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Lyons C, McElwain J, Young O, O'Gorman DA, Harte BH, Kinirons B, Grady D, Laffey JG, Callaghan M. The effect of high-flow nasal oxygen flow rate on gas exchange in apnoeic patients: a randomised controlled trial. Anaesthesia 2024; 79:576-582. [PMID: 38100148 DOI: 10.1111/anae.16200] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 05/12/2024]
Abstract
High-flow nasal oxygen can be administered at induction of anaesthesia for the purposes of pre-oxygenation and apnoeic oxygenation. This intervention is claimed to enhance carbon dioxide elimination during apnoea, but the extent to which this occurs remains poorly quantified. The optimal nasal oxygen flow rate for gas exchange is also unknown. In this study, 114 patients received pre-oxygenation with high-flow nasal oxygen at 50 l.min-1. At the onset of apnoea, patients were allocated randomly to receive one of three nasal oxygen flow rates: 0 l.min-1; 70 l.min-1; or 120 l.min-1. After 4 minutes of apnoea, all oxygen delivery was ceased, tracheal intubation was performed, and oxygen delivery was recommenced when SpO2 was 92%. Mean (SD) PaCO2 rise during the first minute of apnoea was 1.39 (0.39) kPa, 1.41 (0.29) kPa, and 1.26 (0.38) kPa in the 0 l.min-1, 70 l.min-1 and 120 l.min-1 groups, respectively; p = 0.16. During the second, third and fourth minutes of apnoea, mean (SD) rates of rise in PaCO2 were 0.34 (0.08) kPa.min-1, 0.36 (0.06) kPa.min-1 and 0.37 (0.07) kPa.min-1 in the 0 l.min-1, 70 l.min-1 and 120 l.min-1 groups, respectively; p = 0.17. After 4 minutes of apnoea, median (IQR [range]) arterial oxygen partial pressures in the 0 l.min-1, 70 l.min-1 and 120 l.min-1 groups were 24.5 (18.6-31.4 [12.3-48.3]) kPa; 36.6 (28.1-43.8 [9.8-56.9]) kPa; and 37.6 (26.5-45.4 [11.0-56.6]) kPa, respectively; p < 0.001. Median (IQR [range]) times to desaturate to 92% after the onset of apnoea in the 0 l.min-1, 70 l.min-1 and 120 l.min-1 groups, were 412 (347-509 [190-796]) s; 533 (467-641 [192-958]) s; and 531 (462-681 [326-1007]) s, respectively; p < 0.001. In conclusion, the rate of carbon dioxide accumulation in arterial blood did not differ significantly between apnoeic patients who received high-flow nasal oxygen and those who did not.
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Affiliation(s)
- C Lyons
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
| | - J McElwain
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
| | - O Young
- Department of Ear, Nose and Throat Surgery, Galway University Hospitals, Galway, Ireland
| | - D A O'Gorman
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
| | - B H Harte
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
| | - B Kinirons
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
| | - D Grady
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
| | - J G Laffey
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
- Anaesthesia and Intensive Care Medicine, University of Galway, Galway, Ireland
| | - M Callaghan
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
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2
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Serafini SC, van Meenen DMP, Pisani L, Neto AS, Ball L, de Abreu MG, Algera AG, Azevedo L, Bellani G, Dondorp AM, Fan E, Laffey JG, Pham T, Tschernko EM, Schultz MJ, van der Woude MCE. Different ventilation intensities among various categories of patients ventilated for reasons other than ARDS--A pooled analysis of 4 observational studies. J Crit Care 2024; 81:154531. [PMID: 38341938 DOI: 10.1016/j.jcrc.2024.154531] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/23/2024] [Accepted: 01/30/2024] [Indexed: 02/13/2024]
Abstract
PURPOSE We investigated driving pressure (ΔP) and mechanical power (MP) and associations with clinical outcomes in critically ill patients ventilated for reasons other than ARDS. MATERIALS AND METHODS Individual patient data analysis of a pooled database that included patients from four observational studies of ventilation. ΔP and MP were compared among invasively ventilated non-ARDS patients with sepsis, with pneumonia, and not having sepsis or pneumonia. The primary endpoint was ΔP; secondary endpoints included MP, ICU mortality and length of stay, and duration of ventilation. RESULTS This analysis included 372 (11%) sepsis patients, 944 (28%) pneumonia patients, and 2040 (61%) patients ventilated for any other reason. On day 1, median ΔP was higher in sepsis (14 [11-18] cmH2O) and pneumonia patients (14 [11-18]cmH2O), as compared to patients not having sepsis or pneumonia (13 [10-16] cmH2O) (P < 0.001). Median MP was also higher in sepsis and pneumonia patients. ΔP, as opposed to MP, was associated with ICU mortality in sepsis and pneumonia patients. CONCLUSIONS The intensity of ventilation differed between patients with sepsis or pneumonia and patients receiving ventilation for any other reason; ΔP was associated with higher mortality in sepsis and pneumonia patients. REGISTRATION This post hoc analysis was not registered; the individual studies that were merged into the used database were registered at clinicaltrials.gov: NCT01268410 (ERICC), NCT02010073 (LUNG SAFE), NCT01868321 (PRoVENT), and NCT03188770 (PRoVENT-iMiC).
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Affiliation(s)
- Simon Corrado Serafini
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy; Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands.
| | - David M P van Meenen
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Department of Anesthesiology, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands
| | - Luigi Pisani
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Section of Operational Research, Doctors with Africa, Padova, Italy; Department of Anesthesiology and Intensive Care Medicine, Miulli Regional Hospital, Acquaviva delle Fonti, Italy; Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy; Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genova, Italy
| | - Marcelo Gama de Abreu
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anna Geke Algera
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands
| | - Luciano Azevedo
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Department of Emergency Medicine, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Giacomo Bellani
- Centro Interdipartimentale di Scienze Mediche (CISMed), Università di Trento, Italy; UOC anesthesia and Intensive Care 1, Ospedale Santa Chiara, APSS, Trento, Italy
| | - Arjen M Dondorp
- Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland, and Galway University Hospitals Ireland, Galway, Ireland
| | - Tai Pham
- Equipe d'Epidémiologie Respiratoire integrative, Université Paris-Saclay, Paris, France; Department of Intensive Care, Hôpital de Bicêtre, Paris, France
| | - Edda M Tschernko
- Clinical Department of Cardiothoracic Vascular Surgery Anesthesia and Intensive Care Medicine, Medical University Wien, Vienna, Austria
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK; Clinical Department of Cardiothoracic Vascular Surgery Anesthesia and Intensive Care Medicine, Medical University Wien, Vienna, Austria
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Curley GF, O’Kane CM, McAuley DF, Matthay MA, Laffey JG. Cell-based Therapies for Acute Respiratory Distress Syndrome: Where Are We Now? Am J Respir Crit Care Med 2024; 209:789-797. [PMID: 38324017 PMCID: PMC10995569 DOI: 10.1164/rccm.202311-2046cp] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/07/2024] [Indexed: 02/08/2024] Open
Abstract
There is considerable interest in the potential for cell-based therapies, particularly mesenchymal stromal cells (MSCs) and their products, as a therapy for acute respiratory distress syndrome (ARDS). MSCs exert effects via diverse mechanisms including reducing excessive inflammation by modulating neutrophil, macrophage and T-cell function, decreasing pulmonary permeability and lung edema, and promoting tissue repair. Clinical studies indicate that MSCs are safe and well tolerated, with promising therapeutic benefits in specific clinical settings, leading to regulatory approvals of MSCs for specific indications in some countries.This perspective reassesses the therapeutic potential of MSC-based therapies for ARDS given insights from recent cell therapy trials in both COVID-19 and in 'classic' ARDS, and discusses studies in graft-vs.-host disease, one of the few licensed indications for MSC therapies. We identify important unknowns in the current literature, address challenges to clinical translation, and propose an approach to facilitate assessment of the therapeutic promise of MSC-based therapies for ARDS.
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Affiliation(s)
- Gerard F. Curley
- Department of Anaesthesia, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Cecilia M. O’Kane
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Daniel F. McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
- Department of Critical Care, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Michael A. Matthay
- Department of Medicine and Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - John G. Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Healthcare System, Galway, Ireland; and
- Anaesthesia, School of Medicine, College of Medicine, Nursing and Health Sciences, and CÚRAM Centre for Research in Medical Devices, University of Galway, Galway, Ireland
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4
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Matthay MA, Arabi Y, Arroliga AC, Bernard G, Bersten AD, Brochard LJ, Calfee CS, Combes A, Daniel BM, Ferguson ND, Gong MN, Gotts JE, Herridge MS, Laffey JG, Liu KD, Machado FR, Martin TR, McAuley DF, Mercat A, Moss M, Mularski RA, Pesenti A, Qiu H, Ramakrishnan N, Ranieri VM, Riviello ED, Rubin E, Slutsky AS, Thompson BT, Twagirumugabe T, Ware LB, Wick KD. A New Global Definition of Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:37-47. [PMID: 37487152 PMCID: PMC10870872 DOI: 10.1164/rccm.202303-0558ws] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [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] [Received: 03/20/2023] [Accepted: 07/24/2023] [Indexed: 07/26/2023] Open
Abstract
Background: Since publication of the 2012 Berlin definition of acute respiratory distress syndrome (ARDS), several developments have supported the need for an expansion of the definition, including the use of high-flow nasal oxygen, the expansion of the use of pulse oximetry in place of arterial blood gases, the use of ultrasound for chest imaging, and the need for applicability in resource-limited settings. Methods: A consensus conference of 32 critical care ARDS experts was convened, had six virtual meetings (June 2021 to March 2022), and subsequently obtained input from members of several critical care societies. The goal was to develop a definition that would 1) identify patients with the currently accepted conceptual framework for ARDS, 2) facilitate rapid ARDS diagnosis for clinical care and research, 3) be applicable in resource-limited settings, 4) be useful for testing specific therapies, and 5) be practical for communication to patients and caregivers. Results: The committee made four main recommendations: 1) include high-flow nasal oxygen with a minimum flow rate of ⩾30 L/min; 2) use PaO2:FiO2 ⩽ 300 mm Hg or oxygen saturation as measured by pulse oximetry SpO2:FiO2 ⩽ 315 (if oxygen saturation as measured by pulse oximetry is ⩽97%) to identify hypoxemia; 3) retain bilateral opacities for imaging criteria but add ultrasound as an imaging modality, especially in resource-limited areas; and 4) in resource-limited settings, do not require positive end-expiratory pressure, oxygen flow rate, or specific respiratory support devices. Conclusions: We propose a new global definition of ARDS that builds on the Berlin definition. The recommendations also identify areas for future research, including the need for prospective assessments of the feasibility, reliability, and prognostic validity of the proposed global definition.
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Affiliation(s)
- Michael A. Matthay
- Department of Medicine
- Department of Anesthesia
- Cardiovascular Research Institute, and
| | - Yaseen Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Gordon Bernard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Lung Research, and
| | | | - Laurent J. Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Carolyn S. Calfee
- Department of Medicine
- Department of Anesthesia
- Cardiovascular Research Institute, and
| | - Alain Combes
- Médecine Intensive – Réanimation, Sorbonne Université, APHP Hôpital Pitié-Salpêtrière, Paris, France
| | - Brian M. Daniel
- Respiratory Therapy, University of California, San Francisco, San Francisco, California
| | - Niall D. Ferguson
- Interdepartmental Division of Critical Care Medicine and
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michelle N. Gong
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Jeffrey E. Gotts
- Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | | | - John G. Laffey
- Anesthesia, University Hospital Galway, University of Galway, Galway, Ireland
| | | | - Flavia R. Machado
- Intensive Care Department, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Thomas R. Martin
- Department of Medicine, University of Washington, Seattle, Washington
| | - Danny F. McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Alain Mercat
- Medical ICU, Angers University Hospital, Angers, France
| | - Marc Moss
- Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | | | - Antonio Pesenti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Haibo Qiu
- Critical Care Medicine, Zhongda Hospital, Nanjing, China
| | | | - V. Marco Ranieri
- Emergency and Intensive Care Medicine, Alma Mater Studorium University of Bologna, Bologna, Italy
| | - Elisabeth D. Riviello
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Arthur S. Slutsky
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Theogene Twagirumugabe
- Department of Anesthesia, Critical Care, and Emergency Medicine, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda; and
| | - Lorraine B. Ware
- Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Katherine D. Wick
- Department of Medicine, University of California, Davis, Davis, California
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5
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Pavlov I, Li J, Kharat A, Luo J, Ibarra-Estrada M, Perez Y, McNicolas B, Poole D, Roca O, Vines D, Tavernier E, Allen T, Shyamsundar M, Ehrmann S, Simpson SQ, Guérin C, Laffey JG. Awake prone positioning in acute hypoxaemic respiratory failure: An international expert guidance. J Crit Care 2023; 78:154401. [PMID: 37639921 DOI: 10.1016/j.jcrc.2023.154401] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/12/2023] [Accepted: 08/11/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Awake prone positioning (APP) of non-intubated patients with acute hypoxaemic respiratory failure (AHRF) has been inconsistently adopted into routine care of patients with COVID-19, likely due to apparent conflicting evidence from recent trials. This short guideline aims to provide evidence-based recommendations for the use of APP in various clinical scenarios. METHODS An international multidisciplinary panel, assembled for their expertise and representativeness, and supported by a methodologist, performed a systematic literature search, summarized the available evidence derived from randomized clinical trials, and developed recommendations using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. RESULTS The panel strongly recommends that APP rather than standard supine care be used in patients with COVID-19 receiving advanced respiratory support (high-flow nasal cannula, continuous positive airway pressure or non-invasive ventilation). Due to lack of evidence from randomized controlled trials, the panel provides no recommendation on the use of APP in patients with COVID-19 supported with conventional oxygen therapy, nor in patients with AHRF due to causes other than COVID-19. CONCLUSION APP should be routinely implemented in patients with COVID-19 receiving advanced respiratory support.
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Affiliation(s)
- Ivan Pavlov
- Department of Emergency Medicine, Hôpital de Verdun, Montréal, Québec, Canada
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Aileen Kharat
- Department of Respiratory Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Jian Luo
- Respiratory Medicine Unit and Oxford NIHR Biomedical Research Centre, NDM Experimental Medicine, University of Oxford, Oxford, UK
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Yonatan Perez
- Médecine Intensive Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Bairbre McNicolas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals and School of Medicine, University of Galway, Galway, Ireland
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | - Oriol Roca
- Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Parc del Taulí 1, Sabadell, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - David Vines
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Elsa Tavernier
- Methods in Patient-Centered Outcomes and Health Research, INSERM UMR 1246, Nantes, France; Clinical Investigation Centre, INSERM 1415 CHRU Tours, Tours, France
| | - Thérèse Allen
- Retired Nurse, and Patient Representative, Galway, Ireland
| | - Murali Shyamsundar
- Wellcome-Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, Clinical Investigation Center, INSERM 1415, INSERM, Centre d'Etude des Pathologies Respiratoires, Université de Tours - All in Tours, U1100, France
| | | | - Claude Guérin
- Université de Lyon, Lyon, France; Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS, 7200, Créteil, France
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals and School of Medicine, University of Galway, Galway, Ireland.
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6
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McCarthy SD, Tilbury MA, Masterson CH, MacLoughlin R, González HE, Laffey JG, Wall JG, O'Toole D. Aerosol Delivery of a Novel Recombinant Modified Superoxide Dismutase Protein Reduces Oxidant Injury and Attenuates Escherichia coli Induced Lung Injury in Rats. J Aerosol Med Pulm Drug Deliv 2023; 36:246-256. [PMID: 37638822 DOI: 10.1089/jamp.2022.0069] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Background: Acute respiratory distress syndrome (ARDS) is a life-threatening respiratory failure syndrome with diverse etiologies characterized by increased permeability of alveolar-capillary membranes, pulmonary edema, and acute onset hypoxemia. During the ARDS acute phase, neutrophil infiltration into the alveolar space results in uncontrolled release of reactive oxygen species (ROS) and proteases, overwhelming antioxidant defenses and causing alveolar epithelial and lung endothelial injury. Objectives: To investigate the therapeutic potential of a novel recombinant human Cu-Zn-superoxide dismutase (SOD) fusion protein in protecting against ROS injury and for aerosolized SOD delivery to treat Escherichia coli induced ARDS. Methods: Fusion proteins incorporating human Cu-Zn-SOD (hSOD1), with (pep1-hSOD1-his) and without (hSOD1-his) a fused hyaluronic acid-binding peptide, were expressed in E. coli. Purified proteins were evaluated in in vitro assays with human bronchial epithelial cells and through aerosolized delivery to the lung of an E. coli-induced ARDS rat model. Results: SOD proteins exhibited high SOD activity in vitro and protected bronchial epithelial cells from oxidative damage. hSOD1-his and pep1-hSOD1-his retained SOD activity postnebulization and exhibited no adverse effects in the rat. Pep1-hSOD1-his administered through instillation or nebulization to the lung of an E. coli-induced pneumonia rat improved arterial oxygenation and lactate levels compared to vehicle after 48 hours. Static lung compliance was improved when the pep1-hSOD1-his protein was delivered by instillation. White cell infiltration to the lung was significantly reduced by aerosolized delivery of protein, and reduction of cytokine-induced neutrophil chemoattractant-1, interferon-gamma, and interleukin 6 pro-inflammatory cytokine concentrations in bronchoalveolar lavage was observed. Conclusions: Aerosol delivery of a novel recombinant modified SOD protein reduces oxidant injury and attenuates E. coli induced lung injury in rats. The results provide a strong basis for further investigation of the therapeutic potential of hSOD1 in the treatment of ARDS.
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Affiliation(s)
- Sean D McCarthy
- SFI Centre for Medical Devices (CÚRAM), University of Galway, Galway, Ireland
- Regenerative Medicine Institute (REMEDI), University of Galway, Galway, Ireland
- Discipline of Anaesthesia, School of Medicine, University of Galway, Galway, Ireland
| | - Maura A Tilbury
- SFI Centre for Medical Devices (CÚRAM), University of Galway, Galway, Ireland
- Microbiology, School of Biological and Chemical Sciences, University of Galway, Galway, Ireland
| | - Claire H Masterson
- SFI Centre for Medical Devices (CÚRAM), University of Galway, Galway, Ireland
- Regenerative Medicine Institute (REMEDI), University of Galway, Galway, Ireland
- Microbiology, School of Biological and Chemical Sciences, University of Galway, Galway, Ireland
| | | | - Héctor E González
- SFI Centre for Medical Devices (CÚRAM), University of Galway, Galway, Ireland
- Regenerative Medicine Institute (REMEDI), University of Galway, Galway, Ireland
- Discipline of Anaesthesia, School of Medicine, University of Galway, Galway, Ireland
| | - John G Laffey
- SFI Centre for Medical Devices (CÚRAM), University of Galway, Galway, Ireland
- Regenerative Medicine Institute (REMEDI), University of Galway, Galway, Ireland
- Discipline of Anaesthesia, School of Medicine, University of Galway, Galway, Ireland
| | - J Gerard Wall
- SFI Centre for Medical Devices (CÚRAM), University of Galway, Galway, Ireland
- Microbiology, School of Biological and Chemical Sciences, University of Galway, Galway, Ireland
| | - Daniel O'Toole
- SFI Centre for Medical Devices (CÚRAM), University of Galway, Galway, Ireland
- Regenerative Medicine Institute (REMEDI), University of Galway, Galway, Ireland
- Discipline of Anaesthesia, School of Medicine, University of Galway, Galway, Ireland
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7
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Russotto V, Lascarrou JB, Tassistro E, Parotto M, Antolini L, Bauer P, Szułdrzyński K, Camporota L, Putensen C, Pelosi P, Sorbello M, Higgs A, Greif R, Grasselli G, Valsecchi MG, Fumagalli R, Foti G, Caironi P, Bellani G, Laffey JG, Myatra SN. Efficacy and adverse events profile of videolaryngoscopy in critically ill patients: subanalysis of the INTUBE study. Br J Anaesth 2023; 131:607-616. [PMID: 37208282 DOI: 10.1016/j.bja.2023.04.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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] [Received: 02/16/2023] [Revised: 03/23/2023] [Accepted: 04/14/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Tracheal intubation is a high-risk procedure in the critically ill, with increased intubation failure rates and a high risk of other adverse events. Videolaryngoscopy might improve intubation outcomes in this population, but evidence remains conflicting, and its impact on adverse event rates is debated. METHODS This is a subanalysis of a large international prospective cohort of critically ill patients (INTUBE Study) performed from 1 October 2018 to 31 July 2019 and involving 197 sites from 29 countries across five continents. Our primary aim was to determine the first-pass intubation success rates of videolaryngoscopy. Secondary aims were characterising (a) videolaryngoscopy use in the critically ill patient population and (b) the incidence of severe adverse effects compared with direct laryngoscopy. RESULTS Of 2916 patients, videolaryngoscopy was used in 500 patients (17.2%) and direct laryngoscopy in 2416 (82.8%). First-pass intubation success was higher with videolaryngoscopy compared with direct laryngoscopy (84% vs 79%, P=0.02). Patients undergoing videolaryngoscopy had a higher frequency of difficult airway predictors (60% vs 40%, P<0.001). In adjusted analyses, videolaryngoscopy increased the probability of first-pass intubation success, with an OR of 1.40 (95% confidence interval [CI] 1.05-1.87). Videolaryngoscopy was not significantly associated with risk of major adverse events (odds ratio 1.24, 95% CI 0.95-1.62) or cardiovascular events (odds ratio 0.78, 95% CI 0.60-1.02). CONCLUSIONS In critically ill patients, videolaryngoscopy was associated with higher first-pass intubation success rates, despite being used in a population at higher risk of difficult airway management. Videolaryngoscopy was not associated with overall risk of major adverse events. CLINICAL TRIAL REGISTRATION NCT03616054.
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Affiliation(s)
- Vincenzo Russotto
- Department of Anesthesia and Critical Care, University Hospital San Luigi Gonzaga, University of Turin, Italy
| | | | - Elena Tassistro
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 Center), University of Milano-Bicocca, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Matteo Parotto
- Department of Anesthesiology and Pain Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Laura Antolini
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 Center), University of Milano-Bicocca, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Konstanty Szułdrzyński
- Department of Anesthesiology and Intensive Care, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland; Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Luigi Camporota
- Health Centre for Human and Applied Physiological Sciences, Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Massimiliano Sorbello
- Anesthesia and Intensive Care, Policlinico Vittorio Emanuele San Marco University Hospital, Catania, Italy
| | - Andy Higgs
- Anaesthesia and Intensive Care Medicine, Warrington Teaching Hospitals NHS Foundation Trust, Warrington, UK
| | - Robert Greif
- Department of Anaesthesiology and Pain Therapy, Bern University Hospital, University of Bern, Bern, Switzerland; School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Giacomo Grasselli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria G Valsecchi
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 Center), University of Milano-Bicocca, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Anesthesiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Pietro Caironi
- Department of Anesthesia and Critical Care, University Hospital San Luigi Gonzaga, University of Turin, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - John G Laffey
- Regenerative Medicine Institute at CURAM Centre for Medical Devices, School of Medicine, University of Galway, Galway, Ireland; Anesthesia and Intensive Care Medicine, University Hospital Galway, Galway, Ireland.
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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8
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Gorman EA, Rynne J, Gardiner HJ, Rostron AJ, Bannard-Smith J, Bentley AM, Brealey D, Campbell C, Curley G, Clarke M, Dushianthan A, Hopkins P, Jackson C, Kefela K, Krasnodembskaya A, Laffey JG, McDowell C, McFarland M, McFerran J, McGuigan P, Perkins GD, Silversides J, Smythe J, Thompson J, Tunnicliffe WS, Welters IDM, Amado-Rodríguez L, Albaiceta G, Williams B, Shankar-Hari M, McAuley DF, O'Kane CM. Repair of Acute Respiratory Distress Syndrome in COVID-19 by Stromal Cells (REALIST-COVID Trial): A Multicenter, Randomized, Controlled Clinical Trial. Am J Respir Crit Care Med 2023; 208:256-269. [PMID: 37154608 DOI: 10.1164/rccm.202302-0297oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/05/2023] [Indexed: 05/10/2023] Open
Abstract
Rationale: Mesenchymal stromal cells (MSCs) may modulate inflammation, promoting repair in coronavirus disease (COVID-19)-related acute respiratory distress syndrome (ARDS). Objectives: We investigated the safety and efficacy of ORBCEL-C (CD362 [cluster of differentiation 362]-enriched, umbilical cord-derived MSCs) in COVID-19-related ARDS. Methods: In this multicenter, randomized, double-blind, allocation-concealed, placebo-controlled trial (NCT03042143), patients with moderate to severe COVID-19-related ARDS were randomized to receive ORBCEL-C (400 million cells) or placebo (Plasma-Lyte 148). The primary safety and efficacy outcomes were the incidence of serious adverse events and oxygenation index at Day 7, respectively. Secondary outcomes included respiratory compliance, driving pressure, PaO2:FiO2 ratio, and Sequential Organ Failure Assessment score. Clinical outcomes relating to duration of ventilation, lengths of ICU and hospital stays, and mortality were collected. Long-term follow-up included diagnosis of interstitial lung disease at 1 year and significant medical events and mortality at 2 years. Transcriptomic analysis was performed on whole blood at Days 0, 4, and 7. Measurements and Main Results: Sixty participants were recruited (final analysis: n = 30 received ORBCEL-C, n = 29 received placebo; 1 participant in the placebo group withdrew consent). Six serious adverse events occurred in the ORBCEL-C group and three in the placebo group (risk ratio, 2.9 [95% confidence interval, 0.6-13.2]; P = 0.25). Day 7 mean (SD) oxygenation index did not differ (ORBCEL-C, 98.3 [57.2] cm H2O/kPa; placebo, 96.6 [67.3] cm H2O/kPa). There were no differences in secondary surrogate outcomes or in mortality at Day 28, Day 90, 1 year, or 2 years. There was no difference in the prevalence of interstitial lung disease at 1 year or significant medical events up to 2 years. ORBCEL-C modulated the peripheral blood transcriptome. Conclusion: ORBCEL-C MSCs were safe in subjects with moderate to severe COVID-19-related ARDS but did not improve surrogates of pulmonary organ dysfunction.
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Affiliation(s)
- Ellen A Gorman
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - Jennifer Rynne
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh, United Kingdom
| | - Hannah J Gardiner
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - Anthony J Rostron
- Sunderland Royal Hospital, South Tyneside and Sunderland National Health Service Foundation Trust, Sunderland, United Kingdom
- Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Andrew M Bentley
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester, United Kingdom
| | - David Brealey
- University College Hospital London, London, United Kingdom
| | | | - Gerard Curley
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mike Clarke
- Northern Ireland Clinical Trials Unit, Belfast, United Kingdom
| | - Ahilanadan Dushianthan
- University Hospital Southampton, Southampton, United Kingdom
- National Institute for Health and Care Research Southampton Biomedical Research Centre, University of Southampton, Southampton, United Kingdom
| | - Phillip Hopkins
- King's Trauma Centre, King's College Hospital, London, United Kingdom
| | - Colette Jackson
- Northern Ireland Clinical Trials Unit, Belfast, United Kingdom
| | - Kallirroi Kefela
- Department of Critical Care, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Anna Krasnodembskaya
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - John G Laffey
- Regenerative Medicine Institute at CÚRAM Centre for Research in Medical Devices, University of Galway, Galway, Ireland
| | - Cliona McDowell
- Northern Ireland Clinical Trials Unit, Belfast, United Kingdom
| | - Margaret McFarland
- Department of Critical Care, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Jamie McFerran
- Northern Ireland Clinical Trials Unit, Belfast, United Kingdom
| | - Peter McGuigan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
- Department of Critical Care, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Gavin D Perkins
- Critical Care Unit, University Hospitals Birmingham, Birmingham, United Kingdom
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Jonathan Silversides
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
- Department of Critical Care, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Jon Smythe
- National Health Service Blood and Transplant, Oxford, United Kingdom
| | - Jacqui Thompson
- National Health Service Blood and Transplant, Birmingham, United Kingdom
| | | | - Ingeborg D M Welters
- Intensive Care Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
- Institute of Life Course Medical Sciences, University of Liverpool, Liverpool Centre for Cardiovascular Science, Liverpool, United Kingdom
| | - Laura Amado-Rodríguez
- Centro de Investigación Biomédica en Red-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Guillermo Albaiceta
- Centro de Investigación Biomédica en Red-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Oviedo, Spain
- Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain; and
| | - Barry Williams
- Independent Patient and Public Representative, Sherborne, United Kingdom
| | - Manu Shankar-Hari
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh, United Kingdom
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
- Department of Critical Care, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Cecilia M O'Kane
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
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9
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Madden MG, McNicholas BA, Laffey JG. Assessing the usefulness of a large language model to query and summarize unstructured medical notes in intensive care. Intensive Care Med 2023; 49:1018-1020. [PMID: 37338549 DOI: 10.1007/s00134-023-07128-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Affiliation(s)
| | - Bairbre A McNicholas
- Anaesthesia and Intensive Care Medicine, School of Medicine, University of Galway, Galway, Ireland
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, SAOLTA University Health Care Group, Galway, Ireland
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, University of Galway, Galway, Ireland.
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, SAOLTA University Health Care Group, Galway, Ireland.
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10
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Bechel MA, Madotto F, Pah AR, Bellani G, Laffey JG, Pham T, Amaral LAN, Weiss CH. Validation of a tool for estimating clinician recognition of ARDS using data from the international LUNG SAFE study. PLOS Digit Health 2023; 2:e0000325. [PMID: 37624759 PMCID: PMC10456149 DOI: 10.1371/journal.pdig.0000325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 07/10/2023] [Indexed: 08/27/2023]
Abstract
Under-recognition of acute respiratory distress syndrome (ARDS) by clinicians is an important barrier to adoption of evidence-based practices such as low tidal volume ventilation. The burden created by the COVID-19 pandemic makes it even more critical to develop scalable data-driven tools to improve ARDS recognition. The objective of this study was to validate a tool for accurately estimating clinician ARDS recognition rates using discrete clinical characteristics easily available in electronic health records. We conducted a secondary analysis of 2,705 ARDS and 1,261 non-ARDS hypoxemic patients in the international LUNG SAFE cohort. The primary outcome was validation of a tool that estimates clinician ARDS recognition rates from health record data. Secondary outcomes included the relative impact of clinical characteristics on tidal volume delivery and clinician documentation of ARDS. In both ARDS and non-ARDS patients, greater height was associated with lower standardized tidal volume (mL/kg PBW) (ARDS: adjusted β = -4.1, 95% CI -4.5 --3.6; non-ARDS: β = -7.7, 95% CI -8.8 --6.7, P<0.00009 [where α = 0.01/111 with the Bonferroni correction]). Standardized tidal volume has already been normalized for patient height, and furthermore, height was not associated with clinician documentation of ARDS. Worsening hypoxemia was associated with both increased clinician documentation of ARDS (β = -0.074, 95% CI -0.093 --0.056, P<0.00009) and lower standardized tidal volume (β = 1.3, 95% CI 0.94-1.6, P<0.00009) in ARDS patients. Increasing chest imaging opacities, plateau pressure, and clinician documentation of ARDS also were associated with lower tidal volume in ARDS patients. Our EHR-based data-driven approach using height, gender, ARDS documentation, and lowest standardized tidal volume yielded estimates of clinician ARDS recognition rates of 54% for mild, 63% for moderate, and 73% for severe ARDS. Our tool replicated clinician-reported ARDS recognition in the LUNG SAFE study, enabling the identification of ARDS patients at high risk of being unrecognized. Our approach can be generalized to other conditions for which there is a need to increase adoption of evidence-based care.
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Affiliation(s)
- Meagan A. Bechel
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia, United States of America
| | - Fabiana Madotto
- IRCCS Multimedica, Value-based Healthcare Unit, Sesto San Giovanni, Milan, Italy
| | - Adam R. Pah
- Kellogg School of Management, Northwestern University, Evanston, Illinois, United States of America
| | - Giacomo Bellani
- ASST Monza, Sam Gerardo Hospital and Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - John G. Laffey
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Tài Pham
- Service de médecine intensive-réanimation, AP-HP, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm U1018, Equipe d’Epidémiologie respiratoire intégrative, CESP, 94807, Villejuif, France
| | - Luís A. Nunes Amaral
- Department of Chemical and Biological Engineering, Northwestern University, Evanston, Illinois, United States of America
- Northwestern Institute on Complex Systems, Northwestern University, Evanston, Illinois, United States of America
- Department of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Curtis H. Weiss
- Department of Medicine, NorthShore University HealthSystem, Evanston, Illinois, United States of America
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11
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Hannon DM, Jones T, Conolly J, Judge C, Iqbal T, Shahzad A, Madden M, Kirrane F, Conneely P, Harte BH, O'Halloran M, Laffey JG. Development and assessment of the performance of a shared ventilatory system that uses clinically available components to individualize tidal volumes. BMC Anesthesiol 2023; 23:239. [PMID: 37454135 PMCID: PMC10349497 DOI: 10.1186/s12871-023-02200-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVES To develop and assess a system for shared ventilation using clinically available components to individualize tidal volumes. DESIGN Evaluation and in vitro validation study SETTING: Ventilator shortage during the SARS-CoV-2 pandemic. PARTICIPANTS The team consisted of physicians, bioengineers, computer programmers, and medical technology professionals. METHODS Using clinically available components, a system of ventilation consisting of two ventilatory limbs was assembled and connected to a ventilator. Monitors for each limb were developed using open-source software. Firstly, the effect of altering ventilator settings on tidal volumes delivered to each limb was determined. Secondly, the impact of altering the compliance and resistance of one limb on the tidal volumes delivered to both limbs was analysed. Experiments were repeated three times to determine system variability. RESULTS The system permitted accurate and reproducible titration of tidal volumes to each limb over a range of ventilator settings and simulated lung conditions. Alteration of ventilator inspiratory pressures, of respiratory rates, and I:E ratio resulted in very similar tidal volumes delivered to each limb. Alteration of compliance and resistance in one limb resulted in reproducible alterations in tidal volume to that test lung, with little change to tidal volumes in the other lung. All tidal volumes delivered were reproducible. CONCLUSIONS We demonstrate the reliability of a shared ventilation system assembled using commonly available clinical components that allows titration of individual tidal volumes. This system may be useful as a strategy of last resort for Covid-19, or other mass casualty situations, where the need for ventilators exceeds supply.
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Affiliation(s)
- David M Hannon
- Department of Anaesthesia, School of Medicine, Galway University Hospitals, University of Galway, Galway, Ireland
- Translational Medical Device Lab, University of Galway, Galway, Ireland
| | - Tim Jones
- Translational Medical Device Lab, University of Galway, Galway, Ireland
| | - Jack Conolly
- Translational Medical Device Lab, University of Galway, Galway, Ireland
| | - Conor Judge
- Translational Medical Device Lab, University of Galway, Galway, Ireland
| | - Talha Iqbal
- Smart Sensors Lab, School of Medicine, University of Galway, Galway, Ireland
| | - Atif Shahzad
- Smart Sensors Lab, School of Medicine, University of Galway, Galway, Ireland
| | - Michael Madden
- School of Computer Science, National University of Ireland Galway, Galway, Ireland
| | - Frank Kirrane
- Department of Medical Physics and Clinical Engineering, Galway University Hospitals, Galway, Ireland
| | - Peter Conneely
- Department of Medical Physics and Clinical Engineering, Galway University Hospitals, Galway, Ireland
| | - Brian H Harte
- Department of Anaesthesia, School of Medicine, Galway University Hospitals, University of Galway, Galway, Ireland
| | - Martin O'Halloran
- Translational Medical Device Lab, University of Galway, Galway, Ireland
- CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, University of Galway, Galway, Ireland
| | - John G Laffey
- Department of Anaesthesia, School of Medicine, Galway University Hospitals, University of Galway, Galway, Ireland.
- Translational Medical Device Lab, University of Galway, Galway, Ireland.
- CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, University of Galway, Galway, Ireland.
- School of Medicine, Clinical Sciences Institute, University of Galway, Galway, Ireland.
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12
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Grasselli G, Calfee CS, Camporota L, Poole D, Amato MBP, Antonelli M, Arabi YM, Baroncelli F, Beitler JR, Bellani G, Bellingan G, Blackwood B, Bos LDJ, Brochard L, Brodie D, Burns KEA, Combes A, D'Arrigo S, De Backer D, Demoule A, Einav S, Fan E, Ferguson ND, Frat JP, Gattinoni L, Guérin C, Herridge MS, Hodgson C, Hough CL, Jaber S, Juffermans NP, Karagiannidis C, Kesecioglu J, Kwizera A, Laffey JG, Mancebo J, Matthay MA, McAuley DF, Mercat A, Meyer NJ, Moss M, Munshi L, Myatra SN, Ng Gong M, Papazian L, Patel BK, Pellegrini M, Perner A, Pesenti A, Piquilloud L, Qiu H, Ranieri MV, Riviello E, Slutsky AS, Stapleton RD, Summers C, Thompson TB, Valente Barbas CS, Villar J, Ware LB, Weiss B, Zampieri FG, Azoulay E, Cecconi M. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med 2023; 49:727-759. [PMID: 37326646 PMCID: PMC10354163 DOI: 10.1007/s00134-023-07050-7] [Citation(s) in RCA: 97] [Impact Index Per Article: 97.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.
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Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | | | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Francesca Baroncelli
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Geoff Bellingan
- Intensive Care Medicine, University College London, NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurent Brochard
- Keenan Research Center, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Critical Care, Unity Health Toronto - Saint Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013, Paris, France
| | - Sonia D'Arrigo
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Sharon Einav
- Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology and Critical Care, Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Departments of Medicine and Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jean-Pierre Frat
- CHU De Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM, CIC-1402, IS-ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Claude Guérin
- University of Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7200, Créteil, France
| | - Margaret S Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Catherine L Hough
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi Teaching Hospital, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier, France
| | - Nicole P Juffermans
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken Der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arthur Kwizera
- Makerere University College of Health Sciences, School of Medicine, Department of Anesthesia and Intensive Care, Kampala, Uganda
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, College of Medicine Nursing and Health Sciences, University of Galway, Galway, Ireland
- Anesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospitals Groups, Galway, Ireland
| | - Jordi Mancebo
- Intensive Care Department, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Alain Mercat
- Département de Médecine Intensive Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - Nuala J Meyer
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Canada
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Michelle Ng Gong
- Division of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Laurent Papazian
- Bastia General Hospital Intensive Care Unit, Bastia, France
- Aix-Marseille University, Faculté de Médecine, Marseille, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mariangela Pellegrini
- Anesthesia and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Marco V Ranieri
- Alma Mater Studiorum - Università di Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Elisabeth Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charlotte Summers
- Department of Medicine, University of Cambridge Medical School, Cambridge, UK
| | - Taylor B Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Carmen S Valente Barbas
- University of São Paulo Medical School, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jesús Villar
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM CVK), Charitè - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Fernando G Zampieri
- Academic Research Organization, Albert Einstein Hospital, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris Cité University, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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13
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McNicholas BA, Ibarra-Estrada M, Perez Y, Li J, Pavlov I, Kharat A, Vines DL, Roca O, Cosgrave D, Guerin C, Ehrmann S, Laffey JG. Awake prone positioning in acute hypoxaemic respiratory failure. Eur Respir Rev 2023; 32:32/168/220245. [PMID: 37137508 PMCID: PMC10155045 DOI: 10.1183/16000617.0245-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/22/2023] [Indexed: 05/05/2023] Open
Abstract
Awake prone positioning (APP) of patients with acute hypoxaemic respiratory failure gained considerable attention during the early phases of the coronavirus disease 2019 (COVID-19) pandemic. Prior to the pandemic, reports of APP were limited to case series in patients with influenza and in immunocompromised patients, with encouraging results in terms of tolerance and oxygenation improvement. Prone positioning of awake patients with acute hypoxaemic respiratory failure appears to result in many of the same physiological changes improving oxygenation seen in invasively ventilated patients with moderate-severe acute respiratory distress syndrome. A number of randomised controlled studies published on patients with varying severity of COVID-19 have reported apparently contrasting outcomes. However, there is consistent evidence that more hypoxaemic patients requiring advanced respiratory support, who are managed in higher care environments and who can be prone for several hours, benefit most from APP use. We review the physiological basis by which prone positioning results in changes in lung mechanics and gas exchange and summarise the latest evidence base for APP primarily in COVID-19. We examine the key factors that influence the success of APP, the optimal target populations for APP and the key unknowns that will shape future research.
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Affiliation(s)
- Bairbre A McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - Yonatan Perez
- Clinical Investigation Center, INSERM 1415, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, Hôpital de Hautepierre, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Ivan Pavlov
- Department of Emergency Medicine, Hôpital de Verdun, Montréal, QC, Canada
| | - Aileen Kharat
- Department of Respiratory Medicine, Geneva University Hospital, Geneva, Switzerland
| | - David L Vines
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Oriol Roca
- Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - David Cosgrave
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
| | - Claude Guerin
- University of Lyon, Lyon and INSERM 955, Créteil, France
| | - Stephan Ehrmann
- Clinical Investigation Center, INSERM 1415, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, CHRU Tours, Tours, France
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
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14
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Gonzalez H, McCarthy S, Masterson C, Byrnes D, Sallent I, Horan E, Elliman SJ, Vella G, Mello AP, Silva JD, Krasnodembskaya AD, MacLoughlin R, Laffey JG, O'Toole D. Nebulised mesenchymal stem cell derived extracellular vesicles ameliorate E. coli induced pneumonia in a rodent model. Stem Cell Res Ther 2023; 14:151. [PMID: 37280647 DOI: 10.1186/s13287-023-03385-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 05/24/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Mesenchymal stem cell (MSC) derived extracellular vesicles (EVs) have been proposed as an alternative to cell therapy, creating new possible delivery modalities such as nebulisation. We wished to investigate the therapeutic potential of directly nebulised MSC-EVs in the mitigation of Escherichia coli-induced pneumonia. METHODS EV size, surface markers and miRNA content were assessed pre- and post-nebulisation. BEAS2B and A459 lung cells were exposed to lipopolysaccharide (LPS) and treated with nebulised bone marrow (BM) or umbilical cord (UC) MSC-EVs. Viability assays (MTT) and inflammatory cytokine assays were performed. THP-1 monocytes were stimulated with LPS and nebulised BM- or UC-EVs and phagocytosis activity was measured. For in vivo experiments, mice received LPS intratracheally (IT) followed by BM- or UC-EVs intravenously (IV) and injury markers assessed at 24 h. Rats were instilled with E. coli bacteria IT and BM- or UC-EVs delivered IV or by direct nebulisation. At 48 h, lung damage was assessed by physiological parameters, histology and inflammatory marker presence. RESULTS MSC-EVs retained their immunomodulatory and wound healing capacity after nebulisation in vitro. EV integrity and content were also preserved. Therapy with IV or nebulised MSC-EVs reduced the severity of LPS-induced lung injury and E. coli-induced pneumonia by reducing bacterial load and oedema, increasing blood oxygenation and improving lung histological scores. MSC-EV treated animals also showed lower levels of inflammatory cytokines and inflammatory-related markers. CONCLUSIONS MSC-EVs given IV attenuated LPS-induced lung injury, and nebulisation of MSC-EVs did not affect their capacity to attenuate lung injury caused by E. coli pneumonia, as evidenced by reduction in bacterial load and improved lung physiology.
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Affiliation(s)
- Hector Gonzalez
- REMEDI at CÚRAM Centre for Medical Device Research, University of Galway, Galway, Ireland
| | - Sean McCarthy
- REMEDI at CÚRAM Centre for Medical Device Research, University of Galway, Galway, Ireland
| | - Claire Masterson
- REMEDI at CÚRAM Centre for Medical Device Research, University of Galway, Galway, Ireland
| | - Declan Byrnes
- REMEDI at CÚRAM Centre for Medical Device Research, University of Galway, Galway, Ireland
| | - Ignacio Sallent
- REMEDI at CÚRAM Centre for Medical Device Research, University of Galway, Galway, Ireland
| | - Emma Horan
- Orbsen Therapeutics, IDA Business Park, Dangan, Galway, Ireland
| | | | - Gabriele Vella
- Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Adriele P Mello
- Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Johnatas D Silva
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Anna D Krasnodembskaya
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | | | - John G Laffey
- REMEDI at CÚRAM Centre for Medical Device Research, University of Galway, Galway, Ireland
| | - Daniel O'Toole
- REMEDI at CÚRAM Centre for Medical Device Research, University of Galway, Galway, Ireland.
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15
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González HE, McCarthy SD, Masterson C, Laffey JG, MacLoughlin R, O’Toole D. Nebulized mesenchymal stem cell derived conditioned medium ameliorates Escherichia coli induced pneumonia in a rat model. Front Med (Lausanne) 2023; 10:1162615. [PMID: 37332742 PMCID: PMC10272576 DOI: 10.3389/fmed.2023.1162615] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/16/2023] [Indexed: 06/20/2023] Open
Abstract
Background Mesenchymal stem cells (MSC) have shown immense therapeutic promise in a range of inflammatory diseases, including acute respiratory distress syndrome (ARDS), and are rapidly advancing through clinical trials. Among their multimodal mechanisms of action, MSCs exert strong immunomodulatory effects via their secretome, which contains cytokines, small molecules, extracellular vesicles, and a range of other factors. Recent studies have shown that the MSC secretome can recapitulate many of the beneficial effects of the MSC itself. We aimed to determine the therapeutic capacity of the MSC secretome in a rat bacterial pneumonia model, especially when delivered directly to the lung by nebulization which is a technique more appropriate for the ventilated patient. Methods Conditioned medium (CM) was generated from human bone marrow derived MSCs in the absence of antibiotics and serum supplements. Post-nebulization lung penetration was estimated through nebulization of CM to a cascade impactor and simulated lung and quantification of collected total protein and IL-8 cytokine. Control and nebulized CM was added to a variety of lung cell culture models and injury resolution assessed. In a rat E. coli pneumonia model, CM was instilled or administered by nebulization and lung injury and inflammation assessed at 48 h. Results MSC-CM was predicted to have good distal lung penetration and delivery when administered by nebulizer. Both control and nebulized CM reduced NF-κB activation and inflammatory cytokine production in lung cell culture, while promoting cell viability and would closure in oxidative stress and scratch wound models. In a rat bacterial pneumonia model, both instilled and nebulizer delivered CM improved lung function, increasing blood oxygenation and reducing carbon dioxide levels compared to unconditioned medium controls. A reduction in bacterial load was also observed in both treatment groups. Inflammatory cytokines were reduced significantly by both liquid and aerosol CM administration, with less IL-1β, IL-6, and CINC1 in these groups compared to controls. Conclusion MSC-CM is a potential therapeutic for pneumonia ARDS, and administration is compatible with vibrating mesh nebulization.
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Affiliation(s)
- Héctor E. González
- REMEDI at CÚRAM Medical Devices Center and Discipline of Anesthesia, University of Galway, Galway, Ireland
| | - Sean D. McCarthy
- REMEDI at CÚRAM Medical Devices Center and Discipline of Anesthesia, University of Galway, Galway, Ireland
| | - Claire Masterson
- REMEDI at CÚRAM Medical Devices Center and Discipline of Anesthesia, University of Galway, Galway, Ireland
| | - John G. Laffey
- REMEDI at CÚRAM Medical Devices Center and Discipline of Anesthesia, University of Galway, Galway, Ireland
| | | | - Daniel O’Toole
- REMEDI at CÚRAM Medical Devices Center and Discipline of Anesthesia, University of Galway, Galway, Ireland
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16
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Fahy Y, Laffey JG, McNicholas B. Sodium-Glucose Cotransporter 2 Inhibitor-induced Ketoacidosis and Non-Ketotic Acidosis: When Is There a Role for Bicarbonate? Ann Am Thorac Soc 2023; 20:911-916. [PMID: 37261785 DOI: 10.1513/annalsats.202209-780cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Affiliation(s)
- Yvonne Fahy
- Department of Anaesthesia, Intensive Care and Pain Medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - John G Laffey
- Department of Anaesthesia, Intensive Care and Pain Medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland; and
| | - Bairbre McNicholas
- Department of Anaesthesia, Intensive Care and Pain Medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland; and
- Department of Nephrology, University Hospital Galway, Galway, Ireland
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17
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Pham T, Heunks L, Bellani G, Madotto F, Aragao I, Beduneau G, Goligher EC, Grasselli G, Laake JH, Mancebo J, Peñuelas O, Piquilloud L, Pesenti A, Wunsch H, van Haren F, Brochard L, Laffey JG, Acharya SP, Amin P, Arabi Y, Aragao I, Bauer P, Beduneau G, Beitler J, Berkius J, Bugedo G, Camporota L, Cerny V, Cho YJ, Clarkson K, Estenssoro E, Goligher E, Grasselli G, Gritsan A, Hashemian SM, Hermans G, Heunks LM, Jovanovic B, Kurahashi K, Laake JH, Matamis D, Moerer O, Molnar Z, Ozyilmaz E, Panka B, Papali A, Peñuelas Ó, Perbet S, Piquilloud L, Qiu H, Razek AA, Rittayamai N, Roldan R, Serpa Neto A, Szuldrzynski K, Talmor D, Tomescu D, Van Haren F, Villagomez A, Zeggwagh AA, Abe T, Aboshady A, Acampo-de Jong M, Acharya S, Adderley J, Adiguzel N, Agrawal VK, Aguilar G, Aguirre G, Aguirre-Bermeo H, Ahlström B, Akbas T, Akker M, Al Sadeh G, Alamri S, Algaba A, Ali M, Aliberti A, Allegue JM, Alvarez D, Amador J, Andersen FH, Ansari S, Apichatbutr Y, Apostolopoulou O, Arabi Y, Arellano D, Arica M, Arikan H, Arinaga K, Arnal JM, Asano K, Asín-Corrochano M, Avalos Cabrera JM, Avila Fuentes S, Aydemir S, Aygencel G, Azevedo L, Bacakoglu F, Badie J, Baedorf Kassis E, Bai G, Balaraj G, Ballico B, Banner-Goodspeed V, Banwarie P, Barbieri R, Baronia A, Barrett J, Barrot L, Barrueco-Francioni JE, Barry J, Bauer P, Bawangade H, Beavis S, Beck E, Beehre N, Belenguer Muncharaz A, Bellani G, Belliato M, Bellissima A, Beltramelli R, Ben Souissi A, Benitez-Cano A, Benlamin M, Benslama A, Bento L, Benvenuti D, Berkius J, Bernabe L, Bersten A, Berta G, Bertini P, Bertram-Ralph E, Besbes M, Bettini LR, Beuret P, Bewley J, Bezzi M, Bhakhtiani L, Bhandary R, Bhowmick K, Bihari S, Bissett B, Blythe D, Bocher S, Boedjawan N, Bojanowski CM, Boni E, Boraso S, Borelli M, Borello S, Borislavova M, Bosma KJ, Bottiroli M, Boyd O, Bozbay S, Briva A, Brochard L, Bruel C, Bruni A, Buehner U, Bugedo G, Bulpa P, Burt K, Buscot M, Buttera S, Cabrera J, Caccese R, Caironi P, Canchos Gutierrez I, Canedo N, Cani A, Cappellini I, Carazo J, Cardonnet LP, Carpio D, Carriedo D, Carrillo R, Carvalho J, Caser E, Castelli A, Castillo Quintero M, Castro H, Catorze N, Cengiz M, Cereijo E, Ceunen H, Chaintoutis C, Chang Y, Chaparro G, Chapman C, Chau S, Chavez CE, Chelazzi C, Chelly J, Chemouni F, Chen K, Chena A, Chiarandini P, Chilton P, Chiumello D, Cho YJ, Chou-Lie Y, Chudeau N, Cinel I, Cinnella G, Clark M, Clark T, Clarkson K, Clementi S, Coaguila L, Codecido AJ, Collins A, Colombo R, Conde J, Consales G, Cook T, Coppadoro A, Cornejo R, Cortegiani A, Coxo C, Cracchiolo AN, Crespo Ramirez M, Crova P, Cruz J, Cubattoli L, Çukurova Z, Curto F, Czempik P, D'Andrea R, da Silva Ramos F, Dangers L, Danguy des Déserts M, Danin PE, Dantas F, Daubin C, Dawei W, de Haro C, de Jesus Montelongo F, De Mendoza D, de Pablo R, De Pascale G, De Rosa S, Decavèle M, Declercq PL, Deicas A, del Carmen Campos Moreno M, Dellamonica J, Delmas B, Demirkiran O, Demirkiran H, Dendane T, di Mussi R, Diakaki C, Diaz A, Diaz W, Dikmen Y, Dimoula A, Doble P, Doha N, Domingos G, Dres M, Dries D, Duggal A, Duke G, Dunts P, Dybwik K, Dykyy M, Eckert P, Efe S, Elatrous S, Elay G, Elmaryul AS, Elsaadany M, Elsayed H, Elsayed S, Emery M, Ena S, Eng K, Englert JA, Erdogan E, Ergin Ozcan P, Eroglu E, Escobar M, Esen F, Esen Tekeli A, Esquivel A, Esquivel Gallegos H, Ezzouine H, Facchini A, Faheem M, Fanelli V, Farina MF, Fartoukh M, Fehrle L, Feng F, Feng Y, Fernandez I, Fernandez B, Fernandez-Rodriguez ML, Ferrando C, Ferreira da Silva MJ, Ferreruela M, Ferrier J, Flamm Zamorano MJ, Flood L, Floris L, Fluckiger M, Forteza C, Fortunato A, Frans E, Frattari A, Fredes S, Frenzel T, Fumagalli R, Furche MA, Fusari M, Fysh E, Galeas-Lopez JL, Galerneau LM, Garcia A, Garcia MF, Garcia E, Garcia Olivares P, Garlicki J, Garnero A, Garofalo E, Gautam P, Gazenkampf A, Gelinotte S, Gelormini D, Ghrenassia E, Giacomucci A, Giannoni R, Gigante A, Glober N, Gnesin P, Gollo Y, Gomaa D, Gomero Paredes R, Gomes R, Gomez RA, Gomez O, Gomez A, Gondim L, Gonzalez M, Gonzalez I, Gonzalez-Castro A, Gordillo Romero O, Gordo F, Gouin P, Graf Santos J, Grainne R, Grando M, Granov Grabovica S, Grasselli G, Grasso S, Grasso R, Grimmer L, Grissom C, Gritsan A, Gu Q, Guan XD, Guarracino F, Guasch N, Guatteri L, Gueret R, Guérin C, Guerot E, Guitard PG, Gül F, Gumus A, Gurjar M, Gutierrez P, Hachimi A, Hadzibegovic A, Hagan S, Hammel C, Han Song J, Hanlon G, Hashemian SM, Heines S, Henriksson J, Herbrecht JE, Heredia Orbegoso GO, Hermans G, Hermon A, Hernandez R, Hernandez C, Herrera L, Herrera-Gutierrez M, Heunks L, Hidalgo J, Hill D, Holmquist D, Homez M, Hongtao X, Hormis A, Horner D, Hornos MC, Hou M, House S, Housni B, Hugill K, Humphreys S, Humbert L, Hunter S, Hwa Young L, Iezzi N, Ilutovich S, Inal V, Innes R, Ioannides P, Iotti GA, Ippolito M, Irie H, Iriyama H, Itagaki T, Izura J, Izza S, Jabeen R, Jamaati H, Jamadarkhana S, Jamoussi A, Jankowski M, Jaramillo LA, Jeon K, Jeong Lee S, Jeswani D, Jha S, Jiang L, Jing C, Jochmans S, Johnstad BA, Jongmin L, Joret A, Jovanovic B, Junhasavasdikul D, Jurado MT, Kam E, Kamohara H, Kane C, Kara I, Karakurt S, Karnjanarachata C, Kataoka J, Katayama S, Kaushik S, Kelebek Girgin N, Kerr K, Kerslake I, Khairnar P, Khalid A, Khan A, Khanna AK, Khorasanee R, Kienhorst D, Kirakli C, Knafelj R, Kol MK, Kongpolprom N, Kopitko C, Korkmaz Ekren P, Kubisz-Pudelko A, Kulcsar Z, Kumasawa J, Kurahashi K, Kuriyama A, Kutchak F, Laake JH, Labarca E, Labat F, Laborda C, Laca Barrera MA, Lagache L, Landaverde Lopez A, Lanspa M, Lascari V, Le Meur M, Lee SH, Lee YJ, Lee J, Lee WY, Lee J, Legernaes T, Leiner T, Lemiale V, Leonor T, Lepper PM, Li D, Li H, Li O, Lima AR, Lind D, Litton E, Liu N, Liu L, Liu J, Llitjos JF, Llorente B, Lopez R, Lopez CE, Lopez Nava C, Lovazzano P, Lu M, Lucchese F, Lugano M, Lugo Goytia G, Luo H, Lynch C, Macheda S, Madrigal Robles VH, Maggiore SM, Magret Iglesias M, Malaga P, Mallapura Maheswarappa H, Malpartida G, Malyarchikov A, Mansson H, Manzano A, Marey I, Marin N, Marin MDC, Markman E, Martin F, Martin A, Martin Dal Gesso C, Martinez F, Martínez-Fidalgo C, Martin-Loeches I, Mas A, Masaaki S, Maseda E, Massa E, Mattsson A, Maugeri J, McCredie V, McCullough J, McGuinness S, McKown A, Medve L, Mei C, Mellado Artigas R, Mendes V, Mervat MKE, Michaux I, Mikhaeil M, Milagros O, Milet I, Millan MT, Minwei Z, Mirabella L, Mishra S, Mistraletti G, Mochizuki K, Moerer O, Moghal A, Mojoli F, Molin A, Molnar Z, Montiel R, Montini L, Monza G, Mora Aznar M, Morakul S, Morales M, Moreno Torres D, Morocho Tutillo DR, Motherway C, Mouhssine D, Mouloudi E, Muñoz T, Munoz de Cabo C, Mustafa M, Muthuchellappan R, Muthukrishnan M, Muttini S, Nagata I, Nahar D, Nakanishi M, Nakayama I, Namendys-Silva SA, Nanchal R, Nandakumar S, Nasi A, Nasir K, Navalesi P, Naz Aslam T, Nga Phan T, Nichol A, Niiyama S, Nikolakopoulou S, Nikolic E, Nitta K, Noc M, Nonas S, Nseir S, Nur Soyturk A, Obata Y, Oeckler R, Oguchi M, Ohshimo S, Oikonomou M, Ojados A, Oliveira MT, Oliveira Filho W, Oliveri C, Olmos A, Omura K, Orlandi MC, Orsenigo F, Ortiz-Ruiz De Gordoa L, Ota K, Ovalle Olmos R, Öveges N, Oziemski P, Ozkan Kuscu O, Özyilmaz E, Pachas Alvarado F, Pagella G, Palaniswamy V, Palazon Sanchez EL, Palmese S, Pan G, Pan W, Panka B, Papanikolaou M, Papavasilopoulou T, Parekh A, Parke R, Parrilla FJ, Parrilla D, Pasha T, Pasin L, Patão L, Patel M, Patel G, Pati BK, Patil J, Pattnaik S, Paul D, Pavesi M, Pavlotsky VA, Paz G, Paz E, Pecci E, Pellegrini C, Peña Padilla AG, Perchiazzi G, Pereira T, Pereira V, Perez M, Perez Calvo C, Perez Cheng M, Perez Maita R, Pérez-Araos R, Perez-Teran P, Perez-Torres D, Perkins G, Persona P, Petnak T, Petrova M, Pham T, Philippart F, Picetti E, Pierucci E, Piervincenzi E, Pinciroli R, Pintado MC, Piquilloud L, Piraino T, Piras S, Piras C, Pirompanich P, Pisani L, Platas E, Plotnikow G, Porras W, Porta V, Portilla M, Portugal J, Povoa P, Prat G, Pratto R, Preda G, Prieto I, Prol-Silva E, Pugh R, Qi Y, Qian C, Qin T, Qiu H, Qu H, Quintana T, Quispe Sierra R, Quispe Soto R, Rabbani R, Rabee M, Rabie A, Rahe Pereira MA, Rai A, Raj Ashok S, Rajab M, Ramdhani N, Ramey E, Ranieri M, Rathod D, Ray B, Redwanul Huq SM, Regli A, Reina R, Resano Sarmiento N, Reynaud F, Rialp G, Ricart P, Rice T, Richardson A, Rieder M, Rinket M, Rios F, Rios F, Risso Vazquez A, Rittayamai N, Riva I, Rivette M, Roca O, Roche-Campo F, Rodriguez C, Rodriguez G, Rodriguez Gonzalez D, Rodriguez Tucto XY, Rogers A, Romano ME, Rørtveit L, Rose A, Roux D, Rouze A, Rubatto Birri PN, Ruilan W, Ruiz Robledo A, Ruiz-Aguilar AL, Sadahiro T, Saez I, Sagardia J, Saha R, Saha R, Saiphoklang N, Saito S, Salem M, Sales G, Salgado P, Samavedam S, Sami Mebazaa M, Samuelsson L, San Juan Roman N, Sanchez P, Sanchez-Ballesteros J, Sandoval Y, Sani E, Santos M, Santos C, Sanui M, Saravanabavan L, Sari S, Sarkany A, Sauneuf B, Savioli M, Sazak H, Scano R, Schneider F, Schortgen F, Schultz MJ, Schwarz GL, Seçkin Yücesoy F, Seely A, Seiler F, Seker Tekdos Y, Seok Chan K, Serano L, Serednicki W, Serpa Neto A, Setten M, Shah A, Shah B, Shang Y, Shanmugasundaram P, Shapovalov K, Shebl E, Shiga T, Shime N, Shin P, Short J, Shuhua C, Siddiqui S, Silesky Jimenez JI, Silva D, Silva Sales B, Simons K, Sjøbø BÅ, Slessor D, Smiechowicz J, Smischney N, Smith P, Smith T, Smith M, Snape S, Snyman L, Soetens F, Sook Hong K, Sosa Medellin MÁ, Soto G, Souloy X, Sousa E, Sovatzis S, Sozutek D, Spadaro S, Spagnoli M, Spångfors M, Spittle N, Spivey M, Stapleton A, Stefanovic B, Stephenson L, Stevenson E, Strand K, Strano MT, Straus S, Sun C, Sun R, Sundaram V, SunPark T, Surlemont E, Sutherasan Y, Szabo Z, Szuldrzynski K, Tainter C, Takaba A, Tallott M, Tamasato T, Tang Z, Tangsujaritvijit V, Taniguchi L, Taniguchi D, Tarantino F, Teerapuncharoen K, Temprano S, Terragni P, Terzi N, Thakur A, Theerawit P, Thille AW, Thomas M, Thungtitigul P, Thyrault M, Tilouch N, Timenetsky K, Tirapu J, Todeschini M, Tomas R, Tomaszewski C, Tonetti T, Tonnelier A, Trinder J, Trongtrakul K, Truwit J, Tsuei B, Tulaimat A, Turan S, Turkoglu M, Tyagi S, Ubeda A, Vagginelli F, Valenti MF, Vallverdu I, Van Axel A, van den Hul I, van der Hoeven H, Van Der Meer N, Van Haren F, Vanhoof M, Vargas-Ordoñez M, Vaschetto R, Vascotto E, Vatsik M, Vaz A, Vazquez-Sanchez A, Ventura S, Vermeijden JW, Vidal A, Vieira J, Vilela Costa Pinto B, Villagomez A, Villagra A, Villegas Succar C, Vinorum OG, Vitale G, Vj R, Vochin A, Voiriot G, Volta CA, von Seth M, Wajdi M, Walsh D, Wang S, Wardi G, Ween-Velken NC, Wei BL, Weller D, Welsh D, Welters I, Wert M, Whiteley S, Wilby E, Williams E, Williams K, Wilson A, Wojtas J, Won Huh J, Wrathall D, Wright C, Wu JF, Xi G, Xing ZJ, Xu H, Yamamoto K, Yan J, Yáñez J, Yang X, Yates E, Yazicioglu Mocin O, Ye Z, Yildirim F, Yoshida N, Yoshido HHL, Young Lee B, Yu R, Yu G, Yu T, Yuan B, Yuangtrakul N, Yumoto T, Yun X, Zakalik G, Zaki A, Zalba-Etayo B, Zambon M, Zang B, Zani G, Zarka J, Zerbi SM, Zerman A, Zetterquist H, Zhang J, Zhang H, Zhang W, Zhang G, Zhang W, Zhao H, Zheng J, Zhu B, Zumaran R. Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study. Lancet Respir Med 2023; 11:465-476. [PMID: 36693401 DOI: 10.1016/s2213-2600(22)00449-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/07/2022] [Accepted: 11/10/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. METHODS WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. FINDINGS Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. INTERPRETATION In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. FUNDING European Society of Intensive Care Medicine, European Respiratory Society.
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Affiliation(s)
- Tài Pham
- Service de Médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de Recherche CARMAS, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France; Université Paris-Saclay, UVSQ, Université Paris-Sud, Inserm U1018, Equipe d'Epidémiologie Respiratoire Intégrative, CESP, 94807, Villejuif, France
| | - Leo Heunks
- Department of Intensive Care Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Fabiana Madotto
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Aragao
- Department of Intensive Care Medicine, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Gaëtan Beduneau
- Normandie University, UNIROUEN, UR 3830, CHU Rouen, Department of Medical Intensive Care, F-76000 Rouen, France
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, Division of Respirology, Toronto General Hospital Research Institute University Health Network, Toronto, Canada
| | - Giacomo Grasselli
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Jon Henrik Laake
- Department of Anaesthesiology and Department of Research and Development, Division of Critical Care and Emergencies, Oslo University Hospital, Oslo, Norway
| | - Jordi Mancebo
- Department of Intensive Care Medicine, Hospital Universitari Sant Pau, Barcelona, Spain
| | - Oscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red, CIBER de Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Antonio Pesenti
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Frank van Haren
- College of Health and Medicine, Australian National University, Canberra, ACT, Australia; Intensive Care Unit, St George Hospital, Sydney, NSW, Australia
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, Clinical Sciences Institute, Galway University Hospitals, Galway, Ireland; School of Medicine, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.
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Byrnes D, Masterson CH, Gonzales HE, McCarthy SD, O'Toole DP, Laffey JG. Multiple Dosing and Preactivation of Mesenchymal Stromal Cells Enhance Efficacy in Established Pneumonia Induced by Antimicrobial-Resistant Klebsiella pneumoniae in Rodents. Int J Mol Sci 2023; 24:ijms24098055. [PMID: 37175761 PMCID: PMC10179238 DOI: 10.3390/ijms24098055] [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] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/22/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Abstract
Antimicrobial-resistant (AMR) bacteria, such as Klebsiella species, are an increasingly common cause of hospital-acquired pneumonia, resulting in high mortality and morbidity. Harnessing the host immune response to AMR bacterial infection using mesenchymal stem cells (MSCs) is a promising approach to bypass bacterial AMR mechanisms. The administration of single doses of naïve MSCs to ARDS clinical trial patient cohorts has been shown to be safe, although efficacy is unclear. The study tested whether repeated MSC dosing and/or preactivation, would attenuate AMR Klebsiella pneumonia-induced established pneumonia. Rat models of established K. pneumoniae-induced pneumonia were randomised to receive intravenous naïve or cytomix-preactivated umbilical cord MSCs as a single dose at 24 h post pneumonia induction with or without a subsequent dose at 48 h. Physiological indices, bronchoalveolar lavage (BAL), and tissues were obtained at 72 h post pneumonia induction. A single dose of naïve MSCs was largely ineffective, whereas two doses of MSCs were effective in attenuating Klebsiella pneumosepsis, improving lung compliance and oxygenation, while reducing bacteria and injury in the lung. Cytomix-preactivated MSCs were superior to naïve MSCs. BAL neutrophil counts and activation were reduced, and apoptosis increased. MSC therapy reduced cytotoxic BAL T cells, and increased CD4+/CD8+ ratios. Systemically, granulocytes, classical monocytes, and the CD4+/CD8+ ratio were reduced, and nonclassical monocytes were increased. Repeated doses of MSCs-particularly preactivated MSCs-enhance their therapeutic potential in a clinically relevant model of established AMR K. pneumoniae-induced pneumosepsis.
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Affiliation(s)
- Declan Byrnes
- Anaesthesia, School of Medicine, University of Galway, H91 TR33 Galway, Ireland
- Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, University of Galway, H91 TR33 Galway, Ireland
| | - Claire H Masterson
- Anaesthesia, School of Medicine, University of Galway, H91 TR33 Galway, Ireland
- Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, University of Galway, H91 TR33 Galway, Ireland
| | - Hector E Gonzales
- Anaesthesia, School of Medicine, University of Galway, H91 TR33 Galway, Ireland
- Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, University of Galway, H91 TR33 Galway, Ireland
| | - Sean D McCarthy
- Anaesthesia, School of Medicine, University of Galway, H91 TR33 Galway, Ireland
- Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, University of Galway, H91 TR33 Galway, Ireland
| | - Daniel P O'Toole
- Anaesthesia, School of Medicine, University of Galway, H91 TR33 Galway, Ireland
- Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, University of Galway, H91 TR33 Galway, Ireland
| | - John G Laffey
- Anaesthesia, School of Medicine, University of Galway, H91 TR33 Galway, Ireland
- Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, University of Galway, H91 TR33 Galway, Ireland
- Department of Anaesthesia, Galway University Hospitals, SAOLTA University Health Group, H91 YR71 Galway, Ireland
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Berre ML, Paulovčáková T, Verissimo CDM, Doyle S, Dalton JP, Masterson C, Martínez ER, Walsh L, Gormley C, Laffey JG, McNicholas B, Simpkin AJ, Kilcoyne M. A new multiplex SARS-CoV-2 antigen microarray showed correlation of IgG, IgA, and IgM antibodies from patients with COVID-19 disease severity and maintenance of relative IgA and IgM antigen binding over time. PLoS One 2023; 18:e0283537. [PMID: 36996259 PMCID: PMC10062637 DOI: 10.1371/journal.pone.0283537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 03/12/2023] [Indexed: 04/01/2023] Open
Abstract
Zoonotic spillover of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to humans in December 2019 caused the coronavirus disease 2019 (COVID-19) pandemic. Serological monitoring is critical for detailed understanding of individual immune responses to infection and protection to guide clinical therapeutic and vaccine strategies. We developed a high throughput multiplexed SARS-CoV-2 antigen microarray incorporating spike (S) and nucleocapsid protein (NP) and fragments expressed in various hosts which allowed simultaneous assessment of serum IgG, IgA, and IgM responses. Antigen glycosylation influenced antibody binding, with S glycosylation generally increasing and NP glycosylation decreasing binding. Purified antibody isotypes demonstrated a binding pattern and intensity different from the same isotype in whole serum, probably due to competition from the other isotypes present. Using purified antibody isotypes from naïve Irish COVID-19 patients, we correlated antibody isotype binding to different panels of antigens with disease severity, with binding to the S region S1 expressed in insect cells (S1 Sf21) significant for IgG, IgA, and IgM. Assessing longitudinal response for constant concentrations of purified antibody isotypes for a patient subset demonstrated that the relative proportion of antigen-specific IgGs decreased over time for severe disease, but the relative proportion of antigen-specific IgA binding remained at the same magnitude at 5 and 9 months post-first symptom onset. Further, the relative proportion of IgM binding decreased for S antigens but remained the same for NP antigens. This may support antigen-specific serum IgA and IgM playing a role in maintaining longer-term protection, important for developing and assessing vaccine strategies. Overall, these data demonstrate the multiplexed platform as a sensitive and useful platform for expanded humoral immunity studies, allowing detailed elucidation of antibody isotypes response against multiple antigens. This approach will be useful for monoclonal antibody therapeutic studies and screening of donor polyclonal antibodies for patient infusions.
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Affiliation(s)
- Marie Le Berre
- Carbohydrate Signalling Group, Infectious Disease Section, School of Chemical and Biological Sciences, University of Galway, Galway, Ireland
| | - Terézia Paulovčáková
- Carbohydrate Signalling Group, Infectious Disease Section, School of Chemical and Biological Sciences, University of Galway, Galway, Ireland
| | - Carolina De Marco Verissimo
- Molecular Parasitology Lab, Centre for One Health and Ryan Institute, School of Natural Sciences, University of Galway, Galway, Ireland
| | - Seán Doyle
- Department of Biology, Maynooth University, Maynooth, Co. Kildare, Ireland
| | - John P. Dalton
- Molecular Parasitology Lab, Centre for One Health and Ryan Institute, School of Natural Sciences, University of Galway, Galway, Ireland
| | - Claire Masterson
- School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, University of Galway, Galway, Ireland
| | - Eduardo Ribes Martínez
- Lambe Institute for Translational Research, School of Medicine, College of Medicine, Nursing and Health Sciences, University of Galway, Galway, Ireland
| | - Laura Walsh
- University College Dublin, Belfield, Dublin, Ireland
| | - Conor Gormley
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John G. Laffey
- School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, University of Galway, Galway, Ireland
- Department of Anaesthesia and Intensive Care Medicine, University Hospital Galway, Saolta University Hospital Group, Galway, Ireland
| | - Bairbre McNicholas
- School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, University of Galway, Galway, Ireland
- Department of Anaesthesia and Intensive Care Medicine, University Hospital Galway, Saolta University Hospital Group, Galway, Ireland
| | - Andrew J. Simpkin
- School of Mathematical and Statistical Sciences, University of Galway, Galway, Ireland
| | - Michelle Kilcoyne
- Carbohydrate Signalling Group, Infectious Disease Section, School of Chemical and Biological Sciences, University of Galway, Galway, Ireland
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Russotto V, Bellani G, Laffey JG. Reply to Leisman and Crowley. Am J Respir Crit Care Med 2023; 207:623-624. [PMID: 36194888 PMCID: PMC10870920 DOI: 10.1164/rccm.202209-1771le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Giacomo Bellani
- University of Milano-BicoccaMonza, Italy and
- Hospital San GerardoMonza, Italy
| | - John G. Laffey
- University of GalwayGalway, Ireland and
- Galway University HospitalsGalway, Ireland
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21
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McCarthy SD, Rohde CB, Angel M, Masterson CH, MacLoughlin R, Fandiño J, González HE, Byrnes D, Laffey JG, O'Toole D. Aerosolized Pulmonary Delivery of mRNA Constructs Attenuates Severity of Escherichia coli Pneumonia in the Rat. Nucleic Acid Ther 2023; 33:148-158. [PMID: 36811461 PMCID: PMC10066785 DOI: 10.1089/nat.2022.0049] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS), a rapid onset inflammatory lung disease with no effective specific therapy, typically has pathogenic etiology termed pneumonia. In previous studies nuclear factor-κB (NF-κB) inhibitor α super-repressor (IκBα-SR) and extracellular superoxide dismutase 3 (SOD3) reduced pneumonia severity when prophylactically delivered by viral vector. In this study, mRNA coding for green fluorescent protein, IκBα-SR, or SOD3 was complexed with cationic lipid, passed through a vibrating mesh nebulizer, and delivered to cell culture or directly to rats undergoing Escherichia coli pneumonia. Injury level was then assessed at 48 h. In vitro, expression was observed as early as 4 h in lung epithelial cells. IκBα-SR and wild-type IκBα mRNAs attenuated inflammatory markers, while SOD3 mRNA induced protective and antioxidant effects. In rat E. coli pneumonia, IκBα-SR mRNA reduced arterial carbon dioxide (pCO2) and reduced lung wet/dry ratio. SOD3 mRNA improved static lung compliance and alveolar-arterial oxygen gradient (AaDO2) and decreased bronchoalveolar lavage (BAL) bacteria load. White cell infiltration and inflammatory cytokine concentrations in BAL and serum were reduced by both mRNA treatments compared to scrambled mRNA controls. These findings indicate nebulized mRNA therapeutics are a promising approach to ARDS therapy, with rapid expression of protein and observable amelioration of pneumonia symptoms.
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Affiliation(s)
- Sean D McCarthy
- CÚRAM and Regenerative Medicine Institute, University of Galway, Galway, Ireland
| | | | - Matt Angel
- Factor Bioscience Ltd., Cambridge, Massachusetts, USA
| | - Claire H Masterson
- CÚRAM and Regenerative Medicine Institute, University of Galway, Galway, Ireland
| | | | - Juan Fandiño
- CÚRAM and Regenerative Medicine Institute, University of Galway, Galway, Ireland
| | - Héctor E González
- CÚRAM and Regenerative Medicine Institute, University of Galway, Galway, Ireland
| | - Declan Byrnes
- CÚRAM and Regenerative Medicine Institute, University of Galway, Galway, Ireland
| | - John G Laffey
- CÚRAM and Regenerative Medicine Institute, University of Galway, Galway, Ireland
| | - Daniel O'Toole
- CÚRAM and Regenerative Medicine Institute, University of Galway, Galway, Ireland
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22
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Jerkic M, Szaszi K, Laffey JG, Rotstein O, Zhang H. Key Role of Mesenchymal Stromal Cell Interaction with Macrophages in Promoting Repair of Lung Injury. Int J Mol Sci 2023; 24:ijms24043376. [PMID: 36834784 PMCID: PMC9965074 DOI: 10.3390/ijms24043376] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/30/2023] [Accepted: 02/04/2023] [Indexed: 02/11/2023] Open
Abstract
Lung macrophages (Mφs) are essential for pulmonary innate immunity and host defense due to their dynamic polarization and phenotype shifts. Mesenchymal stromal cells (MSCs) have secretory, immunomodulatory, and tissue-reparative properties and have shown promise in acute and chronic inflammatory lung diseases and in COVID-19. Many beneficial effects of MSCs are mediated through their interaction with resident alveolar and pulmonary interstitial Mφs. Bidirectional MSC-Mφ communication is achieved through direct contact, soluble factor secretion/activation, and organelle transfer. The lung microenvironment facilitates MSC secretion of factors that result in Mφ polarization towards an immunosuppressive M2-like phenotype for the restoration of tissue homeostasis. M2-like Mφ in turn can affect the MSC immune regulatory function in MSC engraftment and tissue reparatory effects. This review article highlights the mechanisms of crosstalk between MSCs and Mφs and the potential role of their interaction in lung repair in inflammatory lung diseases.
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Affiliation(s)
- Mirjana Jerkic
- The Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, ON M5B 1T8, Canada
- Correspondence:
| | - Katalin Szaszi
- The Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, ON M5B 1T8, Canada
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - John G. Laffey
- The Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, ON M5B 1T8, Canada
- Anaesthesia and Intensive Care Medicine, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Ori Rotstein
- The Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, ON M5B 1T8, Canada
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Haibo Zhang
- The Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, ON M5B 1T8, Canada
- Department of Anesthesiology and Pain Medicine, Interdepartmental Division of Critical Care Medicine and Department of Physiology, University of Toronto, Toronto, ON M5G 1E2, Canada
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23
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Amado-Rodríguez L, Rodríguez-Garcia R, Bellani G, Pham T, Fan E, Madotto F, Laffey JG, Albaiceta GM. Mechanical ventilation in patients with cardiogenic pulmonary edema: a sub-analysis of the LUNG SAFE study. J Intensive Care 2022; 10:55. [PMID: 36567347 PMCID: PMC9791731 DOI: 10.1186/s40560-022-00648-x] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/18/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Patients with acute respiratory failure caused by cardiogenic pulmonary edema (CPE) may require mechanical ventilation that can cause further lung damage. Our aim was to determine the impact of ventilatory settings on CPE mortality. METHODS Patients from the LUNG SAFE cohort, a multicenter prospective cohort study of patients undergoing mechanical ventilation, were studied. Relationships between ventilatory parameters and outcomes (ICU discharge/hospital mortality) were assessed using latent mixture analysis and a marginal structural model. RESULTS From 4499 patients, 391 meeting CPE criteria (median age 70 [interquartile range 59-78], 40% female) were included. ICU and hospital mortality were 34% and 40%, respectively. ICU survivors were younger (67 [57-77] vs 74 [64-80] years, p < 0.001) and had lower driving (12 [8-16] vs 15 [11-17] cmH2O, p < 0.001), plateau (20 [15-23] vs 22 [19-26] cmH2O, p < 0.001) and peak (21 [17-27] vs 26 [20-32] cmH2O, p < 0.001) pressures. Latent mixture analysis of patients receiving invasive mechanical ventilation on ICU day 1 revealed a subgroup ventilated with high pressures with lower probability of being discharged alive from the ICU (hazard ratio [HR] 0.79 [95% confidence interval 0.60-1.05], p = 0.103) and increased hospital mortality (HR 1.65 [1.16-2.36], p = 0.005). In a marginal structural model, driving pressures in the first week (HR 1.12 [1.06-1.18], p < 0.001) and tidal volume after day 7 (HR 0.69 [0.52-0.93], p = 0.015) were related to survival. CONCLUSIONS Higher airway pressures in invasively ventilated patients with CPE are related to mortality. These patients may be exposed to an increased risk of ventilator-induced lung injury. Trial registration Clinicaltrials.gov NCT02010073.
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Affiliation(s)
- Laura Amado-Rodríguez
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avenida del Hospital Universitario s/n, 33011, Oviedo, Spain
- Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain
- Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Madrid, Spain
| | - Raquel Rodríguez-Garcia
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avenida del Hospital Universitario s/n, 33011, Oviedo, Spain
- Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Madrid, Spain
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Tài Pham
- Service de Médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, DMU 4 CORREVE Maladies du Cœur et des Vaisseaux, FHU Sepsis, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
- Université Paris-Saclay, UVSQ, Inserm U1018, Equipe d'Epidémiologie Respiratoire Intégrative, CESP, 94807, Villejuif, France
| | - Eddy Fan
- Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Fabiana Madotto
- Department of Anesthesia, Critical Care and Emergency' Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland
- School of Medicine, Regenerative Medicine Institute at CÚRAM Centre for Research in Medical Devices, University of Galway, Galway, Ireland
| | - Guillermo M Albaiceta
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain.
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avenida del Hospital Universitario s/n, 33011, Oviedo, Spain.
- Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain.
- Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Madrid, Spain.
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24
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McNicholas BA, Ehrmann S, Laffey JG. Awake prone positioning. Intensive Care Med 2022; 48:1793-1795. [PMID: 36151334 PMCID: PMC9510305 DOI: 10.1007/s00134-022-06893-w] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/27/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Bairbre A McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland.,School of Medicine, University of Galway, Galway, Ireland
| | - Stephan Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSEP F-CRIN Research Network, and Centre d'étude Des Pathologies Respiratoires, INSERM U1100, Université de Tours, Tours, France
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland. .,School of Medicine, University of Galway, Galway, Ireland.
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25
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Juffermans NP, Rocco PRM, Laffey JG. Protective ventilation. Intensive Care Med 2022; 48:1629-1631. [PMID: 35939095 PMCID: PMC9592633 DOI: 10.1007/s00134-022-06820-z] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/07/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centre Location AMC, Amsterdam, The Netherlands. .,OLVG Hospital, Amsterdam, The Netherlands.
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, 21941-902, Brazil
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, Clinical Sciences Institute, National University of Ireland, Galway, Ireland.,Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, Galway, Ireland.,Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, SAOLTA University Health Group, Galway, Ireland
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26
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Sheehan JR, Calpin P, Kernan M, Kelly C, Casey S, Murphy D, Alvarez-Iglesias A, Giacomini C, Cody C, Curley G, McGeary S, Hanley C, McNicholas B, van Haren F, Laffey JG, Cosgrave D. The CHARTER-Ireland trial: can nebulised heparin reduce acute lung injury in patients with SARS-CoV-2 requiring advanced respiratory support in Ireland: a study protocol and statistical analysis plan for a randomised control trial. Trials 2022; 23:774. [PMID: 36104785 PMCID: PMC9471050 DOI: 10.1186/s13063-022-06518-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background COVID-19 pneumonia is associated with the development of acute respiratory distress syndrome (ARDS) displaying some typical histological features. These include diffuse alveolar damage with extensive pulmonary coagulation activation. This results in fibrin deposition in the microvasculature, leading to the formation of hyaline membranes in the air sacs. Well-conducted clinical trials have found that nebulised heparin limits pulmonary fibrin deposition, attenuates progression of ARDS, hastens recovery and is safe in non-COVID ARDS. Unfractionated heparin also inactivates the SARS-CoV-2 virus and prevents entry into mammalian cells. Nebulisation of heparin may therefore limit fibrin-mediated lung injury and inhibit pulmonary infection by SARS-CoV-2. Based on these findings, we designed the CHARTER-Ireland Study, a phase 1b/2a randomised controlled study of nebulised heparin in patients requiring advanced respiratory support for COVID-19 pneumonia. Methods This is a multi-centre, phase 1b/IIa, randomised, parallel-group, open-label study. The study will randomise 40 SARs-CoV-2-positive patients receiving advanced respiratory support in a critical care area. Randomisation will be via 1:1 allocation to usual care plus nebulised unfractionated heparin 6 hourly to day 10 while receiving advanced respiratory support or usual care only. The study aims to evaluate whether unfractionated heparin will decrease the procoagulant response associated with ARDS up to day 10. The study will also assess safety and tolerability of nebulised heparin as defined by number of severe adverse events; oxygen index and respiratory oxygenation index of intubated and unintubated, respectively; ventilatory ratio; and plasma concentration of interleukin (IL)-1β, IL6, IL-8, IL-10 and soluble tumour necrosis factor receptor 1, C-reactive protein, procalcitonin, ferritin, fibrinogen and lactate dehydrogenase as well as the ratios of IL-1β/IL-10 and IL-6/IL-10. These parameters will be assessed on days 1, 3, 5 and 10; time to separation from advanced respiratory support, time to discharge from the intensive care unit and number tracheostomised to day 28; and survival to days 28 and 60 and to hospital discharge, censored at day 60. Some clinical outcome data from our study will be included in the international meta-trials, CHARTER and INHALE-HEP. Discussion This trial aims to provide evidence of potential therapeutic benefit while establishing safety of nebulised heparin in the management of ARDS associated with SARs-CoV-2 infection. Trial registration ClinicalTrials.govNCT04511923. Registered on 13 August 2020. Protocol version 8, 22/12/2021 Protocol identifier: NUIG-2020-003 EudraCT registration number: 2020-003349-12 9 October 2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06518-z.
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27
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Geoghegan P, Clarke J, Hogan G, Keogh A, Marsh H, Donnelly K, McEvoy N, Doolan A, Madden SF, Martin-Loeches I, Power M, Laffey JG, Curley GF. Use of a novel "Split" ventilation system in bench and porcine modeling of acute respiratory distress syndrome. Physiol Rep 2022; 10:e15452. [PMID: 36082971 PMCID: PMC9461348 DOI: 10.14814/phy2.15452] [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: 05/19/2022] [Revised: 08/10/2022] [Accepted: 08/13/2022] [Indexed: 11/28/2022] Open
Abstract
Split ventilation (using a single ventilator to ventilate multiple patients) is technically feasible. However, connecting two patients with acute respiratory distress syndrome (ARDS) and differing lung mechanics to a single ventilator is concerning. This study aimed to: (1) determine functionality of a split ventilation system in benchtop tests, (2) determine whether standard ventilation would be superior to split ventilation in a porcine model of ARDS and (3) assess usability of a split ventilation system with minimal specific training. The functionality of a split ventilation system was assessed using test lungs. The usability of the system was assessed in simulated clinical scenarios. The feasibility of the system to provide modified lung protective ventilation was assessed in a porcine model of ARDS (n = 30). In bench testing a split ventilation system independently ventilated two test lungs under conditions of varying compliance and resistance. In usability tests, a high proportion of naïve operators could assemble and use the system. In the porcine model, modified lung protective ventilation was feasible with split ventilation and produced similar respiratory mechanics, gas exchange and biomarkers of lung injury when compared to standard ventilation. Split ventilation can provide some elements of lung protective ventilation and is feasible in bench testing and an in vivo model of ARDS.
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Affiliation(s)
- Pierce Geoghegan
- Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jennifer Clarke
- Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Grace Hogan
- Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Aoife Keogh
- Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Karen Donnelly
- Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Natalie McEvoy
- Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Stephen F Madden
- Data Science Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | | | - John G Laffey
- Department of Anaesthesia and Critical Care, Galway University Hospital, Galway, Ireland
| | - Gerard F Curley
- Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, Dublin, Ireland
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28
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Russotto V, Tassistro E, Myatra SN, Parotto M, Antolini L, Bauer P, Lascarrou JB, Szułdrzyński K, Camporota L, Putensen C, Pelosi P, Sorbello M, Higgs A, Greif R, Pesenti A, Valsecchi MG, Fumagalli R, Foti G, Bellani G, Laffey JG. Peri-intubation Cardiovascular Collapse in Patients Who Are Critically Ill: Insights from the INTUBE Study. Am J Respir Crit Care Med 2022; 206:449-458. [PMID: 35536310 DOI: 10.1164/rccm.202111-2575oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Cardiovascular instability/collapse is a common peri-intubation event in patients who are critically ill. Objectives: To identify potentially modifiable variables associated with peri-intubation cardiovascular instability/collapse (i.e., systolic arterial pressure <65 mm Hg [once] or <90 mm Hg for >30 minutes; new/increased vasopressor requirement; fluid bolus >15 ml/kg, or cardiac arrest). Methods: INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was a multicenter prospective cohort study of patients who were critically ill and undergoing tracheal intubation in a convenience sample of 197 sites from 29 countries across five continents from October 1, 2018, to July 31, 2019. Measurements and Main Results: A total of 2,760 patients were included in this analysis. Peri-intubation cardiovascular instability/collapse occurred in 1,199 out of 2,760 patients (43.4%). Variables associated with this event were older age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.02-1.03), higher heart rate (OR, 1.008; 95% CI, 1.004-1.012), lower systolic blood pressure (OR, 0.98; 95% CI, 0.98-0.99), lower oxygen saturation as measured by pulse oximetry/FiO2 before induction (OR, 0.998; 95% CI, 0.997-0.999), and the use of propofol as an induction agent (OR, 1.28; 95% CI, 1.05-1.57). Patients with peri-intubation cardiovascular instability/collapse were at a higher risk of ICU mortality with an adjusted OR of 2.47 (95% CI, 1.72-3.55), P < 0.001. The inverse probability of treatment weighting method identified the use of propofol as the only factor independently associated with cardiovascular instability/collapse (OR, 1.23; 95% CI, 1.02-1.49). When administered before induction, vasopressors (OR, 1.33; 95% CI, 0.84-2.11) or fluid boluses (OR, 1.17; 95% CI, 0.96-1.44) did not reduce the incidence of cardiovascular instability/collapse. Conclusions: Peri-intubation cardiovascular instability/collapse was associated with an increased risk of both ICU and 28-day mortality. The use of propofol for induction was identified as a modifiable intervention significantly associated with cardiovascular instability/collapse.Clinical trial registered with clinicaltrials.gov (NCT03616054).
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Affiliation(s)
- Vincenzo Russotto
- Department of Anesthesia and Critical Care, University Hospital San Luigi Gonzaga, University of Turin, Italy
| | - Elena Tassistro
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center) and.,School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Matteo Parotto
- Department of Anesthesiology and Pain Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura Antolini
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center) and.,School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Konstanty Szułdrzyński
- Department of Anesthesiology and Intensive Care, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland.,Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Luigi Camporota
- Health Centre for Human and Applied Physiological Sciences, Department of Adult Critical Care, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia e le Neuroscienze, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Massimiliano Sorbello
- Anesthesia and Intensive Care, Policlinico Vittorio Emanuele San Marco University Hospital, Catania, Italy
| | - Andy Higgs
- Anaesthesia and Intensive Care Medicine, Warrington & Halton Teaching Hospitals National Health Service Foundation Trust, Warrington, United Kingdom
| | - Robert Greif
- Department of Anaesthesiology and Pain Therapy, Bern University Hospital, University of Bern, Bern, Switzerland.,School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Grazia Valsecchi
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center) and.,School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Anesthesiology, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - John G Laffey
- Regenerative Medicine Institute at CURAM Centre for Medical Devices, School of Medicine, National University of Ireland Galway, Galway, Ireland; and.,Anesthesia and Intensive Care Medicine, University Hospital Galway, Galway, Ireland
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29
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Mistry S, Brook BS, Saffaran S, Chikhani M, Hannon DM, Laffey JG, Scott TE, Camporota L, Hardman JG, Bates DG. A computational cardiopulmonary physiology simulator accurately predicts individual patient responses to changes in mechanical ventilator settings. Annu Int Conf IEEE Eng Med Biol Soc 2022; 2022:3261-3264. [PMID: 36083938 DOI: 10.1109/embc48229.2022.9871182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
We present new results validating the capability of a high-fidelity computational simulator to accurately predict the responses of individual patients with acute respiratory distress syndrome to changes in mechanical ventilator settings. 26 pairs of data-points comprising arterial blood gasses collected before and after changes in inspiratory pressure, PEEP, FiO2, and I:E ratio from six mechanically ventilated patients were used for this study. Parallelized global optimization algorithms running on a high-performance computing cluster were used to match the simulator to each initial data point. Mean absolute percentage errors between the simulator predicted values of PaO2 and PaCO2 and the patient data after changing ventilator parameters were 10.3% and 12.6%, respectively. Decreasing the complexity of the simulator by reducing the number of independent alveolar compartments reduced the accuracy of its predictions. Clinical Relevance- These results provide further evidence that our computational simulator can accurately reproduce patient responses to mechanical ventilation, highlighting its usefulness as a clinical research tool.
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Weaver L, Saffaran S, Chikhani M, Laffey JG, Scott TE, Camporota L, Hardman JG, Bates DG. Why Reduced Inspiratory Pressure Could Determine Success of Non-Invasive Ventilation in Acute Hypoxic Respiratory Failure. Annu Int Conf IEEE Eng Med Biol Soc 2022; 2022:3265-3268. [PMID: 36085857 DOI: 10.1109/embc48229.2022.9871901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The magnitude of inspiratory effort relief within the first 2 hours of non-invasive ventilation for hypoxic respiratory failure was shown in a recent exploratory clinical study to be an early and accurate predictor of outcome at 24 hours. We simulated the application of non-invasive ventilation to three patients whose physiological and clinical characteristics match the data in that study. Reductions in inspiratory effort corresponding to reductions of esophageal pressure swing greater than 10 cmH2O more than halved the values of total lung stress, driving pressure, power and transpulmonary pressure swing. In the absence of significant reductions in inspiratory pressure, multiple indicators of lung injury increased after application of non-invasive ventilation. Clinical Relevance- We show using computer simulation that reduced inspiratory pressure after application of noninvasive ventilation translates directly into large reductions in multiple well-established indicators of lung injury, providing a potential physiological explanation for recent clinical findings.
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Hanley C, Giacomini C, Brennan A, McNicholas B, Laffey JG. Insights Regarding the Berlin Definition of ARDS from Prospective Observational Studies. Semin Respir Crit Care Med 2022; 43:379-389. [PMID: 35679873 DOI: 10.1055/s-0042-1744306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The definition of acute respiratory distress syndrome (ARDS), has evolved since it was first described in 1967 by Ashbaugh and Petty to the current "Berlin" definition of ARDS developed in 2012 by an expert panel, that provided clarification on the definition of "acute," and on the cardiac failure criteria. It expanded the definition to include patients receiving non-invasive ventilation, and removed the term "acute lung injury" and added a requirement of patients to be receiving a minimum 5 cmH2O expiratory pressure.Since 2012, a series of observational cohort studies have generated insights into the utility and robustness of this definition. This review will examine novel insights into the epidemiology of ARDS, failures in ARDS diagnosis, the role of lung imaging in ARDS, the novel ARDS cohort that is not invasively ventilated, lung compliance profiles in patients with ARDS, sex differences that exist in ARDS management and outcomes, the progression of ARDS following initial diagnosis, and the clinical profile and outcomes of confirmed versus resolved ARDS. Furthermore, we will discuss studies that challenge the utility of distinguishing ARDS from other causes of acute hypoxemic respiratory failure (AHRF) and identify issues that may need to be addressed in a revised definition.
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Affiliation(s)
- Ciara Hanley
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - Camilla Giacomini
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - Aoife Brennan
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - Bairbre McNicholas
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - John G Laffey
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland.,Regenerative Medicine Institute, National University of Ireland, Galway, Ireland
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Rezoagli E, Laffey JG, Bellani G. Monitoring Lung Injury Severity and Ventilation Intensity during Mechanical Ventilation. Semin Respir Crit Care Med 2022; 43:346-368. [PMID: 35896391 DOI: 10.1055/s-0042-1748917] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a severe form of respiratory failure burden by high hospital mortality. No specific pharmacologic treatment is currently available and its ventilatory management is a key strategy to allow reparative and regenerative lung tissue processes. Unfortunately, a poor management of mechanical ventilation can induce ventilation induced lung injury (VILI) caused by physical and biological forces which are at play. Different parameters have been described over the years to assess lung injury severity and facilitate optimization of mechanical ventilation. Indices of lung injury severity include variables related to gas exchange abnormalities, ventilatory setting and respiratory mechanics, ventilation intensity, and the presence of lung hyperinflation versus derecruitment. Recently, specific indexes have been proposed to quantify the stress and the strain released over time using more comprehensive algorithms of calculation such as the mechanical power, and the interaction between driving pressure (DP) and respiratory rate (RR) in the novel DP multiplied by four plus RR [(4 × DP) + RR] index. These new parameters introduce the concept of ventilation intensity as contributing factor of VILI. Ventilation intensity should be taken into account to optimize protective mechanical ventilation strategies, with the aim to reduce intensity to the lowest level required to maintain gas exchange to reduce the potential for VILI. This is further gaining relevance in the current era of phenotyping and enrichment strategies in ARDS.
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Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy
| | - John G Laffey
- School of Medicine, National University of Ireland, Galway, Ireland.,Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy
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Li J, Luo J, Pavlov I, Perez Y, Tan W, Roca O, Tavernier E, Kharat A, McNicholas B, Ibarra-Estrada M, Vines DL, Bosch NA, Rampon G, Simpson SQ, Walkey AJ, Fralick M, Verma A, Razak F, Harris T, Laffey JG, Guerin C, Ehrmann S, Li J, Luo J, Pavlov I, Perez Y, Tan W, Roca O, Tavernier E, Kharat A, McNicholas B, Ibarra-Estrada M, Vines D, Bosch NA, Rampon G, Simpson SQ, Walkey AJ, Fralick M, Verma A, Razak F, Harris T, Laffey JG, Guerin C, Ehrmann S, Mirza S, Xue L, Pavord ID, Plamondon P, Jayaraman D, Shahin J, Dahine J, Kulenkamp A, Pacheco A. Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure: a systematic review and meta-analysis. The Lancet Respiratory Medicine 2022; 10:573-583. [PMID: 35305308 PMCID: PMC8926412 DOI: 10.1016/s2213-2600(22)00043-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 12/12/2022]
Abstract
Background Awake prone positioning has been broadly utilised for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure, but the results from published randomised controlled trials (RCTs) in the past year are contradictory. We aimed to systematically synthesise the outcomes associated with awake prone positioning, and evaluate these outcomes in relevant subpopulations. Methods In this systematic review and meta-analysis, two independent groups of researchers searched MEDLINE, Embase, PubMed, Web of Science, Scopus, MedRxiv, BioRxiv, and ClinicalTrials.gov for RCTs and observational studies (with a control group) of awake prone positioning in patients with COVID-19-related acute hypoxaemic respiratory failure published in English from Jan 1, 2020, to Nov 8, 2021. We excluded trials that included patients intubated before or at enrolment, paediatric patients (ie, younger than 18 years), or trials that did not include the supine position in the control group. The same two independent groups screened studies, extracted the summary data from published reports, and assessed the risk of bias. We used a random-effects meta-analysis to pool individual studies. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty and quality of the evidence. The primary outcome was the reported cumulative intubation risk across RCTs, and effect estimates were calculated as risk ratios (RR;95% CI). The analysis was primarily conducted on RCTs, and observational studies were used for sensitivity analyses. No serious adverse events associated with awake prone positioning were reported. The study protocol was prospectively registered with PROSPERO, CRD42021271285. Findings A total of 1243 studies were identified, we assessed 138 full-text articles and received the aggregated results of three unpublished RCTs; therefore, after exclusions, 29 studies were included in the study. Ten were RCTs (1985 patients) and 19 were observational studies (2669 patients). In ten RCTs, awake prone positioning compared with the supine position significantly reduced the need for intubation in the overall population (RR 0·84 [95% CI 0·72–0·97]). A reduced need for intubation was shown among patients who received advanced respiratory support (ie, high-flow nasal cannula or non-invasive ventilation) at enrolment (RR 0·83 [0·71–0·97]) and in intensive care unit (ICU) settings (RR 0·83 [0·71–0·97]) but not in patients receiving conventional oxygen therapy (RR 0·87 [0·45–1·69]) or in non-ICU settings (RR 0·88 [0·44–1·76]). No obvious risk of bias and publication bias was found among the included RCTs for the primary outcome. Interpretation In patients with COVID-19-related acute hypoxaemic respiratory failure, awake prone positioning reduced the need for intubation, particularly among those requiring advanced respiratory support and those in ICU settings. Awake prone positioning should be used in patients who have acute hypoxaemic respiratory failure due to COVID-19 and require advanced respiratory support or are treated in the ICU. Funding OpenAI, Rice Foundation, National Institute for Health Research, and Oxford Biomedical Research Centre.
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Luo J, Pavlov I, Tavernier E, Laffey JG, Guerin C, Vines D, Perez Y, Roca O, Kharat A, McNicholas B, Ibarra-Estrada M, Tan W, Ehrmann S, Li J. Rethinking the efficacy of awake prone positioning in COVID-19-related acute hypoxaemic respiratory failure – Authors' reply. The Lancet Respiratory Medicine 2022; 10:e54. [PMID: 35659009 PMCID: PMC9154732 DOI: 10.1016/s2213-2600(22)00167-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 12/03/2022]
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Li Bassi G, Laffey JG. Mechanical Ventilation in the Critically Ill Patient. Semin Respir Crit Care Med 2022; 43:319-320. [PMID: 35649431 DOI: 10.1055/s-0042-1749449] [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] [Indexed: 10/18/2022]
Affiliation(s)
- Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD, Australia.,Faculty of Medicine, University of Queensland, St Lucia, QLD, Australia.,Queensland University of Technology, Brisbane, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Queensland, Australia.,Intensive Care Unit, The Wesley Hospital, Auchenflower, Queensland, Australia.,Wesley Medical Research, The Wesley Hospital, Auchenflower, Queensland, Australia
| | - John G Laffey
- School of Medicine, National University of Ireland, Galway, Ireland.,Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, Galway, Ireland
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36
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Rezoagli E, McNicholas BA, Madotto F, Pham T, Bellani G, Laffey JG. Presence of comorbidities alters management and worsens outcome of patients with acute respiratory distress syndrome: insights from the LUNG SAFE study. Ann Intensive Care 2022; 12:42. [PMID: 35596885 PMCID: PMC9123875 DOI: 10.1186/s13613-022-01015-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 01/12/2022] [Accepted: 04/27/2022] [Indexed: 12/12/2022] Open
Abstract
Background The impact of underlying comorbidities on the clinical presentation, management and outcomes in patients with ARDS is poorly understood and deserves further investigation. Objectives We examined these issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. Methods In this secondary analysis of the patient cohort enrolled in the LUNG SAFE study, our primary objective was to determine the frequency, and impact of comorbidities on the management and ICU survival of patients with ARDS. Secondary outcomes relating to comorbidities included their impact on ventilatory management, the development of organ failures, and on end-of-life care. Results Of 2813 patients in the study population, 1692 (60%) had 1 or more comorbidities, of whom 631 (22.4%) had chronic respiratory impairment, 290 (10.3%) had congestive heart failure, 286 (10.2%) had chronic renal failure, 112 (4%) had chronic liver failure, 584 (20.8%) had immune incompetence, and 613 (21.8%) had diabetes. Multiple comorbidities were frequently present, with 423 (25%) having 2 and 182 (11%) having at least 3 or more comorbidities. The use of invasive ventilation (1379 versus 998, 82 versus 89%), neuromuscular blockade (301 versus 249, 18 versus 22%), prone positioning (97 versus 104, 6 versus 9%) and ECMO (32 versus 46, 2 versus 4%) were each significantly reduced in patients with comorbidities as compared to patients with no comorbidity (1692 versus 1121, 60 versus 40%). ICU mortality increased from 27% (n = 303) in patients with no comorbidity to 39% (n = 661) in patients with any comorbidity. Congestive heart failure, chronic liver failure and immune incompetence were each independently associated with increased ICU mortality. Chronic liver failure and immune incompetence were independently associated with more decisions to limitation of life supporting measures. Conclusions Most patients with ARDS have significant comorbidities, they receive less aggressive care, and have worse outcomes. Enhancing the care of these patients must be a priority for future clinical studies. Trial registration LUNG-SAFE is registered with ClinicalTrials.gov, number NCT02010073. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01015-7.
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Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Bairbre A McNicholas
- School of Medicine, National University of Ireland Galway, Galway, Ireland.,Dept of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland
| | - Fabiana Madotto
- Value based healthcare unit, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Tài Pham
- Service de Médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, DMU 4 CORREVE Maladies du Cœur et Des Vaisseaux, FHU Sepsis, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France.,Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm U1018, Equipe d'Epidémiologie respiratoire intégrative, CESP, 94807, Villejuif, France
| | - Giacomo Bellani
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy.,School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - John G Laffey
- School of Medicine, National University of Ireland Galway, Galway, Ireland. .,Dept of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland. .,Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, Galway, Ireland.
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37
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Li Bassi G, Gibbons K, Suen JY, Dalton HJ, White N, Corley A, Shrapnel S, Hinton S, Forsyth S, Laffey JG, Fan E, Fanning JP, Panigada M, Bartlett R, Brodie D, Burrell A, Chiumello D, Elhazmi A, Esperatti M, Grasselli G, Hodgson C, Ichiba S, Luna C, Marwali E, Merson L, Murthy S, Nichol A, Ogino M, Pelosi P, Torres A, Ng PY, Fraser JF. Early short course of neuromuscular blocking agents in patients with COVID-19 ARDS: a propensity score analysis. Crit Care 2022; 26:141. [PMID: 35581612 PMCID: PMC9112652 DOI: 10.1186/s13054-022-03983-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/10/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The role of neuromuscular blocking agents (NMBAs) in coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) is not fully elucidated. Therefore, we aimed to investigate in COVID-19 patients with moderate-to-severe ARDS the impact of early use of NMBAs on 90-day mortality, through propensity score (PS) matching analysis. METHODS We analyzed a convenience sample of patients with COVID-19 and moderate-to-severe ARDS, admitted to 244 intensive care units within the COVID-19 Critical Care Consortium, from February 1, 2020, through October 31, 2021. Patients undergoing at least 2 days and up to 3 consecutive days of NMBAs (NMBA treatment), within 48 h from commencement of IMV were compared with subjects who did not receive NMBAs or only upon commencement of IMV (control). The primary objective in the PS-matched cohort was comparison between groups in 90-day in-hospital mortality, assessed through Cox proportional hazard modeling. Secondary objectives were comparisons in the numbers of ventilator-free days (VFD) between day 1 and day 28 and between day 1 and 90 through competing risk regression. RESULTS Data from 1953 patients were included. After propensity score matching, 210 cases from each group were well matched. In the PS-matched cohort, mean (± SD) age was 60.3 ± 13.2 years and 296 (70.5%) were male and the most common comorbidities were hypertension (56.9%), obesity (41.1%), and diabetes (30.0%). The unadjusted hazard ratio (HR) for death at 90 days in the NMBA treatment vs control group was 1.12 (95% CI 0.79, 1.59, p = 0.534). After adjustment for smoking habit and critical therapeutic covariates, the HR was 1.07 (95% CI 0.72, 1.61, p = 0.729). At 28 days, VFD were 16 (IQR 0-25) and 25 (IQR 7-26) in the NMBA treatment and control groups, respectively (sub-hazard ratio 0.82, 95% CI 0.67, 1.00, p = 0.055). At 90 days, VFD were 77 (IQR 0-87) and 87 (IQR 0-88) (sub-hazard ratio 0.86 (95% CI 0.69, 1.07; p = 0.177). CONCLUSIONS In patients with COVID-19 and moderate-to-severe ARDS, short course of NMBA treatment, applied early, did not significantly improve 90-day mortality and VFD. In the absence of definitive data from clinical trials, NMBAs should be indicated cautiously in this setting.
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Affiliation(s)
- Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside, Brisbane, QLD, 4032, Australia.
- University of Queensland, Brisbane, Australia.
- Institut dInvestigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain.
- Queensland University of Technology, Brisbane, Australia.
- UnitingCare Hospitals, Brisbane, Australia.
- Wesley Medical Research, Brisbane, Australia.
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside, Brisbane, QLD, 4032, Australia
- University of Queensland, Brisbane, Australia
| | - Heidi J Dalton
- INOVA Fairfax Medical Center, Heart and Vascular Institute, Falls Church, VA, USA
| | - Nicole White
- Queensland University of Technology, Brisbane, Australia
| | - Amanda Corley
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside, Brisbane, QLD, 4032, Australia
- University of Queensland, Brisbane, Australia
| | - Sally Shrapnel
- University of Queensland, Brisbane, Australia
- The Australian Research Council Centre of Excellence for Engineered Quantum Systems (EQUS, CE170100009), Brisbane, Australia
| | | | | | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland, and Galway University Hospitals, Galway, Ireland
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside, Brisbane, QLD, 4032, Australia
- University of Queensland, Brisbane, Australia
- UnitingCare Hospitals, Brisbane, Australia
- Wesley Medical Research, Brisbane, Australia
| | - Mauro Panigada
- Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | | | - Daniel Brodie
- Department of Medicine, Columbia College of Physicians and Surgeons, and Center for Acute Respiratory Failure, New-York-Presbyterian Hospital, New York, NY, USA
| | - Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre, School of Public Health, Monash University, Melbourne, Australia
| | - Davide Chiumello
- Ospedale San Paolo, Milan, Italy
- University of Milan, Milan, Italy
| | - Alyaa Elhazmi
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mariano Esperatti
- Hospital Privado de Comunidad, Escuela de Medicina, Universidad Nacional de Mar del Plata, Mar del Plata, Argentina
| | - Giacomo Grasselli
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- University of Milan, Milan, Italy
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health, Monash University, Melbourne, Australia
| | | | - Carlos Luna
- Neumonología, Hospital de Clínicas, UBA, Buenos Aires, Argentina
| | - Eva Marwali
- National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Laura Merson
- ISARIC, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Srinivas Murthy
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- BC Childrens Hospital Research Institute, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health, Monash University, Melbourne, Australia
- University College Dublin-Clinical Research Centre at St Vincents University Hospital, Dublin, Ireland
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - Mark Ogino
- Nemours Alfred I duPont Hospital for Children, Wilmington, DE, USA
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Antoni Torres
- Institut dInvestigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Hospital Clinic of Barcelona, Barcelona, Spain
| | - Pauline Yeung Ng
- Department of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside, Brisbane, QLD, 4032, Australia
- University of Queensland, Brisbane, Australia
- Institut dInvestigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Queensland University of Technology, Brisbane, Australia
- UnitingCare Hospitals, Brisbane, Australia
- Wesley Medical Research, Brisbane, Australia
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Gershengorn HB, Pavlov I, Perez Y, Tavernier E, Ibarra-Estrada M, Vines D, McNicholas B, Roca O, Ehrmann S, Laffey JG, Li J. High-Flow Nasal Cannula Failure Odds Is Largely Independent of Duration of Use in COVID-19. Am J Respir Crit Care Med 2022; 205:1240-1243. [PMID: 35176213 PMCID: PMC9872798 DOI: 10.1164/rccm.202111-2509le] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Hayley B. Gershengorn
- University of Miami Miller School of MedicineMiami, Florida
- Albert Einstein College of MedicineBronx, New York
| | | | - Yonatan Perez
- FCRIN Research NetworkTours, France
- Université de ToursTours, France
| | | | | | | | - Bairbre McNicholas
- Galway University HospitalsGalway, Ireland
- HRB Galway Clinical Research FacilityGalway, Ireland
- National University of IrelandGalway, Ireland
| | - Oriol Roca
- Hospital Universitari Vall d’HebronBarcelona, Spain
- Instituto de Salud Carlos IIIMadrid, Spain
| | - Stephan Ehrmann
- FCRIN Research NetworkTours, France
- Université de ToursTours, France
| | - John G. Laffey
- Galway University HospitalsGalway, Ireland
- HRB Galway Clinical Research FacilityGalway, Ireland
- National University of IrelandGalway, Ireland
| | - Jie Li
- Rush UniversityChicago, Illinois
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39
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Gorman E, Shankar-Hari M, Hopkins P, Tunnicliffe WS, Perkins GD, Silversides J, McGuigan P, Jackson C, Boyle R, McFerran J, McDowell C, Campbell C, McFarland M, Smythe J, Thompson J, Williams B, Curley G, Laffey JG, Clarke M, McAuley DF, O’Kane C. Repair of acute respiratory distress syndrome by stromal cell administration (REALIST): a structured study protocol for an open-label dose-escalation phase 1 trial followed by a randomised, triple-blind, allocation concealed, placebo-controlled phase 2 trial. Trials 2022; 23:401. [PMID: 35562778 PMCID: PMC9099345 DOI: 10.1186/s13063-022-06220-0] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 03/26/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Mesenchymal stromal cells (MSCs) may be of benefit in ARDS due to immunomodulatory and reparative properties. This trial investigates a novel CD362 enriched umbilical cord derived MSC product (REALIST ORBCEL-C), produced to Good Manufacturing Practice standards, in patients with moderate to severe ARDS due to COVID-19 and ARDS due to other causes. METHODS Phase 1 is a multicentre open-label dose-escalation pilot trial. Patients will receive a single infusion of REALIST ORBCEL-C (100 × 106 cells, 200 × 106 cells or 400 × 106 cells) in a 3 + 3 design. Phase 2 is a multicentre randomised, triple blind, allocation concealed placebo-controlled trial. Two cohorts of patients, with ARDS due to COVID-19 or ARDS due to other causes, will be recruited and randomised 1:1 to receive either a single infusion of REALIST ORBCEL-C (400 × 106 cells or maximal tolerated dose in phase 1) or placebo. Planned recruitment to each cohort is 60 patients. The primary safety outcome is the incidence of serious adverse events. The primary efficacy outcome is oxygenation index at day 7. The trial will be reported according to the Consolidated Standards for Reporting Trials (CONSORT 2010) statement. DISCUSSION The development and manufacture of an advanced therapy medicinal product to Good Manufacturing Practice standards within NHS infrastructure are discussed, including challenges encountered during the early stages of trial set up. The rationale to include a separate cohort of patients with ARDS due to COVID-19 in phase 2 of the trial is outlined. TRIAL REGISTRATION ClinicalTrials.gov NCT03042143. Registered on 3 February 2017. EudraCT Number 2017-000584-33.
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Affiliation(s)
- Ellen Gorman
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University, Belfast, UK
| | - Manu Shankar-Hari
- Guy’s and St Thomas’ NHS Foundation Trust London, London, UK
- School of Immunology and Microbial Sciences, King’s College London, London, UK
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh, UK
| | - Phil Hopkins
- Kings Trauma Centre, King’s College London, London, UK
| | | | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Birmingham, Birmingham, UK
| | - Jonathan Silversides
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University, Belfast, UK
- Department of Critical Care, Belfast Health and Social Care Trust, Belfast, UK
| | - Peter McGuigan
- Department of Critical Care, Belfast Health and Social Care Trust, Belfast, UK
| | | | - Roisin Boyle
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | | | | | | | - Margaret McFarland
- Department of Critical Care, Belfast Health and Social Care Trust, Belfast, UK
| | - Jon Smythe
- NHS Blood and Transplant Service, Oxford, UK
| | | | - Barry Williams
- Independent Patient and Public Representative, Sherborne, UK
| | - Gerard Curley
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John G. Laffey
- Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland, Galway, Ireland
| | - Mike Clarke
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | - Daniel F. McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University, Belfast, UK
- Department of Critical Care, Belfast Health and Social Care Trust, Belfast, UK
| | - Cecilia O’Kane
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University, Belfast, UK
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40
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Abstract
Tracheal intubation is among the most commonly performed and high-risk procedures in critical care. Indeed, 45% of patients undergoing intubation experience at least one major peri-intubation adverse event, with cardiovascular instability being the most common event reported in 43%, followed by severe hypoxemia in 9% and cardiac arrest in 3% of cases. These peri-intubation adverse events may expose patients to a higher risk of 28-day mortality, and they are more frequently observed with an increasing number of attempts to secure the airway. The higher risk of peri-intubation complications in critically ill patients, compared with the anaesthesia setting, is the consequence of their deranged physiology (e.g. underlying respiratory failure, shock and/or acidosis) and, in this regard, airway management in critical care has been defined as "physiologically difficult". In recent years, several randomised studies have investigated the most effective preoxy-genation strategies, and evidence for the use of positive pressure ventilation in moderate-to-severe hypoxemic patients is established. On the other hand, evidence on interventions to mitigate haemodynamic collapse after intubation has been elusive. Airway management in COVID-19 patients is even more challenging because of the additional risk of infection for healthcare workers, which has influenced clinical choices in this patient group. The aim of this review is to provide an update of the evidence for intubation in critically ill patients with a focus on understanding peri-intubation risks and evaluating interventions to prevent or mitigate adverse events.
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Affiliation(s)
- Vincenzo Russotto
- From the Department of Anesthesia and Intensive Care, University Hospital San Luigi Gonzaga, University of Turin, Italy (VR), Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza (GB), University of Milano-Bicocca, Milan, Italy (GB), Department of Anaesthesiology, Critical Care and Pain Medicine, Children's Health Ireland at Temple Street, Dublin, Ireland (LSR), Department of Anesthesiology and Pain Medicine; Interdepartmental Division of Critical Care Medicine, University of Toronto (MP), Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada (MP), Regenerative Medicine Institute at CURAM Centre for Medical Devices, School of Medicine, National University of Ireland (JGL) and Anaesthesia and Intensive Care Medicine, University Hospital Galway, Galway, Ireland (JGL) Correspondence to Vincenzo Russotto, Department of Anesthesia and Intensive Care, University Hospital San Luigi Gonzaga, Regione Gonzole, 10, 10043 Orbassano, Turin, Italy
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41
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Mistry S, Das A, Saffaran S, Yehya N, Scott TE, Chikhani M, Laffey JG, Hardman JG, Camporota L, Bates DG. Validation of at-the-bedside formulae for estimating ventilator driving pressure during airway pressure release ventilation using computer simulation. Respir Res 2022; 23:101. [PMID: 35473715 PMCID: PMC9039982 DOI: 10.1186/s12931-022-01985-z] [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: 12/22/2021] [Accepted: 03/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Airway pressure release ventilation (APRV) is widely available on mechanical ventilators and has been proposed as an early intervention to prevent lung injury or as a rescue therapy in the management of refractory hypoxemia. Driving pressure ([Formula: see text]) has been identified in numerous studies as a key indicator of ventilator-induced-lung-injury that needs to be carefully controlled. [Formula: see text] delivered by the ventilator in APRV is not directly measurable in dynamic conditions, and there is no "gold standard" method for its estimation. METHODS We used a computational simulator matched to data from 90 patients with acute respiratory distress syndrome (ARDS) to evaluate the accuracy of three "at-the-bedside" methods for estimating ventilator [Formula: see text] during APRV. RESULTS Levels of [Formula: see text] delivered by the ventilator in APRV were generally within safe limits, but in some cases exceeded levels specified by protective ventilation strategies. A formula based on estimating the intrinsic positive end expiratory pressure present at the end of the APRV release provided the most accurate estimates of [Formula: see text]. A second formula based on assuming that expiratory flow, volume and pressure decay mono-exponentially, and a third method that requires temporarily switching to volume-controlled ventilation, also provided accurate estimates of true [Formula: see text]. CONCLUSIONS Levels of [Formula: see text] delivered by the ventilator during APRV can potentially exceed levels specified by standard protective ventilation strategies, highlighting the need for careful monitoring. Our results show that [Formula: see text] delivered by the ventilator during APRV can be accurately estimated at the bedside using simple formulae that are based on readily available measurements.
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Affiliation(s)
- Sonal Mistry
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK
| | - Anup Das
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK
| | - Sina Saffaran
- Faculty of Engineering Science, University College London, London, WC1E 6BT, UK
| | - Nadir Yehya
- Department of Anaesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy E Scott
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, ICT Centre, Birmingham, B15 2SQ, UK
| | - Marc Chikhani
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, NUI Galway, Galway, Ireland
| | - Jonathan G Hardman
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.,Anaesthesia & Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Luigi Camporota
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK.
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42
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Hannon DM, Mistry S, Das A, Saffaran S, Laffey JG, Brook BS, Hardman JG, Bates DG. Modeling Mechanical Ventilation In Silico-Potential and Pitfalls. Semin Respir Crit Care Med 2022; 43:335-345. [PMID: 35451046 DOI: 10.1055/s-0042-1744446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Computer simulation offers a fresh approach to traditional medical research that is particularly well suited to investigating issues related to mechanical ventilation. Patients receiving mechanical ventilation are routinely monitored in great detail, providing extensive high-quality data-streams for model design and configuration. Models based on such data can incorporate very complex system dynamics that can be validated against patient responses for use as investigational surrogates. Crucially, simulation offers the potential to "look inside" the patient, allowing unimpeded access to all variables of interest. In contrast to trials on both animal models and human patients, in silico models are completely configurable and reproducible; for example, different ventilator settings can be applied to an identical virtual patient, or the same settings applied to different patients, to understand their mode of action and quantitatively compare their effectiveness. Here, we review progress on the mathematical modeling and computer simulation of human anatomy, physiology, and pathophysiology in the context of mechanical ventilation, with an emphasis on the clinical applications of this approach in various disease states. We present new results highlighting the link between model complexity and predictive capability, using data on the responses of individual patients with acute respiratory distress syndrome to changes in multiple ventilator settings. The current limitations and potential of in silico modeling are discussed from a clinical perspective, and future challenges and research directions highlighted.
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Affiliation(s)
- David M Hannon
- Anesthesia and Intensive Care Medicine, School of Medicine, NUI Galway, Ireland
| | - Sonal Mistry
- School of Engineering, University of Warwick, Coventry, United Kingdom
| | - Anup Das
- School of Engineering, University of Warwick, Coventry, United Kingdom
| | - Sina Saffaran
- Faculty of Engineering Science, University College London, London, United Kingdom
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, NUI Galway, Ireland
| | - Bindi S Brook
- School of Mathematical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Jonathan G Hardman
- Anesthesia and Critical Care, Injury Inflammation and Recovery Sciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, United Kingdom
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Laake JH, Småstuen MC, Møller MH, Larsson A, Aslam TN, Hofsø K, Pham T, Fan E, Bellani G, Laffey JG. Patient characteristics, management and outcomes in a Nordic subset of the "large observational study to understand the global impact of severe acute respiratory failure" (LUNG SAFE) study. Acta Anaesthesiol Scand 2022; 66:684-695. [PMID: 35398892 PMCID: PMC9322410 DOI: 10.1111/aas.14069] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 10/22/2021] [Revised: 02/07/2022] [Accepted: 03/28/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The "Large observational study to understand the global impact of severe acute respiratory failure" (LUNG SAFE) study described the worldwide epidemiology and management of patients with acute hypoxaemic respiratory failure (AHRF). Here, we present the Nordic subset of data from the LUNG SAFE cohort. METHODS We extracted LUNG SAFE data for adults fulfilling criteria for AHRF in intensive care units (ICU) in Denmark, Norway and Sweden, including demographics, co-morbidities, clinical assessment and management characteristics, 90-day survival and length-of-stay (LOS). We analysed ICU LOS with linear regression, and associations between risk factors and mortality were quantified using Cox regression. RESULTS We included 192 patients, with a median age of 64 years (IQR 55, 72), and a male-to-female ratio of 2:1. The majority had one or more co-morbidities, and clinicians identified pneumonia as the primary cause of respiratory failure in 56% and acute respiratory distress syndrome (ARDS) in 21%. Median ICU LOS and duration of invasive mechanical ventilation (IMV) were 5 and 3 days. Tidal volumes (TV) were frequently larger than that supported by evidence and IMV allowing for spontaneous ventilation was common. Younger age, co-morbidity, surgical admission and ARDS were associated with ICU LOS. Sixty-one patients (32%) were dead at 90 days. Age and a non-surgical cause of admission were associated with death. CONCLUSIONS In this subset of LUNG SAFE, ARDS was often not recognised in patients with AHRF and management frequently deviated from evidence-based practices. ICU LOS was generally short, and mortality was attributable to known risk factors.
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Affiliation(s)
- Jon Henrik Laake
- Department of Anaesthesiology and Intensive Care Medicine, Division of Emergencies and Critical Care, Rikshospitalet Medical Centre Oslo University Hospital Oslo Norway
- Department of Research and Development, Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
| | - Milada Cvancarova Småstuen
- Faculty of Health Sciences, Department of Nursing and Health Promotion Oslo Metropolitan University Oslo Norway
| | - Morten Hylander Møller
- Department of Intensive Care Rigshospitalet, University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care Copenhagen Denmark
| | - Anders Larsson
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Uppsala University Hospital Uppsala Sweden
| | - Tayyba Naz Aslam
- Department of Anaesthesiology and Intensive Care Medicine, Division of Emergencies and Critical Care, Rikshospitalet Medical Centre Oslo University Hospital Oslo Norway
- Department of Research and Development, Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
| | - Kristin Hofsø
- Department of Research and Development, Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
- Lovisenberg Diaconal University College Oslo Norway
| | - Tài Pham
- Service de médecine intensive‐réanimation, AP‐HP, Hôpital de Bicêtre Hôpitaux Universitaires Paris‐Saclay Le Kremlin‐Bicêtre France
- Université Paris‐Saclay, UVSQ, Univ. Paris‐Sud, Inserm U1018, Equipe d'Epidémiologie respiratoire intégrative, CESP Villejuif France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine and the Institute of Health Policy, Management and Evaluation University of Toronto Toronto Canada
| | - Giacomo Bellani
- Department of Medicine and Surgery University of Milan‐Bicocca and Department of Emercengy, ASST Monza Monza Italy
| | - John G. Laffey
- School of Medicine, National University of Ireland Galway and Dept of Anaesthesia and Intensive Care Medicine Galway University Hospitals Galway Ireland
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Maddali MV, Churpek M, Pham T, Rezoagli E, Zhuo H, Zhao W, He J, Delucchi KL, Wang C, Wickersham N, McNeil JB, Jauregui A, Ke S, Vessel K, Gomez A, Hendrickson CM, Kangelaris KN, Sarma A, Leligdowicz A, Liu KD, Matthay MA, Ware LB, Laffey JG, Bellani G, Calfee CS, Sinha P. Validation and utility of ARDS subphenotypes identified by machine-learning models using clinical data: an observational, multicohort, retrospective analysis. Lancet Respir Med 2022; 10:367-377. [PMID: 35026177 PMCID: PMC8976729 DOI: 10.1016/s2213-2600(21)00461-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/12/2021] [Accepted: 10/12/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Two acute respiratory distress syndrome (ARDS) subphenotypes (hyperinflammatory and hypoinflammatory) with distinct clinical and biological features and differential treatment responses have been identified using latent class analysis (LCA) in seven individual cohorts. To facilitate bedside identification of subphenotypes, clinical classifier models using readily available clinical variables have been described in four randomised controlled trials. We aimed to assess the performance of these models in observational cohorts of ARDS. METHODS In this observational, multicohort, retrospective study, we validated two machine-learning clinical classifier models for assigning ARDS subphenotypes in two observational cohorts of patients with ARDS: Early Assessment of Renal and Lung Injury (EARLI; n=335) and Validating Acute Lung Injury Markers for Diagnosis (VALID; n=452), with LCA-derived subphenotypes as the gold standard. The primary model comprised only vital signs and laboratory variables, and the secondary model comprised all predictors in the primary model, with the addition of ventilatory variables and demographics. Model performance was assessed by calculating the area under the receiver operating characteristic curve (AUC) and calibration plots, and assigning subphenotypes using a probability cutoff value of 0·5 to determine sensitivity, specificity, and accuracy of the assignments. We also assessed the performance of the primary model in EARLI using data automatically extracted from an electronic health record (EHR; EHR-derived EARLI cohort). In Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE; n=2813), a multinational, observational ARDS cohort, we applied a custom classifier model (with fewer variables than the primary model) to determine the prognostic value of the subphenotypes and tested their interaction with the positive end-expiratory pressure (PEEP) strategy, with 90-day mortality as the dependent variable. FINDINGS The primary clinical classifier model had an area under receiver operating characteristic curve (AUC) of 0·92 (95% CI 0·90-0·95) in EARLI and 0·88 (0·84-0·91) in VALID. Performance of the primary model was similar when using exclusively EHR-derived predictors compared with manually curated predictors (AUC=0·88 [95% CI 0·81-0·94] vs 0·92 [0·88-0·97]). In LUNG SAFE, 90-day mortality was higher in patients assigned the hyperinflammatory subphenotype than in those with the hypoinflammatory phenotype (414 [57%] of 725 vs 694 [33%] of 2088; p<0·0001). There was a significant treatment interaction with PEEP strategy and ARDS subphenotype (p=0·041), with lower 90-day mortality in the high PEEP group of patients with the hyperinflammatory subphenotype (hyperinflammatory subphenotype: 169 [54%] of 313 patients in the high PEEP group vs 127 [62%] of 205 patients in the low PEEP group; hypoinflammatory subphenotype: 231 [34%] of 675 patients in the high PEEP group vs 233 [32%] of 734 patients in the low PEEP group). INTERPRETATION Classifier models using clinical variables alone can accurately assign ARDS subphenotypes in observational cohorts. Application of these models can provide valuable prognostic information and could inform management strategies for personalised treatment, including application of PEEP, once prospectively validated. FUNDING US National Institutes of Health and European Society of Intensive Care Medicine.
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Affiliation(s)
- Manoj V Maddali
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, CA, USA; Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Matthew Churpek
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Tai Pham
- Service de Médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, DMU 4 CORREVE Maladies du Cœur et des Vaisseaux, FHU Sepsis, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France; Université Paris-Saclay, UVSQ, Université Paris-Sud, Inserm U1018, Equipe d'Epidémiologie Respiratoire Intégrative, CESP, 94807, Villejuif, France
| | - Emanuele Rezoagli
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Hanjing Zhuo
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA, USA; Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Wendi Zhao
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - June He
- Division of Clinical and Translational Research, Washington University School of Medicine, St Louis, MO, USA
| | - Kevin L Delucchi
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Chunxue Wang
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nancy Wickersham
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J Brennan McNeil
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alejandra Jauregui
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA, USA; Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Serena Ke
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA, USA; Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Kathryn Vessel
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA, USA; Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Antonio Gomez
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | - Carolyn M Hendrickson
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | - Kirsten N Kangelaris
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Aartik Sarma
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Aleksandra Leligdowicz
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA, USA; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Kathleen D Liu
- Division of Nephrology, University of California, San Francisco, San Francisco, CA, USA; Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, USA; Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Michael A Matthay
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA, USA; Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, USA; Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John G Laffey
- School of Medicine, Regenerative Medicine Institute at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland; Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Anesthesia and Intensive Care Medicine, ASST Monza-Ospedale San Gerardo, Monza, Italy
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA, USA; Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Pratik Sinha
- Division of Clinical and Translational Research, Washington University School of Medicine, St Louis, MO, USA; Department of Anesthesia, Division of Critical Care, Washington University, St Louis, MO, USA.
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Ibarra-Estrada M, Li J, Pavlov I, Perez Y, Roca O, Tavernier E, McNicholas B, Vines D, Marín-Rosales M, Vargas-Obieta A, García-Salcido R, Aguirre-Díaz SA, López-Pulgarín JA, Chávez-Peña Q, Mijangos-Méndez JC, Aguirre-Avalos G, Ehrmann S, Laffey JG. Factors for success of awake prone positioning in patients with COVID-19-induced acute hypoxemic respiratory failure: analysis of a randomized controlled trial. Crit Care 2022; 26:84. [PMID: 35346319 PMCID: PMC8958810 DOI: 10.1186/s13054-022-03950-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/14/2022] [Indexed: 12/26/2022] Open
Abstract
Background Awake prone positioning (APP) improves oxygenation in coronavirus disease (COVID-19) patients and, when successful, may decrease the risk of intubation. However, factors associated with APP success remain unknown. In this secondary analysis, we aimed to assess whether APP can reduce intubation rate in patients with COVID-19 and to focus on the factors associated with success.
Methods In this multicenter randomized controlled trial, conducted in three high-acuity units, we randomly assigned patients with COVID-19-induced acute hypoxemic respiratory failure (AHRF) requiring high-flow nasal cannula (HFNC) oxygen to APP or standard care. Primary outcome was intubation rate at 28 days. Multivariate analyses were performed to identify the predictors associated to treatment success (survival without intubation).
Results Among 430 patients randomized, 216 were assigned to APP and 214 to standard care. The APP group had a lower intubation rate (30% vs 43%, relative risk [RR] 0.70; CI95 0.54–0.90, P = 0.006) and shorter hospital length of stay (11 interquartile range [IQR, 9–14] vs 13 [IQR, 10–17] days, P = 0.001). A respiratory rate ≤ 25 bpm at enrollment, an increase in ROX index > 1.25 after first APP session, APP duration > 8 h/day, and a decrease in lung ultrasound score ≥ 2 within the first 3 days were significantly associated with treatment success for APP. Conclusion In patients with COVID-19-induced AHRF treated by HFNC, APP reduced intubation rate and improved treatment success. A longer APP duration is associated with APP success, while the increase in ROX index and decrease in lung ultrasound score after APP can also help identify patients most likely to benefit. Trial registration: This study was retrospectively registered in ClinicalTrials.gov at July 20, 2021. Identification number NCT04477655. https://clinicaltrials.gov/ct2/show/NCT04477655?term=PRO-CARF&draw=2&rank=1 Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03950-0.
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Bos LDJ, Laffey JG, Ware LB, Heijnen NFL, Sinha P, Patel B, Jabaudon M, Bastarache JA, McAuley DF, Summers C, Calfee CS, Shankar-Hari M. Towards a biological definition of ARDS: are treatable traits the solution? Intensive Care Med Exp 2022; 10:8. [PMID: 35274164 PMCID: PMC8913033 DOI: 10.1186/s40635-022-00435-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [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: 11/26/2021] [Accepted: 03/01/2022] [Indexed: 02/07/2023] Open
Abstract
The pathophysiology of acute respiratory distress syndrome (ARDS) includes the accumulation of protein-rich pulmonary edema in the air spaces and interstitial areas of the lung, variable degrees of epithelial injury, variable degrees of endothelial barrier disruption, transmigration of leukocytes, alongside impaired fluid and ion clearance. These pathophysiological features are different between patients contributing to substantial biological heterogeneity. In this context, it is perhaps unsurprising that a wide range of pharmacological interventions targeting these pathophysiological processes have failed to improve patient outcomes. In this manuscript, our goal is to provide a narrative summary of the potential methods to capture the underlying biological heterogeneity of ARDS and discuss how this information could inform future ARDS redefinitions. We discuss what biological tests are available to identify patients with any of the following predominant biological patterns: (1) epithelial and/or endothelial injury, (2) protein rich pulmonary edema and (3) systemic or within lung inflammatory responses.
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Affiliation(s)
- Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, Location AMC, 1105AZ, Amsterdam, The Netherlands.
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, Galway University Hospitals, National University of Ireland Galway, Galway, Ireland
| | - Lorraine B Ware
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nanon F L Heijnen
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Pratik Sinha
- Department of Anesthesiology, School of Medicine, Washington University, St. Louis, USA
| | - Brijesh Patel
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College, London, UK
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France.,GReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France
| | - Julie A Bastarache
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Charlotte Summers
- Department of Medicine, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Manu Shankar-Hari
- School of Immunology and Microbial Sciences, King's College London, London, UK.,Centre for Inflammation Research, The University of Edinburgh, Edinburgh, Scotland, UK
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McElvaney OJ, McEvoy NL, Boland F, McElvaney OF, Hogan G, Donnelly K, Friel O, Browne E, Fraughen DD, Murphy MP, Clarke J, Choileáin ON, O'Connor E, McGuinness R, Boylan M, Kelly A, Hayden JC, Collins AM, Cullen A, Hyland D, Carroll TP, Geoghegan P, Laffey JG, Hennessy M, Martin-Loeches I, McElvaney NG, Curley GF. A randomized, double-blind, placebo-controlled trial of intravenous alpha-1 antitrypsin for acute respiratory distress syndrome secondary to COVID-19. Med 2022; 3:233-248.e6. [PMID: 35291694 PMCID: PMC8913266 DOI: 10.1016/j.medj.2022.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 01/13/2022] [Revised: 02/11/2022] [Accepted: 03/07/2022] [Indexed: 11/16/2022]
Abstract
Background Patients with severe coronavirus disease 2019 (COVID-19) develop a febrile pro-inflammatory cytokinemia with accelerated progression to acute respiratory distress syndrome (ARDS). Here we report the results of a phase 2, multicenter, randomized, double-blind, placebo-controlled trial of intravenous (IV) plasma-purified alpha-1 antitrypsin (AAT) for moderate to severe ARDS secondary to COVID-19 (EudraCT 2020-001391-15). Methods Patients (n = 36) were randomized to receive weekly placebo, weekly AAT (Prolastin, Grifols, S.A.; 120 mg/kg), or AAT once followed by weekly placebo. The primary endpoint was the change in plasma interleukin (IL)-6 concentration at 1 week. In addition to assessing safety and tolerability, changes in plasma levels of IL-1β, IL-8, IL-10, and soluble tumor necrosis factor receptor 1 (sTNFR1) and clinical outcomes were assessed as secondary endpoints. Findings Treatment with IV AAT resulted in decreased inflammation and was safe and well tolerated. The study met its primary endpoint, with decreased circulating IL-6 concentrations at 1 week in the treatment group. This was in contrast to the placebo group, where IL-6 was increased. Similarly, plasma sTNFR1 was substantially decreased in the treatment group while remaining unchanged in patients receiving placebo. IV AAT did not definitively reduce levels of IL-1β, IL-8, and IL-10. No difference in mortality or ventilator-free days was observed between groups, although a trend toward decreased time on ventilator was observed in AAT-treated patients. Conclusions In patients with COVID-19 and moderate to severe ARDS, treatment with IV AAT was safe, feasible, and biochemically efficacious. The data support progression to a phase 3 trial and prompt further investigation of AAT as an anti-inflammatory therapeutic. Funding ECSA-2020-009; Elaine Galwey Research Bursary.
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Affiliation(s)
- Oliver J McElvaney
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Beaumont Hospital, Dublin, Ireland
| | - Natalie L McEvoy
- Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Boland
- Data Science Centre, Division of Biostatistics and Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Oisín F McElvaney
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Beaumont Hospital, Dublin, Ireland
| | - Grace Hogan
- Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | | | | | - Daniel D Fraughen
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Beaumont Hospital, Dublin, Ireland
| | - Mark P Murphy
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jennifer Clarke
- Beaumont Hospital, Dublin, Ireland
- Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | | | | | | | | | - John C Hayden
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ann M Collins
- RCSI Education and Research Centre, Beaumont Hospital, Dublin, Ireland
| | - Ailbhe Cullen
- RCSI Education and Research Centre, Beaumont Hospital, Dublin, Ireland
| | - Deirdre Hyland
- RCSI Education and Research Centre, Beaumont Hospital, Dublin, Ireland
| | - Tomás P Carroll
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - John G Laffey
- Department of Anaesthesia, Galway University Hospitals, SAOLTA University Health Group, Galway, Ireland
| | - Martina Hennessy
- Department of Critical Care Medicine, St. James' Hospital, Dublin, Ireland
| | | | - Noel G McElvaney
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Beaumont Hospital, Dublin, Ireland
| | - Gerard F Curley
- Beaumont Hospital, Dublin, Ireland
- Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, Dublin, Ireland
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Weaver L, Das A, Saffaran S, Yehya N, Chikhani M, Scott TE, Laffey JG, Hardman JG, Camporota L, Bates DG. Optimising respiratory support for early COVID-19 pneumonia: a computational modelling study. Br J Anaesth 2022; 128:1052-1058. [PMID: 35410790 PMCID: PMC8930396 DOI: 10.1016/j.bja.2022.02.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/03/2022] [Accepted: 02/05/2022] [Indexed: 11/06/2022] Open
Abstract
Background Optimal respiratory support in early COVID-19 pneumonia is controversial and remains unclear. Using computational modelling, we examined whether lung injury might be exacerbated in early COVID-19 by assessing the impact of conventional oxygen therapy (COT), high-flow nasal oxygen therapy (HFNOT), continuous positive airway pressure (CPAP), and noninvasive ventilation (NIV). Methods Using an established multi-compartmental cardiopulmonary simulator, we first modelled COT at a fixed FiO2 (0.6) with elevated respiratory effort for 30 min in 120 spontaneously breathing patients, before initiating HFNOT, CPAP, or NIV. Respiratory effort was then reduced progressively over 30-min intervals. Oxygenation, respiratory effort, and lung stress/strain were quantified. Lung-protective mechanical ventilation was also simulated in the same cohort. Results HFNOT, CPAP, and NIV improved oxygenation compared with conventional therapy, but also initially increased total lung stress and strain. Improved oxygenation with CPAP reduced respiratory effort but lung stress/strain remained elevated for CPAP >5 cm H2O. With reduced respiratory effort, HFNOT maintained better oxygenation and reduced total lung stress, with no increase in total lung strain. Compared with 10 cm H2O PEEP, 4 cm H2O PEEP in NIV reduced total lung stress, but high total lung strain persisted even with less respiratory effort. Lung-protective mechanical ventilation improved oxygenation while minimising lung injury. Conclusions The failure of noninvasive ventilatory support to reduce respiratory effort may exacerbate pulmonary injury in patients with early COVID-19 pneumonia. HFNOT reduces lung strain and achieves similar oxygenation to CPAP/NIV. Invasive mechanical ventilation may be less injurious than noninvasive support in patients with high respiratory effort.
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Murphy EJ, Rezoagli E, Pogue R, Simonassi-Paiva B, Abidin IIZ, Fehrenbach GW, O'Neil E, Major I, Laffey JG, Rowan N. Immunomodulatory activity of β-glucan polysaccharides isolated from different species of mushroom - A potential treatment for inflammatory lung conditions. Sci Total Environ 2022; 809:152177. [PMID: 34875322 PMCID: PMC9752827 DOI: 10.1016/j.scitotenv.2021.152177] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 05/08/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is the most common form of acute severe hypoxemic respiratory failure in the critically ill with a hospital mortality of 40%. Alveolar inflammation is one of the hallmarks for this disease. β-Glucans are polysaccharides isolated from a variety of natural sources including mushrooms, with documented immune modulating properties. To investigate the immunomodulatory activity of β-glucans and their potential as a treatment for ARDS, we isolated and measured glucan-rich polysaccharides from seven species of mushrooms. We used three models of in-vitro injury in THP-1 macrophages, Peripheral blood mononuclear cells (CD14+) (PMBCs) isolated from healthy volunteers and lung epithelial cell lines. We observed variance between β-glucan content in extracts isolated from seven mushroom species. The extracts with the highest β-glucan content found was Lentinus edodes which contained 70% w/w and Hypsizygus tessellatus which contained 80% w/w with low levels of α-glucan. The extracts had the ability to induce secretion of up to 4000 pg/mL of the inflammatory cytokine IL-6, and up to 5000 pg/mL and 500 pg/mL of the anti-inflammatory cytokines IL-22 and IL-10, respectively, at a concentration of 1 mg/mL in THP-1 macrophages. In the presence of cytokine injury, IL-8 was reduced from 15,000 pg/mL to as low as 10,000 pg/mL in THP-1 macrophages. After insult with LPS, phagocytosis dropped from 70-90% to as low 10% in CD14+ PBMCs. After LPS insult CCL8 relative gene expression was reduced, and IL-10 relative gene expression increased from 50 to 250-fold in THP-1 macrophages. In lung epithelial cells, both A549 and BEAS-2B after IL-1β insult, IL-8 levels dropped from 10,000 pg/mL to as low as 6000 pg/mL. TNF-α levels dropped 10-fold from 100 pg/mL to just below 10 pg/mL. These results demonstrate the therapeutic potential of β-glucans in inflammatory lung conditions. Findings also advance bio-based research that connects green innovation with One Health applications for the betterment of society.
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Affiliation(s)
- Emma J Murphy
- Bioscience Research Institute, Athlone Institute of Technology, Athlone, Ireland; Department of Graduate Studies, Limerick Institute of Technology, Limerick, Ireland
| | - Emanuele Rezoagli
- Lung Biology Group, Regenerative Medicine Institute at CURAM Centre for Medical Devices, School of Medicine, National University of Ireland Galway, Galway, Ireland; Anaesthesia and Intensive Care Medicine, University Hospital Galway, Galway, Ireland; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.
| | - Robert Pogue
- Bioscience Research Institute, Athlone Institute of Technology, Athlone, Ireland; Post-Graduate Program in Genomic Sciences and Biotechnology, Catholic University of Brasilia, Brazil
| | | | | | | | - Emer O'Neil
- Bioscience Research Institute, Athlone Institute of Technology, Athlone, Ireland
| | - Ian Major
- Materials Research Institute, Athlone Institute of Technology, Athlone, Ireland
| | - John G Laffey
- Lung Biology Group, Regenerative Medicine Institute at CURAM Centre for Medical Devices, School of Medicine, National University of Ireland Galway, Galway, Ireland; Anaesthesia and Intensive Care Medicine, University Hospital Galway, Galway, Ireland
| | - Neil Rowan
- Bioscience Research Institute, Athlone Institute of Technology, Athlone, Ireland
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Pisani L, Algera AG, Neto AS, Azevedo L, Pham T, Paulus F, de Abreu MG, Pelosi P, Dondorp AM, Bellani G, Laffey JG, Schultz MJ, Martinez A, Leal L, Jorge Pereira A, de Oliveira Maia M, Neto JA, Piras C, Caser EB, Moreira CL, Braga Gusman P, Dalcomune DM, Ribeiro de Carvalho AG, Gondim LAR, Castelo Branco Reis LM, da Cunha Ribeiro D, de Assis Simões L, Campos RS, Fernandez Versiani dos Anjos JC, Bruzzi Carvalho F, Alves RA, Nunes LB, Réa-Neto Á, de Oliveira MC, Tannous L, Cardoso Gomes B, Rodriguez FB, Abelha P, Lugarinho ME, Japiassu A, de Melo HK, Lopes EA, Varaschin P, de Souza Dantas VC, Freitas Knibel M, Ponte M, de Azambuja Rodrigues PM, Costa Filho RC, Saddy F, Wanderley Castellões TF, Silva SA, Osorio LAG, Mannarino D, Espinoza R, Righy C, Soares M, Salluh J, Tanaka L, Aragão D, Tavares ME, Kehdi MGP, Rezende VMC, Carbonell RCC, Teixeira C, de Oliveira RP, Maccari JG, Castro PS, Berto P, Schwarz P, Torelly AP, Lisboa T, Moraes E, Dal-Pizzol F, Tomasi Damiani C, Ritter C, Ferreira JC, Teixeira Costa R, Caruso P, Amendola CP, de Oliveira AMRR, Silva UVA, Sanches LC, Almeida RDS, Azevedo LC, Park M, Schettino G, Assunção MS, Silva E, Barboza CE, Junior APN, Marzocchi Tierno PFGM, Malbouisson LM, Oliveira L, Cristovao D, Neto ML, Rego Ê, Fernandes FE, Romano MLP, Cavalcanti AB, de Souza Barros D, Rodgers H, Dixon B, Smith R, Kol M, Wong H, Schmid W, Hermans G, Ceunen H, Bourgeois M, Anquez N, Suzumura ÉA, Decruyenaere J, DeCrop L, Neto AS, Souza dos Santos R, Beraldo D, dos Santos MC, Pellegrini JAS, Piras C, Oliveira V, Munhoz C, Meira KL, Peçanha AC, da Silva Ramos FJ, Maia I, Bahl M, Biondi R, Prado D, Pinto SF, Salgado J, Falcão LF, Macruz T, de Oliveira GA, Cavalcanti AB, Romano MLP, Ruas K, Mecatti GC, Caser EB, Gava IA, Carreño N, Morales M, Avendaño R, Aguirre S, Luciano PM, Sribar A, Klaric V, Skilijic S, Dvorscak MB, Krkusek M, Jurjevic M, Karanovic N, Simurina T, Stourac P, Kratochvil M, Pacheco ED, Máca J, Wrigge H, Schlegel C, Treschan TA, Schaefer M, Aytulun A, Kienbaum P, Clarkson K, Jaafar R, Collins D, Mazza BF, Plant R, Melchionda G, Di Lauro E, Cortegiani A, Russotto V, Caione R, Mestria D, Volta CA, Spadaro S, Botteri M, Machado FR, Seghelini E, Brazzi L, Sales G, D'Antini D, Molin A, Severgnini P, Bacuzzi A, Peluso L, Verrastro P, Raimondo P, Ferreira E, Gecaj-Gashi A, Simonis FD, Tuinman PR, Alberts E, van den Hul I, Kuiper M, de Wilde RBP, Koopmans M, Kose I, Zincircioglu Ç, dos Santos RB, Dogan N, Aydin D, Denker AS, Buyukkocak U, Akgun N, Turan G, Senturk E, Demirtürk Z, Özcan PE, Ekinci O, Colombo AS, Saylan S, Eren G, Ulger F, Dilek A, Ulusoy H, Goktas U, Soyoral L, Toman H, Orak Y, Kahveci F, Nogueira AC, Mills GH, Pinder A, Walker R, Harrison J, Snell J, Seasman C, Pearson R, Sharman M, Kaloo C, Bynorth N, Fernandes JB, Matthews K, Hughes C, Rose A, Simeson K, Niska L, Huneke N, Adderly J, Padilla-Harris C, Oliver R, Brohi F, Nóbrega RS, Wilson N, Talbot H, Wilson D, Smith D, Dark P, Evans T, Fisher N, Montgomery J, Fitzell P, Muench C, do CS Martins B, Hugill K, Cirstea E, Bentley A, Lynch K, White I, Cooper J, Brazier M, Devile M, Parris M, Gill P, Soriano F, Patel T, Criswell J, Trodd D, Griffin D, Martin J, Wreybrown C, Bewley J, Sweet K, Grimmer L, Kozlowski M, Morsch RD, James S, Limb J, Cowton A, Rogerson D, Downes C, Melbourne S, Humphries R, Pulletz M, Moreton S, Janes S, Nunes ALB, Corner A, Linnett V, Ritzema J, Watters M, Windebank S, Chenna S, Howard-Griffin R, Turner K, Suresh S, Blaylock H, de Almeida JP, Bell S, Blenk K, Everett L, Hopkins P, Mellis C, Hadfield D, Harris C, Chan A, Birch S, Pegg C, Hajjar L, Plowright C, Cooper L, Hatton T, McCullagh I, Wright S, Scott C, Boyd C, Holliday M, Poultney U, Crowther H, Moulin S, Thornthwaite S, Hollister N, Hunt J, Skinner A, Matsa R, Salt R, Matthews C, Reschreiter H, Camsooksai J, Venner N, Giannini FP, Barcraft-Barnes H, Tbaily L, Pogson D, Mouland J, Rose S, Lamb N, Tarmey N, Knighton J, Giles J, Weller D, Baptiston Nunes AL, Reed I, Hormis A, Pearson S, Harris M, Howe J, Paddle J, Burt K, Welters I, Walker A, Youds L, Rios F, Hendry S, Shaw D, Williams K, Hollands R, Carnahan M, Stickley J, Miller C, Donaldson D, Tonks L, Creagh-Brown B, Van Haren F, Hull D, Boyd O, Ortiz-Ruiz L, Gopal S, Metherell S, Spencer H, Frey C, Brown C, Clifford G, Leaver S, Sottiaux T, Ryan C, Mellinghoff JM, Prudden SP, Green HG, Roy AR, Furneval JF, Bell AB, Lakhani SL, Fasting LF, Murray LM, Lora FS, Preller K, McInerney A, Beavis S, Whileman A, Toms J, Glenn S, Ramali M, Ghosh A, Bullock C, Barrell L, Azevedo LC, Young E, Robertson H, Faulkner M, MacNaughton P, Tyson S, Pulak P, Sewell TA, Smalley C, Jacob R, Santos C, Depuydt P, Alzugaray P, Vidal Melo MF, Joyce K, Needleman J, Ahsan A, Faiz A, Alam AKMS, Khatoon SN, Nath RK, Rahman Chowdhury MA, Fan E, Banik D, Mondol MK, Bhuiyan SR, Nazneed S, Sultana R, Hamid T, Hossain M, Reza ST, Asaduzzaman M, Salim M, Bugedo G, Mostafa Kamal AH, Taher SM, Taohid TM, Karmaker P, Roy S, Das S, Sarkar SA, Dutta ML, Roy P, Iyer S, Qiu H, Krishna B, Sampath S, Pattnaik R, Kasi CK, Shah J, Dongre A, Reza Hashemian SM, Nooraei N, Raessi Estabragh R, Malekmohammad M, Gonzalez M, Khoundabi B, Mobasher M, Mohd Yunos N, Kassim M, Voon CM, Das SS, Azauddin SNS, Dorasamy D, Tai LL, Mat Nor MB, Silesky J, Zarudin N, Hasan MS, Jamaluddin MFH, Othman Jailani MI, Kayashta G, Adhikari A, Pangeni R, Hashmi M, Joseph S, Akhtar A, Cerny V, Qadeer A, Memon I, Ali SM, Idrees F, Kamal S, Hanif S, Rehman AU, Taqi A, Hussain T, Farooq A, Nielsen J, Khaskheli S, Hayat M, Indraratna K, Beane A, Haniffa R, Samaranayake U, Mathanalagan S, Gunaratne A, Mithraratne N, Thilakasiri K, Jibaja M, Pilimatalawwe C, Dilhani YAH, Fernando M, Ranatunge K, Samarasinghe L, Vaas M, Edirisooriya M, Sigera C, Arumoli J, De Silva K, Pham T, Kudavidanage B, Pinto V, Dissanayake L, Chittawatanarat K, Kongpolprom N, Silachamroon U, Pornsuriyasak P, Petnak T, Singhatas P, Tangsujaritvijit V, Wrigge H, Rungruanghiranya S, Piriyapatsom A, Juntaping K, Trongtrakul K, Thungtitigul P, Tajarernmuang P, Chatmongkolchart S, Bhurayanontachai R, Akaraborworn O, Navasakulpong A, Matamis D, Surasit K, Thwaites L, Nadjm B, Vu Quoc D, Nguyen Thi Thanh H, Nguyen Van K, Duong Bich T, Lam Minh Y, Ranero JL, Hashemian SM, Amin P, Clarkson K, Bellani G, Kurahashi K, Villagomez A, Zeggwagh AA, Heunks LM, Laake JH, Palo JE, do Vale Fernandes A, Sandesc D, Arabi Y, Bumbasierevic V, Lorente JA, Larsson A, Piquilloud L, Abroug F, McAuley DF, McNamee L, Hurtado J, Bajwa E, Démpaire G, Francois GM, Sula H, Nunci L, Cani A, Zazu A, Dellera C, Insaurralde CS, Alejandro RV, Daldin J, Vinzio M, Fernandez RO, Cardonnet LP, Bettini LR, Bisso MC, Osman EM, Setten MG, Lovazzano P, Alvarez J, Villar V, Milstein C, Pozo NC, Grubissich N, Plotnikow GA, Vasquez DN, Ilutovich S, Tiribelli N, Chena A, Pellegrini CA, Saenz MG, Estenssoro E, Brizuela M, Gianinetto H, Gomez PE, Cerrato VI, Bezzi MG, Borello SA, Loiacono FA, Fernandez AM, Knowles S, Reynolds C, Inskip DM, Miller JJ, Kong J, Whitehead C, Bihari S, Seven A, Krstevski A, Rodgers HJ, Millar RT, Mckenna TE, Bailey IM, Hanlon GC, Aneman A, Lynch JM, Azad R, Neal J, Woods PW, Roberts BL, Kol MR, Wong HS, Riss KC, Staudinger T, Wittebole X, Berghe C, Bulpa PA, Dive AM, Verstraete R, Lebbinck H, Depuydt P, Vermassen J, Meersseman P, Ceunen H, Rosa JI, Beraldo DO, Piras C, Ampinelli AMR, Nassar Jr AP, Mataloun S, Moock M, Thompson MM, Gonçalves CH, Antônio ACP, Ascoli A, Biondi RS, Fontenele DC, Nobrega D, Sales VM, Shindhe S, Ismail DMABPH, Laffey J, Beloncle F, Davies KG, Cirone R, Manoharan V, Ismail M, Goligher EC, Jassal M, Nishikawa E, Javeed A, Curley G, Rittayamai N, Parotto M, Ferguson ND, Mehta S, Knoll J, Pronovost A, Canestrini S, Bruhn AR, Garcia PH, Aliaga FA, Farías PA, Yumha JS, Ortiz CA, Salas JE, Saez AA, Vega LD, Labarca EF, Martinez FT, Carreño NG, Lora P, Liu H, Qiu H, Liu L, Tang R, Luo X, An Y, Zhao H, Gao Y, Zhai Z, Ye ZL, Wang W, Li W, Li Q, Zheng R, Yu W, Shen J, Li X, Yu T, Lu W, Wu YQ, Huang XB, He Z, Lu Y, Han H, Zhang F, Sun R, Wang HX, Qin SH, Zhu BH, Zhao J, Liu J, Li B, Liu JL, Zhou FC, Li QJ, Zhang XY, Li-Xin Z, Xin-Hua Q, Jiang L, Gao YN, Zhao XY, Li YY, Li XL, Wang C, Yao Q, Yu R, Chen K, Shao H, Qin B, Huang QQ, Zhu WH, Hang AY, Hua MX, Li Y, Xu Y, Di YD, Ling LL, Qin TH, Wang SH, Qin J, Han Y, Zhou S, Vargas MP, Silesky Jimenez JI, González Rojas MA, Solis-Quesada JE, Ramirez-Alfaro CM, Máca J, Sklienka P, Gjedsted J, Christiansen A, Nielsen J, Villamagua BG, Llano M, Burtin P, Buzancais G, Beuret P, Pelletier N, Mortaza S, Mercat A, Chelly J, Jochmans S, Terzi N, Daubin C, Carteaux G, de Prost N, Chiche JD, Daviaud F, Pham T, Fartoukh M, Barberet G, Biehler J, Dellamonica J, Doyen D, Arnal JM, Briquet A, Hraiech S, Papazian L, Follin A, Roux D, Messika J, Kalaitzis E, Dangers L, Combes A, Au SM, Béduneau G, Carpentier D, Zogheib EH, Dupont H, Ricome S, Santoli FL, Besset SL, Michel P, Gelée B, Danin PE, Goubaux B, Crova PJ, Phan NT, Berkelmans F, Badie JC, Tapponnier R, Gally J, Khebbeb S, Herbrecht JE, Schneider F, Declercq PLM, Rigaud JP, Duranteau J, Harrois A, Chabanne R, Marin J, Bigot C, Thibault S, Ghazi M, Boukhazna M, Ould Zein S, Richecoeur JR, Combaux DM, Grelon F, Le Moal C, Sauvadet EP, Robine A, Lemiale V, Reuter D, Dres M, Demoule A, Goldgran-Toledano D, Baboi L, Guérin C, Lohner R, Kraßler J, Schäfer S, Zacharowski KD, Meybohm P, Reske AW, Simon P, Hopf HBF, Schuetz M, Baltus T, Papanikolaou MN, Papavasilopoulou TG, Zacharas GA, Ourailogloy V, Mouloudi EK, Massa EV, Nagy EO, Stamou EE, Kiourtzieva EV, Oikonomou MA, Avila LE, Cortez CA, Citalán JE, Jog SA, Sable SD, Shah B, Gurjar M, Baronia AK, Memon M, Muthuchellappan R, Ramesh VJ, Shenoy A, Unnikrishnan R, Dixit SB, Rhayakar RV, Ramakrishnan N, Bhardwaj VK, Mahto HL, Sagar SV, Palaniswamy V, Ganesan D, Mohammadreza Hashemian S, Jamaati H, Heidari F, Meaney EA, Nichol A, Knapman KM, O'Croinin D, 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Jovanovic B, Surbatovic M, Veljovic M, Van Haren F. Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies. The Lancet Global Health 2022; 10:e227-e235. [PMID: 34914899 PMCID: PMC8766316 DOI: 10.1016/s2214-109x(21)00485-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/05/2021] [Accepted: 10/01/2021] [Indexed: 12/19/2022] Open
Abstract
Background Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001). Interpretation Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding No funding.
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