medicine, CCM/CVK Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- ARDS/ECMO Centrum Charité, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Rajeev Malhotra
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Lorenzo Berra
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Respiratory Care Department, Massachusetts General Hospital, Boston, MA, USA
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy.
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10
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Tasaka S, Ohshimo S, Takeuchi M, Yasuda H, Ichikado K, Tsushima K, Egi M, Hashimoto S, Shime N, Saito O, Matsumoto S, Nango E, Okada Y, Hayashi K, Sakuraya M, Nakajima M, Okamori S, Miura S, Fukuda T, Ishihara T, Kamo T, Yatabe T, Norisue Y, Aoki Y, Iizuka Y, Kondo Y, Narita C, Kawakami D, Okano H, Takeshita J, Anan K, Okazaki SR, Taito S, Hayashi T, Mayumi T, Terayama T, Kubota Y, Abe Y, Iwasaki Y, Kishihara Y, Kataoka J, Nishimura T, Yonekura H, Ando K, Yoshida T, Masuyama T, Sanui M. ARDS clinical practice guideline 2021. Respir Investig 2022; 60:446-495. [PMID: 35753956 DOI: 10.1016/j.resinv.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/07/2022] [Accepted: 05/13/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. METHODS The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. RESULTS Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D); we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D); we suggest against routinely implementing NO inhalation therapy (GRADE 2C); and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). CONCLUSIONS This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jrs.or.jp/publication/jrs_guidelines/). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.
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Affiliation(s)
- Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Aomori, Japan.
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Kazuya Ichikado
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kenji Tsushima
- International University of Health and Welfare, Tokyo, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Hyogo, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Osamu Saito
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Eishu Nango
- Department of Family Medicine, Seibo International Catholic Hospital, Tokyo, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichiro Hayashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mikio Nakajima
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Satoshi Okamori
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinya Miura
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, Chiba, Japan
| | - Tetsuro Kamo
- Department of Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology, Nishichita General Hospital, Aichi, Japan
| | | | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, Chiba, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Daisuke Kawakami
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Hiromu Okano
- Department of Critical Care and Emergency Medicine, National Hospital Organization Yokohama Medical Center, Kanagawa, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Takuya Hayashi
- Pediatric Emergency and Critical Care Center, Saitama Children's Medical Center, Saitama, Japan
| | - Takuya Mayumi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Saitama, Japan
| | - Yoshifumi Kubota
- Department of Infectious Diseases, Kameda Medical Center, Chiba, Japan
| | - Yoshinobu Abe
- Division of Emergency and Disaster Medicine, Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yuki Kishihara
- Department of Emergency Medicine, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Jun Kataoka
- Department of Critical Care Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Aichi, Japan
| | - Koichi Ando
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Tomoyuki Masuyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
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11
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Redaelli S, Magliocca A, Malhotra R, Ristagno G, Citerio G, Bellani G, Berra L, Rezoagli E. Nitric oxide: Clinical applications in critically ill patients. Nitric Oxide 2022; 121:20-33. [PMID: 35123061 PMCID: PMC10189363 DOI: 10.1016/j.niox.2022.01.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 12/19/2022]
Abstract
Inhaled nitric oxide (iNO) acts as a selective pulmonary vasodilator and it is currently approved by the FDA for the treatment of persistent pulmonary hypertension of the newborn. iNO has been demonstrated to effectively decrease pulmonary artery pressure and improve oxygenation, while decreasing extracorporeal life support use in hypoxic newborns affected by persistent pulmonary hypertension. Also, iNO seems a safe treatment with limited side effects. Despite the promising beneficial effects of NO in the preclinical literature, there is still a lack of high quality evidence for the use of iNO in clinical settings. A variety of clinical applications have been suggested in and out of the critical care environment, aiming to use iNO in respiratory failure and pulmonary hypertension of adults or as a preventative measure of hemolysis-induced vasoconstriction, ischemia/reperfusion injury and as a potential treatment of renal failure associated with cardiopulmonary bypass. In this narrative review we aim to present a comprehensive summary of the potential use of iNO in several clinical conditions with its suggested benefits, including its recent application in the scenario of the COVID-19 pandemic. Randomized controlled trials, meta-analyses, guidelines, observational studies and case-series were reported and the main findings summarized. Furthermore, we will describe the toxicity profile of NO and discuss an innovative proposed strategy to produce iNO. Overall, iNO exhibits a wide range of potential clinical benefits, that certainly warrants further efforts with randomized clinical trials to determine specific therapeutic roles of iNO.
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Affiliation(s)
- Simone Redaelli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Aurora Magliocca
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy
| | - Rajeev Malhotra
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Giuseppe Ristagno
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy; Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Neuroscience Department, NeuroIntensive Care Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, ECMO Center, San Gerardo University Hospital, Monza, Italy
| | - Lorenzo Berra
- Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Respiratory Care Department, Massachusetts General Hospital, Boston, MA, USA
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, ECMO Center, San Gerardo University Hospital, Monza, Italy.
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12
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Brown CJ, Rubel N, Lai J, Ward C, McLean J, Wheelock M, Steuerwald M, Cathers A. Initiation of Inhaled Nitric Oxide by Air Transport Team in Adult COVID-19 Respiratory Failure. Air Med J 2022; 41:406-410. [PMID: 35750450 PMCID: PMC8907015 DOI: 10.1016/j.amj.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/28/2022] [Accepted: 03/02/2022] [Indexed: 11/19/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has caused a significant increase in the volume of critical care flight transports between outlying referral hospitals and tertiary care facilities. Because of the tropism of severe acute respiratory syndrome coronavirus 2, flight crews are often asked to transport mechanically ventilated patients in refractory hypoxemic respiratory failure. The authors present a case series of 5 patients with COVID-19 acute respiratory distress syndrome (ARDS) who were initiated on inhaled nitric oxide (iNO) by the transport team before rotor wing transport and survived the journey in stable or improved condition upon arrival. Previously, no case reports have described adults with COVID-19 ARDS transported after iNO initiation by the transport team. This case series shows the feasibility of iNO initiation by trained air medical transport teams and suggests a short-term stabilizing effect of iNO in patients with ARDS from COVID-19.
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Affiliation(s)
- Connor J Brown
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI.
| | - Nicolas Rubel
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Jason Lai
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Christen Ward
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Justin McLean
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Martin Wheelock
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Michael Steuerwald
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Andrew Cathers
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
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13
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Seo H, Lopez CN, Succar L, Donahue KR. Evaluation of Inhaled Alprostadil in Hospitalized Adult Patients. Ann Pharmacother 2021; 56:671-678. [PMID: 34486414 DOI: 10.1177/10600280211042675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Intermittent inhaled alprostadil (iPGE1) may be a viable alternative to inhaled nitric oxide or epoprostenol for management of right ventricular failure, pulmonary hypertension (pHTN) or acute respiratory distress syndrome (ARDS). However, limited evidence exists regarding iPGE1 use in adults, ideal dosing strategies, or optimal use cases. OBJECTIVE To describe the clinical characteristics of patients receiving iPGE1 and identify specific sub-populations warranting further research. METHODS This was a single-center, retrospective, descriptive analysis of inpatients who received at least one dose of iPGE1. The primary outcome was to describe patient characteristics and alprostadil dosing strategies. Secondary outcomes included changes in respiratory support requirements, hemodynamics, and inotropic/vasoactive use. Outcomes were stratified and compared based on primary therapeutic indication (cardiac or pulmonary). RESULTS Fifty-four patients received iPGE1 40 (75%) for pulmonary (pHTN or ARDS) and 14 (25%) for cardiac indications. There was no difference between indications in the number of patients de-escalated from level of respiratory (53% vs 57%, P = 0.76), inotropic (70% vs 57%, P = 0.39), or vasopressor support (78% vs 57%, P = 0.17). Furthermore, there was no significant improvement in cardiopulmonary parameters at multiple time intervals after iPGE1 initiation. CONCLUSION AND RELEVANCE This is the largest study to date on the use of intermittent iPGE1 in adults. Alprostadil was safely utilized in novel populations; however, efficacy as evaluated by clinical or surrogate endpoints could not be demonstrated and further investigation is needed to determine its potential and optimal place in therapy.
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14
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Liu K, Wang H, Yu SJ, Tu GW, Luo Z. Inhaled pulmonary vasodilators: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:597. [PMID: 33987295 PMCID: PMC8105872 DOI: 10.21037/atm-20-4895] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/30/2020] [Indexed: 02/05/2023]
Abstract
Pulmonary hypertension (PH) is a severe disease that affects people of all ages. It can occur as an idiopathic disorder at birth or as part of a variety of cardiovascular and pulmonary disorders. Inhaled pulmonary vasodilators (IPV) can reduce pulmonary vascular resistance (PVR) and improve RV function with minimal systemic effects. IPV includes inhaled nitric oxide (iNO), inhaled aerosolized prostacyclin, or analogs, including epoprostenol, iloprost, treprostinil, and other vasodilators. In addition to pulmonary vasodilating effects, IPV can also be used to improve oxygenation, reduce inflammation, and protect cell. Off-label use of IPV is common in daily clinical practice. However, evidence supporting the inhalational administration of these medications is limited, inconclusive, and controversial regarding their safety and efficacy. We conducted a search for relevant papers published up to May 2020 in four databases: PubMed, Google Scholar, EMBASE and Web of Science. This review demonstrates that the clinical using and updated evidence of IPV. iNO is widely used in neonates, pediatrics, and adults with different cardiopulmonary diseases. The limitations of iNO include high cost, flat dose-response, risk of significant rebound PH after withdrawal, and the requirement of complex technology for monitoring. The literature suggests that inhaled aerosolized epoprostenol, iloprost, treprostinil and others such as milrinone and levosimendan may be similar to iNO. More research of IPV is needed to determine acceptable inclusion criteria, long-term outcomes, and management strategies including time, dose, and duration.
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Affiliation(s)
- Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Med, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
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15
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Vassiliou AG, Kotanidou A, Dimopoulou I, Orfanos SE. Endothelial Damage in Acute Respiratory Distress Syndrome. Int J Mol Sci 2020; 21:ijms21228793. [PMID: 33233715 PMCID: PMC7699909 DOI: 10.3390/ijms21228793] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 01/01/2023] Open
Abstract
The pulmonary endothelium is a metabolically active continuous monolayer of squamous endothelial cells that internally lines blood vessels and mediates key processes involved in lung homoeostasis. Many of these processes are disrupted in acute respiratory distress syndrome (ARDS), which is marked among others by diffuse endothelial injury, intense activation of the coagulation system and increased capillary permeability. Most commonly occurring in the setting of sepsis, ARDS is a devastating illness, associated with increased morbidity and mortality and no effective pharmacological treatment. Endothelial cell damage has an important role in the pathogenesis of ARDS and several biomarkers of endothelial damage have been tested in determining prognosis. By further understanding the endothelial pathobiology, development of endothelial-specific therapeutics might arise. In this review, we will discuss the underlying pathology of endothelial dysfunction leading to ARDS and emerging therapies. Furthermore, we will present a brief overview demonstrating that endotheliopathy is an important feature of hospitalised patients with coronavirus disease-19 (COVID-19).
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Affiliation(s)
- Alice G. Vassiliou
- 1st Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.); (I.D.)
| | - Anastasia Kotanidou
- 1st Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.); (I.D.)
| | - Ioanna Dimopoulou
- 1st Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.); (I.D.)
| | - Stylianos E. Orfanos
- 1st Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.); (I.D.)
- 2nd Department of Critical Care, School of Medicine, National and Kapodistrian University of Athens, Attikon Hospital, 124 62 Athens, Greece
- Correspondence: or ; Tel.: +30-2107-235-521
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COUNTERPOINT: Does Persistent or Worsening ARDS Refractory to Optimized Ventilation and Proning Deserve a Trial of Prostacyclin? No. Chest 2020; 155:665-668. [PMID: 30955569 DOI: 10.1016/j.chest.2018.11.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 11/20/2018] [Indexed: 11/22/2022] Open
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Kaku S, Nguyen CD, Htet NN, Tutera D, Barr J, Paintal HS, Kuschner WG. Acute Respiratory Distress Syndrome: Etiology, Pathogenesis, and Summary on Management. J Intensive Care Med 2019; 35:723-737. [DOI: 10.1177/0885066619855021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The acute respiratory distress syndrome (ARDS) has multiple causes and is characterized by acute lung inflammation and increased pulmonary vascular permeability, leading to hypoxemic respiratory failure and bilateral pulmonary radiographic opacities. The acute respiratory distress syndrome is associated with substantial morbidity and mortality, and effective treatment strategies are limited. This review presents the current state of the literature regarding the etiology, pathogenesis, and management strategies for ARDS.
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Affiliation(s)
- Shawn Kaku
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Christopher D. Nguyen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Natalie N. Htet
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Dominic Tutera
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Juliana Barr
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Harman S. Paintal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Ware G. Kuschner
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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18
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Papazian L, Aubron C, Brochard L, Chiche JD, Combes A, Dreyfuss D, Forel JM, Guérin C, Jaber S, Mekontso-Dessap A, Mercat A, Richard JC, Roux D, Vieillard-Baron A, Faure H. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care 2019. [PMID: 31197492 DOI: 10.1186/s13613-019-0540-9.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Fifteen recommendations and a therapeutic algorithm regarding the management of acute respiratory distress syndrome (ARDS) at the early phase in adults are proposed. The Grade of Recommendation Assessment, Development and Evaluation (GRADE) methodology has been followed. Four recommendations (low tidal volume, plateau pressure limitation, no oscillatory ventilation, and prone position) had a high level of proof (GRADE 1 + or 1 -); four (high positive end-expiratory pressure [PEEP] in moderate and severe ARDS, muscle relaxants, recruitment maneuvers, and venovenous extracorporeal membrane oxygenation [ECMO]) a low level of proof (GRADE 2 + or 2 -); seven (surveillance, tidal volume for non ARDS mechanically ventilated patients, tidal volume limitation in the presence of low plateau pressure, PEEP > 5 cmH2O, high PEEP in the absence of deleterious effect, pressure mode allowing spontaneous ventilation after the acute phase, and nitric oxide) corresponded to a level of proof that did not allow use of the GRADE classification and were expert opinions. Lastly, for three aspects of ARDS management (driving pressure, early spontaneous ventilation, and extracorporeal carbon dioxide removal), the experts concluded that no sound recommendation was possible given current knowledge. The recommendations and the therapeutic algorithm were approved by the experts with strong agreement.
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Affiliation(s)
- Laurent Papazian
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France.
| | - Cécile Aubron
- Medical Intensive Care Unit, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Bvd Tanguy Prigent, 29609, Brest Cedex, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Jean-Daniel Chiche
- Service de Médecine Intensive - Réanimation, Hôpital Cochin, Hôpitaux Universitaires Paris-Centre, Assistance Publique - Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Alain Combes
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié- Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Didier Dreyfuss
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | - Jean-Marie Forel
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France
| | - Claude Guérin
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Samir Jaber
- Department of Anesthesiology and Intensive Care (DAR B), Saint Eloi University Hospital, Montpellier, France
| | - Armand Mekontso-Dessap
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri-Mondor, AP-HP, DHU A-TVB, 94010, Créteil, France
| | - Alain Mercat
- Medical Intensive Care Department, Angers University Hospital, 4, rue Larrey, 49933, Angers Cedex, France
| | | | - Damien Roux
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | | | - Henri Faure
- Service de Médecine Intensive - Réanimation, Centre Hospitalier Intercommunal Robert Ballanger, 93602, Aulnay-sous-Bois, France
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Papazian L, Aubron C, Brochard L, Chiche JD, Combes A, Dreyfuss D, Forel JM, Guérin C, Jaber S, Mekontso-Dessap A, Mercat A, Richard JC, Roux D, Vieillard-Baron A, Faure H. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care 2019; 9:69. [PMID: 31197492 PMCID: PMC6565761 DOI: 10.1186/s13613-019-0540-9] [Citation(s) in RCA: 397] [Impact Index Per Article: 79.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/27/2019] [Indexed: 12/16/2022] Open
Abstract
Fifteen recommendations and a therapeutic algorithm regarding the management of acute respiratory distress syndrome (ARDS) at the early phase in adults are proposed. The Grade of Recommendation Assessment, Development and Evaluation (GRADE) methodology has been followed. Four recommendations (low tidal volume, plateau pressure limitation, no oscillatory ventilation, and prone position) had a high level of proof (GRADE 1 + or 1 −); four (high positive end-expiratory pressure [PEEP] in moderate and severe ARDS, muscle relaxants, recruitment maneuvers, and venovenous extracorporeal membrane oxygenation [ECMO]) a low level of proof (GRADE 2 + or 2 −); seven (surveillance, tidal volume for non ARDS mechanically ventilated patients, tidal volume limitation in the presence of low plateau pressure, PEEP > 5 cmH2O, high PEEP in the absence of deleterious effect, pressure mode allowing spontaneous ventilation after the acute phase, and nitric oxide) corresponded to a level of proof that did not allow use of the GRADE classification and were expert opinions. Lastly, for three aspects of ARDS management (driving pressure, early spontaneous ventilation, and extracorporeal carbon dioxide removal), the experts concluded that no sound recommendation was possible given current knowledge. The recommendations and the therapeutic algorithm were approved by the experts with strong agreement.
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Affiliation(s)
- Laurent Papazian
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France.
| | - Cécile Aubron
- Medical Intensive Care Unit, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Bvd Tanguy Prigent, 29609, Brest Cedex, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Jean-Daniel Chiche
- Service de Médecine Intensive - Réanimation, Hôpital Cochin, Hôpitaux Universitaires Paris-Centre, Assistance Publique - Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Alain Combes
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié- Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Didier Dreyfuss
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | - Jean-Marie Forel
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France
| | - Claude Guérin
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Samir Jaber
- Department of Anesthesiology and Intensive Care (DAR B), Saint Eloi University Hospital, Montpellier, France
| | - Armand Mekontso-Dessap
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri-Mondor, AP-HP, DHU A-TVB, 94010, Créteil, France
| | - Alain Mercat
- Medical Intensive Care Department, Angers University Hospital, 4, rue Larrey, 49933, Angers Cedex, France
| | | | - Damien Roux
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | | | - Henri Faure
- Service de Médecine Intensive - Réanimation, Centre Hospitalier Intercommunal Robert Ballanger, 93602, Aulnay-sous-Bois, France
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Griffiths MJD, McAuley DF, Perkins GD, Barrett N, Blackwood B, Boyle A, Chee N, Connolly B, Dark P, Finney S, Salam A, Silversides J, Tarmey N, Wise MP, Baudouin SV. Guidelines on the management of acute respiratory distress syndrome. BMJ Open Respir Res 2019; 6:e000420. [PMID: 31258917 PMCID: PMC6561387 DOI: 10.1136/bmjresp-2019-000420] [Citation(s) in RCA: 249] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/01/2019] [Indexed: 12/16/2022] Open
Abstract
The Faculty of Intensive Care Medicine and Intensive Care Society Guideline Development Group have used GRADE methodology to make the following recommendations for the management of adult patients with acute respiratory distress syndrome (ARDS). The British Thoracic Society supports the recommendations in this guideline. Where mechanical ventilation is required, the use of low tidal volumes (<6 ml/kg ideal body weight) and airway pressures (plateau pressure <30 cmH2O) was recommended. For patients with moderate/severe ARDS (PF ratio<20 kPa), prone positioning was recommended for at least 12 hours per day. By contrast, high frequency oscillation was not recommended and it was suggested that inhaled nitric oxide is not used. The use of a conservative fluid management strategy was suggested for all patients, whereas mechanical ventilation with high positive end-expiratory pressure and the use of the neuromuscular blocking agent cisatracurium for 48 hours was suggested for patients with ARDS with ratio of arterial oxygen partial pressure to fractional inspired oxygen (PF) ratios less than or equal to 27 and 20 kPa, respectively. Extracorporeal membrane oxygenation was suggested as an adjunct to protective mechanical ventilation for patients with very severe ARDS. In the absence of adequate evidence, research recommendations were made for the use of corticosteroids and extracorporeal carbon dioxide removal.
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Affiliation(s)
| | - Danny Francis McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, West Midlands, UK
| | | | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Andrew Boyle
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Nigel Chee
- Academic Department of Critical Care, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, NIHR Biomedical Research Centre, University of Manchester, Manchester, Greater Manchester, UK
| | - Simon Finney
- Peri-Operative Medicine, Barts Health NHS Trust, London, UK
| | - Aemun Salam
- Peri-Operative Medicine, Barts Health NHS Trust, London, UK
| | - Jonathan Silversides
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Nick Tarmey
- Academic Department of Critical Care, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - Simon V Baudouin
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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21
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Ma GG, Hao GW, Lai H, Yang XM, Liu L, Wang CS, Tu GW, Luo Z. Initial clinical impact of inhaled nitric oxide therapy for refractory hypoxemia following type A acute aortic dissection surgery. J Thorac Dis 2019; 11:495-504. [PMID: 30962993 PMCID: PMC6409278 DOI: 10.21037/jtd.2019.01.42] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND To evaluate the effect of inhaled nitric oxide (iNO) therapy on oxygenation and clinical outcomes in patients with refractory hypoxemia after surgical reconstruction for acute type A aortic dissection (TAAD). METHODS A before-and-after interventional study was conducted in patients with refractory hypoxemia after surgical reconstruction for TAAD. Postoperative refractory hypoxemia was defined as a persistent PaO2/FiO2 ratio ≤100 mmHg despite conventional therapy. From January to November 2016, conventional treatment was carried out for refractory hypoxemia. From December 2016 to October 2017, on the basis of conventional therapy, we explored the use of iNO to treat refractory hypoxemia. RESULTS Fifty-three TAAD patients with refractory hypoxemia were enrolled in this study. Twenty-seven patients received conventional treatment (conventional group), while the remaining 26 patients received iNO therapy. The PaO2/FiO2 ratio was significantly higher in the iNO group after treatment than in the conventional group when analyzed over the entire 72 hours. The duration of invasive mechanical ventilation was significantly reduced in the iNO group (69.19 vs. 104.56 hours; P=0.003). Other outcomes, such as mortality (3.85% vs. 7.41%, P=1.000), intensive care unit (ICU) duration (9.88 vs. 12.36 days, P=0.059) and hospital stay (16.88 vs. 20.76 days, P=0.060), were not significantly different between the two groups. CONCLUSIONS iNO therapy might play an ameliorative role in patients with refractory hypoxemia after surgical reconstruction for TAAD. This therapy may lead to sustained improvement in oxygenation and reduce the duration of invasive mechanical ventilation.
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Affiliation(s)
- Guo-Guang Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Hao Lai
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Xiao-Mei Yang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Lan Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Chun-Sheng Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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22
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Effects of the use of neuromuscular blocking agents on acute respiratory distress syndrome outcomes: A systematic review. J Am Assoc Nurse Pract 2018; 30:327-332. [DOI: 10.1097/jxx.0000000000000047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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23
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Pappalardo F, Montisci A. Adjunctive therapies during veno-venous extracorporeal membrane oxygenation. J Thorac Dis 2018; 10:S683-S691. [PMID: 29732187 DOI: 10.21037/jtd.2017.10.08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Veno-venous extracorporeal membrane oxygenation (VV ECMO) restores gas exchanges in severely hypoxemic patients. The need for adjunctive therapies usually originates either from refractory hypoxemia during ECMO (defined as the persistence of low blood oxygen levels despite extracorporeal support) or from the attempt to give a specific therapy for acute respiratory distress syndrome (ARDS). In this review, therapeutic strategies to treat refractory and persistent hypoxemia during ECMO are evaluated. In the second part, therapies that can be added on top of VV ECMO to address inflammation and altered vascular permeability in ARDS are examined. The therapies currently available often allow for an effective treatment of hypoxemia during ECMO. ARDS is still lacking a specific therapy, with low-grade evidence sustaining the majority of currently used drugs.
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Affiliation(s)
- Federico Pappalardo
- Department of Anesthesia and Intensive Care and Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Montisci
- Department of Anesthesia and Intensive Care, Cardiothoracic Center, Istituto Clinico Sant'Ambrogio, Gruppo Ospedaliero San Donato, University and Research Hospitals, Milan, Italy
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Yang CY, Chen CS, Yiang GT, Cheng YL, Yong SB, Wu MY, Li CJ. New Insights into the Immune Molecular Regulation of the Pathogenesis of Acute Respiratory Distress Syndrome. Int J Mol Sci 2018; 19:ijms19020588. [PMID: 29462936 PMCID: PMC5855810 DOI: 10.3390/ijms19020588] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 02/11/2018] [Accepted: 02/14/2018] [Indexed: 12/11/2022] Open
Abstract
Acute respiratory distress syndrome is an inflammatory disease characterized by dysfunction of pulmonary epithelial and capillary endothelial cells, infiltration of alveolar macrophages and neutrophils, cell apoptosis, necroptosis, NETosis, and fibrosis. Inflammatory responses have key effects on every phase of acute respiratory distress syndrome. The severe inflammatory cascades impaired the regulation of vascular endothelial barrier and vascular permeability. Therefore, understanding the relationship between the molecular regulation of immune cells and the pulmonary microenvironment is critical for disease management. This article reviews the current clinical and basic research on the pathogenesis of acute respiratory distress syndrome, including information on the microenvironment, vascular endothelial barrier and immune mechanisms, to offer a strong foundation for developing therapeutic interventions.
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Affiliation(s)
- Chin-Yao Yang
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan.
| | - Chien-Sheng Chen
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan.
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan.
| | - Giou-Teng Yiang
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan.
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan.
| | - Yeung-Leung Cheng
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231, Taiwan.
- School of Surgery, Tzu Chi University, Hualien 970, Taiwan.
| | - Su-Boon Yong
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan.
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Show Chwan Memorial Hospital, Changhua 500, Taiwan.
- Department of Nursing, Meiho University, Pingtung 912, Taiwan.
| | - Meng-Yu Wu
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan.
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan.
| | - Chia-Jung Li
- Research Assistant Center, Show Chwan Memorial Hospital, Changhua 500, Taiwan.
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Discovery of caffeic acid phenethyl ester derivatives as novel myeloid differentiation protein 2 inhibitors for treatment of acute lung injury. Eur J Med Chem 2017; 143:361-375. [PMID: 29202400 DOI: 10.1016/j.ejmech.2017.11.066] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 11/22/2017] [Accepted: 11/24/2017] [Indexed: 12/26/2022]
Abstract
Myeloid differentiation protein 2 (MD2) is an essential molecule which recognizes lipopolysaccharide (LPS), leading to initiation of inflammation through the activation of Toll-like receptor 4 (TLR4) signaling. Caffeic acid phenethyl ester (CAPE) from propolis of honeybee hives could interfere interactions between LPS and the TLR4/MD2 complex, and thereby has promising anti-inflammatory properties. In this study, we designed and synthesized 48 CAPE derivatives and evaluated their anti-inflammatory activities in mouse primary peritoneal macrophages (MPMs) activated by LPS. The most active compound, 10s, was found to bind with MD2 with high affinity, which prevented formation of the LPS/MD2/TLR4 complex. The binding mode of 10s revealed that the major interactions with MD2 were established via two key hydrogen bonds and hydrophobic interactions. Furthermore, 10s showed remarkable protective effects against LPS-caused ALI (acute lung injury) in vivo. Taken together, this work provides new lead structures and candidates as MD2 inhibitors for the development of anti-inflammatory drugs.
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Hashimoto S, Sanui M, Egi M, Ohshimo S, Shiotsuka J, Seo R, Tanaka R, Tanaka Y, Norisue Y, Hayashi Y, Nango E. The clinical practice guideline for the management of ARDS in Japan. J Intensive Care 2017; 5:50. [PMID: 28770093 PMCID: PMC5526253 DOI: 10.1186/s40560-017-0222-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 04/19/2017] [Indexed: 12/13/2022] Open
Abstract
Background The Japanese Society of Respiratory Care Medicine and the Japanese Society of Intensive Care Medicine provide here a clinical practice guideline for the management of adult patients with ARDS in the ICU. Method The guideline was developed applying the GRADE system for performing robust systematic reviews with plausible recommendations. The guideline consists of 13 clinical questions mainly regarding ventilator settings and drug therapies (the last question includes 11 medications that are not approved for clinical use in Japan). Results The recommendations for adult patients with ARDS include: we suggest against early tracheostomy (GRADE 2C), we suggest using NPPV for early respiratory management (GRADE 2C), we recommend the use of low tidal volumes at 6-8 mL/kg (GRADE 1B), we suggest setting the plateau pressure at 30cmH20 or less (GRADE2B), we suggest using PEEP within the range of plateau pressures less than or equal to 30cmH2O, without compromising hemodynamics (Grade 2B), and using higher PEEP levels in patients with moderate to severe ARDS (Grade 2B), we suggest using protocolized methods for liberation from mechanical ventilation (Grade 2D), we suggest prone positioning especially in patients with moderate to severe respiratory dysfunction (GRADE 2C), we suggest against the use of high frequency oscillation (GRADE 2C), we suggest the use of neuromuscular blocking agents in patients requiring mechanical ventilation under certain circumstances (GRADE 2B), we suggest fluid restriction in the management of ARDS (GRADE 2A), we do not suggest the use of neutrophil elastase inhibitors (GRADE 2D), we suggest the administration of steroids, equivalent to methylprednisolone 1-2mg/kg/ day (GRADE 2A), and we do not recommend other medications for the treatment of adult patients with ARDS (GRADE1B; inhaled/intravenous β2 stimulants, prostaglandin E1, activated protein C, ketoconazole, and lisofylline, GRADE 1C; inhaled nitric oxide, GRADE 1D; surfactant, GRADE 2B; granulocyte macrophage colony-stimulating factor, N-acetylcysteine, GRADE 2C; Statin.) Conclusions This article was translated from the Japanese version originally published as the ARDS clinical practice guidelines 2016 by the committee of ARDS clinical practice guideline (Tokyo, 2016, 293p, available from http://www.jsicm.org/ARDSGL/ARDSGL2016.pdf). The original article, written for Japanese healthcare providers, provides points of view that are different from those in other countries. Electronic supplementary material The online version of this article (doi:10.1186/s40560-017-0222-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Satoru Hashimoto
- Department of Anesthesiology and Intensive Care, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Moritoki Egi
- Department of anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Hiroshima University, Hiroshima, Japan
| | - Junji Shiotsuka
- Division of Critical Care Medicine, Okinawa Chubu Hospital, Okinawa, Japan
| | - Ryutaro Seo
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ryoma Tanaka
- Pulmonary & Critical Care Medicine, LDS Hospital, Salt Lake City, USA
| | - Yu Tanaka
- Department of Anesthesiology, Nara Medical University, Nara, Japan
| | - Yasuhiro Norisue
- Department of Emergency and Critical Care Medicine, Tokyo Bay Medical Center, Tokyo, Japan
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
| | - Eishu Nango
- Department of General Medicine, Tokyo kita Social Insurance Hospital, Tokyo, Japan
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27
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Abstract
Critical care medicine is a young specialty that has experienced an expansion of research efforts in the last decade. Many physiologic and therapeutic principles or “dogmas” have been challenged, resulting in major “shifts” and minor “drifts” in thinking. This article reviews the available literature about some of these important and sometimes controversial changes, with emphasis on the practical implications of the concepts. Specific areas discussed include supply-dependent oxygen consumption in critical illness, manipulation of the cytokine cascade in sepsis, ventilation in the acute respiratory distress syndrome (ARDS), blood transfusion in the critically ill, the concept of the multiple organ dysfunction syndrome (MODS), the need for nutritional support in the critically ill, and others. Many of the changes discussed involve the recognition that the host response to a severe insult is exceedingly complex, and the understanding of this response and the effects of it at a tissue and cellular level are incomplete. As a result, the ability to impact the outcome of sepsis and MODS has thus far been disappointing, with the possible exception of “lung-protective” ventilation. The final challenge in critical care medicine is to gain information that will allow the practitioner to better understand, prevent, and treat the complex events that result in organ and cellular dysfunction. Future changes in dogma are welcome if they help achieve these goals.
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Affiliation(s)
- Ari Robin Joffe
- Department of Pediatrics, University of Alberta Hospital, University of Alberta, Edmonton, Alberta, Canada.
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Karam O, Gebistorf F, Wetterslev J, Afshari A. The effect of inhaled nitric oxide in acute respiratory distress syndrome in children and adults: a Cochrane Systematic Review with trial sequential analysis. Anaesthesia 2016; 72:106-117. [PMID: 27762438 DOI: 10.1111/anae.13628] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2016] [Indexed: 11/30/2022]
Abstract
Acute respiratory distress syndrome is associated with high mortality and morbidity. Inhaled nitric oxide has been used to improve oxygenation but its role remains controversial. Our primary objective in this systematic review was to examine the effects of inhaled nitric oxide administration on mortality in adults and children with acute respiratory distress syndrome. We included all randomised, controlled trials, irrespective of date of publication, blinding status, outcomes reported or language. Our primary outcome measure was all-cause mortality. We performed several subgroup and sensitivity analyses to assess the effect of inhaled nitric oxide. There was no statistically significant effect of inhaled nitric oxide on longest follow-up mortality (inhaled nitric oxide group 250/654 deaths (38.2%) vs. control group 221/589 deaths (37.5%; relative risk (95% CI) 1.04 (0.9-1.19)). We found a significant improvement in PaO2 /FI O2 ratio at 24 h (mean difference (95% CI) 15.91 (8.25-23.56)), but not at 48 h or 72 h, while four trials indicated improved oxygenation in the inhaled nitric oxide group at 96 h (mean difference (95% CI) 14.51 (3.64-25.38)). There were no statistically significant differences in ventilator-free days, duration of mechanical ventilation, resolution of multi-organ failure, quality of life, length of stay in intensive care unit or hospital, cost-benefit analysis and methaemoglobin and nitrogen dioxide levels. There was an increased risk of renal impairment (risk ratio (95% CI) 1.59 (1.17-2.16)) with inhaled nitric oxide. In conclusion, there is insufficient evidence to support inhaled nitric oxide in any category of critically ill patients with acute respiratory distress syndrome despite a transient improvement in oxygenation, since mortality is not reduced and it may induce renal impairment.
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Affiliation(s)
- O Karam
- Paediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland
| | - F Gebistorf
- Paediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland
| | - J Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark
| | - A Afshari
- The Cochrane Anaesthesia, Critical and Emergency Care Group and Copenhagen Trial Unit and Department of Paediatric and Obstetric Anaesthesia, Rigshospitalet, Copenhagen, Denmark
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Abstract
Nitric oxide has been implicated in numerous biological processes, particularly those involved with the cardiovascular system. Nitric oxide production is closely regulated and influenced by a number of factors in both health and disease. Nitric oxide is involved in maintaining the vascular system in its healthy, nondiseased state by producing vasorelaxation which enhances blood flow and prevents both leukocyte and platelet adhesion to the vascular wall. Dysfunctional endothelial cell nitric oxide production has been implicated in a number of disease states, including hypertension and atherosclerosis, and has been associated with adverse cardiac events. Various recent therapies may exert their beneficial effects in part by enhancing endothelial nitric oxide bloavallability. Nitric oxide has been used therapeutically in a number of cardiorespiratory disease states. An improved understanding of the pathologic processes underlying these diseases has resulted in several alternative agents being investigated and used clinically.
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Affiliation(s)
- Stuart M. Lowson
- Department of Anesthesiology and Surgical-Trauma ICU Co-Director, University of Virginia, Charlottesville, Virginia
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Lee SH, Lee JG, Lee CY, Kim N, Chang MY, You YC, Kim HJ, Paik HC, Oh YJ. Effects of intraoperative inhaled iloprost on primary graft dysfunction after lung transplantation: A retrospective single center study. Medicine (Baltimore) 2016; 95:e3975. [PMID: 27399072 PMCID: PMC5058801 DOI: 10.1097/md.0000000000003975] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
DESIGN Inhaled iloprost was known to alleviate ischemic-reperfusion lung injury. We investigated whether intraoperative inhaled iloprost can prevent the development of primary graft dysfunction after lung transplantation. Data for a consecutive series of patients who underwent lung transplantation with extracorporeal membrane oxygenation were retrieved. By propensity score matching, 2 comparable groups of 30 patients were obtained: patients who inhaled iloprost immediately after reperfusion of the grafted lung (ILO group); patients who did not receive iloprost (non-ILO group). RESULTS The severity of pulmonary infiltration on postoperative days (PODs) 1 to 3 was significantly lower in the ILO group compared to the non-ILO group. The PaO2/FiO2 ratio was significantly higher in the ILO group compared to the non-ILO group (318.2 ± 74.2 vs 275.9 ± 65.3 mm Hg, P = 0.022 on POD 1; 351.4 ± 58.2 vs 295.8 ± 53.7 mm Hg, P = 0.017 on POD 2; and 378.8 ± 51.9 vs 320.2 ± 66.2 mm Hg, P = 0.013 on POD 3, respectively). The prevalence of the primary graft dysfunction grade 3 was lower in the ILO group compared to the non-ILO group (P = 0.042 on POD 1; P = 0.026 on POD 2; P = 0.024 on POD 3, respectively). The duration of ventilator use and intensive care unit were significantly reduced in the ILO group (P = 0.041 and 0.038). CONCLUSIONS Intraoperative inhaled iloprost could prevent primary graft dysfunction and preserve allograft function, thus reducing the length of ventilator care and intensive care unit stay, and improving the overall early post-transplant morbidity in patients undergoing lung transplantation.
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Affiliation(s)
- Su Hyun Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute
| | - Jin Gu Lee
- Department of Thoracic and Cardiovascular Surgery
| | | | - Namo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute
| | - Min-Yung Chang
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Chul You
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute
| | - Hyun Joo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute
| | - Hyo Chae Paik
- Department of Thoracic and Cardiovascular Surgery
- Correspondence: Hyo Chae Paik, Department of Thoracic and Cardiovascular Surgery, Seodaemun-gu, Seoul, Korea (e-mail: ); Young Jun Oh, Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea (e-mail: )
| | - Young Jun Oh
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute
- Correspondence: Hyo Chae Paik, Department of Thoracic and Cardiovascular Surgery, Seodaemun-gu, Seoul, Korea (e-mail: ); Young Jun Oh, Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea (e-mail: )
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Prodhan P, Noviski N. Pediatric Acute Hypoxemic Respiratory Failure: Management of Oxygenation. J Intensive Care Med 2016; 19:140-53. [PMID: 15154995 DOI: 10.1177/0885066604263859] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute hypoxemic respiratory failure (AHRF) is one of the hallmarks of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), which are caused by an inflammatory process initiated by any of a number of potential systemic and/or pulmonary insults that result in heterogeneous disruption of the capillary-pithelial interface. In these critically sick patients, optimizing the management of oxygenation is crucial. Physicians managing pediatric patients with ALI or ARDS are faced with a complex array of options influencing oxygenation. Certain treatment strategies can influence clinical outcomes, such as a lung protective ventilation strategy that specifies a low tidal volume (6 mL/kg) and a plateau pressure limit (30 cm H2O). Other strategies such as different levels of positive end expiratory pressure, altered inspiration to expiration time ratios, recruitment maneuvers, prone positioning, and extraneous gases or drugs may also affect clinical outcomes. This article reviews state-of-the-art strategies on the management of oxygenation in acute hypoxemic respiratory failure in children.
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Affiliation(s)
- Parthak Prodhan
- Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children, Boston, Massachusetts 02114, USA
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Gebistorf F, Karam O, Wetterslev J, Afshari A. Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) in children and adults. Cochrane Database Syst Rev 2016; 2016:CD002787. [PMID: 27347773 PMCID: PMC6464789 DOI: 10.1002/14651858.cd002787.pub3] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Acute hypoxaemic respiratory failure (AHRF) and mostly acute respiratory distress syndrome (ARDS) are critical conditions. AHRF results from several systemic conditions and is associated with high mortality and morbidity in individuals of all ages. Inhaled nitric oxide (INO) has been used to improve oxygenation, but its role remains controversial. This Cochrane review was originally published in 2003, and has been updated in 2010 and 2016. OBJECTIVES The primary objective was to examine the effects of administration of inhaled nitric oxide on mortality in adults and children with ARDS. Secondary objectives were to examine secondary outcomes such as pulmonary bleeding events, duration of mechanical ventilation, length of stay, etc. We conducted subgroup and sensitivity analyses, examined the role of bias and applied trial sequential analyses (TSAs) to examine the level of evidence. SEARCH METHODS In this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015 Issue 11); MEDLINE (Ovid SP, to 18 November 2015), EMBASE (Ovid SP, to 18 November 2015), CAB, BIOSIS and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We handsearched the reference lists of the newest reviews and cross-checked them with our search of MEDLINE. We contacted the main authors of included studies to request any missed, unreported or ongoing studies. The search was run from inception until 18 November 2015. SELECTION CRITERIA We included all randomized controlled trials (RCTs), irrespective of publication status, date of publication, blinding status, outcomes published or language. We contacted trial investigators and study authors to retrieve relevant and missing data. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and resolved disagreements by discussion. Our primary outcome measure was all-cause mortality. We performed several subgroup and sensitivity analyses to assess the effects of INO in adults and children and on various clinical and physiological outcomes. We presented pooled estimates of the effects of interventions as risk ratios (RRs) with 95% confidence intervals (CIs). We assessed risk of bias through assessment of trial methodological components and risk of random error through trial sequential analysis. MAIN RESULTS Our primary objective was to assess effects of INO on mortality. We found no statistically significant effects of INO on longest follow-up mortality: 250/654 deaths (38.2%) in the INO group compared with 221/589 deaths (37.5%) in the control group (RR 1.04, 95% CI 0.9 to 1.19; I² statistic = 0%; moderate quality of evidence). We found no statistically significant effects of INO on mortality at 28 days: 202/587 deaths (34.4%) in the INO group compared with 166/518 deaths (32.0%) in the control group (RR 1.08, 95% CI 0.92 to 1.27; I² statistic = 0%; moderate quality of evidence). In children, there was no statistically significant effects of INO on mortality: 25/89 deaths (28.1%) in the INO group compared with 34/96 deaths (35.4%) in the control group (RR 0.78, 95% CI 0.51 to 1.18; I² statistic = 22%; moderate quality of evidence).Our secondary objective was to assess the benefits and harms of INO. For partial pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FiO2), we found significant improvement at 24 hours (mean difference (MD) 15.91, 95% CI 8.25 to 23.56; I² statistic = 25%; 11 trials, 614 participants; moderate quality of evidence). For the oxygenation index, we noted significant improvement at 24 hours (MD -2.31, 95% CI -2.73 to -1.89; I² statistic = 0%; five trials, 368 participants; moderate quality of evidence). For ventilator-free days, the difference was not statistically significant (MD -0.57, 95% CI -1.82 to 0.69; I² statistic = 0%; five trials, 804 participants; high quality of evidence). There was a statistically significant increase in renal failure in the INO groups (RR 1.59, 95% CI 1.17 to 2.16; I² statistic = 0%; high quality of evidence). AUTHORS' CONCLUSIONS Evidence is insufficient to support INO in any category of critically ill patients with AHRF. Inhaled nitric oxide results in a transient improvement in oxygenation but does not reduce mortality and may be harmful, as it seems to increase renal impairment.
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Affiliation(s)
- Fabienne Gebistorf
- Geneva University HospitalPediatric Intensive Care Unit6 rue Willy DonzéGenevaSwitzerland1205
| | - Oliver Karam
- Children's Hospital of Richmond at VCUDivision of Pediatric Critical Care1250 East Marshall StRichmondVAUSA23298
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Arash Afshari
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013CopenhagenDenmark
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Kim BS, Kyoung KH, Park H. Therapeutic Role of Inhaled Nitric Oxide for Acute Respiratory Failure in the Early Phase of Trauma. JOURNAL OF TRAUMA AND INJURY 2015. [DOI: 10.20408/jti.2015.28.3.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Byoung Sung Kim
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Kyu-Hyouck Kyoung
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hojong Park
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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35
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King C, May CW, Williams J, Shlobin OA. Management of right heart failure in the critically ill. Crit Care Clin 2015; 30:475-98. [PMID: 24996606 DOI: 10.1016/j.ccc.2014.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Right ventricular failure complicates several commonly encountered conditions in the intensive care unit. Right ventricular dilation and paradoxic movement of the interventricular septum on echocardiography establishes the diagnosis. Right heart catheterization is useful in establishing the specific cause and aids clinicians in management. Principles of treatment focus on reversal of the underlying cause, optimization of right ventricular preload and contractility, and reduction of right ventricular afterload. Mechanical support with right ventricular assist device or veno-arterial extracorporeal membrane oxygenation can be used in select patients who fail to improve with optimal medical therapy.
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Affiliation(s)
- Christopher King
- Medical Critical Care Service, Inova Fairfax Hospital, 618 South Royal Street, Alexandria, VA 22314, USA.
| | - Christopher W May
- Advanced Heart Failure and Cardiac Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Jeffrey Williams
- Medical Critical Care Service, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
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36
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Inhaled nitric oxide in cardiac surgery: Evidence or tradition? Nitric Oxide 2015; 49:67-79. [PMID: 26186889 DOI: 10.1016/j.niox.2015.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/08/2015] [Accepted: 06/25/2015] [Indexed: 12/15/2022]
Abstract
Inhaled nitric oxide (iNO) therapy as a selective pulmonary vasodilator in cardiac surgery has been one of the most significant pharmacological advances in managing pulmonary hemodynamics and life threatening right ventricular dysfunction and failure. However, this remarkable story has experienced a roller-coaster ride with high hopes and nearly universal demonstration of physiological benefits but disappointing translation of these benefits to harder clinical outcomes. Most of our understanding on the iNO field in cardiac surgery stems from small observational or single centre randomised trials and even the very few multicentre trials fail to ascertain strong evidence base. As a consequence, there are only weak clinical practice guidelines on the field and only European expert opinion for the use of iNO in routine and more specialised cardiac surgery such as heart and lung transplantation and left ventricular assist device (LVAD) insertion. In this review the authors from a specialised cardiac centre in the UK with a very high volume of iNO usage provide detailed information on the early observations leading to the European expert recommendations and reflect on the nature and background of these recommendations. We also provide a summary of the progress in each of the cardiac subspecialties for the last decade and initial survey data on the views of senior anaesthetic and intensive care colleagues on these recommendations. We conclude that the combination of high price tag associated with iNO therapy and lack of substantial clinical evidence is not sustainable on the current field and we are risking loosing this promising therapy from our daily practice. Overcoming the status quo will not be easy as there is not much room for controlled trials in heart transplantation or in the current atmosphere of LVAD implantation. However, we call for international cooperation to conduct definite studies to determine the place of iNO therapy in lung transplantation and high risk mitral surgery. This will require new collaboration between the pharmaceutical companies, national grant agencies and the clinical community. Until these trials are realized we should gather multi-institutional experience from large retrospective studies and prospective data from a new international registry. We must step up international efforts if we wish to maintain the iNO modality in the armamentarium of hemodynamic tools for the perioperative management of our high risk cardiac surgical patients.
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Dzierba AL, Abel EE, Buckley MS, Lat I. A review of inhaled nitric oxide and aerosolized epoprostenol in acute lung injury or acute respiratory distress syndrome. Pharmacotherapy 2014; 34:279-90. [PMID: 24734313 DOI: 10.1002/phar.1365] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) are conditions associated with an estimated mortality of 40–50%. The use of inhaled vasodilators can help to improve oxygenation without hemodynamic effects. This article reviews relevant studies addressing the safety and efficacy of inhaled nitric oxide (iNO) and aerosolized epoprostenol (aEPO) in the treatment of life-threatening hypoxemia associated with ARDS and ALI. In addition, the article also provides a practicable guide to the clinical application of these therapies. Nine prospective randomized controlled trials were included for iNO reporting on changes in oxygenation or clinical outcomes. Seven reports of aEPO were examined for changes in oxygenation. Based on currently available data, the use of either iNO or aEPO is safe to use in patients with ALI or ARDS to transiently improve oxygenation. No differences have been observed in survival, ventilator-free days, or attenuation in disease severity. Further studies with consistent end points using standard delivery devices and standard modes of mechanical ventilation are needed to determine the overall benefit with iNO or aEPO.
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Abstract
PURPOSE OF REVIEW Despite recent advances in the management of patients with acute respiratory distress syndrome (ARDS) by using protective ventilator strategies, the mortality rate of ARDS remains high. The complexity of the pathogenesis and the heterogeneity of coexisting diseases in patients with ARDS require critical care physicians and researchers to search for multiple therapeutic approaches in order to further improve patient outcome. This review article therefore focuses on the recent studies in the field of pharmacological intervention in ARDS. RECENT FINDINGS A number of approaches for pharmacological intervention have been evaluated in patients with ARDS, but most of them failed to reduce mortality or improve outcomes despite some promising observations seen in preclinical studies. Prior methods such as nitric oxide inhalation, neuromuscular blocking agents and corticosteroids may still have a place in the treatment, while novel therapeutic approaches including the use of angiotensin-converting enzyme inhibitors, statins and stem cells are currently under investigation. SUMMARY Overall, there is no proven pharmacological therapy in ARDS, but some pharmacological interventions were associated with beneficial effects in certain subgroups of patients depending on the cause, underlying diseases, the concurrent supportive therapies and timing. Further clinical trials are warranted to assess multiple outcome measurement of the promising pharmacological interventions in selected patients with ARDS.
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Our paper 20 years later: Inhaled nitric oxide for the acute respiratory distress syndrome—discovery, current understanding, and focussed targets of future applications. Intensive Care Med 2014; 40:1649-58. [DOI: 10.1007/s00134-014-3458-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/18/2014] [Indexed: 11/26/2022]
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Luedike P, Totzeck M, Meyer C, Westenfeld R, Kindgen-Milles D, Kelm M, Rassaf T. Act fast and ventilate soft: the Düsseldorf hands-on translation of the acute respiratory distress syndrome Berlin definition. J Crit Care 2014; 29:883.e1-5. [PMID: 24768567 DOI: 10.1016/j.jcrc.2014.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/23/2014] [Accepted: 03/25/2014] [Indexed: 11/26/2022]
Abstract
Early identification of acute respiratory distress syndrome (ARDS) and forceful implementation of standardized therapy algorithms are the mandatory basis of an effective therapy to improve patient outcome. Recently, a new definition of ARDS was implemented, which simplified the diagnostic criteria for ARDS. Evidence-based therapies are rare, but some cornerstone interventions can be recommended. Lung-protective ventilation with high positive end-expiratory pressure and low tidal volume and early prone positioning in severe cases improve survival rate. We here present an integrated "Düsseldorf hands-on translation" in the form of a "one-page" standard operating procedure in order to fasten and standardize both diagnosis and therapeutic algorithms on an intensive care unit.
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Affiliation(s)
- Peter Luedike
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Matthias Totzeck
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Christian Meyer
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Detlef Kindgen-Milles
- Division of Anaesthesiology, Medical Faculty Heinrich-Heine-University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Tienush Rassaf
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Düsseldorf, Düsseldorf, Germany.
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Inhaled Nitric Oxide Does Not Reduce Mortality in Patients With Acute Respiratory Distress Syndrome Regardless of Severity. Crit Care Med 2014; 42:404-12. [DOI: 10.1097/ccm.0b013e3182a27909] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Khan M, Frankel H. Adjuncts to ventilatory support part 1: nitric oxide, surfactants, prostacyclin, steroids, sedation, and neuromuscular blockade. Curr Probl Surg 2013; 50:424-33. [PMID: 24156839 DOI: 10.1067/j.cpsurg.2013.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) remain major causes of morbidity and mortality in critical care medicine despite advances in therapeutic modalities. ALI can be associated with sepsis, trauma, pharmaceutical or xenobiotic exposures, high oxygen therapy (hyperoxia), and mechanical ventilation. Of the small gas molecules (NO, CO, H₂S) that arise in human beings from endogenous enzymatic activities, the physiological significance of NO is well established, whereas that of CO or H₂S remains controversial. Recent studies have explored the potential efficacy of inhalation therapies using these small gas molecules in animal models of ALI. NO has vasoregulatory and redox-active properties and can function as a selective pulmonary vasodilator. Inhaled NO (iNO) has shown promise as a therapy in animal models of ALI including endotoxin challenge, ischemia/reperfusion (I/R) injury, and lung transplantation. CO, another diatomic gas, can exert cellular tissue protection through antiapoptotic, anti-inflammatory, and antiproliferative effects. CO has shown therapeutic potential in animal models of endotoxin challenge, oxidative lung injury, I/R injury, pulmonary fibrosis, ventilator-induced lung injury, and lung transplantation. H₂S, a third potential therapeutic gas, can induce hypometabolic states in mice and can confer both pro- and anti-inflammatory effects in rodent models of ALI and sepsis. Clinical studies have shown variable results for the efficacy of iNO in lung transplantation and failure for this therapy to improve mortality in ARDS patients. No clinical studies have been conducted with H₂S. The clinical efficacy of CO remains unclear and awaits further controlled clinical studies in transplantation and sepsis.
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Affiliation(s)
- Stefan W Ryter
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Sawheny E, Ellis AL, Kinasewitz GT. Iloprost improves gas exchange in patients with pulmonary hypertension and ARDS. Chest 2013; 144:55-62. [PMID: 23370599 DOI: 10.1378/chest.12-2296] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE We hypothesized that nebulized iloprost would improve ventilation-perfusion matching in patients with pulmonary hypertension and ARDS as reflected by an improved Pao2/Fio2 ratio and Pao2 without adversely affecting lung mechanics or systemic hemodynamics. METHODS Patients with ARDS and pulmonary hypertension were enrolled. With constant ventilator settings, hemodynamics, airway pressures, and gas exchange measured at baseline were compared with values 30 min after administration of 10 μg nebulized iloprost, and again 30 min after a second, larger, 20 μg dose of iloprost, and then a final measurement 2 h after the second dose. The primary outcome variable was Pao2; secondary outcomes were Pao2/Fio2 ratio, mean arterial BP, and lung-compliance ventilatory equivalents for oxygen and CO2. RESULTS After informed consent was obtained, 20 patients (nine men, 11 women; median age, 59 years [interquartile range, 44-66 years]) with ARDS were enrolled. Baseline PaO2 improved from a mean (±SD) of 82 (13) mm Hg to 100 (25) mm Hg after both the first and second doses of iloprost, and the baseline mean (±SD) PaO2/FIO2 ratio of 177 (60) improved to 213 (67) and 212 (70) (all P<.01). PaCO2, peak and plateau airway pressures, systemic BP, and heart rate were not significantly changed after iloprost. CONCLUSIONS The improvement in gas exchange without any detrimental effects on pulmonary mechanics or systemic hemodynamics suggests nebulized iloprost may be a useful therapeutic agent to improve oxygenation in patients with ARDS. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01274481; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Eva Sawheny
- Division of Pulmonary and Critical Care Medicine, University of Oklahoma Health Sciences, Oklahoma City, OK
| | - Ashley L Ellis
- Division of Pulmonary and Critical Care Medicine, University of Oklahoma Health Sciences, Oklahoma City, OK
| | - Gary T Kinasewitz
- Division of Pulmonary and Critical Care Medicine, University of Oklahoma Health Sciences, Oklahoma City, OK.
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Fröhlich S, Murphy N, Ryan D, Boylan JF. Acute respiratory distress syndrome: current concepts and future directions. Anaesth Intensive Care 2013; 41:463-72. [PMID: 23808504 DOI: 10.1177/0310057x1304100405] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute respiratory distress syndrome is one of the leading causes of death in critically ill patients. Recent advances in supportive care have led to a moderate improvement in mortality. In particular, a much lower mortality rate than expected was evident in the severest category of patients (requiring extracorporeal membrane oxygenation) in Australia during the recent H1N1 pandemic. Though improvements in supportive care may have provided some benefit, there remains an absence of effective biological agents that are necessary to achieve further incremental reduction in mortality. This article will review the evidence available for current treatment strategies and discuss future research directions that may eventually improve outcomes in this important global disease.
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Affiliation(s)
- S Fröhlich
- Department of Anaesthesia and Intensive Care Medicine, St Vincent's University Hospital, Dublin, Ireland.
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Budinger GRS, Mutlu GM. Balancing the risks and benefits of oxygen therapy in critically III adults. Chest 2013; 143:1151-1162. [PMID: 23546490 DOI: 10.1378/chest.12-1215] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Oxygen therapy is an integral part of the treatment of critically ill patients. Maintenance of adequate oxygen delivery to vital organs often requires the administration of supplemental oxygen, sometimes at high concentrations. Although oxygen therapy is lifesaving, it may be associated with deleterious effects when administered for prolonged periods at high concentrations. Here, we review the recent advances in our understanding of the molecular responses to hypoxia and high levels of oxygen and review the current guidelines for oxygen therapy in critically ill patients.
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Affiliation(s)
- G R Scott Budinger
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Gökhan M Mutlu
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Roch A, Hraiech S, Dizier S, Papazian L. Pharmacological interventions in acute respiratory distress syndrome. Ann Intensive Care 2013; 3:20. [PMID: 23822630 PMCID: PMC3701581 DOI: 10.1186/2110-5820-3-20] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 06/14/2013] [Indexed: 01/11/2023] Open
Abstract
Pharmacological interventions are commonly considered in acute respiratory distress syndrome (ARDS) patients. Inhaled nitric oxide (iNO) and neuromuscular blockers (NMBs) are used in patients with severe hypoxemia. No outcome benefit has been observed with the systematic use of iNO. However, a sometimes important improvement in oxygenation can occur shortly after starting administration. Therefore, its ease of use and its good tolerance justify iNO optionally combined with almitirne as a rescue therapy on a trial basis. Recent data from the literature support the use of a 48-h infusion of NMBs in patients with a PaO2 to FiO2 ratio <120 mmHg. No strong evidence exists on the increase of ICU-acquired paresis after a short course of NMBs. Fluid management with the goal to obtain zero fluid balance in ARDS patients without shock or renal failure significantly increases the number of days without mechanical ventilation. On the other hand, patients with hemodynamic failure must receive early and adapted fluid resuscitation. Liberal and conservative fluid strategies therefore are complementary and should ideally follow each other in time in the same patient whose hemodynamic state progressively stabilizes. At present, albumin treatment does not appear to be justified for limitation of pulmonary edema and respiratory morbidity. Aerosolized β2-agonists do not improve outcome in patients with ARDS and one study strongly suggests that intravenous salbutamol may worsen outcome in those patients. The early use of high doses of corticosteroids for the prevention of ARDS in septic shock patients or in patients with confirmed ARDS significantly reduced the duration of mechanical ventilation but had no effect or even increased mortality. In patients with persistent ARDS after 7 to 28 days, a randomized trial showed no reduction in mortality with moderate doses of corticosteroids but an increased PaO2 to FiO2 ratio and thoracopulmonary compliance were found, as well as shorter durations of mechanical ventilation and of ICU stay. Conflicting data exist on the interest of low doses of corticosteroids (200 mg/day of hydrocortisone) in ARDS patients. In the context of a persistent ARDS with histological proof of fibroproliferation, a corticosteroid treatment with a progressive decrease of doses can be proposed.
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Affiliation(s)
- Antoine Roch
- URMITE, UM63, CNRS 7278, Aix Marseille Université, IRD 198, Inserm 1095, Marseille, 13005, France
- APHM, CHU Nord, Réanimation, Marseille, 13015, France
- Intensive Care Unit, CHU Nord, Chemin des Bourrely, Marseille, 13015, France
| | - Sami Hraiech
- URMITE, UM63, CNRS 7278, Aix Marseille Université, IRD 198, Inserm 1095, Marseille, 13005, France
- APHM, CHU Nord, Réanimation, Marseille, 13015, France
| | | | - Laurent Papazian
- URMITE, UM63, CNRS 7278, Aix Marseille Université, IRD 198, Inserm 1095, Marseille, 13005, France
- APHM, CHU Nord, Réanimation, Marseille, 13015, France
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Schneider AG, Lipcsey M, Bailey M, Pilcher DV, Bellomo R. Simple translational equations to compare illness severity scores in intensive care trials. J Crit Care 2013; 28:885.e1-8. [PMID: 23566728 DOI: 10.1016/j.jcrc.2013.02.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 01/20/2013] [Accepted: 02/04/2013] [Indexed: 12/22/2022]
Abstract
PURPOSE Comparison of illness severity for intensive care unit populations assessed according to different scoring systems should increase our ability to compare and meta-analyze past and future trials but is currently not possible. Accordingly, we aimed to establish a methodology to translate illness severity scores obtained from one system into another. MATERIALS AND METHODS Using the Australian and New-Zealand intensive care adult patient database, we obtained simultaneous admission Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III scores and Simplified Acute Physiology Score (SAPS) II in 634428 patients admitted to 153 units between 2001 and 2010. We applied linear regression analyses to create models enabling translation of one score into another. Sensitivity analyses were performed after removal of diagnostic categories excluded from the original APACHE database, after matching for similar risk of death, after splitting data according to country of origin (Australia or New Zealand) and after splitting admissions occurring before or after 2006. RESULTS The translational models were APACHE III=3.08×APACHE II+5.75; APACHE III=1.47×SAPS II+8.6; and APACHE II=0.36×SAPS II+4.4. The area under the receiver operating curve for mortality prediction was 0.853 (95% confidence interval, 0.851-0.855) for the "APACHE II derived APACHE III" score and 0.854 (0.852-0.855) for the "SAPS II derived APACHE III" vs 0.854 (0.852-0.855) for the original APACHE III score. Similarly, it was 0.841 (0.839-0.843) for the "SAPS II derived APACHE II score" vs 0.842 (0.840-0.843) for the original APACHE II score. Correlation coefficients as well as intercepts remained very similar in all subgroups analyses. CONCLUSIONS Simple and robust translational formulas can be developed to allow clinicians to compare illness severity between studies involving critically ill patients. Further studies in other countries and health care systems are needed to confirm the generalizability of these results.
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Affiliation(s)
- Antoine G Schneider
- Department of Intensive Care, Austin Health, Intensive Care Unit, Heidelberg, Australia; Department of Epidemiology and Preventive Medicine, The Alfred Center, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
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49
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NILSSON MCA, HAMBRAEUS-JONZON K, ALVING K, WIKLUND P, BERGQUIST M, FREDÉN F. Distant effects of nitric oxide inhalation in lavage-induced lung injury in anaesthetised pigs. Acta Anaesthesiol Scand 2013. [PMID: 23198970 DOI: 10.1111/aas.12030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Inhalation of nitric oxide (INO) exerts both local and distant effects. INO in healthy pigs causes down-regulation of endogenous nitric oxide (NO) production and vasoconstriction in lung regions not reached by INO, especially in hypoxic regions, which augments hypoxic pulmonary vasoconstriction. In contrast, in pigs with endotoxemia-induced lung injury, INO causes increased NO production in lung regions not reached by INO. The aim of this study was to investigate whether INO exerts distant effects in surfactant-depleted lungs. METHODS Twelve pigs were anaesthetised, and the left lower lobe (LLL) was separately ventilated. Lavage injury was induced in all lung regions, except the LLL. In six pigs, 40 ppm INO was given to the LLL (INO group), and the effects on endogenous NO production and blood flow in the lavage-injured lung regions were studied. Six pigs served as a control group. NO concentration in exhaled air (ENO), NO synthase (NOS) activity and cyclic guanosine monophosphate (cGMP) in lung tissue, and regional pulmonary blood flow were measured. RESULTS The calcium (Ca(2+) )-dependent NOS activity was lower (P < 0.05) in the lavage-injured lung regions in the INO group than in the control group. There were no measurable differences between the groups for Ca(2+) -independent NOS activity, cGMP, ENO, or regional pulmonary blood flow. CONCLUSIONS Regional INO did not increase endogenous NO production in lavage-injured lung regions not directly reached by INO, but instead down-regulated the constitutive calcium-dependent nitric oxide synthase activity, indicating that NO may inhibit its own synthesis.
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Affiliation(s)
- M. C. A. NILSSON
- Department of Anesthesiology and Intensive Care; Uppsala University; Uppsala; Sweden
| | - K. HAMBRAEUS-JONZON
- Department of Anesthesiology, Surgical Services and Intensive Care Medicine; Karolinska University Hospital; Stockholm; Sweden
| | - K. ALVING
- Department of Womens and Childrens Health; Uppsala University; Uppsala; Sweden
| | - P. WIKLUND
- Department of Urology; Karolinska University Hospital; Stockholm; Sweden
| | - M. BERGQUIST
- Hedenstierna Laboratory; Uppsala University; Uppsala; Sweden
| | - F. FREDÉN
- Department of Anesthesiology and Intensive Care; Uppsala University; Uppsala; Sweden
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Dechert RE, Haas CF, Ostwani W. Current knowledge of acute lung injury and acute respiratory distress syndrome. Crit Care Nurs Clin North Am 2013; 24:377-401. [PMID: 22920464 DOI: 10.1016/j.ccell.2012.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) continues to be a major cause of mortality in adult and pediatric critical care medicine. This article discusses the pulmonary sequelae associated with ALI and ARDS, the support of ARDS with mechanical ventilation, available adjunctive therapies, and experimental therapies currently being tested. It is hoped that further understanding of the fundamental biology, improved identification of the patient's inflammatory state, and application of therapies directed at multiple sites of action may ultimately prove beneficial for patients suffering from ALI/ARDS.
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Affiliation(s)
- Ronald E Dechert
- Department of Respiratory Care, University of Michigan Health System, 8-720 Mott Hospital, 1540 East Hospital Drive, SPC 4208, Ann Arbor, MI 48109, USA.
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