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Duggal A, Camporota L. Sequencing interventions in ARDS: the critical role of timing and order in standardized management. Intensive Care Med 2024; 50:1133-1136. [PMID: 38695930 DOI: 10.1007/s00134-024-07412-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 03/24/2024] [Indexed: 07/14/2024]
Affiliation(s)
- Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Luigi Camporota
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK.
- Department of Adult Critical Care, Guy's & St Thomas' NHS Foundation Trust, East Wing 1 offices - St Thomas' Hospital, Westminster Bridge, London, SE1 7EH, UK.
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2
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Neyton LPA, Patel RK, Sarma A, Willmore A, Haller SC, Kangelaris KN, Eckalbar WL, Erle DJ, Krummel MF, Hendrickson CM, Woodruff PG, Langelier CR, Calfee CS, Fragiadakis GK. Distinct pulmonary and systemic effects of dexamethasone in severe COVID-19. Nat Commun 2024; 15:5483. [PMID: 38942804 PMCID: PMC11213873 DOI: 10.1038/s41467-024-49756-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 06/18/2024] [Indexed: 06/30/2024] Open
Abstract
Dexamethasone is the standard of care for critically ill patients with COVID-19, but the mechanisms by which it decreases mortality and its immunological effects in this setting are not understood. Here we perform bulk and single-cell RNA sequencing of samples from the lower respiratory tract and blood, and assess plasma cytokine profiling to study the effects of dexamethasone on both systemic and pulmonary immune cell compartments. In blood samples, dexamethasone is associated with decreased expression of genes associated with T cell activation, including TNFSFR4 and IL21R. We also identify decreased expression of several immune pathways, including major histocompatibility complex-II signaling, selectin P ligand signaling, and T cell recruitment by intercellular adhesion molecule and integrin activation, suggesting these are potential mechanisms of the therapeutic benefit of steroids in COVID-19. We identify additional compartment- and cell- specific differences in the effect of dexamethasone that are reproducible in publicly available datasets, including steroid-resistant interferon pathway expression in the respiratory tract, which may be additional therapeutic targets. In summary, we demonstrate compartment-specific effects of dexamethasone in critically ill COVID-19 patients, providing mechanistic insights with potential therapeutic relevance. Our results highlight the importance of studying compartmentalized inflammation in critically ill patients.
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Affiliation(s)
- Lucile P A Neyton
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
| | - Ravi K Patel
- UCSF CoLabs, University of California San Francisco, San Francisco, CA, USA
| | - Aartik Sarma
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
| | - Andrew Willmore
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
| | - Sidney C Haller
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
| | | | - Walter L Eckalbar
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
- UCSF CoLabs, University of California San Francisco, San Francisco, CA, USA
| | - David J Erle
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
- UCSF CoLabs, University of California San Francisco, San Francisco, CA, USA
- Department of Medicine, University of California, San Francisco, CA, USA
- Lung Biology Center, University of California, San Francisco, CA, USA
| | - Matthew F Krummel
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Carolyn M Hendrickson
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
| | - Prescott G Woodruff
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
| | - Charles R Langelier
- Chan Zuckerberg Biohub, San Francisco, CA, USA
- Division of Infectious Diseases, University of California, San Francisco, CA, USA
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
- Department of Medicine, University of California, San Francisco, CA, USA
- Department of Anesthesia, University of California, San Francisco, CA, USA
| | - Gabriela K Fragiadakis
- UCSF CoLabs, University of California San Francisco, San Francisco, CA, USA.
- Division of Rheumatology, University of California, San Francisco, CA, USA.
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3
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Yehya N, Booth TJ, Ardhanari GD, Thompson JM, Lam LM, Till JE, Mai MV, Keim G, McKeone DJ, Halstead ES, Lahni P, Varisco BM, Zhou W, Carpenter EL, Christie JD, Mangalmurti NS. Inflammatory and tissue injury marker dynamics in pediatric acute respiratory distress syndrome. J Clin Invest 2024; 134:e177896. [PMID: 38573766 PMCID: PMC11093602 DOI: 10.1172/jci177896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/27/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUNDThe molecular signature of pediatric acute respiratory distress syndrome (ARDS) is poorly described, and the degree to which hyperinflammation or specific tissue injury contributes to outcomes is unknown. Therefore, we profiled inflammation and tissue injury dynamics over the first 7 days of ARDS, and associated specific biomarkers with mortality, persistent ARDS, and persistent multiple organ dysfunction syndrome (MODS).METHODSIn a single-center prospective cohort of intubated pediatric patients with ARDS, we collected plasma on days 0, 3, and 7. Nineteen biomarkers reflecting inflammation, tissue injury, and damage-associated molecular patterns (DAMPs) were measured. We assessed the relationship between biomarkers and trajectories with mortality, persistent ARDS, or persistent MODS using multivariable mixed effect models.RESULTSIn 279 patients (64 [23%] nonsurvivors), hyperinflammatory cytokines, tissue injury markers, and DAMPs were higher in nonsurvivors. Survivors and nonsurvivors showed different biomarker trajectories. IL-1α, soluble tumor necrosis factor receptor 1, angiopoietin 2 (ANG2), and surfactant protein D increased in nonsurvivors, while DAMPs remained persistently elevated. ANG2 and procollagen type III N-terminal peptide were associated with persistent ARDS, whereas multiple cytokines, tissue injury markers, and DAMPs were associated with persistent MODS. Corticosteroid use did not impact the association of biomarker levels or trajectory with mortality.CONCLUSIONSPediatric ARDS survivors and nonsurvivors had distinct biomarker trajectories, with cytokines, endothelial and alveolar epithelial injury, and DAMPs elevated in nonsurvivors. Mortality markers overlapped with markers associated with persistent MODS, rather than persistent ARDS.FUNDINGNIH (K23HL-136688, R01-HL148054).
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Affiliation(s)
- Nadir Yehya
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas J. Booth
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
| | - Gnana D. Ardhanari
- Division of Pediatric Cardiac Critical Care Medicine, Children’s Heart Institute, Memorial Hermann Hospital, University of Texas Health McGovern Medical School, Houston, Texas, USA
| | - Jill M. Thompson
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
| | - L.K. Metthew Lam
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
| | - Jacob E. Till
- Division of Hematology-Oncology, Department of Medicine, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark V. Mai
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta and Emory University, Atlanta, Georgia, USA
| | - Garrett Keim
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel J. McKeone
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and
| | - E. Scott Halstead
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Patrick Lahni
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Brian M. Varisco
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Research Institute, Little Rock, Arkansas, USA
| | - Wanding Zhou
- Center for Computational and Genomic Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Erica L. Carpenter
- Division of Hematology-Oncology, Department of Medicine, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
- Center for Translational Lung Biology and
- Center for Clinical Epidemiology and Biostatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nilam S. Mangalmurti
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
- Center for Translational Lung Biology and
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4
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McDonald VM, Holland AE. Treatable traits models of care. Respirology 2024; 29:24-35. [PMID: 38087840 DOI: 10.1111/resp.14644] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/22/2023] [Indexed: 12/22/2023]
Abstract
Treatable traits is a personalized approach to the management of respiratory disease. The approach involves a multidimensional assessment to understand the traits present in individual patients. Traits are phenotypic and endotypic characteristics that can be identified, are clinically relevant and can be successfully treated by therapy to improve clinical outcomes. Identification of traits is followed by individualized and targeted treatment to those traits. First proposed for the management of asthma and chronic obstructive pulmonary disease (COPD) the approach is recommended in many other areas of respiratory and now immunology medicine. Models of care for treatable traits have been proposed in different diseases and health care setting. In asthma and COPD traits are identified in three domains including pulmonary, extrapulmonary and behavioural/lifestyle/risk-factors. In bronchiectasis and interstitial lung disease, a fourth domain of aetiological traits has been proposed. As the core of treatable traits is personalized and individualized medicine; there are several key aspects to treatable traits models of care that should be considered in the delivery of care. These include person centredness, consideration of patients' values, needs and preferences, health literacy and engagement. We review the models of care that have been proposed and provide guidance on the engagement of patients in this approach to care.
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Affiliation(s)
- Vanessa M McDonald
- Centre of Excellence in Treatable Traits, National Health and Medical Research Council, Newcastle, New South Wales, Australia
- School of Nursing and Midwifery, College of Health, Medicine and Wellbeing, University of Newcastle, New Lambton Heights, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Anne E Holland
- Centre of Excellence in Treatable Traits, National Health and Medical Research Council, Newcastle, New South Wales, Australia
- Department of Immunology, Respiratory Research@Alfred, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Melbourne, Victoria, Australia
- Physiotherapy, Alfred Health, Melbourne, Victoria, Australia
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5
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Grunwell JR. So, You Say You Want a Revolution? You Tell Me That It's Evolution: Associating Temporal Changes in Pediatric Acute Respiratory Distress Syndrome Plasma Biomarkers With Lung Injury Severity. Pediatr Crit Care Med 2024; 25:80-83. [PMID: 38169340 PMCID: PMC10783528 DOI: 10.1097/pcc.0000000000003328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Affiliation(s)
- Jocelyn R Grunwell
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, GA
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6
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Balcarcel D, Fitzgerald JC, Alcamo AM. Unmasking Critical Illness: Using Machine Learning and Biomarkers to See What Lies Beneath. Pediatr Crit Care Med 2023; 24:869-871. [PMID: 38107599 PMCID: PMC10723798 DOI: 10.1097/pcc.0000000000003314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Affiliation(s)
- Daniel Balcarcel
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julie C. Fitzgerald
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Pediatric Sepsis Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alicia M. Alcamo
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Pediatric Sepsis Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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7
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Sikora A, Jeong H, Yu M, Chen X, Murray B, Kamaleswaran R. Cluster analysis driven by unsupervised latent feature learning of medications to identify novel pharmacophenotypes of critically ill patients. Sci Rep 2023; 13:15562. [PMID: 37730817 PMCID: PMC10511715 DOI: 10.1038/s41598-023-42657-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/13/2023] [Indexed: 09/22/2023] Open
Abstract
Unsupervised clustering of intensive care unit (ICU) medications may identify unique medication clusters (i.e., pharmacophenotypes) in critically ill adults. We performed an unsupervised analysis with Restricted Boltzmann Machine of 991 medications profiles of patients managed in the ICU to explore pharmacophenotypes that correlated with ICU complications (e.g., mechanical ventilation) and patient-centered outcomes (e.g., length of stay, mortality). Six unique pharmacophenotypes were observed, with unique medication profiles and clinically relevant differences in ICU complications and patient-centered outcomes. While pharmacophenotypes 2 and 4 had no statistically significant difference in ICU length of stay, duration of mechanical ventilation, or duration of vasopressor use, their mortality differed significantly (9.0% vs. 21.9%, p < 0.0001). Pharmacophenotype 4 had a mortality rate of 21.9%, compared with the rest of the pharmacophenotypes ranging from 2.5 to 9%. Phenotyping approaches have shown promise in classifying the heterogenous syndromes of critical illness to predict treatment response and guide clinical decision support systems but have never included comprehensive medication information. This first-ever machine learning approach revealed differences among empirically-derived subgroups of ICU patients that are not typically revealed by traditional classifiers. Identification of pharmacophenotypes may enable enhanced decision making to optimize treatment decisions.
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Affiliation(s)
- Andrea Sikora
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA.
| | | | - Mengyun Yu
- Department of Statistics, University of Georgia Franklin College of Arts and Sciences, Athens, USA
| | - Xianyan Chen
- Department of Statistics, University of Georgia Franklin College of Arts and Sciences, Athens, USA
| | - Brian Murray
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA, USA
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
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8
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Neyton LPA, Patel RK, Sarma A, Willmore A, Haller SC, Kangelaris KN, Eckalbar WL, Erle DJ, Krummel MF, Hendrickson CM, Woodruff PG, Langelier CR, Calfee CS, Fragiadakis GK. Distinct pulmonary and systemic effects of dexamethasone in severe COVID-19. RESEARCH SQUARE 2023:rs.3.rs-3168149. [PMID: 37577607 PMCID: PMC10418533 DOI: 10.21203/rs.3.rs-3168149/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Dexamethasone is the standard of care for critically ill patients with COVID-19, but the mechanisms by which it decreases mortality and its immunological effects in this setting are not understood. We performed bulk and single-cell RNA sequencing of the lower respiratory tract and blood, and plasma cytokine profiling to study the effect of dexamethasone on systemic and pulmonary immune cells. We find decreased signatures of antigen presentation, T cell recruitment, and viral injury in patients treated with dexamethasone. We identify compartment- and cell- specific differences in the effect of dexamethasone in patients with severe COVID-19 that are reproducible in publicly available datasets. Our results highlight the importance of studying compartmentalized inflammation in critically ill patients.
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Affiliation(s)
- Lucile P A Neyton
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
| | - Ravi K Patel
- UCSF CoLabs, University of California San Francisco, San Francisco, CA, USA
| | - Aartik Sarma
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
| | - Andrew Willmore
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
| | - Sidney C Haller
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
| | | | - Walter L Eckalbar
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
- UCSF CoLabs, University of California San Francisco, San Francisco, CA, USA
| | - David J Erle
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
- UCSF CoLabs, University of California San Francisco, San Francisco, CA, USA
- Department of Medicine, University of California, San Francisco, CA, USA
- Lung Biology Center, University of California, San Francisco, CA, USA
| | - Matthew F Krummel
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Carolyn M Hendrickson
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
| | - Prescott G Woodruff
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
| | - Charles R Langelier
- Chan Zuckerberg Biohub, San Francisco, CA, USA
- Division of Infectious Diseases, University of California, San Francisco, CA, USA
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
- Department of Medicine, University of California, San Francisco, CA, USA
- Department of Anesthesia, University of California, San Francisco, CA, USA
| | - Gabriela K Fragiadakis
- UCSF CoLabs, University of California San Francisco, San Francisco, CA, USA
- Division of Rheumatology, University of California, San Francisco, CA, USA
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9
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Suber TL, Wendell SG, Mullett SJ, Zuchelkowski B, Bain W, Kitsios GD, McVerry BJ, Ray P, Ray A, Mallampalli RK, Zhang Y, Shah F, Nouraie SM, Lee JS. Serum metabolomic signatures of fatty acid oxidation defects differentiate host-response subphenotypes of acute respiratory distress syndrome. Respir Res 2023; 24:136. [PMID: 37210531 PMCID: PMC10199668 DOI: 10.1186/s12931-023-02447-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 05/09/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Fatty acid oxidation (FAO) defects have been implicated in experimental models of acute lung injury and associated with poor outcomes in critical illness. In this study, we examined acylcarnitine profiles and 3-methylhistidine as markers of FAO defects and skeletal muscle catabolism, respectively, in patients with acute respiratory failure. We determined whether these metabolites were associated with host-response ARDS subphenotypes, inflammatory biomarkers, and clinical outcomes in acute respiratory failure. METHODS In a nested case-control cohort study, we performed targeted analysis of serum metabolites of patients intubated for airway protection (airway controls), Class 1 (hypoinflammatory), and Class 2 (hyperinflammatory) ARDS patients (N = 50 per group) during early initiation of mechanical ventilation. Relative amounts were quantified by liquid chromatography high resolution mass spectrometry using isotope-labeled standards and analyzed with plasma biomarkers and clinical data. RESULTS Of the acylcarnitines analyzed, octanoylcarnitine levels were twofold increased in Class 2 ARDS relative to Class 1 ARDS or airway controls (P = 0.0004 and < 0.0001, respectively) and was positively associated with Class 2 by quantile g-computation analysis (P = 0.004). In addition, acetylcarnitine and 3-methylhistidine were increased in Class 2 relative to Class 1 and positively correlated with inflammatory biomarkers. In all patients within the study with acute respiratory failure, increased 3-methylhistidine was observed in non-survivors at 30 days (P = 0.0018), while octanoylcarnitine was increased in patients requiring vasopressor support but not in non-survivors (P = 0.0001 and P = 0.28, respectively). CONCLUSIONS This study demonstrates that increased levels of acetylcarnitine, octanoylcarnitine, and 3-methylhistidine distinguish Class 2 from Class 1 ARDS patients and airway controls. Octanoylcarnitine and 3-methylhistidine were associated with poor outcomes in patients with acute respiratory failure across the cohort independent of etiology or host-response subphenotype. These findings suggest a role for serum metabolites as biomarkers in ARDS and poor outcomes in critically ill patients early in the clinical course.
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Affiliation(s)
- Tomeka L Suber
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA.
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Stacy G Wendell
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Steven J Mullett
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Benjamin Zuchelkowski
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - William Bain
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Georgios D Kitsios
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bryan J McVerry
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Prabir Ray
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anuradha Ray
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Rama K Mallampalli
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Yingze Zhang
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Faraaz Shah
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Seyed Mehdi Nouraie
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Janet S Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University at St. Louis, St. Louis, MO, USA
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10
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Ramadori GP. SARS-CoV-2-Infection (COVID-19): Clinical Course, Viral Acute Respiratory Distress Syndrome (ARDS) and Cause(s) of Death. Med Sci (Basel) 2022; 10:58. [PMID: 36278528 PMCID: PMC9590085 DOI: 10.3390/medsci10040058] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/26/2022] [Accepted: 09/30/2022] [Indexed: 11/16/2022] Open
Abstract
SARS-CoV-2-infected symptomatic patients often suffer from high fever and loss of appetite which are responsible for the deficit of fluids and of protein intake. Many patients admitted to the emergency room are, therefore, hypovolemic and hypoproteinemic and often suffer from respiratory distress accompanied by ground glass opacities in the CT scan of the lungs. Ischemic damage in the lung capillaries is responsible for the microscopic hallmark, diffuse alveolar damage (DAD) characterized by hyaline membrane formation, fluid invasion of the alveoli, and progressive arrest of blood flow in the pulmonary vessels. The consequences are progressive congestion, increase in lung weight, and progressive hypoxia (progressive severity of ARDS). Sequestration of blood in the lungs worsens hypovolemia and ischemia in different organs. This is most probably responsible for the recruitment of inflammatory cells into the ischemic peripheral tissues, the release of acute-phase mediators, and for the persistence of elevated serum levels of positive acute-phase markers and of hypoalbuminemia. Autopsy studies have been performed mostly in patients who died in the ICU after SARS-CoV-2 infection because of progressive acute respiratory distress syndrome (ARDS). In the death certification charts, after respiratory insufficiency, hypovolemic heart failure should be mentioned as the main cause of death.
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11
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Gorman EA, O'Kane CM, McAuley DF. Acute respiratory distress syndrome in adults: diagnosis, outcomes, long-term sequelae, and management. Lancet 2022; 400:1157-1170. [PMID: 36070788 DOI: 10.1016/s0140-6736(22)01439-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/20/2022] [Accepted: 07/27/2022] [Indexed: 12/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is characterised by acute hypoxaemic respiratory failure with bilateral infiltrates on chest imaging, which is not fully explained by cardiac failure or fluid overload. ARDS is defined by the Berlin criteria. In this Series paper the diagnosis, management, outcomes, and long-term sequelae of ARDS are reviewed. Potential limitations of the ARDS definition and evidence that could inform future revisions are considered. Guideline recommendations, evidence, and uncertainties in relation to ARDS management are discussed. The future of ARDS strives towards a precision medicine approach, and the framework of treatable traits in ARDS diagnosis and management is explored.
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Affiliation(s)
- Ellen A Gorman
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Cecilia M O'Kane
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK.
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12
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Abstract
Contemplating the future should be grounded in history. The rise of post-polio ICUs was inextricably related to mechanical ventilation. Critically ill patients who developed acute respiratory failure often had "congestive atelectasis" (ie, a term used to describe ARDS prior to 1967). Initial mechanical ventilation strategies for treating this condition and others inadvertently led to ventilator-induced lung injury. Both injurious ventilation and later use of overly cautious weaning practices resulted from both limited technology and understanding of ARDS and other aspects of critical illness. The resulting misperceptions, misconceptions, and missed opportunities took decades to rectify and in some instances still persist. This suggests a reluctance to acknowledge that all therapeutic strategies reflect the historical period in which they were developed and the corresponding limited understanding of ARDS pathophysiology at that time. We are at the threshold of a revolutionary moment in critical care. The confluence of enormous clinical data production, massive computing power, advances in understanding the biomolecular and genetic aspects of critical illness, and the emergence of neural networks will have enormous impact on how critical care is practiced in the decades to come. Therefore, it is imperative we understand the long-crooked path needed to reach the era of protective ventilation in order to avoid similar mistakes moving forward. The emerging era is as difficult to fathom as our current practices and technologies were to those practicing 60 years ago. This review explores the history of mechanical ventilation in treating ARDS, describes current protective ventilation strategies, and speculates how ARDS management might look 20 years from now.
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Affiliation(s)
- Richard H Kallet
- Department of Anesthesia and Perioperative Care, University of California, San Francisco at San Francisco General Hospital, San Francisco, California.
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13
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Dahmer MK, Yang G, Zhang M, Quasney MW, Sapru A, Weeks HM, Sinha P, Curley MAQ, Delucchi KL, Calfee CS, Flori H, Matthay MA, Bateman ST, Berg MD, Borasino S, Bysani GK, Cowl AS, Bowens CD, Faustino VS, Fineman LD, Godshall AJ, Hirshberg EL, Kirby AL, McLaughlin GE, Medar SS, Oren PP, Schneider JB, Schwarz AJ, Shanley TP, Source LR, Truemper EJ, Vender Heyden MA, Wittmayer K, Zuppa AF, Wypij D. Identification of phenotypes in paediatric patients with acute respiratory distress syndrome: a latent class analysis. THE LANCET. RESPIRATORY MEDICINE 2022; 10:289-297. [PMID: 34883088 PMCID: PMC8897230 DOI: 10.1016/s2213-2600(21)00382-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/04/2021] [Accepted: 08/09/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Previous latent class analysis of adults with acute respiratory distress syndrome (ARDS) identified two phenotypes, distinguished by the degree of inflammation. We aimed to identify phenotypes in children with ARDS in whom developmental differences might be important, using a latent class analysis approach similar to that used in adults. METHODS This study was a secondary analysis of data aggregated from the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial and the Genetic Variation and Biomarkers in Children with Acute Lung Injury (BALI) ancillary study. We used latent class analysis, which included demographic, clinical, and plasma biomarker variables, to identify paediatric ARDS (PARDS) phenotypes within a cohort of children included in the RESTORE and BALI studies. The association of phenotypes with clinically relevant outcomes and the performance of paediatric data in adult ARDS classification algorithms were also assessed. FINDINGS 304 children with PARDS were included in this secondary analysis. Using latent class analysis, a two-class model was a better fit for the cohort than a one-class model (p<0·001). Latent class analysis identified two classes: class 1 (181 [60%] of 304 patients with PARDS) and class 2 (123 [40%] of 304 patients with PARDS), referred to as phenotype 1 and 2 hereafter. Phenotype 2 was characterised by higher concentrations of inflammatory biomarkers, a higher incidence of vasopressor use, and more frequent diagnosis of sepsis, consistent with the adult hyperinflammatory phenotype. All levels of severity of PARDS were observed across both phenotypes. Children with the hyperinflammatory phenotype (phenotype 2) had worse clinical outcomes than those with the hypoinflammatory phenotype (phenotype 1), with a longer duration of mechanical ventilation (median 10·0 days [IQR 6·3-21·0] for phenotype 2 vs 6·6 days [4·1-10·8] for phenotype 1, p<0·0001), and higher incidence of mortality (17 [13·8%] of 123 patients vs four [2·2%] of 181 patients, p=0·0001). When using adult phenotype classification algorithms in children, the soluble tumour necrosis factor receptor-1 (sTNFr1), vasopressor use, and interleukin (IL)-6 variables gave an area under the curve (AUC) of 0·956, and the sTNFr1, vasopressor use, and IL-8 variables gave an AUC of 0·954, compared with the gold standard of latent class analysis. INTERPRETATION Latent class analysis identified two phenotypes in children with ARDS with characteristics similar to those in adults, including worse outcomes among patients with the hyperinflammatory phenotype. PARDS phenotypes should be considered in design and analysis of future clinical trials in children. FUNDING US National Institutes of Health.
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Affiliation(s)
- Mary K Dahmer
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Guangyu Yang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Michael W Quasney
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Anil Sapru
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA
| | - Heidi M. Weeks
- Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Pratik Sinha
- Department of Anesthesia, Washington University, St. Louis, MO
| | - Martha AQ Curley
- Department of Family and Community Health (School of Nursing), Division of Anesthesia and Critical Care Medicine (Perelman School of Medicine) University of Pennsylvania, Philadelphia, PA; Research Institute; Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Kevin L Delucchi
- Department of Psychiatry & Behavioral Sciences, University of California, San Francisco, San Francisco, CA
| | - Carolyn S Calfee
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA
| | - Heidi Flori
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI
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14
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Masterson CH, Ceccato A, Artigas A, Dos Santos C, Rocco PR, Rolandsson Enes S, Weiss DJ, McAuley D, Matthay MA, English K, Curley GF, Laffey JG. Mesenchymal stem/stromal cell-based therapies for severe viral pneumonia: therapeutic potential and challenges. Intensive Care Med Exp 2021; 9:61. [PMID: 34970706 PMCID: PMC8718182 DOI: 10.1186/s40635-021-00424-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/21/2021] [Indexed: 12/15/2022] Open
Abstract
Severe viral pneumonia is a significant cause of morbidity and mortality globally, whether due to outbreaks of endemic viruses, periodic viral epidemics, or the rarer but devastating global viral pandemics. While limited anti-viral therapies exist, there is a paucity of direct therapies to directly attenuate viral pneumonia-induced lung injury, and management therefore remains largely supportive. Mesenchymal stromal/stem cells (MSCs) are receiving considerable attention as a cytotherapeutic for viral pneumonia. Several properties of MSCs position them as a promising therapeutic strategy for viral pneumonia-induced lung injury as demonstrated in pre-clinical studies in relevant models. More recently, early phase clinical studies have demonstrated a reassuring safety profile of these cells. These investigations have taken on an added importance and urgency during the COVID-19 pandemic, with multiple trials in progress across the globe. In parallel with clinical translation, strategies are being investigated to enhance the therapeutic potential of these cells in vivo, with different MSC tissue sources, specific cellular products including cell-free options, and strategies to ‘licence’ or ‘pre-activate’ these cells, all being explored. This review will assess the therapeutic potential of MSC-based therapies for severe viral pneumonia. It will describe the aetiology and epidemiology of severe viral pneumonia, describe current therapeutic approaches, and examine the data suggesting therapeutic potential of MSCs for severe viral pneumonia in pre-clinical and clinical studies. The challenges and opportunities for MSC-based therapies will then be considered.
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Affiliation(s)
- C H Masterson
- Anaesthesia, School of Medicine, National University of Ireland, Galway, Ireland.,Regenerative Medicine Institute, National University of Ireland, Galway, Ireland
| | - A Ceccato
- Intensive Care Unit, Hospital Universitari Sagrat Cor, Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Sabbadell, Spain
| | - A Artigas
- CIBER de Enfermedades Respiratorias (CIBERES), Sabbadell, Spain.,Critical Center, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | - C Dos Santos
- Keenan Center for Biomedical Research, St. Michael's Hospital, Bond St, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine and Institutes of Medical Sciences, University of Toronto, Toronto, Canada
| | - P R Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,National Institute of Science and Technology for Regenerative Medicine, Rio de Janeiro, Brazil
| | - S Rolandsson Enes
- Department of Experimental Medical Science, Faculty of Medicine, Lund University, Lund, Sweden
| | - D J Weiss
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT, 05405, USA
| | - D McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK.,Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - M A Matthay
- Department of Medicine and Anesthesia, University of California, San Francisco, CA, USA.,Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - K English
- Department of Biology, Maynooth University, Maynooth, Co. Kildare, Ireland.,Kathleen Lonsdale Institute for Human Health Research, Maynooth University, Maynooth, Co. Kildare, Ireland
| | - G F Curley
- Anaesthesia, School of Medicine, Royal College of Surgeons in Ireland, Dublin 9, Ireland
| | - J G Laffey
- Anaesthesia, School of Medicine, National University of Ireland, Galway, Ireland. .,Regenerative Medicine Institute, National University of Ireland, Galway, Ireland. .,Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.
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15
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Dunbar H, Weiss DJ, Rolandsson Enes S, Laffey JG, English K. The Inflammatory Lung Microenvironment; a Key Mediator in MSC Licensing. Cells 2021; 10:cells10112982. [PMID: 34831203 PMCID: PMC8616504 DOI: 10.3390/cells10112982] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 12/12/2022] Open
Abstract
Recent clinical trials of mesenchymal stromal cell (MSC) therapy for various inflammatory conditions have highlighted the significant benefit to patients who respond to MSC administration. Thus, there is strong interest in investigating MSC therapy in acute inflammatory lung conditions, such as acute respiratory distress syndrome (ARDS). Unfortunately, not all patients respond, and evidence now suggests that the differential disease microenvironment present across patients and sub-phenotypes of disease or across disease severities influences MSC licensing, function and therapeutic efficacy. Here, we discuss the importance of licensing MSCs and the need to better understand how the disease microenvironment influences MSC activation and therapeutic actions, in addition to the need for a patient-stratification approach.
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Affiliation(s)
- Hazel Dunbar
- Department of Biology, Maynooth University, W23 F2H6 Maynooth, Ireland;
- Kathleen Lonsdale Institute for Human Health Research, Maynooth University, W23 F2H6 Maynooth, Ireland
| | - Daniel J Weiss
- Department of Medicine, 226 Health Science Research Facility, Larner College of Medicine, University of Vermont, Burlington, VT 05405, USA;
| | - Sara Rolandsson Enes
- Department of Experimental Medical Science, Faculty of Medicine, Lund University, 22100 Lund, Sweden;
| | - John G Laffey
- Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, H91 W2TY Galway, Ireland;
- Department of Anaesthesia, Galway University Hospitals, SAOLTA University Health Group, H91 YR71 Galway, Ireland
| | - Karen English
- Department of Biology, Maynooth University, W23 F2H6 Maynooth, Ireland;
- Kathleen Lonsdale Institute for Human Health Research, Maynooth University, W23 F2H6 Maynooth, Ireland
- Correspondence: ; Tel.: +353-1-7086290
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16
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Sussman MA. VAPIng into ARDS: Acute Respiratory Distress Syndrome and Cardiopulmonary Failure. Pharmacol Ther 2021; 232:108006. [PMID: 34582836 DOI: 10.1016/j.pharmthera.2021.108006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/10/2021] [Accepted: 09/23/2021] [Indexed: 12/12/2022]
Abstract
"Modern" vaping involving battery-operated electronic devices began approximately one dozen years and has quickly evolved into a multibillion dollar industry providing products to an estimated 50 million users worldwide. Originally developed as an alternative to traditional cigarette smoking, vaping now appeals to a diverse demographic including substantial involvement of young people who often have never used cigarettes. The rapid rise of vaping fueled by multiple factors has understandably outpaced understanding of biological effects, made even more challenging due to wide ranging individual user habits and preferences. Consequently while vaping-related research gathers momentum, vaping-associated pathological injury (VAPI) has been established by clinical case reports with severe cases manifesting as acute respiratory distress syndrome (ARDS) with examples of right ventricular cardiac failure. Therefore, basic scientific studies are desperately needed to understand the impact of vaping upon the lungs as well as cardiopulmonary structure and function. Experimental models that capture fundamental characteristics of vaping-induced ARDS are essential to study pathogenesis and formulate recommendations to mitigate harmful effects attributable to ingredients or equipment. So too, treatment strategies to promote recovery from vaping-associated damage require development and testing at the preclinical level. This review summarizes the back story of vaping leading to present day conundrums with particular emphasis upon VAPI-associated ARDS and prioritization of research goals.
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Affiliation(s)
- Mark A Sussman
- SDSU Integrated Regenerative Research Institute and Biology Department, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, USA.
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