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King CS, Ignacio RV, Khangoora V, Nyquist A, Singhal A, Thomas C, Cantres OF, Aryal S, Shlobin OA, Flaherty K, Lasky J, Nathan SD. Hospitalization Rates in Interstitial Lung Disease: An Analysis of the Pulmonary Fibrosis Foundation Registry. Am J Respir Crit Care Med 2024. [PMID: 38236191 DOI: 10.1164/rccm.202309-1708oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/16/2024] [Indexed: 01/19/2024] Open
Abstract
RATIONALE Little is known about hospitalization in other types of interstitial lung disease (ILD) besides idiopathic pulmonary fibrosis (IPF). OBJECTIVES We sought to determine the frequency of hospitalizations in various types of ILD and elucidate the association of hospitalization with outcomes. METHODS An analysis of the Pulmonary Fibrosis Foundation Patient Registry data was performed. Inpatient hospitalization rates and survival following hospitalization were compared for various types of ILD. RESULTS Hospitalization rates were similar across ILD types (40.6% of IPF participants, 42.8% of connective tissue disease related ILD (CTD-ILD), 44.9% of non-IPF idiopathic interstitial pneumonia (IIPs), 46.5% of chronic hypersensitivity pneumonitis (CHP) participants, and 53.3% of "other" ILD participants). All-cause hospitalization was not associated with decreased transplant-free survival (adjusted hazard ratio (AHR) 1.20, 95% CI: 0.98, 1.46, p=0.0759) after adjusting for co-morbidities and severity of illness; however respiratory-related hospitalization was (AHR 1.53, 95% CI: 1.23, 1.90, p=0.0001). CTD-ILD (HR 0.43, 95% CI: 0.25, 0.75, p=0.0031) and non-IPF IIP (HR 0.3, 95% CI: 0.15, 0.58, p=0.005) had a lower risk of death following hospitalization compared to IPF while CHP (HR 0.67, 95% CI: 0.37, 1.20, p=0.1747) and "other-ILD" (HR 0.54, 95% CI: 0.19, 1.54, p=0.25) had a comparable risk to IPF. CONCLUSION Rates of hospitalization are similar across ILD subtypes. The risk of death or transplant following hospitalization is lower in CTD-ILD, CHP and non-IPF IIP compared to IPF participants. In a mixed population of ILD participants, all-cause hospitalizations were not associated with decreased transplant-free survival; however respiratory-related hospitalizations were.
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Affiliation(s)
- Christopher S King
- Inova Fairfax Hospital, 23146, Advanced Lung Disease and Lung Transplant Clinic, Falls Church, Virginia, United States;
| | - Rosalinda V Ignacio
- University of Michigan, 1259, Department of Biostatistics, Ann Arbor, Michigan, United States
| | | | - Alan Nyquist
- Inova Fairfax Hospital, 23146, Advanced Lung Disease and Transplant Program, Falls Church, Virginia, United States
| | - Anju Singhal
- Inova Fairfax Hospital, 23146, Falls Church, Virginia, United States
| | - Christopher Thomas
- Inova Fairfax Hospital, 23146, Advanced Lung Disease and Transplant Program, Falls Church, Virginia, United States
| | | | - Shambhu Aryal
- Inova Fairfax Hospital, 23146, Falls Church, Virginia, United States
| | - Oksana A Shlobin
- Inova Fairfax Hospital, Advanced Lung Disease and Transplant, Falls Church, Virginia, United States
| | | | - Joseph Lasky
- Tulane University, New Orleans, Louisiana, United States
| | - Steven D Nathan
- Inova Fairfax Hospital, 23146, Advanced Lung Disease and Transplant Program, Falls Church, Virginia, United States
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Nathan SD, Tehrani B, Zhao Q, Arias R, Kim D, Pellegrini A, Collins AC, Diviney J, Chakravorty S, Khangoora V, Shlobin OA, Thomas C, Lavon BR, King CS, Chandel A. Pulmonary vascular dysfunction without pulmonary hypertension: A distinct phenotype in idiopathic pulmonary fibrosis. Pulm Circ 2024; 14:e12311. [PMID: 38174158 PMCID: PMC10762875 DOI: 10.1002/pul2.12311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/06/2023] [Accepted: 11/05/2023] [Indexed: 01/05/2024] Open
Abstract
Pulmonary vascular dysfunction in the absence of pulmonary hypertension (PH) has been observed in patients with idiopathic pulmonary fibrosis (IPF). We describe the prevalence and etiology of elevated pulmonary vascular resistance (PVR) without PH among patients with IPF. Hemodynamic, echocardiographic, and functional respiratory imaging (FRI) data was compared between patients with IPF without PH with normal (<3 wood units) and elevated PVR (≥3 wood units). Mortality between these two groups were compared to patients with IPF and PH. Of 205 patients with IPF, there were 146 patients without PH, of whom 114 (78.1%) had a normal PVR and 32 (21.9%) who had a high PVR. Functional testing and hemodynamics were similar in the two groups, except for the cardiac index which was significantly lower in patients with a high PVR (2.3 vs. 2.6 L/min/m2; p = 0.004). Echocardiographic comparison demonstrated a higher tricuspid regurgitant velocity in those with a high PVR (3.4 vs 3.0 m/s; p = 0.046). FRI revealed proportionately fewer large vessels as a proportion of the vasculature in the patients without PH and elevated PVRs. Among patients without PH, PVR was associated with increased mortality. In conclusion, patients with IPF without PH but a high PVR appear to be a distinct phenotype with a prognosis between those with and without PH, likely reflecting the continuum of vascular dysfunction. The basis for this unique hemodynamic profile could not be definitively discerned although FRI suggested an aberrant anatomical vascular response.
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Affiliation(s)
- Steven D. Nathan
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Benham Tehrani
- Cardiology Department, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Qiong Zhao
- Cardiology Department, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Rafael Arias
- Cardiology Department, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Dennis Kim
- Department of MedicineInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Antonia Pellegrini
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Ashley Claire Collins
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Jack Diviney
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | | | - Vikramjit Khangoora
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Christopher Thomas
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | | | - Christopher S. King
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Abhimanyu Chandel
- Department of Pulmonary and Critical CareWalter Reed National Military Medical CenterBethesdaMarylandUSA
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King CS, White E, Aryal S, Shlobin OA, Singhal A, Brown AW, Thomas C, Khangoora V, Nyquist A, Flaherty KR, Nathan SD, Mooney JJ. Factors associated with listing for lung transplantation in IPF patients: An analysis of the pulmonary fibrosis foundation registry. Heliyon 2023; 9:e18618. [PMID: 37600402 PMCID: PMC10432603 DOI: 10.1016/j.heliyon.2023.e18618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 06/27/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Rationale and objectives Lung transplantation is a potentially life-saving treatment option for patients with idiopathic pulmonary fibrosis (IPF); however, not all eligible candidates get referred and listed for transplantation. Amongst IPF patients within the Pulmonary Fibrosis Foundation Patient Registry (PFF-R), we sought to determine the proportion of patients who undergo lung transplant listing and the characteristics associated with transplant listing. Methods An analysis of IPF patients with at least six months of follow-up data was performed. Patients with well-established contraindications to lung transplantation were excluded. Two complementary analyses were performed. The "prevalent" population included all patients with IPF at time of enrollment into the registry. The "incident severe" population included all patients with IPF who progressed to GAP Stage 3. Results Of the 2003 patients in the PFF-R, 475 patients were included in the "prevalent" population. Of this group, only 42 (8.8%) were either listed for or underwent lung transplant. Univariable analysis of the "prevalent" population found age (per 10 year increase, OR 0.531, p = 0.0025), percent predicted FVC (OR 0.572, p=<0.0001), percent predicted DLCO (OR 0.606, p < 0.0001), 6-min walk distance (per 50 m, OR 0.831, p = 0.019), and oxygen use at rest (OR 5.157, p < 0.0001) were predictive of listing. On multivariable analysis, age (per 10 year increase, OR 0.558, p = 0.0088), percent predicted FVC (OR 0.728, p = 0.0161), and oxygen use at rest (OR 3.264, p = 0.0029) remained significant predictors for lung transplant listing. The "incident severe" group consisted of 176 patients (8.8%). 24 patients (13.6%) from this cohort were either listed for or received a transplant. Only age (per 10 year increase, OR 0.0286, p = 0.0465) was associated with transplant listing on univariable analysis in the Incident severe population. Conclusion Only a small proportion of potentially eligible patients with IPF are listed for lung transplantation, even when seen at pulmonary fibrosis centers of excellence. Advanced age appears to be the primary factor associated with failure to be listed. Further refinement of future registry data is required to more clearly delineate exact reasons for low rates of listing.
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Affiliation(s)
- Christopher S. King
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Emily White
- University of Michigan, Department of Biostatistics, USA
| | - Shambhu Aryal
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Anju Singhal
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - A. Whitney Brown
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Christopher Thomas
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Vikramjit Khangoora
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Alan Nyquist
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Kevin R. Flaherty
- University of Michigan Division of Pulmonary & Critical Care Medicine, USA
| | - Steven D. Nathan
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Joshua J. Mooney
- Stanford University, Division of Pulmonary and Critical Care Medicine, USA
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Chandel A, King CS, Ignacio RV, Pastre J, Shlobin OA, Khangoora V, Aryal S, Nyquist A, Singhal A, Flaherty KR, Nathan SD. External validation and longitudinal application of the DO-GAP index to individualise survival prediction in idiopathic pulmonary fibrosis. ERJ Open Res 2023; 9:00124-2023. [PMID: 37228268 PMCID: PMC10204731 DOI: 10.1183/23120541.00124-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 03/07/2023] [Indexed: 05/27/2023] Open
Abstract
Background The Distance-Oxygen-Gender-Age-Physiology (DO-GAP) index has been shown to improve prognostication in idiopathic pulmonary fibrosis (IPF) compared to the Gender-Age-Physiology (GAP) score. We sought to externally validate the DO-GAP index compared to the GAP index for baseline risk assessment in patients with IPF. Additionally, we evaluated the utility of serial change in the DO-GAP index in predicting survival. Methods We performed an analysis of patients with IPF from the Pulmonary Fibrosis Foundation-Patient Registry (PFF-PR). Discrimination and calibration of the two models were assessed to predict transplant-free survival and IPF-related mortality. Joint longitudinal time-to-event modelling was utilised to individualise survival prediction based on DO-GAP index trajectory. Results There were 516 patients with IPF from the PFF-PR with available demographics, pulmonary function tests, 6-min walk test data and outcomes included in this analysis. The DO-GAP index (C-statistic: 0.73) demonstrated improved discrimination in discerning transplant-free survival compared to the GAP index (C-statistic: 0.67). DO-GAP index calibration was adequate, and the model retained predictive accuracy to identify IPF-related mortality (C-statistic: 0.74). The DO-GAP index was similarly accurate in the subset of patients taking antifibrotic medications. Serial change in the DO-GAP index improved model discrimination (cross-validated area under the curve: 0.83) enabling the personalised prediction of disease trajectory in individual patients. Conclusion The DO-GAP index is a simple, validated, multidimensional score that accurately predicts transplant-free survival in patients with IPF and can be adapted longitudinally in individual patients. The DO-GAP may also find use in studies of IPF to risk stratify patients and possibly as a clinical trial end-point.
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Affiliation(s)
- Abhimanyu Chandel
- Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Christopher S. King
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | | | - Jean Pastre
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Vikramjit Khangoora
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Shambhu Aryal
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Alan Nyquist
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Anju Singhal
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Kevin R. Flaherty
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Steven D. Nathan
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
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Thomas C, Chandel A, King CS, Aryal S, Brown AW, Khangoora V, Nyquist A, Singhal A, Fonseca OC, Shlobin O, Nathan SD. Prevalence of pulmonary hypertension in patients with COVID-19 related lung disease listed for lung transplantation: A UNOS registry analysis. Pulm Circ 2023; 13:e12228. [PMID: 37091120 PMCID: PMC10114532 DOI: 10.1002/pul2.12228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/11/2023] [Accepted: 04/09/2023] [Indexed: 04/25/2023] Open
Abstract
COVID-19 related lung disease (CRLD) has emerged as an indication for lung transplantation (LT) in highly select patients. The prevalence and prognostic implication of coexisting pulmonary hypertension (PH) in patients with CRLD listed for LT is not known. Adult patients in the United Network for Organ Sharing database listed for LT for COVID-19 related acute respiratory distress syndrome or fibrosis through March 2022 were identified. The prevalence and impact of precapillary PH on pre- and posttransplantation survival was determined. Time-to-event analysis was used to compare outcomes between those with and without precapillary PH. We identified 245 patients listed for LT for CRLD who had right heart catheterization data available at the time of registry listing. Median age of the cohort was 54 years (interquartile range [IQR]: 46, 60), 56 (22.9%) were female, and the median lung allocation score was 81.3 (IQR: 53.3, 89.4). The prevalence of precapillary PH at the time of transplant listing was 27.9%. There was no significant difference in pretransplant mortality in patients with and without precapillary PH (sHR: 0.5; 95% confidence interval [CI]: 0.1-1.7, p = 0.261). A total of 187 patients ultimately underwent LT; of those, 60 (31.0%) were identified as having precapillary PH during the waitlist period. Posttransplantation survival was similar between patients with and without pretransplant precapillary PH (hazard ratio: 0.96; 95% CI: 0.2-3.7, p = 0.953). We observed a high rate of concomitant precapillary PH in patients listed for LT for CRLD. Though common, coexisting precapillary PH was not associated with a significant difference in either pre- or post-transplantation outcomes.
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Affiliation(s)
- Christopher Thomas
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Abhimanyu Chandel
- Department of Pulmonary and Critical Care MedicineWalter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Christopher S. King
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Shambhu Aryal
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - A. Whitney Brown
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Vikramjit Khangoora
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Alan Nyquist
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Anju Singhal
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Onix Cantres Fonseca
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Oksana Shlobin
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Steven D. Nathan
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
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Thomas C, Klein K, Kennedy J, Psotka M, Isseh I, Tang D, Aryal S, Khangoora V, Nyquist A, Singhal A, Cantres-Fonseca O, Shlobin O, Nathan S, King C. Heart-lung Transplantation for Restrictive Cardiomyopathy and Pulmonary Hypertension Due to Emery-Dreifuss Muscular Dystrophy. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Nyquist A, Khangoora V, Shlobin O, Aryal S, King C, Singhal A, Ahmad K, Brown A, Nathan S. Transplantation of Occult Signet Ring Cell Carcinoma Mimicking Pulmonary Veno-Occlusive Disease. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
Patients with advanced lung disease can develop pulmonary hypertension and succumb to right ventricular failure/cor pulmonale. Patients with pulmonary hypertension owing to chronic lung disease, or World Health Organization group 3 pulmonary hypertension, are more limited and carry a high risk of mortality. Adjunctive therapies remain the cornerstones of treatment. Recent evidence suggests that inhaled pulmonary vasodilator therapy can be helpful in patients with pulmonary hypertension owing to interstitial lung disease. Lung transplantation may be the only life-saving option in select patients, whereas palliative care and hospice should be sought for those who are not candidates as the disease progresses.
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Affiliation(s)
- Kareem Ahmad
- Transplant Department, Advanced Lung Disease and Lung Transplant, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA.
| | - Vikramjit Khangoora
- Transplant Department, Advanced Lung Disease and Lung Transplant, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Steven D Nathan
- Transplant Department, Advanced Lung Disease and Lung Transplant, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA
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Chandel A, Patolia S, Ahmad K, Aryal S, Brown AW, Sahjwani D, Khangoora V, Shlobin OA, Cameron PC, Singhal A, Holtzclaw AW, Desai M, Nathan SD, King CS. Inhaled Nitric Oxide via High-Flow Nasal Cannula in Patients with Acute Respiratory Failure Related to COVID-19. Clin Med Insights Circ Respir Pulm Med 2021; 15:11795484211047065. [PMID: 34602831 PMCID: PMC8485265 DOI: 10.1177/11795484211047065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/31/2021] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Limited evidence exists regarding use of inhaled nitric oxide (iNO) in spontaneously breathing patients. We evaluated the effectiveness of continuous iNO via high-flow nasal cannula (HFNC) in COVID-19 respiratory failure. METHODS We performed a multicenter cohort study of patients with respiratory failure from COVID-19 managed with HFNC. Patients were stratified by administration of iNO via HFNC. Regression analysis was used to compare the need for mechanical ventilation and secondary endpoints including hospital mortality, length of stay, acute kidney injury, need for renal replacement therapy, and need for extracorporeal life support. RESULTS A total of 272 patients were identified and 66 (24.3%) of these patients received iNO via HFNC for a median of 88 h (interquartile range: 44, 135). After 12 h of iNO, supplemental oxygen requirement was unchanged or increased in 52.7% of patients. Twenty-nine (43.9%) patients treated with iNO compared to 79 (38.3%) patients without iNO therapy required endotracheal intubation (P = .47). After multivariable adjustment, there was no difference in need for mechanical ventilation between groups (odds ratio: 1.53; 95% confidence interval [CI]: 0.74-3.17), however, iNO administration was associated with longer hospital length of stay (incidence rate ratio: 1.41; 95% CI: 1.31-1.51). No difference was found for mortality, acute kidney injury, need for renal replacement therapy, or need for extracorporeal life support. CONCLUSION In patients with COVID-19 respiratory failure, iNO delivered via HFNC did not reduce oxygen requirements in the majority of patients or improve clinical outcomes. Given the observed association with increased length of stay, judicious selection of those likely to benefit from this therapy is warranted.
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Affiliation(s)
| | - Saloni Patolia
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | | | | | | | | | | | | | | | | | | | - Mehul Desai
- Inova Fairfax Hospital, Falls Church, VA, USA
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Strich JR, Tian X, Samour M, King CS, Shlobin O, Reger R, Cohen J, Ahmad K, Brown AW, Khangoora V, Aryal S, Migdady Y, Kyte JJ, Joo J, Hays R, Collins AC, Battle E, Valdez J, Rivero J, Kim IH, Erb-Alvarez J, Shalhoub R, Chakraborty M, Wong S, Colton B, Ramos-Benitez MJ, Warner S, Chertow DS, Olivier KN, Aue G, Davey RT, Suffredini AF, Childs RW, Nathan SD. Fostamatinib for the Treatment of Hospitalized Adults With Coronavirus Disease 2019: A Randomized Trial. Clin Infect Dis 2021; 75:e491-e498. [PMID: 34467402 PMCID: PMC9890443 DOI: 10.1093/cid/ciab732] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) requiring hospitalization is characterized by robust antibody production, dysregulated immune response, and immunothrombosis. Fostamatinib is a novel spleen tyrosine kinase inhibitor that we hypothesize will ameliorate Fc activation and attenuate harmful effects of the anti-COVID-19 immune response. METHODS We conducted a double-blind, randomized, placebo-controlled trial in hospitalized adults requiring oxygen with COVID-19 where patients receiving standard of care were randomized to receive fostamatinib or placebo. The primary outcome was serious adverse events by day 29. RESULTS A total of 59 patients underwent randomization (30 to fostamatinib and 29 to placebo). Serious adverse events occurred in 10.5% of patients in the fostamatinib group compared with 22% in placebo (P = .2). Three deaths occurred by day 29, all receiving placebo. The mean change in ordinal score at day 15 was greater in the fostamatinib group (-3.6 ± 0.3 vs -2.6 ± 0.4, P = .035) and the median length in the intensive care unit was 3 days in the fostamatinib group vs 7 days in placebo (P = .07). Differences in clinical improvement were most evident in patients with severe or critical disease (median days on oxygen, 10 vs 28, P = .027). There were trends toward more rapid reductions in C-reactive protein, D-dimer, fibrinogen, and ferritin levels in the fostamatinib group. CONCLUSION For COVID-19 requiring hospitalization, the addition of fostamatinib to standard of care was safe and patients were observed to have improved clinical outcomes compared with placebo. These results warrant further validation in larger confirmatory trials. CLINICAL TRIALS REGISTRATION Clinicaltrials.gov, NCT04579393.
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Affiliation(s)
- Jeffrey R Strich
- Correspondence: J. R. Strich, Critical Care Medicine Department, National Institutes of Health Clinical Center, 10 Center Drive, 2C145, Bethesda, MD 20892 ()
| | - Xin Tian
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Mohamed Samour
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Christopher S King
- Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Oksana Shlobin
- Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Robert Reger
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jonathan Cohen
- Adventist Healthcare Shady Grove Medical Center, Rockville, Maryland, USA
| | - Kareem Ahmad
- Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - A Whitney Brown
- Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Vikramjit Khangoora
- Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Shambhu Aryal
- Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Yazan Migdady
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer Jo Kyte
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jungnam Joo
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Rebecca Hays
- Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - A Claire Collins
- Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Edwinia Battle
- Advanced Lung Disease and Lung Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Janet Valdez
- United States Public Health Service Commissioned Corps, Rockville, Maryland, USA,National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Josef Rivero
- United States Public Health Service Commissioned Corps, Rockville, Maryland, USA,National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Ick Ho Kim
- United States Public Health Service Commissioned Corps, Rockville, Maryland, USA,National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Julie Erb-Alvarez
- United States Public Health Service Commissioned Corps, Rockville, Maryland, USA,National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Ruba Shalhoub
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Mala Chakraborty
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Susan Wong
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Benjamin Colton
- Pharmacy Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Marcos J Ramos-Benitez
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA,Postdoctoral Research Associate Training Program, National Institute of General Medical Sciences, Bethesda, Maryland, USA
| | - Seth Warner
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Daniel S Chertow
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA,United States Public Health Service Commissioned Corps, Rockville, Maryland, USA,National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Kenneth N Olivier
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Georg Aue
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Richard T Davey
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Anthony F Suffredini
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
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Chandel A, Patolia S, Brown AW, Collins AC, Sahjwani D, Khangoora V, Cameron PC, Desai M, Kasarabada A, Kilcullen JK, Nathan SD, King CS. High-Flow Nasal Cannula Therapy in COVID-19: Using the ROX Index to Predict Success. Respir Care 2021; 66:909-919. [PMID: 33328179 DOI: 10.4187/respcare.08631] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Optimal timing of mechanical ventilation in COVID-19 is uncertain. We sought to evaluate outcomes of delayed intubation and examine the ROX index (ie, [[Formula: see text]]/breathing frequency) to predict weaning from high-flow nasal cannula (HFNC) in patients with COVID-19. METHODS We performed a multicenter, retrospective, observational cohort study of subjects with respiratory failure due to COVID-19 and managed with HFNC. The ROX index was applied to predict HFNC success. Subjects that failed HFNC were divided into early HFNC failure (≤ 48 h of HFNC therapy prior to mechanical ventilation) and late failure (> 48 h). Standard statistical comparisons and regression analyses were used to compare overall hospital mortality and secondary end points, including time-specific mortality, need for extracorporeal membrane oxygenation, and ICU length of stay between early and late failure groups. RESULTS 272 subjects with COVID-19 were managed with HFNC. One hundred sixty-four (60.3%) were successfully weaned from HFNC, and 111 (67.7%) of those weaned were managed solely in non-ICU settings. ROX index >3.0 at 2, 6, and 12 hours after initiation of HFNC was 85.3% sensitive for identifying subsequent HFNC success. One hundred eight subjects were intubated for failure of HFNC (61 early failures and 47 late failures). Mortality after HFNC failure was high (45.4%). There was no statistical difference in hospital mortality (39.3% vs 53.2%, P = .18) or any of the secondary end points between early and late HFNC failure groups. This remained true even when adjusted for covariates. CONCLUSIONS In this retrospective review, HFNC was a viable strategy and mechanical ventilation was unecessary in the majority of subjects. In the minority that progressed to mechanical ventilation, duration of HFNC did not differentiate subjects with worse clinical outcomes. The ROX index was sensitive for the identification of subjects successfully weaned from HFNC. Prospective studies in COVID-19 are warranted to confirm these findings and to optimize patient selection for use of HFNC in this disease.
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Affiliation(s)
- Abhimanyu Chandel
- Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Bethesda, Maryland.
| | - Saloni Patolia
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - A Whitney Brown
- Department of Advanced Lung Disease and Transplant, Inova Fairfax Hospital, Falls Church, Virginia
| | - A Claire Collins
- Advanced Lung Disease Research, Inova Fairfax Hospital, Falls Church, Virginia
| | - Dhwani Sahjwani
- Department of Pediatrics, Inova Fairfax Hospital, Falls Church, Virginia
| | - Vikramjit Khangoora
- Department of Advanced Lung Disease and Transplant, Inova Fairfax Hospital, Falls Church, Virginia
| | - Paula C Cameron
- Respiratory Therapy, Inova Fairfax Hospital, Falls Church, Virginia
| | - Mehul Desai
- Medical Critical Care Service, Inova Fairfax Hospital, Falls Church, Virginia
| | | | - Jack K Kilcullen
- Respiratory Therapy, Inova Fairfax Hospital, Falls Church, Virginia
| | - Steven D Nathan
- Department of Advanced Lung Disease and Transplant, Inova Fairfax Hospital, Falls Church, Virginia
| | - Christopher S King
- Department of Advanced Lung Disease and Transplant, Inova Fairfax Hospital, Falls Church, Virginia
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12
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Chandel A, Verster A, Rahim H, Khangoora V, Nathan SD, Ahmad K, Aryal S, Bagnola A, Singhal A, Brown AW, Shlobin OA, King CS. Incidence and prognostic significance of pleural effusions in pulmonary arterial hypertension. Pulm Circ 2021; 11:20458940211012366. [PMID: 33996030 PMCID: PMC8108083 DOI: 10.1177/20458940211012366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/04/2021] [Indexed: 11/21/2022] Open
Abstract
It has been suggested pleural effusions may develop in right heart failure in the absence of left heart disease. The incidence and prognostic significance of pleural effusions in pulmonary arterial hypertension is uncertain. Patients with pulmonary arterial hypertension followed at our tertiary care center were reviewed. Survival was examined based on the subsequent development of a pleural effusion. A total of 191 patients with pulmonary arterial hypertension met the inclusion criteria. The prevalence of pleural effusions on initial assessment was 7.3%. Among patients without a pleural effusion on initial imaging and at least one follow-up computerized tomography (N = 142), pleural effusion developed in 27.5% (N = 39) of patients. No alternative etiology of the effusion was identified in 19 (48.7%) cases and effusions deemed related to pulmonary arterial hypertension occurred at an incident rate of 38.6 cases per 1000 person-years. Of these, 14 (73.7%) were bilateral, 3 (15.8%) were right-sided, and 2 (10.5%) were left-sided. Effusion size was trace or small in 18 patients (94.7%). Development of a new pleural effusion was associated with attenuated survival in unadjusted survival analysis (HR: 3.80; 95% CI: 1.55–9.31), multivariate analysis (HR: 5.13; 95% CI: 1.86–14.16), and after the multivariate model was adjusted for concomitant pericardial effusion (HR: 4.86; 95% CI: 1.51–15.71). Negative impact on survival remained unchanged when effusions more likely related to an alternative cause were removed from analysis. In conclusion, pleural effusions can complicate pulmonary arterial hypertension in the absence of left heart disease. These effusions are frequently small in size, bilateral in location, and their presence is associated with decreased survival. Attenuated survival appears independent of the risk associated with a new pericardial effusion.
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Affiliation(s)
- Abhimanyu Chandel
- Department of Pulmonology and Critical Care, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Alison Verster
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Husna Rahim
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Vikramjit Khangoora
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Kareem Ahmad
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Shambhu Aryal
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Aaron Bagnola
- Department of Pharmacy, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Anju Singhal
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| | - A Whitney Brown
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Christopher S King
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
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Thapaliya A, Marinak L, King C, Brown A, Ahmad K, Khangoora V, Nathan S, Shlobin O. The Effect of Post Operative Tracheostomy on Outcomes in Lung Transplant Patients. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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14
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Chandel A, Patolia S, Looby M, Bade N, Khangoora V, King CS. Association of D-dimer and Fibrinogen With Hypercoagulability in COVID-19 Requiring Extracorporeal Membrane Oxygenation. J Intensive Care Med 2021; 36:689-695. [PMID: 33641491 PMCID: PMC8145413 DOI: 10.1177/0885066621997039] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND D-dimer concentration has been used by institutions to identify candidates for intensified anticoagulant treatment for venous thromboembolism prevention and for the mitigation of the microthrombotic complications associated with COVID-19. Thromboelastography (TEG) maximum amplitude (MA) has been validated as a marker of hypercoagulability and MA ≥68 mm has been utilized as a marker of hypercoagulability in other conditions. METHODS The goal of this study was to evaluate the relationship between coagulation, inflammatory, and TEG parameters in patients with COVID-19 on extracorporeal membrane oxygenation (ECMO). We performed a single-center retrospective analysis of consecutive patients that received ECMO for the treatment of COVID-19. TEG, inflammatory, and coagulation markers were compared in patients with and without a thrombotic complication. Correlation tests were performed to identify the coagulation and inflammatory markers that best predict hypercoagulability as defined by an elevated TEG MA. RESULTS A total of 168 TEGs were available in 24 patients. C-reactive protein and fibrinogen were significantly higher in patients that developed a thrombotic event versus those that did not (P = 0.04 and P = 0.04 respectively). D-dimer was negatively correlated with TEG MA (P < 0.01), while fibrinogen was positively correlated (P < 0.01). A fibrinogen >441 mg/dL was found to have a sensitivity of 91.2% and specificity of 85.7% for the detection of MA ≥68 mm. CONCLUSIONS In critically ill patients with COVID-19 treated with ECMO, D-dimer concentration had an inverse relationship with degree of hypercoagulability as measured by TEG MA. D-dimer elevation may potentially reflect hemostatic perturbation in patients on ECMO or the severity of COVID-19 related sepsis rather than designate patients likely to benefit from anticoagulation. Fibrinogen concentration may represent a more useful marker of hypercoagulability in this population.
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Affiliation(s)
- Abhimanyu Chandel
- Department of Pulmonology and Critical Care, 8395Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Saloni Patolia
- 6886Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Mary Looby
- Department of Pharmacy, 23146Inova Fairfax Hospital, Falls Church, VA, USA
| | - Najeebah Bade
- Department of Hematology, 23146Inova Fairfax Hospital, Falls Church, VA, USA
| | - Vikramjit Khangoora
- Department of Advanced Lung Disease and Transplant, 23146Inova Fairfax Hospital, Falls Church, VA, USA
| | - Christopher S King
- Department of Advanced Lung Disease and Transplant, 23146Inova Fairfax Hospital, Falls Church, VA, USA
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15
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Pastre J, Barnett S, Ksovreli I, Taylor J, Brown AW, Shlobin OA, Ahmad K, Khangoora V, Aryal S, King CS, Nathan SD. Idiopathic pulmonary fibrosis patients with severe physiologic impairment: characteristics and outcomes. Respir Res 2021; 22:5. [PMID: 33407450 PMCID: PMC7788925 DOI: 10.1186/s12931-020-01600-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/10/2020] [Indexed: 01/01/2023] Open
Abstract
RESEARCH QUESTION There is no widely accepted grading system for IPF disease severity, although physiologic impairment based on pulmonary function testing is frequently employed. We sought to describe clinical and functional characteristics as well as outcomes of patients with severe physiologic impairment. PATIENTS AND METHODS IPF patients with severe physiologic impairment defined by FVC ≤ 50% and/or DLco ≤ 30% predicted evaluated in the Inova Advanced Lung Disease Program between 2011 and 2019 were included. Demographic, physiologic, functional treatment and outcome data were collated. RESULTS There were 531 patients with IPF evaluated of whom 242 (46%) had severe physiologic impairment. Mean age was 72 ± 8 years; baseline FVC was 53 ± 17% and DLCO 28 ± 9% of predicted. The mean 6 min walks test (6MWT) distance was 304 ± 121 m with 59% of the patients requiring supplemental oxygen ([Formula: see text] group). There was a poor correlation between the 6MWT distance and both FVC% and DLco%. Patients in the 6MWTRA group had a better transplant-free survival than the [Formula: see text] group (p = 0.002). Patients managed before October 2014 and not receiving antifibrotic therapy had worse outcomes with reduced transplant-free survival compared with patients presenting after this date who did receive antifibrotic therapy (n = 113) (log rank p < 0.0001). CONCLUSION IPF patients often present with severe physiologic impairment which may be poorly correlated with their functional status. Assessment of IPF disease severity should not be based on physiologic impairment alone, but should also encompass functional status as well as need for supplemental oxygen. Antifibrotic therapy in patients with severe physiologic impairment is associated with improved outcomes.
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Affiliation(s)
- Jean Pastre
- Inova Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA, 22042, USA. .,Service de Pneumologie Et Soins Intensifs, Hôpital Européen Georges Pompidou, APHP, Paris, France.
| | - Scott Barnett
- Inova Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA, 22042, USA
| | - Inga Ksovreli
- Inova Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA, 22042, USA
| | - Jeannie Taylor
- Inova Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA, 22042, USA
| | - A Whitney Brown
- Inova Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA, 22042, USA
| | - Oksana A Shlobin
- Inova Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA, 22042, USA
| | - Kareem Ahmad
- Inova Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA, 22042, USA
| | - Vikramjit Khangoora
- Inova Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA, 22042, USA
| | - Shambhu Aryal
- Inova Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA, 22042, USA
| | - Christopher S King
- Inova Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA, 22042, USA
| | - Steven D Nathan
- Inova Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA, 22042, USA
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16
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King CS, Sahjwani D, Brown AW, Feroz S, Cameron P, Osborn E, Desai M, Djurkovic S, Kasarabada A, Hinerman R, Lantry J, Shlobin OA, Ahmad K, Khangoora V, Aryal S, Collins AC, Speir A, Nathan S. Outcomes of mechanically ventilated patients with COVID-19 associated respiratory failure. PLoS One 2020; 15:e0242651. [PMID: 33227024 PMCID: PMC7682899 DOI: 10.1371/journal.pone.0242651] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/09/2020] [Indexed: 01/16/2023] Open
Abstract
Purpose The outcomes of patients requiring invasive mechanical ventilation for COVID-19 remain poorly defined. We sought to determine clinical characteristics and outcomes of patients with COVID-19 managed with invasive mechanical ventilation in an appropriately resourced US health care system. Methods Outcomes of COVID-19 infected patients requiring mechanical ventilation treated within the Inova Health System between March 5, 2020 and April 26, 2020 were evaluated through an electronic medical record review. Results 1023 COVID-19 positive patients were admitted to the Inova Health System during the study period. Of these, 164 (16.0%) were managed with invasive mechanical ventilation. All patients were followed to definitive disposition. 70/164 patients (42.7%) had died and 94/164 (57.3%) were still alive. Deceased patients were older (median age of 66 vs. 55, p <0.0001) and had a higher initial d-dimer (2.22 vs. 1.31, p = 0.005) and peak ferritin levels (2998 vs. 2077, p = 0.016) compared to survivors. 84.3% of patients over 70 years old died in the hospital. Conversely, 67.4% of patients age 70 or younger survived to hospital discharge. Younger age, non-Caucasian race and treatment at a tertiary care center were all associated with survivor status. Conclusion Mortality of patients with COVID-19 requiring invasive mechanical ventilation is high, with particularly daunting mortality seen in patients of advanced age, even in a well-resourced health care system. A substantial proportion of patients requiring invasive mechanical ventilation were not of advanced age, and this group had a reasonable chance for recovery.
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Affiliation(s)
- Christopher S. King
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, United States of America
- * E-mail:
| | - Dhwani Sahjwani
- Department of Pediatrics, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - A. Whitney Brown
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - Saad Feroz
- Department of Pediatrics, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - Paula Cameron
- Respiratory Therapy Department, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - Erik Osborn
- Medical Critical Care Service, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - Mehul Desai
- Medical Critical Care Service, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - Svetolik Djurkovic
- Medical Critical Care Service, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - Aditya Kasarabada
- Medical Critical Care Service, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - Rachel Hinerman
- Medical Critical Care Service, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - James Lantry
- Medical Critical Care Service, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - Kareem Ahmad
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - Vikramjit Khangoora
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - Shambhu Aryal
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - A. Claire Collins
- Advanced Lung Disease Research, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - Alan Speir
- Department of Cardiothoracic Surgery, Inova Fairfax Hospital, Falls Church, VA, United States of America
| | - Steven Nathan
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, United States of America
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17
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King CS, Freiheit E, Brown AW, Shlobin OA, Aryal S, Ahmad K, Khangoora V, Flaherty KR, Venuto D, Nathan SD. Association Between Anticoagulation and Survival in Interstitial Lung Disease: An Analysis of the Pulmonary Fibrosis Foundation Patient Registry. Chest 2020; 159:1507-1516. [PMID: 33075376 DOI: 10.1016/j.chest.2020.10.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 09/22/2020] [Accepted: 10/11/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Aberrations in the coagulation system have been implicated in the pathogenesis of interstitial lung disease (ILD). Anticoagulants have been proposed as a potential therapy in ILD; however, a randomized controlled trial examining warfarin as a treatment for IPF was terminated early due to increased death rates. This has led some to speculate that warfarin specifically may be harmful in ILD, and use of direct oral anticoagulants (DOACs) could result in superior outcomes. RESEARCH QUESTION The goal of this study was to delineate the relationship between anticoagulation and outcomes in patients with ILD through an analysis of the Pulmonary Fibrosis Foundation Patient Registry. STUDY DESIGN AND METHODS An analysis of all patients in the Pulmonary Fibrosis Foundation Patient Registry was performed. Patients were stratified into three groups: no anticoagulation, DOAC use, or warfarin use. Survival was analyzed by using both Kaplan-Meier curves and Cox proportional hazards models. RESULTS Of 1,911 patients included in the analysis, 174 (9.1%) were given anticoagulants; 93 (4.9%) received DOACs, and 81 (4.2%) received warfarin. There was a twofold increased risk of death or transplant for patients receiving DOACS; for warfarin, the risk was over two and half times greater. DOACs were not associated with an increased risk of mortality following adjustment for confounding variables. However, even after adjustment, patients given the anticoagulant warfarin remained at increased risk of mortality. In patients with IPF, warfarin was associated with reduced transplant-free survival, but DOACs were not. There was no statistically significant difference in survival between those receiving warfarin and those receiving a DOAC. INTERPRETATION The need for anticoagulation is associated with an increased risk for death or transplant in patients with ILD, in both the IPF and non-IPF population. Further research is required to determine if warfarin and DOACs present varying safety profiles in patients with ILD.
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Affiliation(s)
- Christopher S King
- Advanced Lung Disease and Transplant Clinic, Inova Fairfax Hospital, Falls Church, VA.
| | - Elizabeth Freiheit
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - A Whitney Brown
- Advanced Lung Disease and Transplant Clinic, Inova Fairfax Hospital, Falls Church, VA
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Clinic, Inova Fairfax Hospital, Falls Church, VA
| | - Shambhu Aryal
- Advanced Lung Disease and Transplant Clinic, Inova Fairfax Hospital, Falls Church, VA
| | - Kareem Ahmad
- Advanced Lung Disease and Transplant Clinic, Inova Fairfax Hospital, Falls Church, VA
| | - Vikramjit Khangoora
- Advanced Lung Disease and Transplant Clinic, Inova Fairfax Hospital, Falls Church, VA
| | - Kevin R Flaherty
- Division of Pulmonary & Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Drew Venuto
- Advanced Lung Disease and Transplant Clinic, Inova Fairfax Hospital, Falls Church, VA
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Clinic, Inova Fairfax Hospital, Falls Church, VA
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Khangoora V, Aryal S, Cochrane A, Fregoso M, Nathan S. SUCCESSFUL CALCINEURIN-INHIBITOR-FREE IMMUNOSUPPRESSION REGIMEN WITH SIROLIMUS AND PREDNISONE IN LUNG TRANSPLANT RECIPIENTS: A CASE SERIES. Chest 2020. [DOI: 10.1016/j.chest.2020.08.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Khangoora V, Sill J. "SAGE-IN-BUD": A RARE CAUSE OF TREE-IN-BUD PULMONARY INFILTRATES. Chest 2019. [DOI: 10.1016/j.chest.2019.08.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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20
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Marik PE, Hooper MH, Khangoora V, Rivera R, Catravas J. Response. Chest 2019; 152:690-691. [PMID: 28889895 DOI: 10.1016/j.chest.2017.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 06/22/2017] [Indexed: 10/18/2022] Open
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Vikramjit Khangoora
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Racquel Rivera
- Department of Pharmacy, Sentara Norfolk General Hospital, Norfolk, VA
| | - John Catravas
- Departments of Medicine and Physiological Sciences, Eastern Virginia Medical School, Norfolk, VA; School of Medical Diagnostic and Translational Sciences, College of Health Sciences, Old Dominion University, Norfolk, VA
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Marik PE, Rivera R, Hooper MH, Khangoora V, Catravas J. Response. Chest 2019; 152:677. [PMID: 28889882 DOI: 10.1016/j.chest.2017.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 05/25/2017] [Indexed: 10/18/2022] Open
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Racquel Rivera
- Department of Pharmacy, Sentara Norfolk General Hospital; and the School of Medical Diagnostic and Translational Sciences, College of Health Sciences, Old Dominion University, Norfolk, VA
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Vikramjit Khangoora
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - John Catravas
- Departments of Medicine and Physiological Sciences, Eastern Virginia Medical School, Norfolk, VA
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Barabutis N, Khangoora V, Marik PE, Catravas JD. Hydrocortisone and Ascorbic Acid Synergistically Prevent and Repair Lipopolysaccharide-Induced Pulmonary Endothelial Barrier Dysfunction. Chest 2017; 152:954-962. [PMID: 28739448 DOI: 10.1016/j.chest.2017.07.014] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/20/2017] [Accepted: 07/12/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Sepsis refers to the dysregulated host immune response elicited by microbial infections resulting in life-threatening organ dysfunction. Sepsis represents a medical challenge, since it is associated with a rate of death as high as 60%. Septic shock is strongly associated with vascular dysfunction and elevated pulmonary capillary permeability. We recently reported that the combination of hydrocortisone (HC), ascorbic acid (vitC), and thiamine dramatically improves outcomes and reduces mortality in patients with sepsis. In the present study, we provide experimental evidence in support of the hypothesis that the combination of HC and vitC enhances endothelial barrier function. METHODS Human lung microvascular endothelial cells were exposed to lipopolysaccharide (LPS) in the absence or presence of HC and vitC. RESULTS LPS alone induced profound hyperpermeability, as reflected in decreased values of transendothelial electrical resistance. vitC alone did not exhibit barrier enhancement properties nor did it affect the LPS-induced hyperpermeability. Similarly, HC alone exhibited only a minor barrier-enhancing and protective effect. Conversely, the combination of HC and vitC, either as before or after treatment, dramatically reversed the LPS-induced barrier dysfunction. The barrier-protective effects of HC and vitC were associated with reversal of LPS-induced p53 and phosphorylated cofilin downregulation and LPS-induced RhoA activation and myosin light chain phosphorylation. CONCLUSIONS These data provide a novel mechanism of endothelial barrier protection and suggest one possible pathway that may contribute to the therapeutic effects of HC and vitC in patients with sepsis.
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Affiliation(s)
- Nektarios Barabutis
- Frank Reidy Research Center for Bioelectrics, College of Health Sciences, Old Dominion University, Norfolk, VA
| | - Vikramjit Khangoora
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - John D Catravas
- School of Medical Diagnostic and Translational Sciences, College of Health Sciences, Old Dominion University, Norfolk, VA; Departments of Medicine and Physiological Sciences, Eastern Virginia Medical School, Norfolk, VA.
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Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest 2017; 151:1229-1238. [PMID: 27940189 DOI: 10.1016/j.chest.2016.11.036] [Citation(s) in RCA: 589] [Impact Index Per Article: 84.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 10/31/2016] [Accepted: 11/16/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The global burden of sepsis is estimated as 15 to 19 million cases annually, with a mortality rate approaching 60% in low-income countries. METHODS In this retrospective before-after clinical study, we compared the outcome and clinical course of consecutive septic patients treated with intravenous vitamin C, hydrocortisone, and thiamine during a 7-month period (treatment group) with a control group treated in our ICU during the preceding 7 months. The primary outcome was hospital survival. A propensity score was generated to adjust the primary outcome. RESULTS There were 47 patients in both treatment and control groups, with no significant differences in baseline characteristics between the two groups. The hospital mortality was 8.5% (4 of 47) in the treatment group compared with 40.4% (19 of 47) in the control group (P < .001). The propensity adjusted odds of mortality in the patients treated with the vitamin C protocol was 0.13 (95% CI, 0.04-0.48; P = .002). The Sepsis-Related Organ Failure Assessment score decreased in all patients in the treatment group, with none developing progressive organ failure. All patients in the treatment group were weaned off vasopressors, a mean of 18.3 ± 9.8 h after starting treatment with the vitamin C protocol. The mean duration of vasopressor use was 54.9 ± 28.4 h in the control group (P < .001). CONCLUSIONS Our results suggest that the early use of intravenous vitamin C, together with corticosteroids and thiamine, are effective in preventing progressive organ dysfunction, including acute kidney injury, and in reducing the mortality of patients with severe sepsis and septic shock. Additional studies are required to confirm these preliminary findings.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Vikramjit Khangoora
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Racquel Rivera
- Department of Pharmacy, Sentara Norfolk General Hospital, Norfolk, VA
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - John Catravas
- School of Medical Diagnostic & Translational Sciences, College of Health Sciences, Old Dominion University, Norfolk, VA; Department of Medicine and Department of Physiological Sciences, Eastern Virginia Medical School, Norfolk, VA
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Khangoora V, McLaughlin M, Sill J. A Case of Reexpansion Pulmonary Edema After Resection of a Large Teratoma, Treated With Extracorporeal Membrane Oxygenation. Chest 2015. [DOI: 10.1378/chest.2280385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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