1
|
Shah N, Katira BH. Role of cardiopulmonary interactions in development of ventilator-induced lung injury-Experimental evidence and clinical Implications. Front Physiol 2023; 14:1228476. [PMID: 37534365 PMCID: PMC10391157 DOI: 10.3389/fphys.2023.1228476] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/07/2023] [Indexed: 08/04/2023] Open
Abstract
Ventilator-induced lung injury (VILI) impacts outcomes in ARDS and optimization of ventilatory strategies improves survival. Decades of research has identified various mechanisms of VILI, largely focusing on airspace forces of plateau pressure, tidal volume and driving pressure. Experimental evidence indicates the role of adverse cardiopulmonary interaction during mechanical ventilation, contributing to VILI genesis mostly by modulating pulmonary vascular dynamics. Under passive mechanical ventilation, high transpulmonary pressure increases afterload on right heart while high pleural pressure reduces the RV preload. Together, they can result in swings of pulmonary vascular flow and pressure. Altered vascular flow and pressure result in increased vascular shearing and wall tension, in turn causing direct microvascular injury accompanied with permeability to water, proteins and cells. Moreover, abrupt decreases in airway pressure, may result in sudden overperfusion of the lung and result in similar microvascular injury, especially when the endothelium is stretched or primed at high positive end-expiratory pressure. Microvascular injury is universal in VILI models and presumed in the diagnosis of ARDS; preventing such microvascular injury can reduce VILI and impact outcomes in ARDS. Consequently, developing cardiovascular targets to reduce macro and microvascular stressors in the pulmonary circulation can potentially reduce VILI. This paper reviews the role of cardiopulmonary interaction in VILI genesis.
Collapse
|
2
|
Motes A, Singh T, Vinan Vega N, Nugent K. A Focused Review of the Initial Management of Patients with Acute Respiratory Distress Syndrome. J Clin Med 2023; 12:4650. [PMID: 37510765 PMCID: PMC10380732 DOI: 10.3390/jcm12144650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/24/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
At present, the management of patients with acute respiratory distress syndrome (ARDS) largely focuses on ventilator settings to limit intrathoracic pressures by using low tidal volumes and on FiO2/PEEP relationships to maintain optimal gas exchange. Acute respiratory distress syndrome is a complex medical disorder that can develop in several primary acute disorders, has a rapid time course, and has several classifications that can reflect either the degree of hypoxemia, the extent of radiographic involvement, or the underlying pathogenesis. The identification of subtypes of patients with ARDS would potentially make precision medicine possible in these patients. This is a very difficult challenge given the heterogeneity in the clinical presentation, pathogenesis, and treatment responses in these patients. The analysis of large databases of patients with acute respiratory failure using statistical methods such as cluster analysis could identify phenotypes that have different outcomes or treatment strategies. However, clinical information available on presentation is unlikely to separate patients into groups that allow for secure treatment decisions or outcome predictions. In some patients, non-invasive positive pressure ventilation provides adequate support through episodes of acute respiratory failure, and the development of specialized units to manage patients with this support might lead to the better use of hospital resources. Patients with ARDS have capillary leak, which results in interstitial and alveolar edema. Early attention to fluid balance in these patients might improve gas exchange and alter the pathophysiology underlying the development of severe ARDS. Finally, more attention to the interaction of patients with ventilators through complex monitoring systems has the potential to identify ventilator dyssynchrony, leading to ventilator adjustments and potentially better outcomes. Recent studies with COVID-19 patients provide tentative answers to some of these questions. In addition, expert clinical investigators have analyzed the promise and difficulties associated with the development of precision medicine in patients with ARDS.
Collapse
Affiliation(s)
- Arunee Motes
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Tushi Singh
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Noella Vinan Vega
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| |
Collapse
|
3
|
Wang T, Zhai Y, Xue H, Zhou W, Ding Y, Nie H. Regulation of Epithelial Sodium Transport by SARS-CoV-2 Is Closely Related with Fibrinolytic System-Associated Proteins. Biomolecules 2023; 13:biom13040578. [PMID: 37189326 DOI: 10.3390/biom13040578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 05/17/2023] Open
Abstract
Dyspnea and progressive hypoxemia are the main clinical features of patients with coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Pulmonary pathology shows diffuse alveolar damage with edema, hemorrhage, and the deposition of fibrinogens in the alveolar space, which are consistent with the Berlin Acute Respiratory Distress Syndrome Criteria. The epithelial sodium channel (ENaC) is a key channel protein in alveolar ion transport and the rate-limiting step for pulmonary edema fluid clearance, the dysregulation of which is associated with acute lung injury/acute respiratory distress syndrome. The main protein of the fibrinolysis system, plasmin, can bind to the furin site of γ-ENaC and induce it to an activation state, facilitating pulmonary fluid reabsorption. Intriguingly, the unique feature of SARS-CoV-2 from other β-coronaviruses is that the spike protein of the former has the same furin site (RRAR) with ENaC, suggesting that a potential competition exists between SARS-CoV-2 and ENaC for the cleavage by plasmin. Extensive pulmonary microthrombosis caused by disorders of the coagulation and fibrinolysis system has also been seen in COVID-19 patients. To some extent, high plasmin (ogen) is a common risk factor for SARS-CoV-2 infection since an increased cleavage by plasmin accelerates virus invasion. This review elaborates on the closely related relationship between SARS-CoV-2 and ENaC for fibrinolysis system-related proteins, aiming to clarify the regulation of ENaC under SARS-CoV-2 infection and provide a novel reference for the treatment of COVID-19 from the view of sodium transport regulation in the lung epithelium.
Collapse
Affiliation(s)
- Tingyu Wang
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Yiman Zhai
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Hao Xue
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Wei Zhou
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Yan Ding
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Hongguang Nie
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| |
Collapse
|
4
|
Yiang GT, Wu YK, Tsai KW, Tzeng IS, Hu WC, Liao MT, Lu KC, Chung HW, Chao YC, Su WL. Immunothrombosis biomarkers as potential predictive factors of acute respiratory distress syndrome in moderate-to-critical COVID-19: A single-center, retrospective cohort study. Immunol Lett 2023; 254:30-38. [PMID: 36702261 PMCID: PMC9869627 DOI: 10.1016/j.imlet.2023.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/18/2023] [Accepted: 01/21/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Immunothrombosis, a process of inflammation and coagulation, is involved in sepsis-induced acute respiratory distress syndrome formation (ARDS). However, the clinical correlation between immunothrombosis biomarkers (including tissue factor [TF] and von Willebrand factor [vWF]) and coronavirus disease 2019 (COVID-19)-related ARDS is unknown. This study investigated ARDS development following moderate-to-critical COVID-19 and examined immunothrombosis biomarkers as ARDS predictors. METHODS This retrospective cohort study included patients with moderate-to-critical COVID-19 (n = 165) admitted to a northern teaching hospital during the 2021 pandemic in Taiwan, who had no COVID-19 vaccinations. Immunothrombosis biomarkers were compared between COVID-19 patients with and without ARDS (no-ARDS) and a control group consisting of 100 healthy individuals. RESULTS The study included 58 ARDS and 107 no-ARDS patients. In multivariable analysis, TF (aOR=1.031, 95% CI: 1.009-1.053, p = 0.006); and vWF (aOR=1.053, 95% CI: 1.002-1.105, p = 0.041) were significantly associated with ARDS episodes, after adjusting for other confounding factors. vWF and TF predicted ARDS with the area under the curve of 0.870 (95% CI: 0.796-0.945). Further mechanical ventilation analysis found TF to be correlated significantly with pCO2 and ventilatory ratio. CONCLUSIONS TF and vWF levels potentially predicted ARDS development within 7 days of admission for COVID-19 after adjusting for traditional risk factors. TF correlated with ventilation impairment in COVID-19 ARDS but further prospective studies are needed.
Collapse
Affiliation(s)
- Giou-Teng Yiang
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan; School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Yao-Kuang Wu
- School of Medicine, Tzu Chi University, Hualien 970, Taiwan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan
| | - Kuo-Wang Tsai
- Department of Medical Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - I-Shiang Tzeng
- Department of Medical Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Wan-Chung Hu
- Department of Clinical Pathology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231, Taiwan
| | - Min-Tser Liao
- Department of Pediatrics, Taoyuan Armed Forces General Hospital, Taoyuan City 325, Taiwan; Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan; Department of Medicine, School of Medicine, College of Medicine, Fu-Jen Catholic University Hospital, Fu-Jen Catholic University, New Taipei City 24205, Taiwan
| | - Kuo-Cheng Lu
- Department of Medicine, School of Medicine, College of Medicine, Fu-Jen Catholic University Hospital, Fu-Jen Catholic University, New Taipei City 24205, Taiwan; Division of Nephrology, Department of Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan
| | - Hsueh-Wen Chung
- School of Nursing, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - You-Chen Chao
- School of Medicine, Tzu Chi University, Hualien 970, Taiwan; Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan
| | - Wen-Lin Su
- School of Medicine, Tzu Chi University, Hualien 970, Taiwan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan.
| |
Collapse
|
5
|
Gavelli F, Shi R, Teboul JL, Azzolina D, Mercado P, Jozwiak M, Chew MS, Huber W, Kirov MY, Kuzkov VV, Lahmer T, Malbrain MLNG, Mallat J, Sakka SG, Tagami T, Pham T, Monnet X. Extravascular lung water levels are associated with mortality: a systematic review and meta-analysis. Crit Care 2022; 26:202. [PMID: 35794612 PMCID: PMC9258010 DOI: 10.1186/s13054-022-04061-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 05/17/2022] [Indexed: 11/18/2022] Open
Abstract
Background The prognostic value of extravascular lung water (EVLW) measured by transpulmonary thermodilution (TPTD) in critically ill patients is debated. We performed a systematic review and meta-analysis of studies assessing the effects of TPTD-estimated EVLW on mortality in critically ill patients.
Methods Cohort studies published in English from Embase, MEDLINE, and the Cochrane Database of Systematic Reviews from 1960 to 1 June 2021 were systematically searched. From eligible studies, the values of the odds ratio (OR) of EVLW as a risk factor for mortality, and the value of EVLW in survivors and non-survivors were extracted. Pooled OR were calculated from available studies. Mean differences and standard deviation of the EVLW between survivors and non-survivors were calculated. A random effects model was computed on the weighted mean differences across the two groups to estimate the pooled size effect. Subgroup analyses were performed to explore the possible sources of heterogeneity. Results Of the 18 studies included (1296 patients), OR could be extracted from 11 studies including 905 patients (464 survivors vs. 441 non-survivors), and 17 studies reported EVLW values of survivors and non-survivors, including 1246 patients (680 survivors vs. 566 non-survivors). The pooled OR of EVLW for mortality from eleven studies was 1.69 (95% confidence interval (CI) [1.22; 2.34], p < 0.0015). EVLW was significantly lower in survivors than non-survivors, with a mean difference of −4.97 mL/kg (95% CI [−6.54; −3.41], p < 0.001). The results regarding OR and mean differences were consistent in subgroup analyses. Conclusions The value of EVLW measured by TPTD is associated with mortality in critically ill patients and is significantly higher in non-survivors than in survivors. This finding may also be interpreted as an indirect confirmation of the reliability of TPTD for estimating EVLW at the bedside. Nevertheless, our results should be considered cautiously due to the high risk of bias of many studies included in the meta-analysis and the low rating of certainty of evidence. Trial registration the study protocol was prospectively registered on PROSPERO: CRD42019126985. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04061-6.
Collapse
|
6
|
Argaiz ER, Rola P, Haycock KH, Verbrugge FH. Fluid management in acute kidney injury: from evaluating fluid responsiveness towards assessment of fluid tolerance. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:786-793. [PMID: 36069621 DOI: 10.1093/ehjacc/zuac104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
Despite the widespread use of intravenous fluids in acute kidney injury (AKI), solid evidence is lacking. Intravenous fluids mainly improve AKI due to true hypovolaemia, which is difficult to discern at the bedside unless it is very pronounced. Empiric fluid resuscitation triggered only by elevated serum creatinine levels or oliguria is frequently misguided, especially in the presence of fluid intolerance syndromes such as increased extravascular lung water, capillary leak, intra-abdominal hypertension, and systemic venous congestion. While fluid responsiveness tests clearly identify patients who will not benefit from fluid administration (i.e. those without an increase in cardiac output), the presence of fluid responsiveness does not guarantee that fluid therapy is indicated or even safe. This review calls for more attention to the concept of fluid tolerance, incorporating it into a practical algorithm with systematic venous Doppler ultrasonography assessment to use at the bedside, thereby lowering the risk of detrimental kidney congestion in AKI.
Collapse
Affiliation(s)
- Eduardo R Argaiz
- Department of Nephrology and Mineral Metabolism, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montréal, QC, Canada
| | - Korbin H Haycock
- Department of Emergency Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| |
Collapse
|
7
|
Li-ping Q, Hong-wei L, Chang-ming H, Yong-yi B, Ang L. Safety and efficacy of pulse-induced contour cardiac output monitoring in elderly patients with coronary artery disease and severe heart failure at coronary care units. Front Cardiovasc Med 2022; 9:910898. [DOI: 10.3389/fcvm.2022.910898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe optimal treatment for elderly patients with severe heart failure depends on the accurate assessment of their hemodynamic status. Due to its less invasive nature, the safety and efficacy of invasive pulse-induced contour cardiac output (PiCCO)-based hemodynamic monitoring remains uncertain.MethodsThis was a prospective observational study. Between January 2016 and July 2020, 190 elderly patients with severe heart failure were consecutively enrolled. The PiCCO group (89 patients) and non-invasive hemodynamic monitoring group (101 patients) were observed. Hospital stays results were evaluated.ResultsNo significant difference in clinical data (P > 0.05) or the incidence of 1-month mortality (16.0 vs. 35.0%, P = 0.141) were observed between groups. The coronary care unit (CCU) stay was shorter in the PiCCO group than in the non-invasive group (40.0 vs. 43.0%, P = 0.049). Indicators such as low Extravascular Lung Water Index (EVLWI), high Body Mass Index (BMI), low Pulmonary Artery Pressure (PAP), and high Left Ventricular Ejection Time (LVET), were associated with favorable clinical results.ConclusionEarly invasive PiCCO monitoring is safe in critically ill elderly patients with severe heart failure. The hospital stay was reduced using PiCCO monitoring. These encouraging PiCCO results favor its use in elderly patients with severe heart failure at CCUs.
Collapse
|
8
|
The Association Between Extravascular Lung Water and Critical Care Outcomes Following Bilateral Lung Transplantation. Transplant Direct 2022; 8:e1376. [PMID: 36176725 PMCID: PMC9514832 DOI: 10.1097/txd.0000000000001376] [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: 01/21/2022] [Revised: 07/02/2022] [Accepted: 07/06/2022] [Indexed: 11/26/2022] Open
Abstract
Primary graft dysfunction (PGD) is a form of acute respiratory failure that complicates 30% of bilateral lung transplants. Higher grades of PGD correlate with higher severity of respiratory failure and unfavorable outcomes. Immediate PGD determination posttransplant‚ however, is not always predictive of PGD over subsequent days or intensive care unit outcomes. We aimed to evaluate whether extravascular lung water index (ELWI) measured immediately post bilateral lung transplant was associated with higher severity of PGD at 72 h and duration of mechanical ventilation.
Collapse
|
9
|
Cheng J, Yang J, Ma A, Dong M, Yang J, Wang P, Xue Y, Zhou Y, Kang Y. The Effects of Airway Pressure Release Ventilation on Pulmonary Permeability in Severe Acute Respiratory Distress Syndrome Pig Models. Front Physiol 2022; 13:927507. [PMID: 35936889 PMCID: PMC9354663 DOI: 10.3389/fphys.2022.927507] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: The aim of the study was to compare the effects of APRV and LTV ventilation on pulmonary permeability in severe ARDS.Methods: Mini Bama adult pigs were randomized into the APRV group (n = 5) and LTV group (n = 5). A severe ARDS animal model was induced by the whole lung saline lavage. Pigs were ventilated and monitored continuously for 48 h.Results: Compared with the LTV group, CStat was significantly better (p < 0.05), and the PaO2/FiO2 ratio showed a trend to be higher throughout the period of the experiment in the APRV group. The extravascular lung water index and pulmonary vascular permeability index showed a trend to be lower in the APRV group. APRV also significantly mitigates lung histopathologic injury determined by the lung histopathological injury score (p < 0.05) and gross pathological changes of lung tissues. The protein contents of occludin (p < 0.05), claudin-5 (p < 0.05), E-cadherin (p < 0.05), and VE-cadherin (p < 0.05) in the middle lobe of the right lung were higher in the APRV group than in the LTV group; among them, the contents of occludin (p < 0.05) and E-cadherin (p < 0.05) of the whole lung were higher in the APRV group. Transmission electron microscopy showed that alveolar–capillary barrier damage was more severe in the middle lobe of lungs in the LTV group.Conclusion: In comparison with LTV, APRV could preserve the alveolar–capillary barrier architecture, mitigate lung histopathologic injury, increase the expression of cell junction protein, improve respiratory system compliance, and showed a trend to reduce extravascular lung water and improve oxygenation. These findings indicated that APRV might lead to more profound beneficial effects on the integrity of the alveolar–capillary barrier architecture and on the expression of biomarkers related to pulmonary permeability.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Yan Kang
- *Correspondence: Yongfang Zhou, ; Yan Kang,
| |
Collapse
|
10
|
Katira BH, Engelberts D, Bouch S, Fliss J, Bastia L, Osada K, Connelly KA, Amato MBP, Ferguson ND, Kuebler WM, Kavanagh BP, Brochard LJ, Post M. Repeated endo-tracheal tube disconnection generates pulmonary edema in a model of volume overload: an experimental study. Crit Care 2022; 26:47. [PMID: 35180891 PMCID: PMC8857825 DOI: 10.1186/s13054-022-03924-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An abrupt lung deflation in rodents results in lung injury through vascular mechanisms. Ventilator disconnections during endo-tracheal suctioning in humans often cause cardio-respiratory instability. Whether repeated disconnections or lung deflations cause lung injury or oedema is not known and was tested here in a porcine large animal model. METHODS Yorkshire pigs (~ 12 weeks) were studied in three series. First, we compared PEEP abruptly deflated from 26 cmH2O or from PEEP 5 cmH2O to zero. Second, pigs were randomly crossed over to receive rapid versus gradual PEEP removal from 20 cmH2O. Third, pigs with relative volume overload, were ventilated with PEEP 15 cmH2O and randomized to repeated ETT disconnections (15 s every 15 min) or no disconnection for 3 h. Hemodynamics, pulmonary variables were monitored, and lung histology and bronchoalveolar lavage studied. RESULTS As compared to PEEP 5 cmH2O, abrupt deflation from PEEP 26 cmH2O increased PVR, lowered oxygenation, and increased lung wet-to-dry ratio. From PEEP 20 cmH2O, gradual versus abrupt deflation mitigated the changes in oxygenation and vascular resistance. From PEEP 15, repeated disconnections in presence of fluid loading led to reduced compliance, lower oxygenation, higher pulmonary artery pressure, higher lung wet-to-dry ratio, higher lung injury score and increased oedema on morphometry, compared to no disconnects. CONCLUSION Single abrupt deflation from high PEEP, and repeated short deflations from moderate PEEP cause pulmonary oedema, impaired oxygenation, and increased PVR, in this large animal model, thus replicating our previous finding from rodents. Rapid deflation may thus be a clinically relevant cause of impaired lung function, which may be attenuated by gradual pressure release.
Collapse
Affiliation(s)
- Bhushan H Katira
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada
- The Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Division of Critical Care Medicine, Department of Paediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Doreen Engelberts
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada
| | - Sheena Bouch
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada
| | - Jordan Fliss
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Luca Bastia
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Kohei Osada
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada
| | - Kim A Connelly
- Keenan Research Centre for Biomedical Sciences, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Niall D Ferguson
- Division of Respirology, Department of Medicine, University Health Network and Sinai Health Systems, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Wolfgang M Kuebler
- Institute of Physiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Brian P Kavanagh
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada
- The Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Departments of Critical Care Medicine and Anaesthesiology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Laurent J Brochard
- Keenan Research Centre for Biomedical Sciences, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Martin Post
- Translational Medicine Program, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., 9th Floor, Toronto, ON, M5G 0A4, Canada.
- The Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
11
|
Zhang Y, Wang C, Wang F, Shi J, Dou J, Shan Y, Sun T, Zhou Y. Lung Ultrasound in Pediatric Acute Respiratory Distress Syndrome Received Extracorporeal Membrane Oxygenation: A Prospective Cohort Study. Front Pediatr 2022; 10:798855. [PMID: 35419318 PMCID: PMC8995848 DOI: 10.3389/fped.2022.798855] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/15/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The aim of this study was to assess the prognostic value of the lung ultrasound (LUS) score in patients with pediatric acute respiratory distress syndrome (pARDS) who received extracorporeal membrane oxygenation (ECMO). METHODS A prospective cohort study was conducted in a pediatric intensive care unit (PICU) of a tertiary hospital from January 2016 to June 2021. The severe pARDS patients who received ECMO were enrolled in this study. LUS score was measured at initiation of ECMO (LUS-0 h), then at 24 h (LUS-24 h), 48 h (LUS-48 h), and 72 h (LUS-72 h) during ECMO, and when weaned from ECMO (LUS-wean). The value of LUS scores at the first 3 days of ECMO as a prognostic predictor was analyzed. RESULTS Twenty-nine children with severe pARDS who received ECMO were enrolled with a median age of 26 (IQR 9, 79) months. The median duration of ECMO support was 162 (IQR 86, 273) h and the PICU mortality was 31.0% (9/29). The values of LUS-72 h and LUS-wean were significantly lower in survivors than that in non-survivors (both P < 0.001). Daily fluid balance volume during the first 3 days of ECMO support were strongly correlated with LUS score [1st day: r = 0.460, P = 0.014; 2nd day: r = 0.540, P = 0.003; 3rd day: r = 0.589, P = 0.001]. The AUC of LUS-72 h for predicting PICU mortality in these patients was 1.000, and the cutoff value of LUS-72 h was 24 with a sensitivity of 100.0% and a specificity of 100.0%. Furthermore, patients were stratified in two groups of LUS-72 h ≥ 24 and LUS-72 h < 24. Consistently, PICU mortality, length of PICU stay, ratio of shock, vasoactive index score value, and the need for continuous renal replacement therapy were significantly higher in the group of LUS-72 h ≥ 24 than in the group of LUS-72 h < 24 (all P < 0.05). CONCLUSION Lung ultrasound score is a promising tool for predicting the prognosis in patients with ARDS under ECMO support. Moreover, LUS-72 h ≥ 24 is associated with high risk of PICU mortality in patients with pARDS who received ECMO.
Collapse
Affiliation(s)
- Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Chunxia Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China.,Clinical Research Unit, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Fei Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyi Shi
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jiaying Dou
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yijun Shan
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ting Sun
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yiping Zhou
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
12
|
Wang W, Xu N, Yu X, Zuo F, Liu J, Wang Y, Zhu G, Jia N, Ren H, Zhang J. Changes of Extravascular Lung Water as an Independent Prognostic Factor for Early Developed ARDS in Severely Burned Patients. J Burn Care Res 2021; 41:402-408. [PMID: 31720689 DOI: 10.1093/jbcr/irz189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
An important feature of acute respiratory distress syndrome (ARDS) is fluid lost into the interstitium of lung combined with its compromised reabsorption, resulting in the elevation of extravascular lung water (EVLW). Although ARDS is known as an early, common, and life-threatening complication in major burns, the issue of whether or how the EVLW index (EVLWI) correlates with its prognosis has not been identified yet. In this retrospectively study, 121 severely burned adults with ARDS occurred in 2 weeks postburn were analyzed and divided into two groups: survivors (73 patients) and nonsurvivors (48 patients) according to the 28-day outcome after injury. Compared with nonsurvivors, survivors exhibited bigger EVLWI reduction in day 2 after ARDS onset (ΔEVLWI2), with no differences in ARDS timing and other EVLWI variables. ΔEVLWI2, rather than EVLWI on 2 days after ARDS onset, was identified as an independent prognostic factor even after adjusting other significant factors by Cox proportional hazard analysis. ROC curve analysis showed that ΔEVLWI2 [AUC = 0.723, 95% CI = (0.631-0.816), P < .001] was a relative predictor for survival on 28-day postburn, with a threshold of 1.9 ml/kg (63.0% sensitivity, 77.1% specificity). Kaplan-Meier survival curve analysis confirmed a significantly higher survival rate on 28-day postburn in patients with ΔEVLWI2 > 1.9 ml/kg (log-rank test: χ 2 =14.780, P < .001). Taken together, our study demonstrated that ΔEVLWI2 is an independent prognostic factor for early ARDS in severe burns. ΔEVLWI2 higher than 1.9 ml/kg might predict a higher survival rate in those patients.
Collapse
Affiliation(s)
- Weiyi Wang
- Dalian Rehabilitation Recuperation Center of PLA Joint Logistics Support Force, Dalian, China.,School of Nursing, Third Military Medical University (Army Medical University), Chongqing, China
| | - Ning Xu
- Department of Pathology, No. 984 Hospital of PLA, Beijing, China
| | - Xiaofeng Yu
- School of Nursing, Third Military Medical University (Army Medical University), Chongqing, China
| | - Fengli Zuo
- School of Nursing, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jie Liu
- Institute of Burn Research, State Key Laboratory of Trauma, Burns, and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yuan Wang
- Institute of Burn Research, State Key Laboratory of Trauma, Burns, and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Guoqin Zhu
- Institute of Burn Research, State Key Laboratory of Trauma, Burns, and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Naixin Jia
- Institute of Burn Research, State Key Laboratory of Trauma, Burns, and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Hui Ren
- School of Nursing, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jiaping Zhang
- Institute of Burn Research, State Key Laboratory of Trauma, Burns, and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| |
Collapse
|
13
|
Kallet RH, Lipnick MS, Burns GD. The Nature of Recruitment and De-Recruitment and Its Implications for Management of ARDS. Respir Care 2021; 66:510-530. [PMID: 33051254 PMCID: PMC9994058 DOI: 10.4187/respcare.08280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Recruitment maneuvers in ARDS are used to improve oxygenation and lung mechanics by applying high airway pressures to reopen collapsed or obstructed peripheral airways and alveoli. In the early 1990s, recruitment maneuvers became a central feature of a variant form of lung-protective ventilation known as open-lung ventilation. This strategy is based on the belief that repetitive opening and closing of distal airspaces induces shear injury and therefore contributes both to ventilator-induced lung injury and ARDS-associated mortality. However, the largest multi-center randomized controlled trial of open-lung ventilation in moderate to severe ARDS reported that recruitment maneuver plateau pressures of 50-60 cm H2O were associated with significantly higher mortality compared to traditional lung-protective ventilation. Despite being based on well conducted preclinical and clinical recruitment maneuver studies, the higher mortality associated with the open-lung ventilation strategy requires re-examining the assumptions and conclusions drawn from those previous studies. This narrative review examines the evidence used to design recruitment maneuver strategies. We also review the radiologic, rheologic, and histopathologic evidence regarding the nature of lung injury and the phenomena of recruitment and de-recruitment as it informs our perceptions of recruitment potential in ARDS. Major lung-protective ventilation clinical trial data and other clinical data are also examined to assess the practical necessity of recruitment maneuvers in ARDS and whether a subset of cases might benefit from pursuing recruitment maneuver therapy. Finally, a less a radical approach to recruitment maneuvers is offered that might achieve the goals of recruitment maneuvers with less risk of harm.
Collapse
Affiliation(s)
- Richard H Kallet
- Respiratory Care Division, Department of Anesthesia and Perioperative Care, University of California San Francisco at San Francisco General Hospital, San Francisco, California.
| | - Michael S Lipnick
- Critical Care Division, Department of Anesthesia and Perioperative Care, University of California San Francisco at San Francisco General Hospital, San Francisco, California
| | - Gregory D Burns
- Respiratory Care Division, Department of Anesthesia and Perioperative Care, University of California San Francisco at San Francisco General Hospital, San Francisco, California
| |
Collapse
|
14
|
Wang F, Wang C, Shi J, Shan Y, Miao H, Sun T, Zhou Y, Zhang Y. Lung ultrasound score assessing the pulmonary edema in pediatric acute respiratory distress syndrome received continuous hemofiltration therapy: a prospective observational study. BMC Pulm Med 2021; 21:40. [PMID: 33494739 PMCID: PMC7830818 DOI: 10.1186/s12890-021-01394-w] [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: 05/24/2020] [Accepted: 01/01/2021] [Indexed: 12/15/2022] Open
Abstract
Background Lung ultrasound score is a potential method for determining pulmonary edema in acute respiratory distress syndrome (ARDS). Continuous renal replacement therapy (CRRT) has become the preferred modality to manage fluid overload during ARDS. The aim of this study was to evaluate the value of lung ultrasound (LUS) score on assessing the effects of CRRT on pulmonary edema and pulmonary function in pediatric ARDS. Methods We conducted a prospective cohort study in 70 children with moderate to severe ARDS in a tertiary university pediatric intensive care unit from January 2016 to December 2019. 37 patients received CRRT (CRRT group) and 33 patients treated by conventional therapy (Non-CRRT group). LUS score was measured within 2 h identified ARDS as the value of 1st, and the following three days as the 2nd, 3rd, and 4th. We used Spearman correlation analysis to develop the relationship between LUS score and parameters related to respiratory dynamics, clinical outcomes as well as daily fluid balance during the first four days after ARDS diagnosed. Results The 1st LUS score in CRRT group were significantly higher than Non-CRRT group (P < 0.001), but the LUS score decreased gradually following CRRT (P < 0.001). LUS score was significantly correlated with Cdyn (dynamic lung compliance) (1st: r = − 0.757, 2nd: r = − 0.906, 3rd: r = − 0.885, 4th: r = − 0.834), OI (oxygenation index) (1st: r = 0.678, 2nd: r = 0.689, 3rd: r = 0.486, 4th: r = 0.324) based on 1st to 4th values (all P < 0.05). Only values of the 3rd and 4th LUS score after ARDS diagnosed were correlated with duration of mechanical ventilation [1st: r = 0.167, P = 0.325; 2nd: r = 0.299, P = 0.072; 3rd: r = 0.579, P < 0.001; 4th: r = 0.483, P = 0.002]. LUS score decreased from 22 (18–25) to 15 (13–18) and OI decreased from 15.92 (14.07–17.73) to 9.49 (8.70–10.58) after CRRT for four days (both P < 0.001). Conclusions LUS score is significantly correlated with lung function parameters in pediatric ARDS. The improvement of pulmonary edema in patient with ARDS received CRRT can be assessed by the LUS score. Trial registration CCTR, ChiCTR-ONC-16009698. Registered 1 November 2016, prospectively registered, http://www.chictr.org.cn/edit.aspx?pid=16535&htm=4. This study adheres to CONSORT guidelines.
Collapse
Affiliation(s)
- Fei Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, 200062, China
| | - Chunxia Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, 200062, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, No.355 Luding Road, Putuo District, Shanghai, 200062, China
| | - Jingyi Shi
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, 200062, China
| | - Yijun Shan
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, 200062, China
| | - Huijie Miao
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, 200062, China
| | - Ting Sun
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, 200062, China
| | - Yiping Zhou
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, 200062, China
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, 200062, China. .,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, No.355 Luding Road, Putuo District, Shanghai, 200062, China.
| |
Collapse
|
15
|
Asar S, Acicbe Ö, Sabaz MS, Tontu F, Canan E, Cukurova Z, Cakar N. Comparison of Respiratory and Hemodynamic Parameters of COVID-19 and Non-COVID-19 ARDS Patients. Indian J Crit Care Med 2021; 25:704-708. [PMID: 34316153 PMCID: PMC8286393 DOI: 10.5005/jp-journals-10071-23856] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background COVID-19 can cause a clinical spectrum from asymptomatic disease to life-threatening respiratory failure and acute respiratory distress syndrome (ARDS). There is an ongoing discussion whether the clinical presentation and ventilatory parameters are the same as typical ARDS or not. There is no clear understanding of how the hemodynamic parameters have been affected in COVID-19 ARDS patients. We aimed to compare hemodynamic and respiratory parameters of moderate and severe COVID-19 and non-COVID-19 ARDS patients. These patients were monitored with an advanced hemodynamic measurement system by the transpulmonary thermodilution method in prone and supine positions. Patients and methods Data of 17 patients diagnosed with COVID-19 and 16 patients diagnosed with other types of diseases with moderate and severe ARDS, mechanically ventilated, placed in a prone position, had advanced hemodynamic measurements with PiCCO, and stayed in the intensive care unit for more than a week were analyzed retrospectively. Patient characteristics and arterial blood gases analysis recorded at admission and respiratory and advanced hemodynamic parameters during the first week were compared in prone and supine positions. Results No difference was observed in the respiratory parameters including respiratory system compliance between COVID-19 and non-COVD-19 patients in prone and supine positions. In comparison of advanced hemodynamic parameters in the first week of intensive care, the extravascular lung water and pulmonary vascular permeability indexes measured in supine position of COVID-19 ARDS patients were found to be significantly higher than non-COVID-19 patients. Duration of prone position was significantly longer in patients diagnosed with COVID-19 ARDS. Conclusions The results of this study suggested that COVID-19 ARDS is a variant of typical ARDS with a different pathophysiology. How to cite this article Asar S, Acicbe Ö, Sabaz MS, Tontu F, Canan E, Cukurova Z, et al. Comparison of Respiratory and Hemodynamic Parameters of COVID-19 and Non-COVID-19 ARDS Patients. Indian J Crit Care Med 2021;25(6):704-708.
Collapse
Affiliation(s)
- Sinan Asar
- Department of Anesthesiology and Reanimation, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Özlem Acicbe
- Department of Anesthesiology and Reanimation, Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Mehmet S Sabaz
- Department of Anesthesiology and Reanimation-Intensive Care Unit, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Furkan Tontu
- Department of Anesthesiology and Reanimation, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Emral Canan
- Department of IMDSoft - QlinICU, Istanbul, Turkey
| | - Zafer Cukurova
- Department of Anesthesiology and Reanimation, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Nahit Cakar
- General Intensive Care Unit, Koç University School of Medicine, Istanbul, Turkey
| |
Collapse
|
16
|
Neutralizing Complement C5a Protects Mice with Pneumococcal Pulmonary Sepsis. Anesthesiology 2020; 132:795-807. [PMID: 32101978 DOI: 10.1097/aln.0000000000003149] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Community-acquired pneumonia and associated sepsis cause high mortality despite antibiotic treatment. Uncontrolled inflammatory host responses contribute to the unfavorable outcome by driving lung and extrapulmonary organ failure. The complement fragment C5a holds significant proinflammatory functions and is associated with tissue damage in various inflammatory conditions. The authors hypothesized that C5a concentrations are increased in pneumonia and C5a neutralization promotes barrier stabilization in the lung and is protective in pneumococcal pulmonary sepsis. METHODS The authors investigated regulation of C5a in pneumonia in a prospective patient cohort and in experimental pneumonia. Two complementary models of murine pneumococcal pneumonia were applied. Female mice were treated with NOX-D19, a C5a-neutralizing L-RNA-aptamer. Lung, liver, and kidney injury and the inflammatory response were assessed by measuring pulmonary permeability (primary outcome), pulmonary and blood leukocytes, cytokine concentrations in lung and blood, and bacterial load in lung, spleen, and blood, and performing histologic analyses of tissue damage, apoptosis, and fibrin deposition (n = 5 to 13). RESULTS In hospitalized patients with pneumonia (n = 395), higher serum C5a concentrations were observed compared to healthy subjects (n = 24; 6.3 nmol/l [3.9 to 10.0] vs. 4.5 nmol/l [3.8 to 6.6], median [25 to 75% interquartile range]; difference: 1.4 [95% CI, 0.1 to 2.9]; P = 0.029). Neutralization of C5a in mice resulted in lower pulmonary permeability in pneumococcal pneumonia (1.38 ± 0.89 vs. 3.29 ± 2.34, mean ± SD; difference: 1.90 [95% CI, 0.15 to 3.66]; P = 0.035; n = 10 or 11) or combined severe pneumonia and mechanical ventilation (2.56 ± 1.17 vs. 7.31 ± 5.22; difference: 4.76 [95% CI, 1.22 to 8.30]; P = 0.011; n = 9 or 10). Further, C5a neutralization led to lower blood granulocyte colony-stimulating factor concentrations and protected against sepsis-associated liver injury. CONCLUSIONS Systemic C5a is elevated in pneumonia patients. Neutralizing C5a protected against lung and liver injury in pneumococcal pneumonia in mice. Early neutralization of C5a might be a promising adjunctive treatment strategy to improve outcome in community-acquired pneumonia.
Collapse
|
17
|
Transpulmonary thermodilution detects rapid and reversible increases in lung water induced by positive end-expiratory pressure in acute respiratory distress syndrome. Ann Intensive Care 2020; 10:28. [PMID: 32124129 PMCID: PMC7052093 DOI: 10.1186/s13613-020-0644-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 02/21/2020] [Indexed: 01/22/2023] Open
Abstract
PURPOSE It has been suggested that, by recruiting lung regions and enlarging the distribution volume of the cold indicator, increasing the positive end-expiratory pressure (PEEP) may lead to an artefactual overestimation of extravascular lung water (EVLW) by transpulmonary thermodilution (TPTD). METHODS In 60 ARDS patients, we measured EVLW (PiCCO2 device) at a PEEP level set to reach a plateau pressure of 30 cmH2O (HighPEEPstart) and 15 and 45 min after decreasing PEEP to 5 cmH2O (LowPEEP15' and LowPEEP45', respectively). Then, we increased PEEP back to the baseline level (HighPEEPend). Between HighPEEPstart and LowPEEP15', we estimated the degree of lung derecruitment either by measuring changes in the compliance of the respiratory system (Crs) in the whole population, or by measuring the lung derecruited volume in 30 patients. We defined patients with a large derecruitment from the other ones as patients in whom the Crs changes and the measured derecruited volume were larger than the median of these variables observed in the whole population. RESULTS Reducing PEEP from HighPEEPstart (14 ± 2 cmH2O) to LowPEEP15' significantly decreased EVLW from 20 ± 4 to 18 ± 4 mL/kg, central venous pressure (CVP) from 15 ± 4 to 12 ± 4 mmHg, the arterial oxygen tension over inspired oxygen fraction (PaO2/FiO2) ratio from 184 ± 76 to 150 ± 69 mmHg and lung volume by 144 [68-420] mL. The EVLW decrease was similar in "large derecruiters" and the other patients. When PEEP was re-increased to HighPEEPend, CVP, PaO2/FiO2 and EVLW significantly re-increased. At linear mixed effect model, EVLW changes were significantly determined only by changes in PEEP and CVP (p < 0.001 and p = 0.03, respectively, n = 60). When the same analysis was performed by estimating recruitment according to lung volume changes (n = 30), CVP remained significantly associated to the changes in EVLW (p < 0.001). CONCLUSIONS In ARDS patients, changing the PEEP level induced parallel, small and reversible changes in EVLW. These changes were not due to an artefact of the TPTD technique and were likely due to the PEEP-induced changes in CVP, which is the backward pressure of the lung lymphatic drainage. Trial registration ID RCB: 2015-A01654-45. Registered 23 October 2015.
Collapse
|
18
|
Critical hemodynamic therapy oriented resuscitation helping reduce lung water production and improve survival. Chin Med J (Engl) 2019; 132:1139-1146. [PMID: 30882456 PMCID: PMC6511433 DOI: 10.1097/cm9.0000000000000205] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Increased extravascular lung water (EVLW) in shock is common in the critically ill patients. This study aimed to explore the effect of cardiac output (CO) on EVLW and its relevant influence on prognosis. METHODS The hemodynamic data of 428 patients with pulse-indicated continuous CO catheterization from Department of Critical Care Medicine, Peking Union Medical College Hospital were retrospectively collected and analyzed. The patients were assigned to acute respiratory distress syndrome group, cardiogenic shock group, septic shock group, and combined shock (cardiogenic and septic) group according to their symptoms. Information on 28-day mortality and renal function was also collected. RESULTS The CO and EVLW index (EVLWI) in the cardiogenic and combined shock groups were lower than those in the other groups (acute respiratory distress syndrome group vs. cardiogenic shock group vs. septic shock group vs. combined shock group: CO, 5.1 [4.0, 6.2] vs. 4.7 [4.0, 5.7] vs. 5.5 [4.3, 6.7] vs. 4.6 [3.5, 5.7] at 0 to 24 h, P = 0.009; 4.6 [3.8, 5.6] vs. 4.8 [4.1, 5.7] vs. 5.3 [4.4, 6.5] vs. 4.5 [3.8, 5.3] at 24 to 48 h, P = 0.048; 4.5 [4.1, 5.4] vs. 4.8 [3.8, 5.5] vs. 5.3 [4.0, 6.4] vs. 4.0 [3.2, 5.4] at 48 to 72 h, P = 0.006; EVLWI, 11.4 [8.7, 19.1] vs. 7.9 [6.6, 10.0] vs. 8.8 [7.4, 11.0] vs. 8.2 [6.7, 11.3] at 0 to 24 h, P < 0.001; 11.8 [7.7, 17.2] vs. 7.8 [6.3, 10.2] vs. 8.7 [6.6, 12.2] vs. 8.0 [6.6, 11.1] at 24 to 48 h, P < 0.001; and 11.3 [7.7, 18.7] vs. 7.5 [6.3, 10.0] vs. 8.8 [6.3, 12.2] vs. 8.4 [6.4, 11.2] at 48 to 72 h, P < 0.001. The trend of the EVLWI in the septic shock group was higher than that in the cardiogenic shock group (P < 0.05). Moreover, there existed some difference in the pulmonary vascular permeability index among the cardiogenic shock group, the septic shock group, and the combined shock group, without statistical significance (P > 0.05). In addition, there was no significant difference in tissue perfusion or renal function among the four groups during the observation period (P > 0.05). However, the cardiogenic shock group had a higher 28-day survival rate than the other three groups [log rank (Mantel-Cox) = 31.169, P < 0.001]. CONCLUSION Tissue-aimed lower CO could reduce the EVLWI and achieve a better prognosis.
Collapse
|
19
|
Chang YR, Choi SH, Chang SW. Are management decisions in critical patients changed with use of hemodynamic parameters from transpulmonary thermodilution technique? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:370. [PMID: 31555684 DOI: 10.21037/atm.2019.06.78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background The assessment of hemodynamic variables is a mainstay in the management of critically ill patients. Hemodynamic variables may help physicians to choose among use of a vasopressor, an inotropic agent, or discontinuation of drugs. In this study, we aimed to investigate the usefulness of advanced hemodynamic variables in clinical decision-making. Methods Surveys regarding the case were administered to 25 surgeons working in nationally designated trauma centers or on trauma teams, using a voting system at a medical conference. The patient was a 67-year-old male with a crush injury of the left leg after a pedestrian traffic accident, who had aggravated pulmonary edema after leg amputation. Three clinical situations were given and the decision choices were: immediately after amputation, in 8 hours, and on the second day after amputation. Three kinds of variables from hemodynamic monitoring systems were provided for each clinical situation: conventional hemodynamic variables, including central venous pressure; variables from pulse contour analysis (PCA) [cardiac output (CO), stroke volume index, stroke volume variation (SVV), and systemic vascular resistance index); and variables from transpulmonary thermodilution (TPTD) technique (global ejection fraction and extravascular lung water index). The changes in decisions according to each provided hemodynamic variable were investigated and analyzed. Results The advanced hemodynamic parameters were considered to have a decisive effect on choosing vasopressors and inotropic agents. The decision was changed in 88% (22/25) of physicians using variables from the advanced monitoring systems. Among them, 82% (18/22) of physicians chose hemodynamic variables from the TPTD technique as their reason for change regarding management of a patient with severe pulmonary edema. Conclusions Advanced monitoring systems might be helpful in decision-making for critically ill patients. Multiple parameters and trends in change could be more important than a single value. Clinicians should select the system most appropriate according to its advantages and limitations, and interpret the variables obtained correctly.
Collapse
Affiliation(s)
- Ye Rim Chang
- Department of Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| | - Seok Ho Choi
- Department of Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| | - Sung Wook Chang
- Department of Thoracic and Cardiovascular Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| |
Collapse
|
20
|
|
21
|
Leopold SJ, Ghose A, Plewes KA, Mazumder S, Pisani L, Kingston HWF, Paul S, Barua A, Sattar MA, Huson MAM, Walden AP, Henwood PC, Riviello ED, Schultz MJ, Day NPJ, Kumar Dutta A, White NJ, Dondorp AM. Point-of-care lung ultrasound for the detection of pulmonary manifestations of malaria and sepsis: An observational study. PLoS One 2018; 13:e0204832. [PMID: 30540757 PMCID: PMC6291079 DOI: 10.1371/journal.pone.0204832] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 09/14/2018] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Patients with severe malaria or sepsis are at risk of developing life-threatening acute respiratory distress syndrome (ARDS). The objective of this study was to evaluate point-of-care lung ultrasound as a novel tool to determine the prevalence and early signs of ARDS in a resource-limited setting among patients with severe malaria or sepsis. MATERIALS AND METHODS Serial point-of-care lung ultrasound studies were performed on four consecutive days in a planned sub study of an observational cohort of patients with malaria or sepsis in Bangladesh. We quantified aeration patterns across 12 lung regions. ARDS was defined according to the Kigali Modification of the Berlin Definition. RESULTS Of 102 patients enrolled, 71 had sepsis and 31 had malaria. Normal lung ultrasound findings were observed in 44 patients on enrolment and associated with 7% case fatality. ARDS was detected in 10 patients on enrolment and associated with 90% case fatality. All patients with ARDS had sepsis, 4 had underlying pneumonia. Two patients developing ARDS during hospitalisation already had reduced aeration patterns on enrolment. The SpO2/FiO2 ratio combined with the number of regions with reduced aeration was a strong prognosticator for mortality in patients with sepsis (AUROC 91.5% (95% Confidence Interval: 84.6%-98.4%)). CONCLUSIONS This study demonstrates the potential usefulness of point-of-care lung ultrasound to detect lung abnormalities in patients with malaria or sepsis in a resource-constrained hospital setting. LUS was highly feasible and allowed to accurately identify patients at risk of death in a resource limited setting.
Collapse
Affiliation(s)
- Stije J. Leopold
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Aniruddha Ghose
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Katherine A. Plewes
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Subash Mazumder
- Department of Radiology, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Luigi Pisani
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Hugh W. F. Kingston
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Sujat Paul
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Anupam Barua
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - M. Abdus Sattar
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Michaëla A. M. Huson
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Andrew P. Walden
- Department of Intensive Care, Royal Berkshire Hospital, Reading, United Kingdom
| | - Patricia C. Henwood
- Department of Emergency Medicine, Brigham and Woman’s Hospital, Boston, Massachusetts, United States of America
| | - Elisabeth D. Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Marcus J. Schultz
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Asok Kumar Dutta
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
22
|
Affiliation(s)
- Salman Ahmad
- Division of Acute Care Surgery, Department of Surgery, University of Missouri Healthcare, Columbia, MO
| |
Collapse
|
23
|
|
24
|
Quantitative computed tomography in comparison with transpulmonary thermodilution for the estimation of pulmonary fluid status: a clinical study in critically ill patients. J Clin Monit Comput 2018; 33:5-12. [PMID: 29680878 DOI: 10.1007/s10877-018-0144-1] [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] [Received: 12/06/2017] [Accepted: 04/16/2018] [Indexed: 01/09/2023]
Abstract
Extravascular lung water (index) (EVLW(I)) can be estimated using transpulmonary thermodilution (TPTD). Computed tomography (CT) with quantitative analysis of lung tissue density has been proposed to quantify pulmonary edema. We compared variables of pulmonary fluid status assessed using quantitative CT and TPTD in critically ill patients. In 21 intensive care unit patients, we performed TPTD measurements directly before and after chest CT. Based on the density data of segmented CT images we calculated the tissue volume (TV), tissue volume index (TVI), and the mean weighted index of voxel aqueous density (VMWaq). CT-derived TV, TVI, and VMWaq did not predict TPTD-derived EVLWI values ≥ 14 mL/kg. There was a significant moderate positive correlation between VMWaq and mean EVLWI (EVLWI before and after CT) (r = 0.45, p = 0.042) and EVLWI after CT (r = 0.49, p = 0.025) but not EVLWI before CT (r = 0.38, p = 0.086). There was no significant correlation between TV and EVLW before CT, EVLW after CT, or mean EVLW. There was no significant correlation between TVI and EVLWI before CT, EVLWI after CT, or mean EVLWI. CT-derived variables did not predict elevated TPTD-derived EVLWI values. In unselected critically ill patients, variables of pulmonary fluid status assessed using quantitative CT cannot be used to predict EVLWI.
Collapse
|
25
|
Kellner M, Noonepalle S, Lu Q, Srivastava A, Zemskov E, Black SM. ROS Signaling in the Pathogenesis of Acute Lung Injury (ALI) and Acute Respiratory Distress Syndrome (ARDS). ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 967:105-137. [PMID: 29047084 PMCID: PMC7120947 DOI: 10.1007/978-3-319-63245-2_8] [Citation(s) in RCA: 226] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The generation of reactive oxygen species (ROS) plays an important role for the maintenance of cellular processes and functions in the body. However, the excessive generation of oxygen radicals under pathological conditions such as acute lung injury (ALI) and its most severe form acute respiratory distress syndrome (ARDS) leads to increased endothelial permeability. Within this hallmark of ALI and ARDS, vascular microvessels lose their junctional integrity and show increased myosin contractions that promote the migration of polymorphonuclear leukocytes (PMNs) and the transition of solutes and fluids in the alveolar lumen. These processes all have a redox component, and this chapter focuses on the role played by ROS during the development of ALI/ARDS. We discuss the origins of ROS within the cell, cellular defense mechanisms against oxidative damage, the role of ROS in the development of endothelial permeability, and potential therapies targeted at oxidative stress.
Collapse
Affiliation(s)
- Manuela Kellner
- Department of Medicine, Center for Lung Vascular Pathobiology, University of Arizona, 1501 N Campbell Ave., Tucson, AZ, 85719, USA
| | - Satish Noonepalle
- Department of Medicine, Center for Lung Vascular Pathobiology, University of Arizona, 1501 N Campbell Ave., Tucson, AZ, 85719, USA
| | - Qing Lu
- Department of Medicine, Center for Lung Vascular Pathobiology, University of Arizona, 1501 N Campbell Ave., Tucson, AZ, 85719, USA
| | - Anup Srivastava
- Department of Medicine, Center for Lung Vascular Pathobiology, University of Arizona, 1501 N Campbell Ave., Tucson, AZ, 85719, USA
| | - Evgeny Zemskov
- Department of Medicine, Center for Lung Vascular Pathobiology, University of Arizona, 1501 N Campbell Ave., Tucson, AZ, 85719, USA
| | - Stephen M Black
- Department of Medicine, Center for Lung Vascular Pathobiology, University of Arizona, 1501 N Campbell Ave., Tucson, AZ, 85719, USA.
| |
Collapse
|
26
|
Protective effects of continuous positive airway pressure on a nonventilated lung during one-lung ventilation: A prospective laboratory study in rats. Eur J Anaesthesiol 2018; 33:776-83. [PMID: 27139568 DOI: 10.1097/eja.0000000000000460] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of one-lung ventilation (OLV) to facilitate intrathoracic surgery is a cause of lung injury. OBJECTIVE We hypothesised that application of continuous positive airway pressure (CPAP) to a nonventilated lung during OLV would prevent alveolar hypoxia and blood flow shift from the nonventilated to the ventilated lung, thereby attenuating lung injury. DESIGN Controlled animal study. SETTINGS University laboratory. STUDY PARTICIPANTS Adult male Sprague-Dawley rats (n = 4 to 8 per group, depending on experiments). INTERVENTIONS Rats were alternately assigned to one of two ventilation protocol groups: control and CPAP groups. Rats received 240 min of OLV followed by 240 min of two-lung reventilation (re-TLV). The nonventilated lungs of rats in the control group were collapsed during OLV whereas rats in the CPAP group received CPAP (5 cmH2O with 100% oxygen) to the nonventilated lungs. MAIN OUTCOME MEASURES Pulmonary blood flow during OLV was measured by quantification of lung radioactivity after intravenous infusion of indium-labelled macroaggregated albumin. Inflammatory cytokines in the lungs after 240 min of OLV, and after the subsequent 240 min of re-TLV were measured. Additionally, we measured lung wet-to-dry weight ratios after re-TLV. We also measured lung malondialdehyde levels after re-TLV as an indicator of reactive oxygen species produced by reoxygenation. RESULTS Application of CPAP attenuated the pulmonary blood flow shift from the nonventilated to the ventilated lung. CPAP decreased the levels of IL-6, CXC chemokine ligand-1 and CC chemokine ligand-2 in both lungs after 240 min of OLV. CPAP also decreased CXC chemokine ligand-1 in the nonventilated lung and CC chemokine ligand-2 in both lungs after re-TLV. Moreover, wet-to-dry weight ratios of both lungs were decreased by application of CPAP. However, lung malondialdehyde concentrations were not affected by CPAP. CONCLUSIONS CPAP applied to the nonventilated lung during OLV suppresses blood flow shift and decreases inflammatory cytokines and water content in both lungs. Application of CPAP may attenuate lung injury during and after OLV.
Collapse
|
27
|
Endo Y, Tamura J, Ishizuka T, Itami T, Hanazono K, Miyoshi K, Sano T, Yamashita K, Muir WW. Stroke volume variation (SVV) and pulse pressure variation (PPV) as indicators of fluid responsiveness in sevoflurane anesthetized mechanically ventilated euvolemic dogs. J Vet Med Sci 2017; 79:1437-1445. [PMID: 28690287 PMCID: PMC5573834 DOI: 10.1292/jvms.16-0287] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Changes in stroke volume variation (SVV) and pulse pressure variation (PPV) in response to fluid infusion were experimentally evaluated during vecuronium infusion and sevoflurane anesthesia in 5 adult, mechanically ventilated, euvolemic, beagle dogs. Sequential increases in central venous pressure (CVP; 3-7[baseline], 8-12, 13-17, 18-22 and 23-27 mmHg) were produced by infusing lactated Ringer's solution and 6% hydroxyethyl starch solution. Heart rate (beats/min), right atrial pressure (RAP, mmHg), pulmonary arterial pressure (PAP, mmHg), pulmonary capillary wedge pressure (PCWP, mmHg), transpulmonary thermodilution cardiac output (TPTDCO, l/min), stroke volume (SV, ml/beat), arterial blood pressure (ABP, mmHg), extravascular lung water (EVLW, ml), pulmonary vascular permeability index (PVPI, calculated), SVV (%), PPV (%) and systemic vascular resistance (SVR, dynes/sec/cm5) were determined at each predetermined CVP range. Heart rate (P=0.019), RAP (P<0.001), PAP (P<0.001), PCWP (P<0.001), TPTDCO (P=0.009) and SV (P=0.04) increased and SVR (P<0.001), SVV (P<0.001) and PPV (P<0.001) decreased associated with each stepwise increase in CVP. Arterial blood pressure, EVLW, PVPI and the arterial partial pressures of oxygen and carbon dioxide did not change. The changes in SVV and PPV directly reflected the fluid load and the minimum threshold values for detecting fluid responsiveness were SVV ≥11% and PPV ≥7% in dogs.
Collapse
Affiliation(s)
- Yusuke Endo
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8591, Japan
| | - Jun Tamura
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8591, Japan
| | - Tomohito Ishizuka
- Veterinary Teaching Hospital, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido 060-0818, Japan
| | - Takaharu Itami
- Veterinary Teaching Hospital, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido 060-0818, Japan
| | - Kiwamu Hanazono
- Veterinary Teaching Hospital, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido 060-0818, Japan
| | - Kenjiro Miyoshi
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8591, Japan
| | - Tadashi Sano
- Department of Veterinary Nursing Science, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8591, Japan
| | - Kazuto Yamashita
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8591, Japan
| | - William W Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, Tennessee 37752, U.S.A
| |
Collapse
|
28
|
Monnet X, Teboul JL. Transpulmonary thermodilution: advantages and limits. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017. [PMID: 28625165 PMCID: PMC5474867 DOI: 10.1186/s13054-017-1739-5] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background For complex patients in the intensive care unit or in the operating room, many questions regarding their haemodynamic management cannot be answered with simple clinical examination. In particular, arterial pressure allows only a rough estimation of cardiac output. Transpulmonary thermodilution is a technique that provides a full haemodynamic assessment through cardiac output and other indices. Main body Through the analysis of the thermodilution curve recorded at the tip of an arterial catheter after the injection of a cold bolus in the venous circulation, transpulmonary thermodilution intermittently measures cardiac output. This measure allows the calibration of pulse contour analysis. This provides continuous and real time monitoring of cardiac output, which is not possible with the pulmonary artery catheter. Transpulmonary thermodilution provides several variables beyond cardiac output. It estimates the end-diastolic volume of the four cardiac cavities, which is a marker of cardiac preload. It provides an estimation of the systolic function of the combined ventricles. It is more direct than the pulmonary artery catheter, but does not allow the distinct estimation of right and left cardiac function. It is easier and faster to perform than echocardiography, but does not provide a full evaluation of the cardiac structure and function. Transpulmonary thermodilution has the unique advantage of being able to estimate at the bedside extravascular lung water, which quantifies the volume of pulmonary oedema, and pulmonary vascular permeability, which quantifies the degree of a pulmonary capillary leak. Both indices are helpful for guiding fluid strategy, especially in case of acute respiratory distress syndrome. Conclusions Transpulmonary thermodilution provides a full cardiovascular evaluation that allows one to answer many questions regarding haemodynamic management. It belongs to the category of “advanced” devices that are indicated for the most critically ill and/or complex patients.
Collapse
Affiliation(s)
- Xavier Monnet
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, F-94270, France. .,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, F-94270, France. .,Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France.
| | - Jean-Louis Teboul
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, F-94270, France.,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, F-94270, France
| |
Collapse
|
29
|
Evaluation of Reperfusion Pulmonary Edema by Extravascular Lung Water Measurements After Pulmonary Endarterectomy. Crit Care Med 2017; 45:e409-e417. [DOI: 10.1097/ccm.0000000000002259] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
30
|
Yuanbo Z, Jin W, Fei S, Liangong L, Xunfa L, Shihai X, Aijun S. ICU management based on PiCCO parameters reduces duration of mechanical ventilation and ICU length of stay in patients with severe thoracic trauma and acute respiratory distress syndrome. Ann Intensive Care 2016; 6:113. [PMID: 27873292 PMCID: PMC5118373 DOI: 10.1186/s13613-016-0217-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 11/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed to assess whether a management algorithm using data obtained with a PiCCO system can improve clinical outcomes in critically ill patients with acute respiratory distress syndrome (ARDS). RESULTS The PaO2/FiO2 ratio increased over time in both groups, with a sharper increase in the PiCCO group. There was no difference in 28-day mortality (3.2 vs. 3.6%, P = 0.841). Days on mechanical ventilation (3 vs. 5 days, P = 0.002) and ICU length of stay (6 vs. 11 days, P = 0.004) were significantly lower in the PiCCO group than in the CVP group. Treatment costs were lower in the PiCCO group than in the CVP group. Multivariate logistic regression model showed that the monitoring method (PiCCO vs. CVP) was independently associated with the length of ICU stay [odds ratio (OR) 3.16, 95% confidence interval (95% CI) 1.55-6.63, P = 0.001], as well as shock (OR 3.41, 95% CI 1.74-6.44, P = 0.002), shock and ARDS (OR 3.46, 95% CI 1.79-6.87, P = 0.002), and APACHE II score (OR 1.17, 95% CI 1.02-1.86, P = 0.014). CONCLUSIONS This study investigated the usefulness of the PiCCO system in improving outcomes for patient with severe thoracic trauma and ARDS and provided new evidence for fluid management in critical care settings.
Collapse
Affiliation(s)
- Zhong Yuanbo
- Emergency Center, Shenzhen People's Hospital, Shenzhen, 518020, China
| | - Wang Jin
- Emergency Center, Shenzhen People's Hospital, Shenzhen, 518020, China
| | - Shi Fei
- Emergency Center, Shenzhen People's Hospital, Shenzhen, 518020, China
| | - Long Liangong
- Emergency Center, Shenzhen People's Hospital, Shenzhen, 518020, China
| | - Liu Xunfa
- Emergency Center, Shenzhen People's Hospital, Shenzhen, 518020, China
| | - Xu Shihai
- Emergency Center, Shenzhen People's Hospital, Shenzhen, 518020, China
| | - Shan Aijun
- Emergency Center, Shenzhen People's Hospital, Shenzhen, 518020, China.
| |
Collapse
|
31
|
Saugel B, Jakobus J, Huber W, Hoffmann D, Holzapfel K, Protzer U, Schmid RM, Umgelter A. Herpes simplex virus in bronchoalveolar lavage fluid of medical intensive care unit patients: Association with lung injury and outcome. J Crit Care 2016; 32:138-44. [DOI: 10.1016/j.jcrc.2015.11.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/07/2015] [Accepted: 11/24/2015] [Indexed: 01/31/2023]
|
32
|
Barbas CSV, Ísola AM, Farias AMDC, Cavalcanti AB, Gama AMC, Duarte ACM, Vianna A, Serpa Neto A, Bravim BDA, Pinheiro BDV, Mazza BF, de Carvalho CRR, Toufen Júnior C, David CMN, Taniguchi C, Mazza DDDS, Dragosavac D, Toledo DO, Costa EL, Caser EB, Silva E, Amorim FF, Saddy F, Galas FRBG, Silva GS, de Matos GFJ, Emmerich JC, Valiatti JLDS, Teles JMM, Victorino JA, Ferreira JC, Prodomo LPDV, Hajjar LA, Martins LC, Malbouisson LMS, Vargas MADO, Reis MAS, Amato MBP, Holanda MA, Park M, Jacomelli M, Tavares M, Damasceno MCP, Assunção MSC, Damasceno MPCD, Youssef NCM, Teixeira PJZ, Caruso P, Duarte PAD, Messeder O, Eid RC, Rodrigues RG, de Jesus RF, Kairalla RA, Justino S, Nemer SN, Romero SB, Amado VM. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva 2016; 26:215-39. [PMID: 25295817 PMCID: PMC4188459 DOI: 10.5935/0103-507x.20140034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2013] [Indexed: 12/13/2022] Open
Abstract
Perspectives on invasive and noninvasive ventilatory support for critically ill
patients are evolving, as much evidence indicates that ventilation may have positive
effects on patient survival and the quality of the care provided in intensive care
units in Brazil. For those reasons, the Brazilian Association of Intensive Care
Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and
the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e
Tisiologia - SBPT), represented by the Mechanical Ventilation Committee
and the Commission of Intensive Therapy, respectively, decided to review the
literature and draft recommendations for mechanical ventilation with the goal of
creating a document for bedside guidance as to the best practices on mechanical
ventilation available to their members. The document was based on the available
evidence regarding 29 subtopics selected as the most relevant for the subject of
interest. The project was developed in several stages, during which the selected
topics were distributed among experts recommended by both societies with recent
publications on the subject of interest and/or significant teaching and research
activity in the field of mechanical ventilation in Brazil. The experts were divided
into pairs that were charged with performing a thorough review of the international
literature on each topic. All the experts met at the Forum on Mechanical Ventilation,
which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to
collaboratively draft the final text corresponding to each sub-topic, which was
presented to, appraised, discussed and approved in a plenary session that included
all 58 participants and aimed to create the final document.
Collapse
Affiliation(s)
- Carmen Sílvia Valente Barbas
- Corresponding author: Carmen Silvia Valente Barbas, Disicplina de
Pneumologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São
Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, Zip code - 05403-900 - São Paulo
(SP), Brazil, E-mail:
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Tao B, Liu L, Wang N, Wang W, Jiang J, Zhang J. Effects of hydrogen-rich saline on aquaporin 1, 5 in septic rat lungs. J Surg Res 2016; 202:291-8. [PMID: 27229103 DOI: 10.1016/j.jss.2016.01.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 01/06/2016] [Accepted: 01/07/2016] [Indexed: 01/20/2023]
Abstract
Aquaporin 1(AQP1) and AQP5 have an important role in eliminating extravascular lung water, an increase of which contributes to lung injury in patients with sepsis and its consequent mortality. It has been reported that hydrogen-rich saline (HRS) has protective effects against sepsis-related lung injury. In this study, we hypothesized that the protective effect occurred by preserving the expression of AQP1 and AQP5. To test this hypothesis, male Sprague-Dawley rats received intratracheal administration of lipopolysaccharide (LPS) followed by intraperitoneal injection of HRS. Lung function, wet-to-dry weight ratio, and histopathology scores were determined. The expression of AQP1 and AQP5 at the messenger RNA and protein levels, as well as the involved pathways, was explored by quantitative polymerase chain reaction and Western blot. LPS significantly impaired lung function and downregulated the expression of AQP1 and AQP5 in the rat lung, all of which were attenuated by HRS treatment. Moreover, HRS treatment inhibited LPS-induced activation of p38 mitogen-activated protein kinase and jun N-terminal kinase, which is associated with LPS-induced downregulation of AQP1 and AQP5.
Collapse
Affiliation(s)
- Bingdong Tao
- Department of Anesthesiology, Shengjing Hospital, China Medical University, Shenyang, People's Republic of China
| | - Lidan Liu
- Department of Anesthesiology, Shengjing Hospital, China Medical University, Shenyang, People's Republic of China
| | - Ni Wang
- Department of Anesthesiology, Shengjing Hospital, China Medical University, Shenyang, People's Republic of China
| | - Wei Wang
- Department of Anesthesiology, Shengjing Hospital, China Medical University, Shenyang, People's Republic of China
| | - Jingjing Jiang
- Department of Anesthesiology, Shengjing Hospital, China Medical University, Shenyang, People's Republic of China
| | - Jin Zhang
- Department of Anesthesiology, Shengjing Hospital, China Medical University, Shenyang, People's Republic of China.
| |
Collapse
|
34
|
Jozwiak M, Teboul JL, Monnet X. Extravascular lung water in critical care: recent advances and clinical applications. Ann Intensive Care 2015; 5:38. [PMID: 26546321 PMCID: PMC4636545 DOI: 10.1186/s13613-015-0081-9] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 10/27/2015] [Indexed: 12/16/2022] Open
Abstract
Extravascular lung water (EVLW) is the amount of fluid that is accumulated in the interstitial and alveolar spaces. In lung oedema, EVLW increases either because of increased lung permeability or because of increased hydrostatic pressure in the pulmonary capillaries, or both. Increased EVLW is always potentially life-threatening, mainly because it impairs gas exchange and reduces lung compliance. The only technique that provides an easy measurement of EVLW at the bedside is transpulmonary thermodilution. The validation of EVLW measurements by thermodilution was based on studies showing reasonable correlations with gravimetry or thermo-dye dilution in experimental and clinical studies. EVLW should be indexed to predicted body weight. This indexation reduces the proportion of ARDS patients for whom EVLW is in the normal range. Compared to non-indexed EVLW, indexed EVLW (EVLWI) is better correlated with the lung injury score and the oxygenation and it is a better predictor of mortality of patients with acute lung injury or acute respiratory distress syndrome (ARDS). Transpulmonary thermodilution also provides the pulmonary vascular permeability index (PVPI), which is an indirect reflection of the integrity of the alveolocapillary barrier. As clinical applications, EVLWI and PVPI may be useful to guide fluid management of patients at risk of fluid overload, as during septic shock and ARDS. High EVLWI and PVPI values predict mortality in several categories of critically ill patients, especially during ARDS. Thus, fluid administration should be limited when EVLWI is already high. Whatever the value of EVLWI, PVPI may indicate that fluid administration is particularly at risk of aggravating lung oedema. In the acute phase of haemodynamic resuscitation during septic shock and ARDS, high EVLWI and PVPI values may warn of the risk of fluid overload and prevent excessive volume expansion. At the post-resuscitation phase, they may prompt initiation of fluid removal thereby achieving a negative fluid balance.
Collapse
Affiliation(s)
- Mathieu Jozwiak
- Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France. .,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
| | - Jean-Louis Teboul
- Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France. .,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
| | - Xavier Monnet
- Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France. .,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
| |
Collapse
|
35
|
Santa Cruz R, Alvarez LV, Heredia R, Villarejo F. Acute Respiratory Distress Syndrome: Mortality in a Single Center According to Different Definitions. J Intensive Care Med 2015; 32:326-332. [PMID: 26438417 DOI: 10.1177/0885066615608159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Mortality in acute lung injury (ALI) remains high, with outcome data arising mostly from multicenter studies. We undertook this investigation to determine hospital mortality in patients with ALI in a single center. METHODS We studied patients admitted between 2005 and 2012 with ALI and acute respiratory distress syndrome (ARDS) according to the American European Consensus Conference (AECC) criteria and recorded clinical variables. Thereafter, patients were classified as subgroups according to the AECC and Berlin definition in order to compare the clinical characteristics and outcomes. RESULTS In the 93 patients comprising the study, hospital mortality was 38%. Mortality at 28 days was 36%. Multivariate analysis associated hospital mortality with age and Pao2/Fio2 on day 1 ( P < .001). Differences resulted between the subgroups of AECC (ALI vs ARDS) and Berlin (mild vs moderate vs severe ARDS) in the lung injury score, Pao2/Fio2, Pao2/PAo2, PaCo2 on day 1, and hospital mortality. CONCLUSION The overall hospital mortality (38%) was similar to that of other studies and according to the presence of ARDS (Pao2/Fio2 ≤ 200), we found significant differences between ALI and ARDS (AECC) and between mild and moderate or severe ARDS (Berlin) in baseline respiratory variables and mortality.
Collapse
Affiliation(s)
- Roberto Santa Cruz
- 1 Hospital Regional Rio Gallegos, Rio Gallegos, Argentina.,2 School of Medicine, University of Magallanes, Punta Arenas, Chile
| | | | | | | |
Collapse
|
36
|
Chen W, Chen YY, Tsai CF, Chen SCC, Lin MS, Ware LB, Chen CM. Incidence and Outcomes of Acute Respiratory Distress Syndrome: A Nationwide Registry-Based Study in Taiwan, 1997 to 2011. Medicine (Baltimore) 2015; 94:e1849. [PMID: 26512593 PMCID: PMC4985407 DOI: 10.1097/md.0000000000001849] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Most epidemiological studies of acute respiratory distress syndrome (ARDS) have been conducted in western countries, and studies in Asia are limited. The aim of our study was to evaluate the incidence, in-hospital mortality, and 1-year mortality of ARDS in Taiwan.We conducted a nationwide inpatient cohort study based on the Taiwan National Health Insurance Research Database between 1997 and 2011. A total of 40,876 ARDS patients (68% male; mean age 66 years) were identified by International Classification of Diseases, 9th edition coding and further analyzed for clinical characteristics, medical costs, and mortality.The overall crude incidence of ARDS was 15.74 per 100,000 person-years, and increased from 2.53 to 19.26 per 100,000 person-years during the study period. The age-adjusted incidence of ARDS was 15.19 per 100,000 person-years. The overall in-hospital mortality was 57.8%. In-hospital mortality decreased from 59.7% in 1997 to 47.5% in 2011 (P < 0.001). The in-hospital mortality rate was lowest (33.5%) in the youngest patients (age 18-29 years) and highest (68.2%) in the oldest patients (>80 years, P < 0.001). The overall 1-year mortality rate was 72.1%, and decreased from 75.8% to 54.7% during the study period. Patients who died during hospitalization were older (69 ± 17 versus 62 ± 19, P < 0.001) and predominantly male (69.8% versus 65.3%, P < 0.001). In addition, patients who died during hospitalization had significantly higher medical costs (6421 versus 5825 US Dollars, P < 0.001) and shorter lengths of stay (13 versus 19 days, P < 0.001) than patients who survived.We provide the first large-scale epidemiological analysis of ARDS incidence and outcomes in Asia. Although the overall incidence was lower than has been reported in a prospective US study, this may reflect underdiagnosis by International Classification of Diseases, 9th edition code and identification of only patients with more severe ARDS in this analysis. Overall, there has been a decreasing trend in in-hospital and 1-year mortality rates in recent years, likely because of the implementation of lung-protective ventilation.
Collapse
Affiliation(s)
- Wei Chen
- From the Department of Life Sciences, National Chung Hsing University, Taichung (WC, CMC); Division of Pulmonary and Critical Care Medicine, Chia-Yi Christian Hospital, Chiayi (WC, MSL); College of Nursing, Dayeh University, Changhua (WC); Department of Respiratory Therapy, China Medical University, Taichung (WC); Department of Internal Medicine, Chia-Yi Christian Hospital (YYC); Department of Medical Research, Ditmanson Medical Foundation Chia-Yi Christian Hospital (CFT, SCCC); Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi, Taiwan (MSL); Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN (LBW); and Rong-Hsing Translational Medicine Center, and iEGG Center, National Chung Hsing University, Taichung, Taiwan (CMC)
| | | | | | | | | | | | | |
Collapse
|
37
|
Liu T, Warburton RR, Hill NS, Kayyali US. Anthrax lethal toxin-induced lung injury and treatment by activating MK2. J Appl Physiol (1985) 2015; 119:412-9. [PMID: 26066827 DOI: 10.1152/japplphysiol.00335.2015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 06/10/2015] [Indexed: 11/22/2022] Open
Abstract
Anthrax is associated with severe vascular leak, which is caused by the bacterial lethal toxin (LeTx). Pleural effusions and pulmonary edema that occur in anthrax are believed to reflect endothelial injury caused by the anthrax toxin. Since vascular leak can also be observed consistently in rats injected intravenously with LeTx, the latter might present a simple physiologically relevant animal model of acute lung injury (ALI). Such a model could be utilized in evaluating and developing better treatment for ALI or acute respiratory distress syndrome (ARDS), as other available rodent models do not consistently produce the endothelial permeability that is a major component of ARDS. The biological activity of LeTx resides in the lethal factor metalloprotease that specifically degrades MAP kinase kinases (MKKs). Recently, we showed that LeTx inactivation of p38 MAP kinase signaling via degradation of MKK3 in pulmonary vascular endothelial cells can be linked to compromise of the endothelial permeability barrier. LeTx effects were linked specifically to blocking activation of p38 substrate and MAP kinase-activated protein kinase 2 (MAPKAPK2 or MK2) and phosphorylation of the latter's substrate, heat shock protein 27 (HSP27). We have now designed a peptide that directly and specifically activates MK2, causing HSP27 phosphorylation in cells and in vivo. The MK2-activating peptide (MK2-AP) also blocks the effects of LeTx on endothelial barriers in cultured cells and reduces LeTx-induced pulmonary vascular leak in rats. Hence, MK2-AP has the therapeutic potential to counteract anthrax or pulmonary edema and vascular leak due to other causes.
Collapse
Affiliation(s)
- Tiegang Liu
- Pulmonary, Critical Care, and Sleep Division, Department of Medicine/Tupper Research Institute, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - Rod R Warburton
- Pulmonary, Critical Care, and Sleep Division, Department of Medicine/Tupper Research Institute, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - Nicholas S Hill
- Pulmonary, Critical Care, and Sleep Division, Department of Medicine/Tupper Research Institute, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - Usamah S Kayyali
- Pulmonary, Critical Care, and Sleep Division, Department of Medicine/Tupper Research Institute, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| |
Collapse
|
38
|
Yuan SM. Postperfusion lung syndrome: physiopathology and therapeutic options. Braz J Cardiovasc Surg 2015; 29:414-25. [PMID: 25372917 PMCID: PMC4412333 DOI: 10.5935/1678-9741.20140071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 08/19/2014] [Indexed: 11/20/2022] Open
Abstract
Postperfusion lung syndrome is rare but can be lethal. The underlying mechanism
remains uncertain but triggering inflammatory cascades have become an accepted
etiology. A better understanding of the pathophysiology and the roles of inflammatory
mediators in the development of the syndrome is imperative in the determination of
therapeutic options and promotion of patients' prognosis and survival. Postperfusion
lung syndrome is similar to adult respiratory distress syndrome in clinical features,
diagnostic approaches and management strategies. However, the etiologies and
predisposing risk factors may differ between each other. The prognosis of the
postperfusion lung syndrome can be poorer in comparison to acute respiratory distress
syndrome due to the secondary multiple organ failure and triple acid-base imbalance.
Current management strategies are focusing on attenuating inflammatory responses and
preventing from pulmonary ischemia-reperfusion injury. Choices of cardiopulmonary
bypass circuit and apparatus, innovative cardiopulmonary bypass techniques, modified
surgical maneuvers and several pharmaceutical agents can be potential preventive
strategies for acute lung injury during cardiopulmonary bypass.
Collapse
Affiliation(s)
- Shi-Min Yuan
- Teaching Hospital, The First Hospital of Putian, Fujian Medical University, Putian, China
| |
Collapse
|
39
|
MORIMONT P, GUIOT J, DESAIVE T, TCHANA-SATO V, JANSSEN N, CAGNINA A, HELLA D, BLAFFART F, DEFRAIGNE JO, LAMBERMONT B. Veno-venous extracorporeal CO2 removal improves pulmonary hemodynamics in a porcine ARDS model. Acta Anaesthesiol Scand 2015; 59:448-56. [PMID: 25736472 DOI: 10.1111/aas.12497] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 01/22/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Protective lung ventilation is recommended in patients with acute respiratory distress syndrome (ARDS) to minimize additional injuries to the lung. However, hypercapnic acidosis resulting from ventilation at lower tidal volume enhances pulmonary hypertension and might induce right ventricular (RV) failure. We investigated if extracorporeal veno-venous CO2 removal therapy could have beneficial effects on pulmonary circulation and RV function. METHODS This study was performed on an experimental model of ARDS obtained in eight anaesthetized pigs connected to a volume-cycled ventilator. A micromanometer-tipped catheter was inserted into the main pulmonary artery and an admittance micromanometer-tipped catheter was inserted into the right ventricle. RV-arterial coupling was derived from RV pressure-volume loops. ARDS was obtained by repeated bronchoalveolar lavage. Protective ventilation was then achieved, and the pigs were connected to a pump-driven extracorporeal membrane oxygenator (PALP, Maquet, Germany) in order to achieve CO2 removal. RESULTS ARDS induced severe hypercapnic acidosis. Systolic pulmonary artery pressure significantly increased from 29.6±1.8 to 43.9±2.0 mmHg (P<0.001). After the PALP was started, acidosis was corrected and normocarbia was maintained despite protective ventilation. Pulmonary artery pressure significantly decreased to 31.6±3.2 mmHg (P<0.001) and RV-arterial coupling significantly improved (RV-arterial coupling index=1.03±0.33 vs. 0.55±0.41, P<0.05). CONCLUSION Veno-venous CO2 removal therapy enabled protective ventilation while maintaining normocarbia during ARDS. CO2 removal decreased pulmonary hypertension and improved RV function. This technique may be an effective lung- and RV-protective adjunct to mechanical ventilation.
Collapse
Affiliation(s)
- P. MORIMONT
- Medical Intensive Care Unit; University Hospital of Liege; Liege Belgium
- GIGA-Research; Cardiovascular Sciences; University of Liege; Liege Belgium
| | - J. GUIOT
- Medical Intensive Care Unit; University Hospital of Liege; Liege Belgium
- GIGA-Research; Cardiovascular Sciences; University of Liege; Liege Belgium
| | - T. DESAIVE
- GIGA-Research; Cardiovascular Sciences; University of Liege; Liege Belgium
| | - V. TCHANA-SATO
- GIGA-Research; Cardiovascular Sciences; University of Liege; Liege Belgium
| | - N. JANSSEN
- GIGA-Research; Cardiovascular Sciences; University of Liege; Liege Belgium
| | - A. CAGNINA
- GIGA-Research; Cardiovascular Sciences; University of Liege; Liege Belgium
| | - D. HELLA
- School of Perfusion; University of Liege; Liege Belgium
| | - F. BLAFFART
- School of Perfusion; University of Liege; Liege Belgium
| | - J.-O. DEFRAIGNE
- GIGA-Research; Cardiovascular Sciences; University of Liege; Liege Belgium
- Department of Cardiothoracic Surgery; University Hospital of Liege; Liege Belgium
| | - B. LAMBERMONT
- Medical Intensive Care Unit; University Hospital of Liege; Liege Belgium
- GIGA-Research; Cardiovascular Sciences; University of Liege; Liege Belgium
| |
Collapse
|
40
|
Hoeboer SH, Oudemans-van Straaten HM, Groeneveld ABJ. Albumin rather than C-reactive protein may be valuable in predicting and monitoring the severity and course of acute respiratory distress syndrome in critically ill patients with or at risk for the syndrome after new onset fever. BMC Pulm Med 2015; 15:22. [PMID: 25888398 PMCID: PMC4381515 DOI: 10.1186/s12890-015-0015-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 02/19/2015] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND We studied the value of routine biochemical variables albumin, C-reactive protein (CRP) and lactate dehydrogenase (LDH) to improve prediction and monitoring of acute respiratory distress syndrome (ARDS) severity in the intensive care unit. METHODS In 101 critically ill patients, with or at risk for ARDS after new onset fever, data were collected on days (D) 0, 1, 2, and 7 after inclusion. ARDS was defined by the Berlin definition and lung injury score (LIS). RESULTS At baseline, 48 patients had mild to severe ARDS according to Berlin and 87 according to LIS (Rs = 0.54, P < 0.001). Low baseline albumin levels were moderately associated with maximum Berlin and LIS categories within 7 days; an elevated CRP level was moderately associated with maximum Berlin categories only. The day-by-day Berlin and LIS categories were inversely associated with albumin levels (P = 0.01, P < 0.001) and directly with CRP levels (P = 0.02, P = 0.04, respectively). Low albumin levels had monitoring value for ARDS severity on all study days (area under the receiver operating characteristic curve, AUROC, 0.62-0.82, P < 0.001-0.03), whereas supranormal CRP levels performed less . When the Berlin or LIS category increased, albumin levels decreased ≥1 g/L (AUROC 0.72-0.77, P = 0.001) and CRP increased ≥104 mg/L (only significant for Berlin, AUROC 0.69, P = 0.04). When the LIS decreased, albumin levels increased ≥1 g/L (AUROC 0.68, P = 0.02). LDH was higher in 28-day non-survivors than survivors (P = 0.007). CONCLUSIONS Overall, albumin may be of greater value than CRP in predicting and monitoring the severity and course of ARDS in critically patients with or at risk for the syndrome after new onset fever. Albumin levels below 20 g/L as well as a decline over a week are associated with ARDS of increasing severity, irrespective of its definition. LDH levels predicted 28-day mortality.
Collapse
Affiliation(s)
- Sandra H Hoeboer
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
| | | | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
| |
Collapse
|
41
|
Laight NS, Levin AI. Transcardiopulmonary Thermodilution-Calibrated Arterial Waveform Analysis: A Primer for Anesthesiologists and Intensivists. J Cardiothorac Vasc Anesth 2015; 29:1051-64. [PMID: 26279223 DOI: 10.1053/j.jvca.2015.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Nicola S Laight
- Department of Anesthesiology and Critical Care, University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa
| | - Andrew I Levin
- Department of Anesthesiology and Critical Care, University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa.
| |
Collapse
|
42
|
Das A, Cole O, Chikhani M, Wang W, Ali T, Haque M, Bates DG, Hardman JG. Evaluation of lung recruitment maneuvers in acute respiratory distress syndrome using computer simulation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:8. [PMID: 25578295 PMCID: PMC4329196 DOI: 10.1186/s13054-014-0723-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 12/16/2014] [Indexed: 02/03/2023]
Abstract
Introduction Direct comparison of the relative efficacy of different recruitment maneuvers (RMs) for patients with acute respiratory distress syndrome (ARDS) via clinical trials is difficult, due to the heterogeneity of patient populations and disease states, as well as a variety of practical issues. There is also significant uncertainty regarding the minimum values of positive end-expiratory pressure (PEEP) required to ensure maintenance of effective lung recruitment using RMs. We used patient-specific computational simulation to analyze how three different RMs act to improve physiological responses, and investigate how different levels of PEEP contribute to maintaining effective lung recruitment. Methods We conducted experiments on five ‘virtual’ ARDS patients using a computational simulator that reproduces static and dynamic features of a multivariable clinical dataset on the responses of individual ARDS patients to a range of ventilator inputs. Three recruitment maneuvers (sustained inflation (SI), maximal recruitment strategy (MRS) followed by a titrated PEEP, and prolonged recruitment maneuver (PRM)) were implemented and evaluated for a range of different pressure settings. Results All maneuvers demonstrated improvements in gas exchange, but the extent and duration of improvement varied significantly, as did the observed mechanism of operation. Maintaining adequate post-RM levels of PEEP was seen to be crucial in avoiding cliff-edge type re-collapse of alveolar units for all maneuvers. For all five patients, the MRS exhibited the most prolonged improvement in oxygenation, and we found that a PEEP setting of 35 cm H2O with a fixed driving pressure of 15 cm H2O (above PEEP) was sufficient to achieve 95% recruitment. Subsequently, we found that PEEP titrated to a value of 16 cm H2O was able to maintain 95% recruitment in all five patients. Conclusions There appears to be significant scope for reducing the peak levels of PEEP originally specified in the MRS and hence to avoid exposing the lung to unnecessarily high pressures. More generally, our study highlights the huge potential of computer simulation to assist in evaluating the efficacy of different recruitment maneuvers, in understanding their modes of operation, in optimizing RMs for individual patients, and in supporting clinicians in the rational design of improved treatment strategies. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0723-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Anup Das
- School of Engineering, University of Warwick, Library Road, Coventry, CV4 7AL, UK.
| | - Oana Cole
- Anaesthesia & Critical Care Research Group, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK.
| | - Marc Chikhani
- Anaesthesia & Critical Care Research Group, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK.
| | - Wenfei Wang
- School of Engineering, University of Warwick, Library Road, Coventry, CV4 7AL, UK.
| | - Tayyba Ali
- Anaesthesia & Critical Care Research Group, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK.
| | - Mainul Haque
- Anaesthesia & Critical Care Research Group, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK.
| | - Declan G Bates
- School of Engineering, University of Warwick, Library Road, Coventry, CV4 7AL, UK.
| | - Jonathan G Hardman
- Anaesthesia & Critical Care Research Group, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK.
| |
Collapse
|
43
|
Mizunuma M, Ishikura H, Nakamura Y, Muranishi K, Morimoto S, Kaneyama H, Izutani Y, Nishida T, Murai A. Endocan can be a predictive marker of severity of sepsis but cannot be a marker of acute respiratory distress syndrome in ICU patients. Crit Care 2015. [PMCID: PMC4471512 DOI: 10.1186/cc14315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
44
|
Tagami T, Tosa R, Omura M, Fukushima H, Kaneko T, Endo T, Rinka H, Murai A, Yamaguchi J, Yoshikawa K, Saito N, Uzu H, Kase Y, Takatori M, Izumino H, Nakamura T, Seo R, Kitazawa Y, Sugita M, Takahashi H, Kuroki Y, Irahara T, Kanemura T, Yokota H, Kushimoto S. Effect of a selective neutrophil elastase inhibitor on mortality and ventilator-free days in patients with increased extravascular lung water: a post hoc analysis of the PiCCO Pulmonary Edema Study. J Intensive Care 2014; 2:67. [PMID: 25705423 PMCID: PMC4336272 DOI: 10.1186/s40560-014-0067-y] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 12/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neutrophil elastase plays an important role in the development and progression of acute respiratory distress syndrome (ARDS). Although the selective elastase inhibitor, sivelestat, is widely used in Japan for treating ARDS patients, its effectiveness remains controversial. The aim of the current study was to investigate the effects of sivelestat in ARDS patients with evidence of increased extravascular lung water by re-analyzing a large multicenter study database. METHODS A post hoc analysis of the PiCCO Pulmonary Edema Study was conducted. This multicenter prospective cohort study included 23 institutions in Japan. Adult mechanically ventilated ARDS patients with an extravascular lung water index of >10 mL/kg were included and propensity score analyses were performed. The endpoints were 28-day mortality and ventilator-free days (VFDs). RESULTS Patients were categorized into sivelestat (n = 87) and control (n = 77) groups, from which 329 inverse probability-weighted group patients (162 vs. 167) were generated. The overall 28-day mortality was 31.1% (51/164). There was no significant difference in 28-day mortality between the study groups (sivelestat vs. control; unmatched: 29.9% vs. 32.5%; difference, -2.6%, 95% confidence interval (CI), -16.8 to 14.2; inverse probability-weighted: 24.7% vs. 29.5%, difference, -4.8%, 95% CI, -14.4 to 9.6). Although administration of sivelestat did not alter the number of ventilator-free days (VFDs) in the unmatched (9.6 vs. 9.7 days; difference, 0.1, 95% CI, -3.0 to 3.1), the inverse probability-weighted analysis identified significantly more VFDs in the sivelestat group than in the control group (10.7 vs. 8.4 days, difference, -2.3, 95% CI, -4.4 to -0.2). CONCLUSIONS Although sivelestat did not significantly affect 28-day mortality, this treatment may have the potential to increase VFDs in ARDS patients with increased extravascular lung water. Prospective randomized controlled studies are required to confirm the results of the current study.
Collapse
Affiliation(s)
- Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603 Japan ; Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryoichi Tosa
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Fukushima, Japan
| | - Mariko Omura
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Fukushima, Japan
| | - Hidetada Fukushima
- Department of Emergency and Critical Care Medicine, Nara Medical University, Nara, Japan
| | - Tadashi Kaneko
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Tomoyuki Endo
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Miyagi, Japan
| | - Hiroshi Rinka
- Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Akira Murai
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Junko Yamaguchi
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kazuhide Yoshikawa
- Shock Trauma and Emergency Medical Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Nobuyuki Saito
- Department of Emergency and Critical Care Medicine, Nippon Medical School Chiba Hokusou Hospital, Chiba, Japan
| | - Hideaki Uzu
- Department of Emergency and Critical Care Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Yoichi Kase
- Critical Care Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Makoto Takatori
- Department of Anesthesia and Intensive Care, Hiroshima City Hospital, Hiroshima, Japan
| | - Hiroo Izumino
- Advanced Emergency and Critical Care Center, Kansai Medical University Takii Hospital, Osaka, Japan
| | | | - Ryutarou Seo
- Intensive Care Unit, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Yasuhide Kitazawa
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Osaka, Japan
| | - Manabu Sugita
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Hiroyuki Takahashi
- Department of Intensive Care Medicine, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
| | - Yuichi Kuroki
- Department of Emergency and Critical Care Medicine, Social Insurance Chukyo Hospital, Aichi, Japan
| | - Takayuki Irahara
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Takashi Kanemura
- Emergency and Critical Care Medicine, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603 Japan
| | - Shigeki Kushimoto
- Division of Emergency Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| |
Collapse
|
45
|
Abstract
This review documents important progress made in 2013 in the field of critical care respirology, in particular with regard to acute respiratory failure and acute respiratory distress syndrome. Twenty-five original articles published in the respirology and critical care sections of Critical Care are discussed in the following categories: pre-clinical studies, protective lung ventilation – how low can we go, non-invasive ventilation for respiratory failure, diagnosis and prognosis in acute respiratory distress syndrome and respiratory failure, and promising interventions for acute respiratory distress syndrome.
Collapse
|
46
|
Abstract
Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.
Collapse
|
47
|
Sweatt AJ, Levitt JE. Evolving epidemiology and definitions of the acute respiratory distress syndrome and early acute lung injury. Clin Chest Med 2014; 35:609-24. [PMID: 25453413 DOI: 10.1016/j.ccm.2014.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This article reviews the evolving definitions and epidemiology of the acute respiratory distress syndrome (ARDS) and highlights current efforts to improve identification of high-risk patients, thus to target prevention and early treatment before progression to ARDS. This information will be important for general practitioners and intensivists interested in improving the care of patients at risk for ARDS, and clinical researchers interested in designing clinical trials targeting the prevention and early treatment of acute lung injury.
Collapse
Affiliation(s)
- Andrew J Sweatt
- Division of Pulmonary and Critical Care Medicine, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Joseph E Levitt
- Division of Pulmonary and Critical Care Medicine, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA.
| |
Collapse
|
48
|
Yang S, Wu H, Zhao J, Wu X, Zhao J, Ning Q, Xu Y, Xie J. Feasibility of 8-OHdG formation and hOGG1 induction in PBMCs for assessing oxidative DNA damage in the lung of COPD patients. Respirology 2014; 19:1183-90. [PMID: 25154311 DOI: 10.1111/resp.12378] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 05/06/2014] [Accepted: 06/27/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Oxidative stress has long been recognized to play a role in chronic obstructive pulmonary disease (COPD); however, approaches for assessing oxidative stress are lacking. The objective of this study was to address the feasibility of measuring 8-oxo-7, 8-dihydro-2'-deoxyguanosine (8-OHdG) formation and human 8-oxoguanine DNA glycosylase (hOGG1) induction in peripheral blood mononuclear cell (PBMC) to assess oxidative deoxyribonucleic acid (DNA) damage in the lung of smoking COPD patients. METHODS PBMC were obtained from 412 participants including 129 smokers with COPD, 143 healthy smokers and 140 healthy non-smokers. Lung tissue specimens and PBMC were obtained from smoker COPD (n = 12), healthy smokers (n = 12) and healthy non-smokers (n = 10). 8-OHdG and hOGG1 were detected, and correlation analysis was conducted for assessing the feasibility. RESULTS Oxidative DNA damage (8-OHdG formation) along with impaired induction of hOGG1 expression in the lung was a prominent feature for smokers COPD patients. PBMC originated from smokers COPD patients also displayed similar features to that of lung tissues. Correlation analysis suggests that PBMC could be used as a surrogate for oxidative DNA damage in lung of smokers COPD patients. Indeed, 8-OHdG levels in PBMC DNA were negatively correlated with lung function, while hOGG1 induction in PBMC was associated with improved lung function in smokers COPD patients. CONCLUSIONS COPD patients manifest oxidative DNA damage of 8-OHdG along with impaired hOGG1 expression in the lung, whereas 8-OHdG formation and hOGG1 induction in PBMC could be a biomarker of oxidative DNA damage in the lung.
Collapse
Affiliation(s)
- Shifang Yang
- Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | | | | | | | | | | | | |
Collapse
|
49
|
Tagami T, Nakamura T, Kushimoto S, Tosa R, Watanabe A, Kaneko T, Fukushima H, Rinka H, Kudo D, Uzu H, Murai A, Takatori M, Izumino H, Kase Y, Seo R, Takahashi H, Kitazawa Y, Yamaguchi J, Sugita M, Takahashi H, Kuroki Y, Kanemura T, Morisawa K, Saito N, Irahara T, Yokota H. Early-phase changes of extravascular lung water index as a prognostic indicator in acute respiratory distress syndrome patients. Ann Intensive Care 2014; 4:27. [PMID: 25593743 PMCID: PMC4273855 DOI: 10.1186/s13613-014-0027-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 07/31/2014] [Indexed: 01/11/2023] Open
Abstract
Background The features of early-phase acute respiratory distress syndrome (ARDS) are leakage of fluid into the extravascular space and impairment of its reabsorption, resulting in extravascular lung water (EVLW) accumulation. The current study aimed to identify how the initial EVLW values and their change were associated with mortality. Methods This was a post hoc analysis of the PiCCO Pulmonary Edema Study, a multicenter prospective cohort study that included 23 institutions. Single-indicator transpulmonary thermodilution-derived EVLW index (EVLWi) and conventional prognostic factors were prospectively collected over 48 h after enrollment. Associations between 28-day mortality and each variable including initial (on day 0), mean, maximum, and Δ (subtracting day 2 from day 0) EVLWi were evaluated. Results We evaluated 192 ARDS patients (median age, 69 years (quartile, 24 years); Sequential Organ Failure Assessment (SOFA) score on admission, 10 (5); all-cause 28-day mortality, 31%). Although no significant differences were found in initial, mean, or maximum EVLWi, Δ-EVLWi was significantly higher (i.e., more reduction in EVLWi) in survivors than in non-survivors (3.0 vs. −0.3 mL/kg, p = 0.006). Age, maximum, and Δ-SOFA scores and Δ-EVLW were the independent predictors for survival according to the Cox proportional hazard model. Patients with Δ-EVLWi > 2.8 had a significantly higher incidence of survival than those with Δ-EVLWi ≤ 2.8 (log-rank test, χ2 = 7.08, p = 0.008). Conclusions Decrease in EVLWi during the first 48 h of ARDS may be associated with 28-day survival. Serial EVLWi measurements may be useful for understanding the pathophysiologic conditions in ARDS patients. A large multination confirmative trial is required.
Collapse
Affiliation(s)
- Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan ; Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
| | - Toshiaki Nakamura
- Intensive Care Unit, Nagasaki University Hospital, Nagasaki 852-8501, Japan
| | - Shigeki Kushimoto
- Division of Emergency Medicine, Tohoku University Graduate School of Medicine, Miyagi 986-2242, Japan
| | - Ryoichi Tosa
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Fukushima 965-8611, Japan
| | - Akihiro Watanabe
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Tadashi Kaneko
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Yamaguchi 755-8505, Japan
| | - Hidetada Fukushima
- Department of Emergency and Critical Care Medicine, Nara Medical University, Nara 634-8522, Japan
| | - Hiroshi Rinka
- Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka 534-0021, Japan
| | - Daisuke Kudo
- Division of Emergency Medicine, Tohoku University Graduate School of Medicine, Miyagi 986-2242, Japan
| | - Hideaki Uzu
- Department of Emergency and Critical Care Medicine, Kurume University School of Medicine, Fukuoka 830-0011, Japan
| | - Akira Murai
- Department of Emergency and Critical Care Medicine, Fukuoka University Hospital, Fukuoka 814-0180, Japan
| | - Makoto Takatori
- Department of Anesthesia and Intensive Care, Hiroshima City Hospital, Hiroshima 730-8518, Japan
| | - Hiroo Izumino
- Advanced Emergency and Critical Care Center, Kansai Medical University Takii Hospital, Osaka 570-8507, Japan
| | - Yoichi Kase
- Department of Critical Care Medicine, Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Ryutarou Seo
- Intensive Care Unit, Kobe City Medical Center General Hospital, Hyogo 650-0046, Japan
| | - Hiroyuki Takahashi
- Shock Trauma and Emergency Medical Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo 113-8519, Japan
| | - Yasuhide Kitazawa
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Osaka 570-8506, Japan
| | - Junko Yamaguchi
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | - Manabu Sugita
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Tokyo 177-8521, Japan
| | - Hiroyuki Takahashi
- Department of Intensive Care Medicine, Saiseikai Yokohamashi Tobu Hospital, Kanagawa 230-8765, Japan
| | - Yuichi Kuroki
- Department of Emergency and Critical Care Medicine, Social Insurance Chukyo Hospital, Aichi 457-8510, Japan
| | - Takashi Kanemura
- Emergency and Critical Care Medicine, National Hospital Organization Disaster Medical Center, Tokyo 190-0014, Japan
| | - Kenichiro Morisawa
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kanagawa 216-8511, Japan
| | - Nobuyuki Saito
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Chiba Hokusou Hospital, Chiba 270-1694, Japan
| | - Takayuki Irahara
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tama Nagayama Hospital, Tokyo 206-8512, Japan
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| |
Collapse
|
50
|
Accuracy of ultrasound B-lines score and E/Ea ratio to estimate extravascular lung water and its variations in patients with acute respiratory distress syndrome. J Clin Monit Comput 2014; 29:169-76. [DOI: 10.1007/s10877-014-9582-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 05/07/2014] [Indexed: 10/25/2022]
|