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Monti G, Marzaroli M, Tucciariello MT, Ferrara B, Meroi F, Nakhnoukh C, Zambon M, Borghi G, Guarracino F, Manazza M, Ajello V, Belletti A, Biuzzi C, Plumari V, Filippini M, Cuffaro R, Racanelli G, Pontillo D, Rauch S, Oliva FM, Tescione M, Baiardo Redaelli M, Melegari G, Maj G, Navalesi P, Gerardi M, Caccioppola A, Bruni A, Ballotta A, Ferri C, Orso D, Di Benedetto V, Baldassarri R, Franceschini G, Alamami A, Pasin L, Putzu A, Romero Garcia CS, Chen YS, Noto A, Yavorovskiy A, Hajjar LA, Cortegiani A, Likhvantsev V, Konkayev A, Finco G, Sales G, Brazzi L, Paternoster G, Bellomo R, Zangrillo A, Landoni G, Di Tomasso N, PIONEER Study Group. Pirfenidone to prevent fibrosis in acute respiratory distress syndrome: The PIONEER study protocol. Contemp Clin Trials 2025; 153:107883. [PMID: 40090666 DOI: 10.1016/j.cct.2025.107883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Collaborators] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2024] [Revised: 03/07/2025] [Accepted: 03/12/2025] [Indexed: 03/18/2025]
Abstract
BACKGROUND Pulmonary fibrosis is a major complication of the Acute Respiratory Distress Syndrome (ARDS). Pirfenidone is an approved treatment for idiopathic pulmonary fibrosis. It may attenuate ARDS-related fibrosis and decrease the need for prolonged ventilation. Accordingly, we aimed to evaluate the effect of pirfenidone on ventilator-free days in patients with ARDS. METHODS In a multi-center, randomized, double-blind, placebo-controlled trial, we plan to randomly assign 130 adults invasively ventilated for ARDS to receive pirfenidone or placebo for up to 28 days. The primary outcome is days alive and ventilator free at 28 days. Secondary outcomes include ICU-free days, hospital free days all at 28 day, ICU mortality and hospital mortality. We will also assess fibroproliferative changes on high-resolution CT scans at ICU discharge and quality of life. Data analysis will be on an intention-to-treat basis. DISCUSSION The trial is ongoing and currently recruiting. It will be the first randomized controlled study to investigate whether, compared to placebo, pirfenidone increases the number of days alive and ventilator-free in patients with ARDS. Its double-blind multicenter design will provide internal validity, minimal bias, and a degree of external validity. If our hypothesis is confirmed, this treatment would justify larger trials of this intervention. TRIAL REGISTRATION This trial was registered on ClinicalTrials.gov with the trial identification NCT05075161.
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Affiliation(s)
- Giacomo Monti
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Matteo Marzaroli
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Brian Ferrara
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Meroi
- Department of Emergency "Santa Maria Della Misericordia", Azienda Sanitaria Universitaria Friuli Centrale, University Hospital of Udine, Udine, Italy
| | - Cristina Nakhnoukh
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Zambon
- Anestesia e Rianimazione, Ospedale Uboldo - Cernusco sul Naviglio ASST Melegnano e Martesana, Cernusco Sul Naviglio, Italy
| | - Giovanni Borghi
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Guarracino
- Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Marco Manazza
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valentina Ajello
- Department of Cardiothoracic Anesthesia, University Hospital Tor Vergata, Rome, Italy
| | - Alessandro Belletti
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cesare Biuzzi
- Department of Medical Science, Surgery and Neurosciences, Trauma Anesthesia and Intensive Care Unit, University Hospital of Siena, Siena, Italy
| | - Valentina Plumari
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Filippini
- Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Brescia, Italy
| | - Raffaele Cuffaro
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Racanelli
- Anesthesia and ICU 1° Department, Casa Sollievo della Sofferenza Opera San Pio da Pietrelcina Hospital, San Giovanni Rotondo, Italy
| | - Domenico Pontillo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Simon Rauch
- Department of Anesthesia and Intensive Care Medicine, Merano Hospital, Merano, Italy
| | - Federico Mattia Oliva
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Tescione
- Anesthesia and Intensive Care Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Martina Baiardo Redaelli
- Department of Biotechnologies and Life Science, University of Insubria, Varese, Italy; Azienda Ospedaliera Ospedale di Circolo e Fondazione Macchi di Varese, Varese, Italy
| | - Gabriele Melegari
- Department of Anaesthesia and Intensive Care, AOU Policlinico di Modena, Modena, Italy
| | - Giulia Maj
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AOU SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy; Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | | | - Alessio Caccioppola
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Bruni
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Andrea Ballotta
- Department of Cardiac Anesthesia and Intensive Care Unit, Cardiac Anaesthesia and Intensive Care Unit, Centro Cardiologico Monzino, IRCSS, Milan, Italy
| | - Camilla Ferri
- Hospital Pharmacy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daniele Orso
- Department of Emergency "Santa Maria Della Misericordia", Azienda Sanitaria Universitaria Friuli Centrale, University Hospital of Udine, Udine, Italy
| | - Vincenzo Di Benedetto
- Anestesia e Rianimazione, Ospedale Uboldo - Cernusco sul Naviglio ASST Melegnano e Martesana, Cernusco Sul Naviglio, Italy
| | - Rubia Baldassarri
- Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Giulia Franceschini
- Department of Cardiothoracic Anesthesia, University Hospital Tor Vergata, Rome, Italy
| | - Ans Alamami
- Department of Critical Care Medicine, Hamad General Hospital, Doha, Qatar
| | - Laura Pasin
- Anesthesia and Intensive Care Unit, Casa di Cura Villa Maria, Padua, Italy
| | - Alessandro Putzu
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Carolina Soledad Romero Garcia
- Department of Anaesthesiology and Critical Care, Hospital General Universitario De Valencia, Valencia, Spain; Methodology Department, European University of Valencia, Valencia, Spain
| | | | - Alberto Noto
- Division of Anesthesia and Critical Care, Department of Human Pathology of the adult and evolutive age "Gaetano Barresi", University of Messina, Messina, Italy
| | - Andrey Yavorovskiy
- Department of Anesthesiology and Intensive Care, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health, Moscow, Russia
| | | | - Andrea Cortegiani
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy; Department of Anaesthesia, Intensive Care and Emergency, University Hospital Policlinico Paolo Giaccone, Palermo, Italy
| | - Valery Likhvantsev
- Department of Anesthesiology and Intensive Care, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health, Moscow, Russia; Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Aidos Konkayev
- Astana Medical University, Astana, Kazakhstan; National Scientific Center of Traumatology and Orthopedia, Astana, Kazakhstan
| | - Gabriele Finco
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Gabriele Sales
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Gianluca Paternoster
- Department of Health Science, Anesthesia and ICU, School of Medicine University of Basilicata San Carlo Hospital, Potenza, Italy
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Alberto Zangrillo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| | - Nora Di Tomasso
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Collaborators
Matteo Aldo Bonizzoni, Matteo Borello, Benedetta Chiodi, Filippo D'Amico, Noemi De Piccoli, Sara Fiorito, Stefano Fresilli, Giuseppe Giardina, Rosa Labanca, Rosalba Lembo, Margherita Licheri, Rosario Losiggio, Marilena Marmiere, Pasquale Nardelli, Lisa Notarianni, Anita Nutta, Alessandro Oriani, Alessandro Ortalda, Marina Pieri, Alessandro Pruna, Erica Ronca, Tommaso Scquizzato, Stefano Turi, Simone Vietri, Enrico Tomasi, Marta Veneziano, Özgün Ömer Asiller, Benazir Azimova, Aituar Kabibulatov, Luca Doroni, Michela Villano, Levan Berikashvili, Kristina Kadantseva, Simone Piva, Maria Carmela Izzi, Serena Milano, Maria Silvia Sannicandro, Andreja Möller Petrun, Giorgia Montrucchio, Valentina Sanna, Umberto Simonetti, Martina Ollosu, Salvatore Sardo, Simone Bresssan, Natascia D'Andrea, Manuela Lugano, Giulia Roveri, Paolo Seraglio, Mariachiara Ippolito, Giulia Catalisano, Rita Perna, Andrea Farinaccio, Marzia Flaminio, Roberto Scaini, Francesco Corradi, Giada Cucciolini, Clara Scopelliti, Eugenio Giuseppe Vadalà, Renato Ricciardi, Leandro Utino Taniguchi, Pedro Vitale Mendes, Łukasz Krzych, Luca Cabrini,
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Liu D, Weng S, Fu C, Guo R, Chen M, Shi B, Weng J. Autophagy in Acute Lung Injury. Cell Biochem Biophys 2025; 83:1415-1425. [PMID: 39527232 DOI: 10.1007/s12013-024-01604-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2024] [Indexed: 11/16/2024]
Abstract
Acute lung injury (ALI) is a critical condition marked by rapid-onset respiratory failure due to extensive inflammation and increased pulmonary vascular permeability, often progressing to acute respiratory distress syndrome (ARDS) with high mortality. Autophagy, a cellular degradation process essential for removing damaged organelles and proteins, plays a crucial role in regulating lung injury and repair. This review examines the protective role of autophagy in maintaining cellular function and reducing inflammation and oxidative stress in ALI. It underscores the necessity of precise regulation to fully harness the therapeutic potential of autophagy in this context. We summarize the mechanisms by which autophagy influences lung injury and repair, discuss the interplay between autophagy and apoptosis, and examine potential therapeutic strategies, including autophagy inducers, targeted autophagy signaling pathways, antioxidants, anti-inflammatory drugs, gene editing, and stem cell therapy. Understanding the role of autophagy in ALI could lead to novel interventions for improving patient outcomes and reducing mortality rates associated with this severe condition.
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Affiliation(s)
- Danjuan Liu
- Department of Critical Care Medicine, the Affiliated Hospital of Putian University, Putian, 351100, China
| | - Shuoyun Weng
- School of Optometry and Ophthalmology, Wenzhou Medical University, Wenzhou, China
| | - Chunjin Fu
- Department of Critical Care Medicine, the Affiliated Hospital of Putian University, Putian, 351100, China
| | - Rongjie Guo
- Department of Critical Care Medicine, the Affiliated Hospital of Putian University, Putian, 351100, China
| | - Min Chen
- Department of Critical Care Medicine, the Affiliated Hospital of Putian University, Putian, 351100, China
| | - Bingbing Shi
- Department of Critical Care Medicine, the Affiliated Hospital of Putian University, Putian, 351100, China
| | - Junting Weng
- Department of Critical Care Medicine, the Affiliated Hospital of Putian University, Putian, 351100, China.
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Zalucky AA, Dianti J, Neyton LPA, Sinha P, Liu KD, Matthay MA, Thompson BT, Goligher EC, Calfee CS. Elastance May Determine the Neuromuscular Blockade Effect on Mortality in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2025; 211:966-974. [PMID: 39998496 DOI: 10.1164/rccm.202406-1231oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 02/24/2025] [Indexed: 02/26/2025] Open
Abstract
Rationale: Patients with acute respiratory distress syndrome (ARDS) have a reduction in functional lung volume that results in increased respiratory system elastance (Ers); however, the extent of this increase varies by patient. Patients with high Ers are at risk of excess lung-distending pressures and may derive greater clinical benefit from neuromuscular blockade (NMB). Objectives: We sought to evaluate whether the effect of early NMB administration on mortality varies according to baseline physiological and biological biomarkers of lung injury, including Ers. Methods: We conducted a secondary analysis of the Reevaluation of Systemic Early Neuromuscular Blockade, or ROSE, trial. Bayesian logistic regression modeling was used to estimate the posterior probability of NMB effect moderation by baseline Ers, ventilatory ratio, and select ARDS plasma biomarkers on 90-day mortality. Measurements and Main Results: The probability of mortality benefit with NMB increased substantially with higher baseline Ers (posterior probability of interaction, 92%; interaction odds ratio = 0.76; 90% credible interval = 0.59-0.99). In patients with an Ers ⩾2 cm H2O/(ml/kg), the posterior probability of benefit was 96% (median absolute risk reduction, 9%; 90% credible interval = 0.5-17.9). The effect of NMB did not vary meaningfully according to ventilatory ratio (posterior probability of interaction, 62%) or baseline plasma levels of receptor for advanced glycation end-products, tumor necrosis factor receptor-1, IL-6, or IL-8 (posterior probabilities of interaction: 12%, 18%, 44%, and 22% respectively). Conclusions: These findings suggest that the mortality benefit of NMB varies with baseline Ers. High Ers may represent a physiological phenotype of acute respiratory distress syndrome. Future prospective testing to confirm benefit in this potentially treatment-responsive group is needed.
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Affiliation(s)
- Ann A Zalucky
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine and
- Department of Critical Care Medicine, Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Foothills Medical Center, Alberta Health Services, Calgary, Alberta, Canada
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Surgery, Anaesthesia, and Paediatrics, and
| | - Lucile P A Neyton
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine and
| | - Pratik Sinha
- Division of Clinical and Translational Research and Division of Critical Care, Department of Anaesthesiology, Washington University School of Medicine, Saint Louis, Missouri
| | | | - Michael A Matthay
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine and
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Harvard School of Medicine, Boston, Massachusetts; and
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Surgery, Anaesthesia, and Paediatrics, and
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine and
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
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Yan Y, Bao J, Cai S, Zhong X, Geng B, Liang J, Deng Z, Chen Z, Qin Z, Hu H, Zeng Z. The effects of prolonged prone positioning on response and prognosis in patients with acute respiratory distress syndrome: a retrospective cohort study. J Intensive Care 2025; 13:24. [PMID: 40336057 PMCID: PMC12057286 DOI: 10.1186/s40560-025-00795-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2025] [Accepted: 04/24/2025] [Indexed: 05/09/2025] Open
Abstract
BACKGROUND Prone positioning improves outcomes in patients with acute respiratory distress syndrome (ARDS), but the optimal duration in critical care settings remains uncertain. This study aims to evaluate the investigates the impact of prone ventilation duration on clinical outcomes. METHODS This retrospective study was conducted on ARDS patients admitted to the intensive care unit (ICU), Nanfang hospital of Southern Medical University, who received prone positioning. Patients were categorized into two groups: the prolonged prone positioning (PPP) (≥ 16 h) group and the standard prone positioning (SPP) (< 16 h) group. Propensity score matching (PSM) was employed to balance baseline characteristics. Cox proportional hazards, regression models were utilized to evaluate the association between the prone duration and clinical outcomes. Kaplan-Meier survival curves were generated to compare 28-day mortality, with log-rank tests analyzing differences. Restricted cubic spline (RCS) were applied to investigate the time-response between prone duration, PaCO₂, PaO₂, positive end-expiratory pressure, response rate, and 28-day mortality. In addition, the incidence of prone position-related complications was assessed in both groups. RESULTS A total of 234 patients with ARDS were included, with an overall 28-day mortality of 49.1% (115/234). After PSM, 81 matched pairs were compared. The PPP group had lower 28-day mortality (46.9% vs. 53.1%; hazard ratios (HR): 0.53; 95% CI 0.32-0.85; P = 0.033) and improved prone positioning response rate [70.5% vs. 60.5%; odds ratio (OR): 1.46; 95% CI 1.23-1.89; P = 0.025]. RCS analysis suggested a reduction in mortality with prone durations ≥ 16 h, and longer durations correlated with better prone response. However, no significant association was found between PPP and reduced ICU or hospital length of stay. RCS analysis indicated a gradual decrease in 28-day mortality with increasing duration of prone positioning, and longer duration were associated with a higher likelihood of a prone response. There were no significant differences in prone ventilation-related complications between the two groups. CONCLUSIONS PPP (≥ 16 h) is associated with reduced 28-day mortality and improved response rates in ICU patients with ARDS, without increasing complication risks. Prospective studies are needed to further validate these results.
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Affiliation(s)
- Yuhang Yan
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- School of Nursing, Southern Medical University, Guangzhou, 510515, China
| | - Junying Bao
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Shumin Cai
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Xiangning Zhong
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- School of Nursing, Southern Medical University, Guangzhou, 510515, China
| | - Bingxuan Geng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Jingyi Liang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Zhiya Deng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Zhongqing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Zaisheng Qin
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - HongBin Hu
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
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Kelly-Hedrick M, Liu S, Hatfield J, Soto AL, Bartlett AM, Heo HJ, O’Callaghan E, Arulraja E, Kaplan S, Ohnuma T, Krishnamoorthy V, Colton K, Komisarow J. Management of traumatic brain injury and acute respiratory distress syndrome-What evidence exists? A scoping review. J Intensive Care Soc 2025; 26:205-222. [PMID: 39834359 PMCID: PMC11742134 DOI: 10.1177/17511437241311398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2025] Open
Abstract
Introduction Up to 20% of patients with traumatic brain injury (TBI) develop acute respiratory distress syndrome (ARDS), which is associated with increased odds of mortality. Guideline-based treatment for ARDS includes "lung protective" ventilation strategies, some of which are in opposition to "brain protective" strategies used for ventilation with patients with TBI. We conducted a scoping review of ventilation management strategies with clinical outcomes among patients with TBI and ARDS. Methods We searched three databases (MEDLINE, Embase, Web of Science) using a systematic search strategy. We included any studies of patients with TBI and ARDS with ventilation strategies including PEEP, oxygenation, prone positioning, recruitment maneuvers, pulmonary vasodilators (e.g., nitric oxide), high frequency oscillatory ventilation (HFOV), and extracorporeal membrane oxygenation (ECMO). All clinical outcomes were included. Extracted data included details about sample (age, gender), study design, inclusion/exclusion criteria, intervention details, and outcomes. Results The search returned 10,514 articles, 35 of which met final inclusion criteria. Interventions studied included ECMO (n = 13 articles), HFOV (n = 4), PEEP interventions (n = 3), prone positioning (n = 3), vasodilators (n = 4), and other lung recruitment maneuvers (n = 9). No randomized controlled trials were identified; studies were mostly case reports (n = 18/35, 51%) and series (n = 7/35, 20%), with some cohort studies (n = 5/35, 14%) and non-randomized experimental trials (n = 5/35, 14%), all at single institutions. Outcomes included physiologic changes (e.g., change in cerebrodynamics or hemodynamics with intervention) and clinical outcomes such as mortality, complications, or neurologic recovery. Five studies (14%) included pediatric patients. Discussion In this scoping review of ventilatory strategies for patients with concurrent TBI and ARDS, we found variation in heterogeneity of study design, interventions, and outcomes. Studies were mostly case report/series and observational studies, seriously limiting our ability to draw conclusions about effectiveness of interventions. Targeted areas of further research are discussed.
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Affiliation(s)
- Margot Kelly-Hedrick
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Sunny Liu
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | | | | | - Helen J. Heo
- Duke University School of Medicine, Durham, NC, USA
| | | | | | - Samantha Kaplan
- Duke University Medical Center Library and Archives, Durham, NC, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Anesthesiology, Duke University, Durham, NC, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Anesthesiology, Duke University, Durham, NC, USA
- Population Health Sciences, Duke University, Durham, NC, USA
| | | | - Jordan Komisarow
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
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Ching PR, Pedersen LL. Severe Pneumonia. Med Clin North Am 2025; 109:705-720. [PMID: 40185557 DOI: 10.1016/j.mcna.2024.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2025]
Abstract
Severe pneumonia is a leading cause of mortality and morbidity worldwide. Being a complex condition caused by a variety of microorganisms including bacteria, viruses, and fungi, it requires intensive care. A combination of early initiation of antimicrobial therapy and adjunctive nonantimicrobial interventions improve patient outcomes. This article reviews the most recent data on the epidemiology, microbiology, diagnosis, and management of severe pneumonia.
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Affiliation(s)
- Patrick R Ching
- Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, 1000 East Marshall Street, Suite 107, Richmond, VA 23298, USA; Healthcare Infection Prevention Program, Virginia Commonwealth University Health, Richmond, VA, USA.
| | - Laura L Pedersen
- Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, 1000 East Marshall Street, Suite 107, Richmond, VA 23298, USA
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Pettenuzzo T, Balzani E, Sella N, Giani M, Bassi M, Fincati V, Cescon R, Pacchiarini G, Pandolfo G, Ceccato R, Grønlykke L, Staudacher DL, Nesseler N, Raasveld SJ, Carron M, Pistollato E, Mormando G, Zarantonello F, De Cassai A, Boscolo A, Rezoagli E, Foti G, Navalesi P. Prone positioning during veno-venous extracorporeal membrane oxygenation: a systematic review and meta-analysis. Intensive Care Med 2025:10.1007/s00134-025-07877-2. [PMID: 40298974 DOI: 10.1007/s00134-025-07877-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2024] [Accepted: 03/19/2025] [Indexed: 04/30/2025]
Abstract
PURPOSE The evidence supporting the benefit on clinical outcomes of prone positioning during veno-venous extracorporeal membrane oxygenation (V-V ECMO) for acute hypoxemic respiratory failure remains inconclusive. We aimed to assess the association of prone positioning, compared to no prone positioning, with 28-day mortality and other clinical outcomes in different patient subgroups. METHODS A systematic review and meta-analysis of randomized and non-randomized controlled trials (RCTs) using a random-effects model was conducted. An electronic database search up to September 1st, 2024 was performed (PROSPERO CRD42024517602). The RoB 2 and ROBINS-I tools were used for risk of bias assessments. RESULTS We analyzed two RCTs and 20 non-RCTs (3,465 patients). Compared to no prone positioning, the use of prone positioning was associated with lower 28-day (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.42-0.98, p = 0.040, I2 = 66%, low certainty of evidence [CoE]) and hospital mortality (OR 0.67, 95% CI 0.54-0.83, p < 0.001, I2 = 39%, low CoE), despite fewer 28-day ventilator-free days and longer ECMO duration. Younger age (p = 0.005), a higher sequential organ failure assessment (SOFA) score (p = 0.022), non-Covid-19 etiology (p = 0.003), and lower rates of prone positioning before cannulation (p = 0.049) were associated with a greater benefit from prone positioning. CONCLUSION In this analysis, among patients supported with V-V ECMO for acute hypoxemic respiratory failure, we observed improved 28-day and hospital mortality in those who received prone positioning, compared to those who did not. However, these findings do not imply causation. Further research is needed to clarify the role of prone positioning in this population.
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Affiliation(s)
- Tommaso Pettenuzzo
- Institute of Anesthesia and Intensive Care, University Hospital of Padua, Padua, Italy
| | - Eleonora Balzani
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Nicolò Sella
- Institute of Anesthesia and Intensive Care, University Hospital of Padua, Padua, Italy
| | - Marco Giani
- Emergency Medicine Department, San Gerardo Hospital, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Mara Bassi
- Department of Medicine, University of Padua, Padua, Italy
| | | | | | - Giorgia Pacchiarini
- Institute of Anesthesia and Intensive Care, University Hospital of Padua, Padua, Italy
| | | | | | - Lars Grønlykke
- Department of Cardiothoracic Anesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Dawid L Staudacher
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Nicolas Nesseler
- Department of Anesthesia and Critical Care, Rennes University Hospital, Rennes, France
- Centre d'Investigation Clinique de Rennes, University of Rennes, Rennes, France
| | - Senta Jorinde Raasveld
- Department of Critical Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Michele Carron
- Institute of Anesthesia and Intensive Care, University Hospital of Padua, Padua, Italy
- Department of Medicine, University of Padua, Padua, Italy
| | | | - Giulia Mormando
- Department of Medicine, University of Padua, Padua, Italy
- Emergency Medicine Department, Padua University Hospital, Padua, Italy
| | | | - Alessandro De Cassai
- Institute of Anesthesia and Intensive Care, University Hospital of Padua, Padua, Italy
- Department of Medicine, University of Padua, Padua, Italy
| | - Annalisa Boscolo
- Institute of Anesthesia and Intensive Care, University Hospital of Padua, Padua, Italy
- Department of Medicine, University of Padua, Padua, Italy
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Emanuele Rezoagli
- Emergency Medicine Department, San Gerardo Hospital, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giuseppe Foti
- Emergency Medicine Department, San Gerardo Hospital, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Paolo Navalesi
- Institute of Anesthesia and Intensive Care, University Hospital of Padua, Padua, Italy.
- Department of Medicine, University of Padua, Padua, Italy.
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8
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López-Fernández YM, Martínez-de-Azagra A, Reyes-Domínguez SB, Gómez-Zamora A, Herrera-Castillo L, Coca-Pérez A, Parrilla-Parrilla J, Medina A, García-Iñiguez JP, Brezmes-Raposo M, Hernández-Yuste A, Llorente de la Fuente AM, Ibarra de la Rosa I, León-González JS, Trastoy-Quintela J, Arjona-Villanueva D, González-Martín JM, Szakmany T, Villar J. The Prevalence and Outcome of Acute Hypoxemic Respiratory Failure (PANDORA) Study in Mechanically Ventilated Children: Prospective Multicenter Epidemiology in Spain, 2019-2021. Pediatr Crit Care Med 2025:00130478-990000000-00486. [PMID: 40277417 DOI: 10.1097/pcc.0000000000003743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2025]
Abstract
OBJECTIVES To describe the epidemiology and outcome of children with acute hypoxemic respiratory failure (AHRF) and/or pediatric acute respiratory distress syndrome (PARDS). DESIGN Prospective, observational study in six nonconsecutive 2-month blocks form October 2019 to September 2021. SETTING A network of 22 PICUs in Spain. PATIENTS Consecutive children (7 d to 15 yr old) with a diagnosis of AHRF, defined by Pao2/Fio2 ratio less than or equal to 300 mm Hg, who needed invasive mechanical ventilation (IMV) using positive end-expiratory pressure (PEEP) greater than or equal to 5 cm H2O and Fio2 greater than or equal to 0.3. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcomes were AHRF prevalence and PICU mortality. The secondary outcomes were the prevalence of IMV with PARDS (IMV-PARDS) and the use of adjunctive therapies. There were 6545 PICU admissions: 1374 (21%) underwent IMV and 181 (2.8%) had AHRF. Ninety-one patients (1.4% of PICU admissions, 6.6% of IMV cases, and 50.3% of AHRF cases) met the Second Pediatric Acute Lung Injury Consensus Conference IMV-PARDS criteria. At baseline, mean (± sd) tidal volume was 7.4 ± 1.8 mL/kg ideal body weight, PEEP 8.4 ± 3.1 cm H2O, Fio2 0.68 ± 0.23, and plateau pressure 25.7 ± 6.3 cm H2O. Unlike patients with PARDS, adjunctive therapies were used infrequently in non-PARDS AHRF patients. AHRF patients without PARDS had more ventilator-free days than PARDS patients (16.4 ± 9.4 vs. 11.2 ± 10.5; p = 0.002). All-cause PICU mortality in AHRF cases was higher in PARDS vs. non-PARDS patients (30.8% [95% CI, 21.5-41.3] vs. (14.4% [95% CI, 7.9-23.4]; p = 0.01). CONCLUSIONS In our 2019-2021 PICU population, the prevalence of AHRF is 2.8% of IMV cases. Of such patients, the prevalence of PARDS was 50.3%, and there was a 30.8% mortality, which was higher than in cases of AHRF without PARDS.
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Affiliation(s)
- Yolanda M López-Fernández
- Pediatric Intensive Care Unit, Department of Pediatrics, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
| | | | - Susana B Reyes-Domínguez
- Pediatric Intensive Care Unit, Department of Pediatrics, Arrixaca University Hospital, Murcia, Spain
| | - Ana Gómez-Zamora
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario La Paz, Madrid, Spain
| | - Laura Herrera-Castillo
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Ana Coca-Pérez
- Pediatric Intensive Care Unit, Department of Pediatrics, Ramon y Cajal University Hospital, Madrid, Spain
| | - Julio Parrilla-Parrilla
- Pediatric Intensive Care Unit, Department of Pediatrics, Virgen del Rocío University Hospital, Seville, Spain
| | - Alberto Medina
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Juan P García-Iñiguez
- Pediatric Intensive Care Unit, Department of Pediatrics, Miguel Servet University Hospital, Aragón Health Research Institute, Zaragoza, Spain
| | - Marta Brezmes-Raposo
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Clínico Universitario, Valladolid, Spain
| | - Alexandra Hernández-Yuste
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | - Ignacio Ibarra de la Rosa
- Pediatric Intensive Care Unit, Department of Pediatrics, Reina Sofía University Hospital, Cordoba, Spain
| | - José S León-González
- Pediatric Intensive Care Unit, Complejo Hospitalario Universitario Ntra. Sra. de Candelaria, Santa Cruz de Tenerife, Tenerife, Spain
| | - Javier Trastoy-Quintela
- Pediatric Intensive Care Unit, Department of Pediatrics, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - David Arjona-Villanueva
- Pediatric Intensive Care Unit, Department of Pediatrics, Complejo Hospitalario Universitario de Toledo, Toledo, Spain
| | - Jesús M González-Martín
- Department of Pediatrics, CIBER de Enfermedades respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Department of Pediatrics, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Tamas Szakmany
- Department of Anesthesia, Intensive Care and Pain Medicine, Cardiff University, Cardiff, United Kingdom
| | - Jesús Villar
- Department of Pediatrics, CIBER de Enfermedades respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit at Hospital Universitario Dr. Negrín, Fundación Canaria Instituto de Investigación Sanitaria de Canarias, Las Palmas de Gran Canaria, Spain
- Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, Canada
- Faculty of Health Sciences, Universidad del Atlántico Medico, Las Palmas, Spain
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9
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Stoffel ST, Juhasz SA, Wood ME, Danciu T, Wiggins AR, O'Neil ER, Manninen ES. Double the Trouble: Successful Cannulation and Air Transportation of Two Obese Trauma Patients Requiring Extracorporeal Membrane Oxygenation. Mil Med 2025; 190:e1309-e1313. [PMID: 39985237 DOI: 10.1093/milmed/usaf045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2024] [Revised: 11/27/2024] [Accepted: 02/06/2025] [Indexed: 02/24/2025] Open
Abstract
Acute Respiratory Distress Syndrome (ARDS) is a known and severe complication of thoracic trauma. Many patients, despite appropriate ventilator and medical support, continue to worsen requiring additional cardiopulmonary support with extracorporeal membrane oxygenation (ECMO). Additionally, obesity adds a layer of complexity in the management of trauma ARDS on ECMO. We describe the first U.S. Military air transportation mission via Critical Care Air Transport (CCAT) involving the cannulation and transportation of 2 obese trauma patients requiring ECMO support. We reviewed a cohort of 2 obese patients with ARDS secondary to trauma cannulated for venovenous ECMO and simultaneously transferred via Critical Care Air Transport to a DoD ECMO Center. We describe the logistics involved in the transport and management of obese trauma patients on ECMO. Both patients were safely cannulated and transported without complications, and survived their ECMO run and hospital stay. This is the first air transport of 2 obese ECMO patients simultaneously in U.S. Military history. This transport highlights the safety of cannulation and transportation of obese trauma patients, in addition to the flexibility and logistics needed to successfully complete an ECMO military transport.
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Affiliation(s)
- Steven T Stoffel
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Sarah A Juhasz
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
| | - Matthew E Wood
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
| | - Theodor Danciu
- Department of Anesthesia, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Amanda R Wiggins
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
| | - Erika R O'Neil
- Department of Pediatrics, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Erik S Manninen
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
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10
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Diniz-Silva F, Serpa A, Ferreira JC. Application of new ARDS guidelines at the bedside. CRITICAL CARE SCIENCE 2025; 37:e20250171. [PMID: 40243861 PMCID: PMC12040422 DOI: 10.62675/2965-2774.20250171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 07/22/2024] [Indexed: 04/18/2025]
Affiliation(s)
- Fabia Diniz-Silva
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilDivision of Pulmonology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Ary Serpa
- Monash UniversitySchool of Public Health and Preventive MedicineAustralian and New Zealand Intensive Care Research CentreMelbourneAustraliaAustralian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University - Melbourne, Australia.
| | - Juliana Carvalho Ferreira
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilDivision of Pulmonology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
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11
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Maccagnan Pinheiro Besen BA, Rosa Ramos JG, Aragão I. Brazilian joint statement on the management of mechanically ventilated patients: where did we come from? Where should we go? CRITICAL CARE SCIENCE 2025; 37:e20250028. [PMID: 40243860 PMCID: PMC12040420 DOI: 10.62675/2965-2774.20250028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2025] [Accepted: 01/25/2025] [Indexed: 04/18/2025]
Affiliation(s)
- Bruno Adler Maccagnan Pinheiro Besen
- Universidade de São PauloFaculdade de MedicinaSão PauloSPBrazilPostgraduate Programme in Medical Sciences, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
- Instituto D’Or de Pesquisa e EnsinoSão PauloSPBrazilInstituto D’Or de Pesquisa e Ensino - São Paulo (SP), Brazil.
| | - João Gabriel Rosa Ramos
- Clínica FlorenceSalvadorBABrazilClínica Florence - Salvador (BA), Brazil.
- Universidade Federal da BahiaFaculdade de MedicinaSalvadorBABrazilFaculdade de Medicina, Universidade Federal da Bahia - Salvador (BA), Brazil.
| | - Irene Aragão
- Centro Hospitalar Universitário do PortoHospital de Santo AntonioIntensive Care Unit and EmergencyPortoPortugualIntensive Care Unit and Emergency, Hospital de Santo Antonio, Centro Hospitalar Universitário do Porto - Porto, Portugual.
- Universidade do PortoInstituto de Ciências Biomédicas Abel SalazarPortoPortugalInstituto de Ciências Biomédicas Abel Salazar, Universidade do Porto - Porto, Portugal.
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12
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Heffernan M, Quinn J, Tschautscher C, Newberry R, Cathers A, Bernardoni B. Stabilization of Cardiogenic Shock for Critical Care Transport, a Simulation. JOURNAL OF EDUCATION & TEACHING IN EMERGENCY MEDICINE 2025; 10:S31-S57. [PMID: 40336691 PMCID: PMC12054092 DOI: 10.21980/j82354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 02/26/2025] [Indexed: 05/09/2025]
Abstract
Audience This simulation is designed for critical care transport providers but can be easily adapted for the inpatient setting. It is applicable to an interdisciplinary team including nurses, respiratory therapists, medical students, emergency medicine residents, and emergency medicine attendings. Introduction Cardiogenic shock carries an incredibly high burden of morbidity and mortality. Acute myocardial infarction accounts for 81% of cardiogenic shock patients and is a common indication for transfer to a tertiary care facility.1 Hypotension due to cardiogenic shock is often refractory to volume resuscitation and often requires pharmacologic intervention. Additionally, the resultant end organ dysfunction frequently requires advanced ventilatory support.1-6 This simulation aims to educate critical care transport providers on the best practices for management of the cardiogenic shock patients requiring resuscitation and intubation prior to transport. Educational Objectives By the end of this simulation session, learners will be able to: 1) recognize the need for intubation in an unstable patient in cardiogenic shock who requires transport, 2) appropriately titrate bi-Level non-invasive ventilatory support (BiPAP) to optimize oxygenation and ventilation in preparation for intubation, 3) choose appropriate vasoactive medications to support the hemodynamics of a patient in cardiogenic shock, 4) perform rapid sequence intubation using appropriate induction and paralytic agents and dosing for a patient in cardiogenic shock, 5) choose appropriate initial lung-protective ventilator settings, and 6) implement an adequate analgesia and sedation plan for transport of an intubated patient in cardiogenic shock. Educational Methods This session was conducted using high-fidelity simulation, allowing learners to manage a patient in cardiogenic shock and respiratory distress requiring intubation. Each session was followed by a debriefing and discussion. Research Methods Qualitative feedback provided by participants during the discussion session was utilized to adjust the simulation between each session. In addition, participants were surveyed using a five-point Likert scale (strongly disagree to strongly agree) on if the simulation met their professional and educational needs, its efficacy and appropriateness for Level, and whether it would change future practice. Results A total of 36 learners, including 20 physicians and 16 nurses, participated in the simulation over a total of nine sessions. Twenty out of the thirty-six participants completed the survey (both RNs and MDs) and 100% responded "strongly agree" to all four prompts (top response out of a five Likert scale). Feedback provided by participants was used after each session to adjust the simulation. Changes implemented included the addition of a nurse confederate, greater emphasis on management and titration of non-invasive ventilation for optimal preoxygenation, and initiation of post intubation sedation and analgesia. Discussion Cardiogenic shock is a common cause of mortality, often requires transport, and is particularly challenging to manage. This simulation was overall effective at educating learners on the resuscitation of cardiogenic shock, including appropriate use of vasopressors and ventilatory support. Topics Cardiogenic shock, hypoxic respiratory failure, vasopressor management, airway management, intubation, non-invasive positive pressure ventilation management, ventilatory management, emergency medicine, critical care transport medicine.
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Affiliation(s)
- Matthew Heffernan
- University of Wisconsin-Madison School of Medicine and Public Health, Department of Emergency Medicine, Madison, WI
- UW Med Flight, Madison, WI
| | - Jennifer Quinn
- University of Wisconsin-Madison School of Medicine and Public Health, Department of Emergency Medicine, Madison, WI
- UW Med Flight, Madison, WI
| | - Craig Tschautscher
- University of Wisconsin-Madison School of Medicine and Public Health, Department of Emergency Medicine, Madison, WI
- UW Med Flight, Madison, WI
| | - Ryan Newberry
- University of Wisconsin-Madison School of Medicine and Public Health, Department of Emergency Medicine, Madison, WI
- UW Med Flight, Madison, WI
| | - Andrew Cathers
- University of Wisconsin-Madison School of Medicine and Public Health, Department of Emergency Medicine, Madison, WI
- UW Med Flight, Madison, WI
| | - Brittney Bernardoni
- University of Wisconsin-Madison School of Medicine and Public Health, Department of Emergency Medicine, Madison, WI
- UW Med Flight, Madison, WI
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13
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Karanth SK, Azhar SZ, Corrales-Martinez MJ, Krishnamoorthy V, Wongsripuemtet PT, Cobert J, Hashemaghaie M, Raghunathan K. The effect of culture on the benefits of awake prone positioning for adults with COVID-19 acute respiratory distress syndrome: A systematic review and meta-analysis. EUROPEAN JOURNAL OF ANAESTHESIOLOGY AND INTENSIVE CARE 2025; 4:e0068. [PMID: 40206341 PMCID: PMC11977753 DOI: 10.1097/ea9.0000000000000068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2024] [Accepted: 01/05/2025] [Indexed: 04/11/2025]
Abstract
BACKGROUND Randomised controlled trials (RCTs) conducted early during the pandemic showed that awake prone positioning (APP) significantly reduced the risk of intubation among adults with COVID-19 acute respiratory distress syndrome (ARDS), but more recent studies have questioned this benefit. We hypothesise that the effects of APP may vary with the national Power Distance Index (PDI), a measure of hierarchy in local culture. OBJECTIVE To conduct a meta-analysis examining the effects of APP in adults with COVID-19 ARDS and examine whether effects differ between nations with a PDI less than 80 versus at least 80 (low versus high deference to authority). DESIGN Systematic review and meta-analysis of RCTs. DATA SOURCES Cumulated Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, Embase, Medline and Scopus were searched to November 2024. ELIGIBILITY CRITERIA All RCTs that compared APP with standard care in adults with COVID-19-related ARDS or Acute Hypoxaemic Respiratory Failure (AHRF) were included. RESULTS Twenty-two RCTs were identified with 3615 patients having valid data. APP reduced the risk of intubation [relative risk (RR) 0.80, 95% confidence interval (CI), 0.72 to 0.90]. Effects were greater in nations with a PDI at least 80 (RR 0.67, 95% CI, 0.54 to 0.82), and there was equipoise in nations with a PDI less than 80 (RR 0.89, 95% CI, 0.75 to 1.05). Intubation rates in the high PDI nations decreased from 32.3% (n = 512) with standard care to 21.2% (n = 508) with APP. The reduction in intubations with APP was less pronounced in nations with low PDI, from 20.1% (n = 1012) with standard care to 17.1% (n = 1084). The risk of mortality reduced with APP (RR 0.86, 95% CI, 0.74 to 0.99). Fidelity of APP, specifically, adherence to the recommended duration, was higher in nations with PDI at least 80 (P = 0.04). CONCLUSION APP reduces the risk of intubation and mortality, but the significance of this benefit varies with the cultural context. Effects are strong in nations with a higher PDI, where intubation rates are lower and adherence to APP higher.
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Affiliation(s)
- Sowmyashree Kota Karanth
- From the Department of Anesthesiology, Duke University, Durham, North Carolina (SKK, MJC-M, VK, PTW, MH, KR), Department of Emergency Medicine, Louisiana State University Health Sciences Center Shreveport, Shreveport, Lousiana (SZA) and Department of Anesthesiology, University of California, San Francisco, California, USA (JC)
| | - Saajid Z Azhar
- From the Department of Anesthesiology, Duke University, Durham, North Carolina (SKK, MJC-M, VK, PTW, MH, KR), Department of Emergency Medicine, Louisiana State University Health Sciences Center Shreveport, Shreveport, Lousiana (SZA) and Department of Anesthesiology, University of California, San Francisco, California, USA (JC)
| | - Maria J Corrales-Martinez
- From the Department of Anesthesiology, Duke University, Durham, North Carolina (SKK, MJC-M, VK, PTW, MH, KR), Department of Emergency Medicine, Louisiana State University Health Sciences Center Shreveport, Shreveport, Lousiana (SZA) and Department of Anesthesiology, University of California, San Francisco, California, USA (JC)
| | - Vijay Krishnamoorthy
- From the Department of Anesthesiology, Duke University, Durham, North Carolina (SKK, MJC-M, VK, PTW, MH, KR), Department of Emergency Medicine, Louisiana State University Health Sciences Center Shreveport, Shreveport, Lousiana (SZA) and Department of Anesthesiology, University of California, San Francisco, California, USA (JC)
| | - Pattrapun T Wongsripuemtet
- From the Department of Anesthesiology, Duke University, Durham, North Carolina (SKK, MJC-M, VK, PTW, MH, KR), Department of Emergency Medicine, Louisiana State University Health Sciences Center Shreveport, Shreveport, Lousiana (SZA) and Department of Anesthesiology, University of California, San Francisco, California, USA (JC)
| | - Julien Cobert
- From the Department of Anesthesiology, Duke University, Durham, North Carolina (SKK, MJC-M, VK, PTW, MH, KR), Department of Emergency Medicine, Louisiana State University Health Sciences Center Shreveport, Shreveport, Lousiana (SZA) and Department of Anesthesiology, University of California, San Francisco, California, USA (JC)
| | - Mona Hashemaghaie
- From the Department of Anesthesiology, Duke University, Durham, North Carolina (SKK, MJC-M, VK, PTW, MH, KR), Department of Emergency Medicine, Louisiana State University Health Sciences Center Shreveport, Shreveport, Lousiana (SZA) and Department of Anesthesiology, University of California, San Francisco, California, USA (JC)
| | - Karthik Raghunathan
- From the Department of Anesthesiology, Duke University, Durham, North Carolina (SKK, MJC-M, VK, PTW, MH, KR), Department of Emergency Medicine, Louisiana State University Health Sciences Center Shreveport, Shreveport, Lousiana (SZA) and Department of Anesthesiology, University of California, San Francisco, California, USA (JC)
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14
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Maso I, Luvizutto GJ, Miranda JMDA, Nascimento CFD, Bonome LAM, Pinto EB, Klitzke FM, Souza RM, Moro CHC, Bazan R, Jesus PAPD, Rocha EDMC, Minelli C, Martins SO, Baggio JADO. A physiotherapy protocol* for stroke patients in acute hospital settings: expert consensus from the Brazilian early stroke rehabilitation task force. ARQUIVOS DE NEURO-PSIQUIATRIA 2025; 83:1-18. [PMID: 40262822 DOI: 10.1055/s-0045-1806924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/24/2025]
Abstract
The present protocol provides general recommendations based on the best evidence currently available for physiotherapists to use as a guide for the care of stroke patients during hospitalization. The Brazilian Early Stroke Rehabilitation Task Force, comprising physical therapy experts and researchers from different Brazilian states, was organized to develop this care protocol based on a bibliographical survey, including meta-analyses, systematic reviews, clinical trials, and other more recent and relevant scientific publications. Professionals working in stroke units were also included in the task force to ensure the practicality of the protocol in different contexts. This protocol provides guidance on assessment strategies, safety criteria for the mobilization of patients with stroke, recommendations for mobilization and proper positioning, as well as evidence-based practices for treatment during hospitalization, including preventive measures for shoulder pain and shoulder-hand syndrome. The protocol also provides information on the organization of the physiotherapy service at stroke units, guidelines for hospital discharge, and quality indicators for physiotherapy services. We have included detailed activities that can be performed during mobilization in the supplementary material, such as postural control training, sensory and perceptual stimulation, task-oriented training, and activities involving an enriched environment. The protocol was written in a user-friendly format to facilitate its application in different social and cultural contexts, utilizing resources readily available in most clinical settings.
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Affiliation(s)
- Iara Maso
- Hospital Geral Roberto Santos, Unidade de AVC, Salvador BA, Brazil
- Escola Bahiana de Medicina e Saúde Pública, Grupo de Pesquisa Comportamento Motor e Reabilitação Neurofuncional, Salvador BA, Brazil
| | - Gustavo José Luvizutto
- Universidade Federal do Triângulo Mineiro, Departamento de Fisioterapia Aplicada, Uberaba MG, Brazil
| | | | - Carla Ferreira do Nascimento
- Hospital Geral Roberto Santos, Unidade de AVC, Salvador BA, Brazil
- Escola Bahiana de Medicina e Saúde Pública, Grupo de Pesquisa Comportamento Motor e Reabilitação Neurofuncional, Salvador BA, Brazil
| | | | - Elen Beatriz Pinto
- Escola Bahiana de Medicina e Saúde Pública, Grupo de Pesquisa Comportamento Motor e Reabilitação Neurofuncional, Salvador BA, Brazil
| | - Fabiane Maria Klitzke
- Hospital Municipal São José, Programa de Residência Multiprofissional em Neurologia, Joinville SC, Brazil
| | - Ricardo Machado Souza
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas, Unidade de AVC, Ribeirão Preto SP, Brazil
| | | | - Rodrigo Bazan
- Universidade Estadual Paulista, Faculdade de Medicina de Botucatu, Botucatu SP, Brazil
| | - Pedro Antonio Pereira de Jesus
- Hospital Geral Roberto Santos, Unidade de AVC, Salvador BA, Brazil
- Universidade Federal da Bahia, Instituto de Ciências da Saúde, Salvador BA, Brazil
| | | | - Cesar Minelli
- Hospital Carlos Fernando Malzoni, Matão SP, Brazil
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Programa de Pós-Graduação do Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | - Sheila Ouriques Martins
- Hospital de Clínicas de Porto Alegre, Porto Alegre RS, Brazil
- Universidade Federal do Rio Grande do Sul, Porto Alegre RS, Brazil
- Rede Brasil AVC, Porto Alegre RS, Brazil
- World Stroke Organization, Geneva, Switzerland
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15
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Mokra D, Porvaznik I, Mokry J. N-Acetylcysteine in the Treatment of Acute Lung Injury: Perspectives and Limitations. Int J Mol Sci 2025; 26:2657. [PMID: 40141299 PMCID: PMC11942046 DOI: 10.3390/ijms26062657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2025] [Revised: 03/03/2025] [Accepted: 03/13/2025] [Indexed: 03/28/2025] Open
Abstract
N-acetylcysteine (NAC) can take part in the treatment of chronic respiratory diseases because of the potent mucolytic, antioxidant, and anti-inflammatory effects of NAC. However, less is known about its use in the treatment of acute lung injury. Nowadays, an increasing number of studies indicates that early administration of NAC may reduce markers of oxidative stress and alleviate inflammation in animal models of acute lung injury (ALI) and in patients suffering from distinct forms of acute respiratory distress syndrome (ARDS) or pulmonary infections including community-acquired pneumonia or Coronavirus Disease (COVID)-19. Besides low costs, easy accessibility, low toxicity, and rare side effects, NAC can also be combined with other drugs. This article provides a review of knowledge on the mechanisms of inflammation and oxidative stress in various forms of ALI/ARDS and critically discusses experience with the use of NAC in these disorders. For preparing the review, articles published in the English language from the PubMed database were used.
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Affiliation(s)
- Daniela Mokra
- Department of Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, SK-03601 Martin, Slovakia
| | - Igor Porvaznik
- Department of Laboratory Medicine, Faculty of Health Sciences, Catholic University in Ružomberok, SK-03401 Ružomberok, Slovakia;
| | - Juraj Mokry
- Department of Pharmacology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, SK-03601 Martin, Slovakia;
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16
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Villar J, González-Martín JM, Fernández C, Añón JM, Ferrando C, Mora-Ordoñez JM, Martínez D, Mosteiro F, Ambrós A, Fernández L, Murcia I, Vidal A, Pestaña D, Romera MA, Montiel R, Domínguez-Berrot AM, Soler JA, Gómez-Bentolila E, Steyerberg EW, Szakmany T. Early Prediction of ICU Mortality in Patients with Acute Hypoxemic Respiratory Failure Using Machine Learning: The MEMORIAL Study. J Clin Med 2025; 14:1711. [PMID: 40095813 PMCID: PMC11900058 DOI: 10.3390/jcm14051711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2025] [Revised: 02/25/2025] [Accepted: 02/26/2025] [Indexed: 03/19/2025] Open
Abstract
Background: Early prediction of ICU death in acute hypoxemic respiratory failure (AHRF) could inform clinicians for targeting therapies to reduce harm and increase survival. We sought to determine clinical modifiable and non-modifiable features during the first 24 h of AHRF associated with ICU death. Methods: This is a development, testing, and validation study using data from a prospective, multicenter, nation-based, observational cohort of 1241 patients with AHRF (defined as PaO2/FiO2 ≤ 300 mmHg on mechanical ventilation [MV] with positive end-expiratory pressure [PEEP] ≥ 5 cmH2O and FiO2 ≥ 0.3) from any etiology. Using relevant features captured at AHRF diagnosis and within 24 h, we developed a logistic regression model following variable selection by genetic algorithm and machine learning (ML) approaches. Results: We analyzed 1193 patients, after excluding 48 patients with no data at 24 h after AHRF diagnosis. Using repeated random sampling, we selected 75% (n = 900) for model development and testing, and 25% (n = 293) for final validation. Risk modeling identified six major predictors of ICU death, including patient's age, and values at 24 h of PEEP, FiO2, plateau pressure, tidal volume, and number of extrapulmonary organ failures. Performance with ML methods was similar to logistic regression and achieved a high area under the receiver operating characteristic curve (AUROC) of 0.88, 95%CI 0.86-0.90. Validation confirmed adequate model performance (AUROC 0.83, 95%CI 0.78-0.88). Conclusions: ML and traditional methods led to an encouraging model to predict ICU death in ventilated AHRF as early as 24 h after diagnosis. More research is needed to identify modifiable factors to prevent ICU deaths.
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Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029 Madrid, Spain; (J.M.G.-M.); (J.M.A.); (C.F.)
- Research Unit, Hospital Universitario Dr. Negrín, Fundación Canaria Instituto de Investigación Sanitaria, 35019 Las Palmas de Gran Canaria, Spain
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada
- Faculty of Health Sciences, Universidad del Atlántico Medio, 35017 Las Palmas, Spain
| | - Jesús M. González-Martín
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029 Madrid, Spain; (J.M.G.-M.); (J.M.A.); (C.F.)
- Research Unit, Hospital Universitario Dr. Negrín, 35019 Las Palmas de Gran Canaria, Spain; (C.F.); (E.G.-B.)
| | - Cristina Fernández
- Research Unit, Hospital Universitario Dr. Negrín, 35019 Las Palmas de Gran Canaria, Spain; (C.F.); (E.G.-B.)
| | - José M. Añón
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029 Madrid, Spain; (J.M.G.-M.); (J.M.A.); (C.F.)
- Intensive Care Unit, Hospital Universitario La Paz, IdiPaz, 28029 Madrid, Spain
| | - Carlos Ferrando
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, 28029 Madrid, Spain; (J.M.G.-M.); (J.M.A.); (C.F.)
- Surgical Intensive Care Unit, Department of Anesthesia, Hospital Clinic, IDIBAPS, 08036 Barcelona, Spain
| | - Juan M. Mora-Ordoñez
- Intensive Care Unit, Hospital Universitario Reginal Carlos Haya, 29010 Málaga, Spain;
| | - Domingo Martínez
- Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, 30120 Murcia, Spain; (D.M.); (J.A.S.)
| | - Fernando Mosteiro
- Intensive Care Unit, Hospital Universitario A Coruña, 15006 La Coruña, Spain;
| | - Alfonso Ambrós
- Intensive Care Unit, Hospital General Universitario de Ciudad Real, 13005 Ciudad Real, Spain;
| | - Lorena Fernández
- Intensive Care Unit, Hospital Universitario Río Hortega, 47012 Valladolid, Spain;
| | - Isabel Murcia
- Intensive Care Unit, Complejo Hospitalario Universitario de Albacete, 02006 Albacete, Spain;
| | - Anxela Vidal
- Intensive Care Unit, Hospital Universitario Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | - David Pestaña
- Surgical Intensive Care Unit, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain;
| | - Miguel A. Romera
- Intensive Care Unit, Hospital Universitario Puerta de Hierro, 28222 Madrid, Spain;
| | - Raquel Montiel
- Intensive Care Unit, Hospital Universitario N.S. de Candelaria, 38010 Santa Cruz de Tenerife, Spain;
| | | | - Juan A. Soler
- Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, 30120 Murcia, Spain; (D.M.); (J.A.S.)
| | - Estrella Gómez-Bentolila
- Research Unit, Hospital Universitario Dr. Negrín, 35019 Las Palmas de Gran Canaria, Spain; (C.F.); (E.G.-B.)
| | - Ewout W. Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
- Julius Center, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Tamas Szakmany
- Department of Anesthesia, Intensive Care and Pain Medicine, Cardiff University, Cardiff CF10 3AT, UK;
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17
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Dao CX, Dang TQ, Luong CQ, Manabe T, Nguyen MH, Pham DT, Pham QT, Vu TT, Truong HT, Nguyen HH, Nguyen CB, Khuong DQ, Dang HD, Nguyen TA, Pham TT, Bui GTH, Van Bui C, Nguyen QH, Tran TH, Nguyen TC, Vo KH, Vu LT, Phan NT, Nguyen PTH, Nguyen CD, Nguyen AD, Van Nguyen C, Nguyen BG, Do SN. Predictive validity of the sequential organ failure assessment score for mortality in patients with acute respiratory distress syndrome in Vietnam. Sci Rep 2025; 15:7406. [PMID: 40033012 PMCID: PMC11876689 DOI: 10.1038/s41598-025-92199-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Accepted: 02/25/2025] [Indexed: 03/05/2025] Open
Abstract
Evaluating the prognosis of ARDS patients using grading systems can enhance treatment decisions. This retrospective observational study evaluated the predictive accuracy of the SOFA score, APACHE II score, SpO2/FiO2 ratio, and PaO2/FiO2 ratio for mortality in ARDS patients in Vietnam. The study included 335 adult ARDS patients admitted to a central hospital from August 2015 to August 2023. Among them, 66.9% were male, the median age was 55 years, and 61.5% died in the hospital. The SOFA (AUROC: 0.651) and APACHE II scores (AUROC: 0.693) showed poor discriminatory ability for hospital mortality. The SpO2/FiO2 (AUROC: 0.595) and PaO2/FiO2 ratios (AUROC: 0.595) also displayed poor discriminatory ability. In multivariable analyses, after adjusting for the same set of confounding variables, the APACHE II score (adjusted OR: 1.152), SpO2/FiO2 ratio (adjusted OR: 0.985), and PaO2/FiO2 ratio (adjusted OR: 0.989) were independently associated with hospital mortality. Although the SOFA score (adjusted OR: 1.132) indicated a potential association with hospital mortality, it did not reach statistical significance (p = 0.081). However, a SOFA score of ≥ 10 emerged as an independent predictor (adjusted OR: 3.398) of hospital mortality. These findings emphasize the need for further studies to develop more accurate scoring systems for predicting outcomes in ARDS patients.
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Affiliation(s)
- Co Xuan Dao
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, VNU University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Tuan Quoc Dang
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam.
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam.
| | - Chinh Quoc Luong
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, VNU University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Toshie Manabe
- Nagoya City University School of Data Science, Nagoya, Aichi, Japan
- Center for Clinical Research, Nagoya City University Hospital, Nagoya, Aichi, Japan
| | - My Ha Nguyen
- Department of Health Organization and Management, Faculty of Public Health, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - Dung Thi Pham
- Department of Nutrition and Food Safety, Faculty of Public Health, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - Quynh Thi Pham
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Intensive Care Unit, University Medical Center Ho Chi Minh City, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Tai Thien Vu
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Emergency Department, Thai Nguyen National Hospital, Thai Nguyen City, Thai Nguyen, Vietnam
| | - Hau Thi Truong
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
| | - Hai Hoang Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Emergency Department, Agriculture General Hospital, Hanoi, Vietnam
| | - Cuong Ba Nguyen
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Dai Quoc Khuong
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Hien Duy Dang
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Tuan Anh Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Thach The Pham
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, VNU University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Giang Thi Huong Bui
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
| | - Cuong Van Bui
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, VNU University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Department of Intensive Care for Tropical Diseases, Bach Mai Institute for Tropical Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Quan Huu Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, VNU University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Thong Huu Tran
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, VNU University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Tan Cong Nguyen
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, VNU University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Khoi Hong Vo
- Department of Neuro Intensive Care and Emergency Neurology, Neurology Center, Bach Mai Hospital, Hanoi, Vietnam
- Department of Neurology, Hanoi Medical University, Hanoi, Vietnam
- Department of Neurology, Faculty of Medicine, VNU University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Lan Tuong Vu
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Nga Thu Phan
- Department of Health Organization and Management, Faculty of Public Health, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - Phuong Thi Ha Nguyen
- Department of Nutrition and Food Safety, Faculty of Public Health, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - Cuong Duy Nguyen
- Department of Emergency and Critical Care Medicine, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - Anh Dat Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Chi Van Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Binh Gia Nguyen
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Pre-Hospital Emergency Medicine, Faculty of Medicine, VNU University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Son Ngoc Do
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, No. 01, Ton That Tung Street, Dong Da District, Hanoi, 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, VNU University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
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18
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Mady AF, Hamido HM, Abdulrahman B, Mady AA, Aletreby AW, Abdalla AA, Gano JQ, Hashim Aletreby WT. Effect of Nebulized Furosemide on the Mortality of Adult, Mechanically Ventilated Acute Respiratory Distress Syndrome (ARDS) Patients: Protocol of a Randomized Clinical Trial (The ENHALE Trial). Cureus 2025; 17:e81006. [PMID: 40260371 PMCID: PMC12011351 DOI: 10.7759/cureus.81006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2025] [Indexed: 04/23/2025] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) affects a significant proportion of ICU patients and has a high mortality rate. The inflammation of the alveolar-capillary membrane is pathognomonic and characterized by increased capillary permeability and pulmonary edema. A safe, readily available anti-inflammatory agent delivered directly to the lungs could be a promising therapeutic approach. All these properties apply to nebulized furosemide. Objectives The primary objective of this study is to analyze 28-day all-cause ICU mortality while the secondary objectives include assessing hospital mortality, ICU and hospital length of stay (LOS), ventilator-free days at 28 days, successful extubation rate, and adverse events. Methods A double-blind, placebo-controlled, parallel-arm superiority RCT using an intention-to-treat (ITT) analysis to assess whether nebulized furosemide reduces mortality in adult mechanically ventilated ARDS patients will be employed. Results The results of descriptive and inferential analyses will be tabulated, and the significant results will be presented.
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Affiliation(s)
- Ahmed F Mady
- Anesthesiology and Intensive Care, Tanta University Hospitals, Tanta, EGY
- Critical Care Medicine, King Saud Medical City, Riyadh, SAU
| | - Hend M Hamido
- Critical Care Medicine, King Saud Medical City, Riyadh, SAU
| | | | - Anas A Mady
- College of Medicine, Alfaisal University College of Medicine, Riyadh, SAU
| | | | - Ahmed A Abdalla
- College of Medicine, Alfaisal University College of Medicine, Riyadh, SAU
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19
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Juanola A, Tiwari N, Solé C, Adebayo D, Wong F, Ginès P. Organ dysfunction and failure in liver disease. Liver Int 2025; 45:e15622. [PMID: 37222263 DOI: 10.1111/liv.15622] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 05/15/2023] [Indexed: 05/25/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a complex syndrome defined by the existence of different organ failures (OFs) in patients with chronic liver disease, mainly cirrhosis. Several definitions have been proposed to define the syndrome, varying in the grade of the subjacent liver disease, the type of precipitants and the organs considered in the definition. Liver, coagulation, brain, kidney, circulatory and pulmonary are the six types of OFs proposed in the different classifications, with different prevalence worldwide. Irrespective of the definition used, patients who develop ACLF present a hyperactive immune system, profound haemodynamic disturbances and several metabolic alterations that finally lead to organ dysfunction. These disturbances are triggered by different factors such as bacterial infections, alcoholic hepatitis, gastrointestinal bleeding or hepatitis B virus flare, among others. Because patients with ACLF present high short-term mortality, a prompt recognition is needed to start treatment of the trigger event and specific organ support. Liver transplantation is also feasible in carefully selected patients and should be evaluated.
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Affiliation(s)
- Adrià Juanola
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - Neha Tiwari
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Cristina Solé
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
- Department of Gastroenterology and Hepatology, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Danielle Adebayo
- Department of Gastroenterology, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Florence Wong
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Pere Ginès
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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20
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Peach BC, Arkin LC, Esparza L, Hassan S, Shinn L. Intensive Care Unit Memories and Trauma Triggers for Acute Respiratory Distress Syndrome Survivors Hospitalized During the COVID-19 Pandemic. Dimens Crit Care Nurs 2025; 44:77-84. [PMID: 39853725 DOI: 10.1097/dcc.0000000000000681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2025] Open
Abstract
BACKGROUND Intensive care unit (ICU) admissions can be traumatic for critically ill, ventilated acute respiratory distress syndrome (ARDS) patients due to fear of death, an inability to verbally communicate, reliance on health care professionals, and invasive medical interventions. Adult ARDS patients hospitalized during the COVID-19 pandemic were strictly isolated and had limited to no visitation from loved ones, impacting their access to support systems. OBJECTIVE To explore the memories and sensory triggers for them (if applicable) of adult ARDS survivors hospitalized during the COVID-19 pandemic. METHODS This study used a phenomenological design with an interpretative descriptive approach. Semistructured interviews with open-ended questions were conducted with survivors. Thematic analysis of 16 ARDS survivors' responses to ICU memories and sensory triggers questions was completed to identify the most prevalent themes. RESULTS Major themes for vivid memories included (1) altered reality, (2) vivid nonsense dreams, (3) medical treatment/procedures, and (4) feeling lonely/isolated. Themes for triggers included (1) seeing doctors/nurses/hospitals and medical equipment or seeing/hearing media depictions of them, (2) hearing ringtones and beeping/alarms, (3) seeing/hearing helicopters, (4) smelling cleaning products, and (5) seeing/touching scars. DISCUSSION/CONCLUSIONS Fifteen of the 16 ARDS survivors reported traumatic vivid memories, often triggered by sensory stimuli they encountered in their everyday lives. It is important for acute care and outpatient nurses to understand the impact of an ICU admission on ARDS survivors' mental health, so they can adopt evidence-based interventions to prevent or limit these effects.
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21
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Karvellas CJ, Gustot T, Fernandez J. Management of the acute on chronic liver failure in the intensive care unit. Liver Int 2025; 45:e15659. [PMID: 37365997 PMCID: PMC11815614 DOI: 10.1111/liv.15659] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/01/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.
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Affiliation(s)
- Constantine J. Karvellas
- Department of Critical Care MedicineUniversity of AlbertaEdmontonCanada
- Division of Gastroenterology (Liver Unit)University of AlbertaEdmontonCanada
| | - Thierry Gustot
- Department of Gastroenterology, Hepato‐Pancreatology and Digestive Oncology, H.U.B.CUB Hôpital ErasmeBrusselsBelgium
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital ClinicUniversity of Barcelona, IDIBAPS and CIBERehdBarcelonaSpain
- EF CLIF, EASL‐CLIF ConsortiumBarcelonaSpain
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22
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Chandler JK, Jandali B, Joyce K, Smith D, Chollet-Hinton L, Ratnayake I, Brownback KR. Outcomes of Prone Positioning in Mechanically Ventilated COVID-19 Patients. Respir Care 2025. [PMID: 40028865 DOI: 10.1089/respcare.11259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2025]
Abstract
Background: Prone positioning in mechanically ventilated patients with severe ARDS is associated with reduced mortality. COVID-19 causes variable pulmonary involvement in some patients suffering from severe respiratory failure and ARDS. Although proning in the COVID-19 patient population is increasingly common, more data are needed to fully understand its utility in those with ARDS due to COVID-19. Methods: We conducted a single-center retrospective study, inclusive of 100 consecutive subjects intubated for ARDS from COVID-19, admitted to the ICU from September 2020 to December 2020. Data were collected daily from time of intubation for 7 d along with 30-d outcomes. Results: The study included a total of 53 subjects proned and 47 nonproned during their hospitalization. Proned subjects had a mean age of 61.8 years and 56.6% were male, compared with a mean age of 66.3 years and 57.4% male in the nonproned group. Age, sex, other baseline characteristics, and treatments were similar between groups, except that proned subjects had a higher body mass index than nonproned subjects (34.1 ± 7.5 vs 30.5 ± 7.4, kg/m2 P = .02) and lower initial P/F ratios (119.1 ± 54.5 vs 154.0 ± 92.7 mm Hg, P = .047). Proned subjects received more neuromuscular blockade (OR 6.63, 95% CI 3.25-13.12, P < .001) and higher sedation levels (two sedatives: OR = 3.00, 95% CI 1.77-5.08; ≥3 sedatives: OR = 7.13, 95% CI 3.96-12.81) with similar ICU stays, ventilator days, newly initiated renal replacement therapy, and 30-d outcomes including being alive, out of the ICU, or discharged from the hospital when compared with nonproned subjects. There were a total of 15 (28.3%) complications related to proning. Proned subjects were reintubated significantly less than the nonproned group (1.9% vs 19.1%, P = .006). Conclusions: Proning mechanically ventilated COVID-19 subjects was associated with more frequent use of neuromuscular blockade and sedation, and lower rates of re-intubation, for respiratory failure when compared with nonproned subjects.
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Affiliation(s)
- Jonathan K Chandler
- Dr. Chandler, Jandali, Joyce, Smith, and Brownback are affiliated with Division of Pulmonary Disease, Critical Care and Sleep Medicine, The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Badr Jandali
- Dr. Chandler, Jandali, Joyce, Smith, and Brownback are affiliated with Division of Pulmonary Disease, Critical Care and Sleep Medicine, The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Katie Joyce
- Dr. Chandler, Jandali, Joyce, Smith, and Brownback are affiliated with Division of Pulmonary Disease, Critical Care and Sleep Medicine, The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Dale Smith
- Dr. Chandler, Jandali, Joyce, Smith, and Brownback are affiliated with Division of Pulmonary Disease, Critical Care and Sleep Medicine, The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Lynn Chollet-Hinton
- Dr. Chollet-Hinton and Ratnayake are affiliated with Department of Biostatistics & Data Science, The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Isuru Ratnayake
- Dr. Chollet-Hinton and Ratnayake are affiliated with Department of Biostatistics & Data Science, The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Kyle R Brownback
- Dr. Chandler, Jandali, Joyce, Smith, and Brownback are affiliated with Division of Pulmonary Disease, Critical Care and Sleep Medicine, The University of Kansas School of Medicine, Kansas City, Kansas, USA
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Ferreira JC, Vianna AODA, Pinheiro BV, Maia IS, Baldisserotto SV, Isola AM. Joint statement on evidence-based practices in mechanical ventilation: suggestions from two Brazilian medical societies. J Bras Pneumol 2025; 51:e20240255. [PMID: 39936726 PMCID: PMC11796564 DOI: 10.36416/1806-3756/e20240255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2024] [Accepted: 09/04/2024] [Indexed: 02/13/2025] Open
Abstract
Mechanical ventilation can be a life-saving intervention, but its implementation requires a multidisciplinary approach, with an understanding of its indications and contraindications due to the potential for complications. The management of mechanical ventilation should be part of the curricula during clinical training; however, trainees and practicing professionals frequently report low confidence in managing mechanical ventilation, often seeking additional sources of knowledge. Review articles, consensus statements and clinical practice guidelines have become important sources of guidance in mechanical ventilation, and although clinical practice guidelines offer rigorously developed recommendations, they take a long time to develop and can address only a limited number of clinical questions. The Associação de Medicina Intensiva Brasileira and the Sociedade Brasileira de Pneumologia e Tisiologia sponsored the development of a joint statement addressing all aspects of mechanical ventilation, which was divided into 38 topics. Seventy-five experts from all regions of Brazil worked in pairs to perform scoping reviews, searching for publications on their specific topic of mechanical ventilation in the last 20 years in the highest impact factor journals in the areas of intensive care, pulmonology, and anesthesiology. Each pair produced suggestions and considerations on their topics, which were presented to the entire group in a plenary session for modification when necessary and approval. The result was a comprehensive document encompassing all aspects of mechanical ventilation to provide guidance at the bedside. In this article, we report the methodology used to produce the document and highlight the most important suggestions and considerations of the document, which has been made available to the public in Portuguese.
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Affiliation(s)
- Juliana Carvalho Ferreira
- . Division of Pulmonology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil
| | | | - Bruno Valle Pinheiro
- . Hospital Universitário, Department of Internal Medicine, Faculdade de Medicina, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil
| | - Israel Silva Maia
- . Department of Internal Medicine, Universidade Federal de Santa Catarina - Florianópolis (SC), Brazil
- . Hospital Nereu Ramos - Florianópolis (SC), Brazil
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24
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Tariparast PA, Roedl K, Horvatits T, Drolz A, Kluge S, Fuhrmann V. Impact of acute respiratory distress syndrome on outcome in critically ill patients with liver cirrhosis. Sci Rep 2025; 15:4301. [PMID: 39905232 PMCID: PMC11794433 DOI: 10.1038/s41598-025-88606-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2024] [Accepted: 01/29/2025] [Indexed: 02/06/2025] Open
Abstract
We investigated the occurrence and outcome of respiratory failure and ARDS in critically ill patients with liver cirrhosis. This is a retrospective analysis of patients with liver cirrhosis at an ICU during an 8-Year period. An assessment of acute on chronic liver failure as well as the presence and grade of ARDS within the first 72 h of admission to the ICU was performed. A total of 735 patients during the study period. Median age was 58 (50-69) years and 61% (n = 447) were male. 57% (n = 421) of the patients received mechanical ventilation (MV). Liver specific as well as ICU scores on admission were significantly higher in patients with MV. Necessity of vasopressor support (86%vs.25%, p < 0.001) and RRT (50%vs.11%, p < 0.001) was more frequent in patients with MV. The incidence of ARDS within the first 72 h of admission was 8% (n = 61). We observed a 28-day mortality or liver transplantation rate of 54% (n = 196) and 66% (n = 66%) in patients with MV and ARDS, respectively. After 90-days 63% (n = 226) with MV and 70% (n = 43) with ARDS were dead or received liver transplantation. ARDS is a prognostic factor for mortality in patients with liver cirrhosis admitted to the ICU. One out of ten critically ill cirrhotic patients develop ARDS within 72 h after admission. Although mortality rates are high initially critical care therapy should not be withheld and must be reevaluated regularly.
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Affiliation(s)
- Pischtaz Adel Tariparast
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Thomas Horvatits
- Department of Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Drolz
- Department of Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Department of Medicine and Gastroenterology, Heilig Geist-Hospital, Cologne, Germany
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25
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Ferreira JC, Vianna AODA, Pinheiro BV, Maia IS, Baldisserotto SV, Isola AM. Joint statement on evidence-based practices in mechanical ventilation: suggestions from two Brazilian medical societies. CRITICAL CARE SCIENCE 2025; 37:e20250242en. [PMID: 39907364 PMCID: PMC11805462 DOI: 10.62675/2965-2774.20250242-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Accepted: 10/03/2024] [Indexed: 02/06/2025]
Abstract
Mechanical ventilation can be a life-saving intervention, but its implementation requires a multidisciplinary approach, with an understanding of its indications and contraindications due to the potential for complications. The management of mechanical ventilation should be part of the curricula during clinical training; however, trainees and practicing professionals frequently report low confidence in managing mechanical ventilation, often seeking additional sources of knowledge. Review articles, consensus statements and clinical practice guidelines have become important sources of guidance in mechanical ventilation, and although clinical practice guidelines offer rigorously developed recommendations, they take a long time to develop and can address only a limited number of clinical questions. The Associação de Medicina Intensiva Brasileira and the Sociedade Brasileira de Pneumologia e Tisiologia sponsored the development of a joint statement addressing all aspects of mechanical ventilation, which was divided into 38 topics. Seventy-five experts from all regions of Brazil worked in pairs to perform scoping reviews, searching for publications on their specific topic of mechanical ventilation in the last 20 years in the highest impact factor journals in the areas of intensive care, pulmonology, and anesthesiology. Each pair produced suggestions and considerations on their topics, which were presented to the entire group in a plenary session for modification when necessary and approval. The result was a comprehensive document encompassing all aspects of mechanical ventilation to provide guidance at the bedside. In this article, we report the methodology used to produce the document and highlight the most important suggestions and considerations of the document, which has been made available to the public in Portuguese.
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Affiliation(s)
- Juliana Carvalho Ferreira
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazilDivision of Pulmonology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | | | - Bruno Valle Pinheiro
- Department of Internal MedicineFaculdade de MedicinaUniversidade Federal de Juiz de ForaJuiz de ForaMGBrazilHospital Universitário, Department of Internal Medicine, Faculdade de Medicina, Universidade Federal de Juiz de Fora - Juiz de Fora (MG),Brazil.
| | - Israel Silva Maia
- Department of Internal MedicineUniversidade Federal de Santa CatarinaFlorianópolisSCBrazilDepartment of Internal Medicine, Universidade Federal de Santa Catarina - Florianópolis (SC),Brazil.
- Hospital Nereu RamosFlorianópolisSCBrazilHospital Nereu Ramos - Florianópolis (SC), Brazil.
| | - Sérgio Vasconcellos Baldisserotto
- Santa Casa de Misericórdia de Porto AlegrePorto AlegreRSBrazilSanta Casa de Misericórdia de Porto Alegre - Porto Alegre (RS), Brazil.
| | - Alexandre Marini Isola
- Department of Continuing EducationImed GroupSão PauloSPBrazilDepartment of Continuing Education, Imed Group - São Paulo (SP), Brazil
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26
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Olmos M, Fuentes N, Busico M, Gallardo A, Vitali A, Costa ELV, Amato MBP, Bruhn A, Esperatti M, Argentine Collaborative Group on High Flow, Prone Positioning. Effectiveness of bundle of care on tolerance of awake-prone positioning in patients with acute respiratory failure. A multicenter observational study. Intensive Care Med 2025; 51:332-341. [PMID: 39961842 DOI: 10.1007/s00134-025-07804-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Collaborators] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2024] [Accepted: 01/15/2025] [Indexed: 03/14/2025]
Abstract
PURPOSE This study aimed to assess the impact of a bundle of care strategy on the duration of awake prone positioning (AW-PP) and other key clinical outcomes in patients with acute respiratory failure (ARF) who require high-flow nasal oxygen (HFNO). METHODS In this secondary analysis of a prospective, multicenter cohort study, we included patients admitted with COVID-19-related ARF who required HFNO. The protocol encouraged AW-PP for as long as possible. The main exposure was a bundle of care including light sedation, monitoring, and information to patients about the strategy (bundle) compared to no bundle (control). The primary outcome was the duration of AW-PP (hours/day), while secondary outcomes included endotracheal intubation and in-hospital mortality. Directed acyclic graphs (DAGs) were employed to identify variables related to both exposure and outcomes. Four models were used to evaluate exposure-outcome associations: inverse probability of treatment weighting (IPTW), "double-robust" approximation (DR), traditional regression (TR), and mixed-effects model (MEM). RESULTS Out of 499 patients, 197 were exposed to bundle, and 302 did not. The exposure group had a median (IQR) AW-PP duration of 16 (10-18) hours/day, compared to 10 (7-14) hours/day in the control group. Regression coefficients (95% CI) were 3.39 (1.67-5.11), 3.35 (1.55-5.14), 3.95 (2.63-5.28), and 3.72 (2.5-4.94) for IPTW, DR, TR and MEM, respectively. The odds ratios (95% CI) for intubation were 0.34 (0.15-0.76), 0.23 (0.10-0.50), 0.42 (0.23-0.77), and 0.48 (0.16-0.49), and for in-hospital mortality were 0.38 (0.11-1.27), 0.43 (0.14-1.26), 0.47 (0.22-0.91), and 0.46 (0.12-1.43) in the respective models. CONCLUSION In the evaluated population of patients with COVID-19-related ARF, implementing a bundle-of-care strategy was associated with a longer AW-PP exposure and a reduced risk of endotracheal intubation. TRIAL REGISTRATION NUMBER ClinicalTrials.gov. Identifier NCT05178212. Date of registration: January 5th, 2022. STUDY TYPE Observational.
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Affiliation(s)
- Matías Olmos
- Intensive Care Department, Hospital Privado de Comunidad, Cordoba 4545, (7600), Mar del Plata, Argentina
| | - Nora Fuentes
- Intensive Care Department, Hospital Privado de Comunidad, Cordoba 4545, (7600), Mar del Plata, Argentina
- Escuela Superior de Medicina, Universidad Nacional de Mar del Plata, Mar del Plata, Argentina
| | - Marina Busico
- Intensive Care Unit, Clínica Olivos SMG, Olivos, Buenos Aires, Argentina
- Sociedad Argentina de Terapia Intensiva, Cnel. Niceto Vega, Buenos Aires, Argentina
| | - Adrian Gallardo
- Intensive Care Unit, Sanatorio Clínica Modelo de Morón, Morón, Buenos Aires, Argentina
- Universidad de Morón, Morón, Buenos Aires, Argentina
| | - Alejandra Vitali
- Intensive Care Unit, Sanatorio de La Trinidad Palermo, Ciudad Autónoma de, Buenos Aires, Argentina
| | - Eduardo L V Costa
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), São Paulo, Brazil
- Hospital Sírio-Libanês, Research and Education Institute, São Paulo, Brazil
| | - Marcelo B P Amato
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Sao Paulo, Brazil
| | - Alejandro Bruhn
- Departement of Intensive Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Mariano Esperatti
- Intensive Care Department, Hospital Privado de Comunidad, Cordoba 4545, (7600), Mar del Plata, Argentina.
- Escuela Superior de Medicina, Universidad Nacional de Mar del Plata, Mar del Plata, Argentina.
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Collaborators
Hiromi Kakisu, Jorgelina Quintana, Javier Osatnik, Pablo Comimiani, Santiago Nicolas Saavedra, Ana Inés Lagazio, Nahuel Esteban Romano, Agustin Matarrese, Mariela Adriana Mogaadouro, Claudia Navarro Moreno, Greta Dennise Rebaza Niquin, Anabel Miranda Tirado, María Constanza Viñas, Juan Manuel Pintos, Maria Eugenia Gonzalez, Marisol Mariela Laiz, Jose Garcia Urrutia, Micaela Ruiz Seifert, Emilce Mastroberti, Ana Elizabeth Grimbee, Leonel Stein, Ariel Juan Latronico, Silvia Laura Menéndez,
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Protti A, Madotto F, Florio G, Bove T, Carlesso E, Casella G, Dalla Corte F, Foti G, Giudici R, Langer T, Montalto C, Rezoagli E, Santini A, Terragni P, Zanella A, Grasselli G, Cecconi M. A tidal volume of 7 mL/kg PBW or higher may be safe for COVID-19 patients. J Crit Care 2025; 85:154921. [PMID: 39326356 DOI: 10.1016/j.jcrc.2024.154921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 08/09/2024] [Accepted: 09/16/2024] [Indexed: 09/28/2024]
Abstract
PURPOSE The novel coronavirus disease (COVID-19) has revived the debate on the optimal tidal volume during acute respiratory distress syndrome (ARDS). Some experts recommend 6 mL/kg of predicted body weight (PBW) for all patients, while others suggest 7-9 mL/kg PBW for those with compliance >50 mL/cmH2O. We investigated whether a tidal volume ≥ 7 ml/kg PBW may be safe in COVID-19 patients, particularly those with compliance >50 mL/cmH2O. MATERIALS AND METHODS This secondary analysis of a multicenter study compares the Intensive Care Unit (ICU) mortality among 600 patients ventilated with <7 or ≥ 7 mL/kg PBW. Compliance was categorized as <40, 40-50, or > 50 mL/cmH2O. RESULTS 346 patients were ventilated with <7 (6.2 ± 0.5) mL/kg PBW and 254 with ≥7 (7.9 ± 0.9) mL/kg PBW. ICU mortality was 33 % and 29 % in the two groups (p = 0.272). At multivariable regression analysis, tidal volume ≥ 7 mL/kg PBW was associated with lower ICU mortality in the overall population (odds ratio: 0.62 [95 %-confidence interval: 0.40-0.95]) and in each compliance category. CONCLUSIONS A tidal volume ≥ 7 (up to 9) mL/kg PBW was associated with lower ICU mortality in these COVID-19 patients, including those with compliance <40 mL/cmH2O. This finding should be interpreted cautiously due to the retrospective study design. TRIAL REGISTRATION ClinicalTrails.govNCT04388670.
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Affiliation(s)
- Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Fabiana Madotto
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gaetano Florio
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care Medicine, ASUFC University-Hospital of Central Friuli, Udine, Italy; Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Eleonora Carlesso
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giampaolo Casella
- Dipartimento di Anestesia e Rianimazione, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesca Dalla Corte
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy; School of Medicine and Surgery, University of Milan-Bicocca, Monza, MB, Italy
| | - Riccardo Giudici
- Dipartimento di Anestesia e Rianimazione, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Thomas Langer
- Dipartimento di Anestesia e Rianimazione, Grande Ospedale Metropolitano Niguarda, Milan, Italy; School of Medicine and Surgery, University of Milan-Bicocca, Monza, MB, Italy
| | - Carlo Montalto
- Department of Anesthesiology and Intensive Care, Carlo Poma Hospital, Azienda Socio-Sanitaria Territoriale of Mantova, Mantova, Italy
| | - Emanuele Rezoagli
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy; School of Medicine and Surgery, University of Milan-Bicocca, Monza, MB, Italy
| | - Alessandro Santini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Pierpaolo Terragni
- Division of Anesthesia and General Intensive Care, Department of Medical, Surgical and Experimental Sciences, University Hospital of Sassari, University of Sassari, Sassari, Italy
| | - Alberto Zanella
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Giacomo Grasselli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - 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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Fumagalli B, Giani M, Bombino M, Fumagalli D, Merelli M, Chiesa G, Rona R, Bellani G, Rezoagli E, Foti G. Pressure Support Ventilation During Extracorporeal Membrane Oxygenation Support in Patients With Acute Respiratory Distress Syndrome. ASAIO J 2025; 71:171-176. [PMID: 39116298 PMCID: PMC11761049 DOI: 10.1097/mat.0000000000002285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024] Open
Abstract
In the initial phases of veno-venous extracorporeal membrane oxygenation (VV ECMO) support for severe acute respiratory distress syndrome (ARDS), ultraprotective controlled mechanical ventilation (CMV) is typically employed to limit the progression of lung injury. As patients recover, transitioning to assisted mechanical ventilation can be considered to reduce the need for prolonged sedation and paralysis. This study aimed to evaluate the feasibility of transitioning to pressure support ventilation (PSV) during VV ECMO and to explore variations in respiratory mechanics and oxygenation parameters following the transition to PSV. This retrospective monocentric study included 191 adult ARDS patients treated with VV ECMO between 2009 and 2022. Within this population, 131 (69%) patients were successfully switched to PSV during ECMO. Pressure support ventilation was associated with an increase in respiratory system compliance ( p = 0.02) and a reduction in pulmonary shunt fraction ( p < 0.001). Additionally, improvements in the cardiovascular Sequential Organ Failure Assessment score and a reduction in pulmonary arterial pressures ( p < 0.05) were recorded. Ninety-four percent of patients who successfully transitioned to PSV were weaned from ECMO, and 118 (90%) were discharged alive from the intensive care unit (ICU). Of those who did not reach PSV, 74% died on ECMO, whereas the remaining patients were successfully weaned from extracorporeal support. In conclusion, PSV is feasible during VV ECMO and potentially correlates with improvements in respiratory function and hemodynamics.
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Affiliation(s)
- Benedetta Fumagalli
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Marco Giani
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Michela Bombino
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Denise Fumagalli
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Milena Merelli
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Gaia Chiesa
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Roberto Rona
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Giacomo Bellani
- Department of Medical Sciences, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari di Trento, Trento, Italy
| | - Emanuele Rezoagli
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Giuseppe Foti
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
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Yan Y, Geng B, Liang J, Wen Y, Bao J, Zhong X, Chen M, Liu L, Duan J, Zeng Z, An S, Chen Z, Hu H. A prediction model for nonresponsive outcomes in critically ill patients with acute respiratory distress syndrome undergoing prone position ventilation: A retrospective cohort study. Intensive Crit Care Nurs 2025; 86:103804. [PMID: 39180911 DOI: 10.1016/j.iccn.2024.103804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 08/07/2024] [Accepted: 08/10/2024] [Indexed: 08/27/2024]
Abstract
OBJECTIVE This study aimed to develop a reliable and effective nomogram model to identify high-risk populations with non-response to prone position ventilation (PPV) in acute respiratory distress syndrome (ARDS) patients. METHODS This retrospective cohort study included 175 patients with ARDS undergoing PPV. An improvement of ≥ 20 mmHg in the PaO2/FiO2 after the first PPV was defined as a 'response'. For the construction of the model, all patients were randomly assigned to the train and validation cohort according to 2:1. Multivariate logistic regression was useed to develop the nomogram. The area under the receiver operating characteristic curve (AUC), decision curve and calibration curve were assessed to evaluate the efficiency, clinical utility and calibration of the model. RESULTS The overall rate of non-response to PPV in ARDS patients was approximately 32.6 %. In the training cohort and validation cohort, the rate are 29.9 % and 34.5 % respectively. Murray score ≥ 2.5 (OR: 4.29), procalcitonin (PCT) ≥ 2 ng/mL (OR: 2.52), N-terminal pro-B-type natriuretic peptide (Nt-proBNP) ≥ 2000 pg/ml (OR: 2.44), and hemoglobin ≤ 90 g/L (OR: 2.39) were independently associated with the rate of non-response to PPV and combined in prediction model. The model demonstrated good predictive value with AUC of 0.817 and 0.828 in the train and validation cohort. Calibration curve showed good calibration and decision curve analysis indicated favorable clinical utility. CONCLUSIONS This study constructed a risk prediction model for non-response to PPV, which demonstrated good predictive value and clinical utility. IMPLICATIONS FOR CLINICAL PRACTICE Early identification of prone position response in ARDS is essential for timely alternative treatments, improving patient prognosis and healthcare efficiency. The predictive model included representative indicators of patients with ARDS, encompassing parameters such as the acute lung injury (Murray score), cardiac function (Nt-proBNP), infectious status (PCT), and hemoglobin levels.
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Affiliation(s)
- Yuhang Yan
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China; School of Nursing, Southern Medical University, Guangzhou, China
| | - Bingxuan Geng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jingyi Liang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yinghong Wen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junying Bao
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiangning Zhong
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China; School of Nursing, Southern Medical University, Guangzhou, China
| | - Meijia Chen
- School of Nursing, Southern Medical University, Guangzhou, China; Department of Respiratory and Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Li Liu
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jiaxin Duan
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shengli An
- Department of Biostatistics, School of Public Health (Guangdong Provincial Key Laboratory of Tropical Disease Research), Southern Medical University, Guangzhou, China.
| | - Zhongqing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - HongBin Hu
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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De Rosa S, Sella N, Bellani G, Foti G, Cortegiani A, Lorenzoni G, Gregori D, Boscolo A, Cattin L, Elhadi M, Fullin G, Garofalo E, Gottin L, Grassetto A, Maggiore SM, Momesso E, Peta M, Poole D, Rona R, Tiberio I, Zanoletti A, Rezoagli E, Navalesi P. Oxygenation improvement and duration of prone positioning are associated with ICU mortality in mechanically ventilated COVID-19 patients. Ann Intensive Care 2025; 15:20. [PMID: 39875763 PMCID: PMC11775368 DOI: 10.1186/s13613-025-01438-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2024] [Accepted: 01/13/2025] [Indexed: 01/30/2025] Open
Abstract
BACKGROUND Prone position has been diffusely applied in mechanically ventilated COVID-19 patients. Our aim is ascertaining the association between the physiologic response and the length of the first cycle of prone position and intensive care unit (ICU) mortality. METHODS International registry including COVID-19 adult patients who underwent prone positioning. We measured the difference for arterial partial pressure of oxygen to inspired fraction of oxygen ratio (PaO2/FiO2), ventilatory ratio, and respiratory system compliance (Crs) between baseline supine position and at either the end of the first cycle of prone position (Delta-PP) or re-supination (Delta-PostPP). RESULTS We enrolled 1816 patients from 53 centers. Delta-PP and Delta-PostPP for PaO2/FiO2 were both associated with ICU mortality [OR (95% CI) 0.48 (0.38, 0.59), and OR (95% CI) 0.60 (0.52, 0.68), respectively]. Ventilatory ratio had a non-linear relationship with ICU mortality for Delta-PP (p = 0.022) and Delta-PostPP (p = 0.004). Delta-PP, while not Delta-PostPP, for Crs was associated with ICU mortality [OR (95% CI) 0.80 (0.65, 0.98)]. The length of the first cycle of prone position showed an inverse relationship with ICU mortality [OR (95% CI) 0.82 (0.73, 0.91)]. At the multivariable analysis, the duration of the first cycle of prone position, Delta-PP and Delta-PostPP for PaO2/FiO2, and Delta-PostPP for ventilatory ratio were independently associated with ICU mortality. CONCLUSION In COVID-19 patients with acute respiratory failure receiving invasive mechanical ventilation and prone positioning, the physiological response to prone position is associated with ICU mortality. Prolonging the duration of the first cycle of prone position is associated with improved survival.
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Affiliation(s)
- Silvia De Rosa
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy
- UOC Anestesia e Rianimazione, AULSS8 Berica, Ospedale San Bortolo, Vicenza, Italy
| | - Nicolò Sella
- Institute of Anesthesia and Intensive Care, Padova University Hospital, Padua, Italy
| | - Giacomo Bellani
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy
| | - Giuseppe Foti
- Department of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Andrea Cortegiani
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padua, Italy
| | - Annalisa Boscolo
- Institute of Anesthesia and Intensive Care, Padova University Hospital, Padua, Italy
- Department of Medicine (DIMED), University of Padua, Via Vincenzo Gallucci 13, 35125, Padua, PD, Italy
| | - Lucia Cattin
- UOC Anestesia e Rianimazione, AULSS8 Berica, Ospedale San Bortolo, Vicenza, Italy
| | | | - Giorgio Fullin
- Anesthesia and Intensive Care, Ospedale All'Angelo, Mestre, Italy
| | - Eugenio Garofalo
- Anaesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Leonardo Gottin
- Dipartimento di Emergenza e Terapie Intensive, UOC di Anestesia e Terapia Intensiva Cardio-Toraco-Vascolare, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Alberto Grassetto
- UOC Anestesia E Rianimazione, Ospedale di Vittorio Veneto, Vittorio Veneto, TV, Italy
| | - Salvatore Maurizio Maggiore
- University Department of Innovative Technologies in Medicine and Dentistry, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Elena Momesso
- Anaesthesia and Intensive Care Unit, Ospedali di San Donà di Piave e Jesolo, San Donà di Piave, Italy
| | - Mario Peta
- Department of Anesthesia and Intensive Care, Santa Maria dei Battuti-Ca' Foncello Hospital, Treviso, Italy
| | - Daniele Poole
- Anesthesia and Critical Care Unit, Ospedale di Belluno, Belluno, Italy
| | - Roberto Rona
- Department of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Ivo Tiberio
- UOC Anestesia e Rianimazione, Padova University Hospital, Padua, Italy
| | - Andrea Zanoletti
- Anesthesia and Intensive Care Unit, Manerbio Hospital, Manerbio, Italy
| | - Emanuele Rezoagli
- Department of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Paolo Navalesi
- Institute of Anesthesia and Intensive Care, Padova University Hospital, Padua, Italy.
- Department of Medicine (DIMED), University of Padua, Via Vincenzo Gallucci 13, 35125, Padua, PD, Italy.
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Maclean N, Davies P, Lewis S. Is prone positioning a valid intervention for ARDS in the deployed intensive care unit? BMJ Mil Health 2025; 171:4-7. [PMID: 38569719 DOI: 10.1136/military-2022-002302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 02/26/2024] [Indexed: 04/05/2024]
Abstract
Prone positioning is an intervention used for patients with acute respiratory distress syndrome (ARDS) whose hypoxia is worsening despite conventional treatment. Previously used infrequently, it became an important treatment escalation strategy for hypoxia during the COVID-19 pandemic. Current evidence for prone positioning suggests increased survivability in intubated patients with moderate to severe ARDS who are prone for >12 hours a day. As a relatively low-cost, low-tech intervention with a growing evidence base, the viability of prone positioning in the deployed land environment is considered in this article. The practical technique of prone positioning is easy to teach to healthcare staff experienced in manual handling. However, it requires significant resources, in particular staff numbers, and time to execute and maintain, and necessitates a pressure-minimising mattress. Additionally, staff are placed at increased risk of musculoskeletal injuries and potential exposure to aerosolised microbes if there is a disconnection of the breathing system. We conclude that in the deployed 2/1/2/12 facility (or larger), with access to higher staff numbers and high-specification mattresses, prone positioning is a valid escalation technique for intubated hypoxic patients with ARDS. However, in smaller facilities where resources are constrained, its implementation is unlikely to be achievable.
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Affiliation(s)
| | - P Davies
- Frimley Park Hospital NHS Foundation Trust, Frimley, UK
- Joint Hosptial Group (South East), Frimley, UK
| | - S Lewis
- Frimley Park Hospital NHS Foundation Trust, Frimley, UK
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Guo C, Zhang Y, Kong C, Liu W, Li M, Yang J, Sun J, Wang Y, Yu J. Electroacupuncture pretreatment ameliorates Golgi stress and the inflammation response against endotoxin-induced lung injury. Int Immunopharmacol 2025; 146:113868. [PMID: 39709911 DOI: 10.1016/j.intimp.2024.113868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Revised: 12/05/2024] [Accepted: 12/12/2024] [Indexed: 12/24/2024]
Abstract
BACKGROUND Sepsis is a life-threatening condition involving organ dysfunction characterized by a generalized inflammatory syndrome, and the associated mortality rate is high. Electroacupuncture (EA) exerts benefits in endotoxemia-induced lung injury, mainly through lung inflammation reduction and cellular homeostasis, although the anti-inflammatory mechanisms underlying these benefits remain to be completely understood. METHODS Mice were pretreated with EA or sham EA therapy 5 days prior to the induction of endotoxemia through the administration of lipopolysaccharide (LPS) and cecal ligation and puncture (CLP). Histopathological changes, systemic inflammation and cell death in the lungs were assessed. Transmission electron microscopy was employed to visually identify the structure of the Golgi complex. We examined proteins involved in maintaining the structural integrity of the Golgi apparatus and proteins associated with Golgi stress. The potential molecular mechanisms were investigated through overexpression of CREB3. RESULTS EA pretreatment effectively rescued the lung from pathological changes, lung edema, cell apoptosis, and survival rate in septic mice, along with the improvement of physiological parameters. Endotoxemia strongly induces fragmented Golgi stacks, leading to fragmentation and disintegration of its shape, inducing cell apoptosis, and causing the outbreak of a large amount of inflammation in the lungs. EA therapy can significantly inhibit the fragmented process of Golgi stress to rescue the morphological changes and exert anti-inflammatory effects. And this protective effect may be related to downregulation of cAMP responsive element binding protein 3 (CREB3) and ADP-Ribosylation Factor 4 (ARF4), one of the key pathways involved in Golgi stress response. However, Sham EA (SEA) treatment did not substantially improve the fragmentation, stacking, and separation of Golgi organization, and inflammatory damage induced by endotoxin remains. This study discovered that overexpression of CREB3 may diminish the protective efficacy of EA. CONCLUSION Administering EA pretreatment at precisely selected acupoints notably improves the survival rate in mice challenged with endotoxemia and concurrently exerts a protective effect against inflammatory lung injury. This salutary impact is speculated to be mediated through the augmentation of the Golgi apparatus's stress response.
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Affiliation(s)
- Chenxu Guo
- Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China.
| | - Yuan Zhang
- Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China; Institute of Integrative Medicine for Acute Abdominal Diseases, Tianjin, China; Tianjin Key Laboratory of Acute Abdomen Disease Associated Organ Injury and ITCWM Repair, Tianjin, China.
| | - Chang Kong
- Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China.
| | - Weiqiang Liu
- Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China.
| | - Menghan Li
- Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China.
| | - Jing Yang
- Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China; Institute of Integrative Medicine for Acute Abdominal Diseases, Tianjin, China; Tianjin Key Laboratory of Acute Abdomen Disease Associated Organ Injury and ITCWM Repair, Tianjin, China.
| | - Jiaxuan Sun
- Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China.
| | - Yimeng Wang
- Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China.
| | - Jianbo Yu
- Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China; Institute of Integrative Medicine for Acute Abdominal Diseases, Tianjin, China; Tianjin Key Laboratory of Acute Abdomen Disease Associated Organ Injury and ITCWM Repair, Tianjin, China.
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Jiang L, Chen H, Chang W, Sun Q, Yuan X, Wu Z, Xie J, Liu L, Yang Y. Time-varying intensity of ventilatory inefficiency and mortality in patients with acute respiratory distress syndrome. Ann Intensive Care 2025; 15:6. [PMID: 39804548 PMCID: PMC11729588 DOI: 10.1186/s13613-025-01427-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2024] [Accepted: 12/12/2024] [Indexed: 01/16/2025] Open
Abstract
BACKGROUND The association between bedside ventilatory parameters-specifically arterial carbon dioxide pressure (PaCO2) and ventilatory ratio (VR)-and mortality in patients with acute respiratory distress syndrome (ARDS) remains a topic of debate. Additionally, the persistence of this association over time is unclear. This study aims to investigate the relationship between 28-day mortality in ARDS patients and their longitudinal exposure to ventilatory inefficiency, as reflected by serial measurements of PaCO2 and VR. METHODS We conducted a secondary analysis of four randomized controlled trials (FACTT, ALTA, EDEN, and SAILS) from the ARDS Network. All included patients were intubated and received mechanical ventilation. Patients were excluded if they underwent extracorporeal life support or were on mechanical ventilation for less than one day. The primary outcome was 28-day mortality. Bayesian joint models were employed to estimate the strength of associations over time. RESULTS A total of 2,851 patients were included in our analysis. The overall 28-day mortality rate was 21.3%, with a median duration of invasive mechanical ventilation of 9 days (IQR: 4-28 days). After adjustment, each daily increment in PaCO2 (HR 1.008, 95% CI 0.997-1.018) was not associated with mortality, while a daily increment in VR (HR 1.548, 95% CI 1.309-1.835) was associated with increased mortality. This association persisted during the prolonged stages (Days 0-23) of mechanical ventilation. Furthermore, a significant increase in the risk of death was related to daily exposure to VR > 2 (HR 1.088 per day, 95% CI 1.034-1.147) and its cumulative effect (HR 1.085 per area, 95% CI 1.050-1.122), whereas PaCO2 was found to be insignificant. CONCLUSION VR, which reflects ventilatory inefficiency, should be closely monitored during invasive mechanical ventilation. Cumulative exposure to high intensities of VR may be associated with increased mortality in patients with ARDS.
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Affiliation(s)
- Lianlian Jiang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Wei Chang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Qin Sun
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Xueyan Yuan
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Zongsheng Wu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China.
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Zagales R, Lee P, Kumar S, Yates Z, Awan MU, Cruz F, Strause J, Schuemann KR, Elkbuli A. Optimizing Management of Acute Respiratory Distress Syndrome in Critically Ill Surgical Patients: A Systematic Review. J Surg Res 2025; 305:385-397. [PMID: 39755005 DOI: 10.1016/j.jss.2024.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 09/22/2024] [Accepted: 10/26/2024] [Indexed: 01/06/2025]
Abstract
INTRODUCTION This systematic review aims to evaluate the optimal management of acute respiratory distress syndrome (ARDS) in critically ill surgical patients, specifically focusing on positioning, extracorporeal membrane oxygenation (ECMO) use, ventilation, fluid resuscitation, and pharmacological treatments. METHODS A systematic review was conducted utilizing four databases including PubMed, Google Scholar, EMBASE, and ProQuest. This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with The International Prospective Register of Systematic Reviews. Studies published until May 20, 2024, that assessed the management of ARDS in critically ill surgical adult populations were included in our review. The primary outcome of interest was mortality, with secondary outcomes like intensive care unit (ICU) length of stay (LOS), ventilator days, and oxygenation also being considered. RESULTS A total of fifteen studies met inclusion criteria; four studies assessed positional interventions, four assessed treatments with ECMO, three assessed mechanical ventilation settings, and four assessed fluid resuscitation and medications. Prone position was found to decrease mortality, ICU LOS, ventilator days, and increased oxygenation (P < 0.001). ECMO utilization decreased the overall mortality rate when compared to patients without ECMO (36.4% versus 43.9%, P < 0.001). Maintaining a tidal volume ≤8 mL/kg body weight and plateau pressure ≤35 cm H2O on mechanical ventilation also decreased patient mortality (P < 0.001). Finally, conservative fluid management decreased ICU LOS, whereas methylprednisolone use demonstrated decreased mortality. CONCLUSIONS Prone positioning, ECMO utilization, lung protective ventilation settings, and methylprednisolone reduced mortality among surgical patients with ARDS. In addition, prone positioning and conservative fluid management were associated with decreased ICU LOS, ventilator days, and improved oxygenation status.
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Affiliation(s)
- Ruth Zagales
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Philip Lee
- University of Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii
| | - Sanjan Kumar
- University of Central Florida College of Medicine, Orlando, Florida
| | - Zachary Yates
- University of Central Florida College of Medicine, Orlando, Florida
| | - Muhammad Usman Awan
- NOVA Southeastern University, Kiran Patel College of Allopathic Medicine, Fort Lauderdale, Florida
| | - Francis Cruz
- University of Alabama School of Medicine, Birmingham, Alabama
| | - Jacob Strause
- Florida International University, Herbert Wertheim College of Medicine, Miami, Florida
| | - Kathleen R Schuemann
- Division of Trauma and Surgical Critical Care, Department of Surgery, Orlando Regional Medical Center, Orlando, Florida; Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
| | - Adel Elkbuli
- Division of Trauma and Surgical Critical Care, Department of Surgery, Orlando Regional Medical Center, Orlando, Florida; Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida.
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Huang D, Tian H, Song W, Wang J, Yao Z, Xiong L, Jiang C, Zhang A, Ke X. Effects of innovative modular prone positioning tools in patients with acute respiratory distress syndrome due to COVID-19 during awake prone position: a prospective randomized controlled trial. Eur J Med Res 2024; 29:636. [PMID: 39734220 DOI: 10.1186/s40001-024-02252-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 12/22/2024] [Indexed: 12/31/2024] Open
Abstract
OBJECTIVES Our aim is to investigate the effects of a innovative modular prone positioning tools on patients with acute respiratory distress syndrome (ARDS) caused by COVID-19 during awake prone positioning (AW-PP). METHODS This prospective randomized controlled study initially enrolled 168 patients with COVID-19 due to ARDS. However, 92 were subsequently disqualified, leaving 76 patients who were randomly assigned to either the observation group (n = 38) or the control group (n = 38). The observation group utilized innovative modular prone positioning tools for non-invasive respiratory support (NIRS), while the control group used soft pillows for the same treatment. Data were collected on comfort levels, adverse events, and efficacy indicators. Additionally, the comfort, incidence of adverse events, and treatment efficacy in both groups were evaluated. RESULTS The observation group had shorter the daily duration spent on executing the AW-PP (2.74 ± 0.86 min vs. 4.64 ± 1.02 min, P < 0.001), longer the daily total AW-PP (8.52 ± 1.01 h vs. 6.03 ± 0.66 h, P < 0.001), longer the daily duration until the first position adjustment (59.89 ± 12.73 min vs. 36.57 ± 8.69 min, P < 0.001), and lower the daily frequency of position adjustments during the AW-PP (11.03 ± 2.67 vs. 17.95 ± 2.58, P < 0.001) in comparison with the control group. No significant differences were observed in intubation rates, mortality, the daily number of hours under HFNO and NIV, escalated to NIV from HFNO, and hospital length of stay between the groups (P > 0.05). However, the observation group experienced significantly fewer adverse events, including kinking NIRS circuit, pain, shortness of breath, dizziness, and pressure ulcers (P < 0.05). CONCLUSION Innovative modular prone positioning tools improved efficiency, comfort, and reduced adverse events during AW-PP but did not affect intubation rates or mortality.
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Affiliation(s)
- Dunbing Huang
- Department of Rehabilitation Medicine, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, No.1279 Sanmen Road, Hongkou District, Shanghai, China
| | - Huan Tian
- Department of Rehabilitation Medicine, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, No.1279 Sanmen Road, Hongkou District, Shanghai, China
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Wei Song
- Department of Rehabilitation Medicine, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, No.1279 Sanmen Road, Hongkou District, Shanghai, China
| | - Jiaqi Wang
- Department of Rehabilitation Medicine, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, No.1279 Sanmen Road, Hongkou District, Shanghai, China
| | - Zizhe Yao
- Department of Rehabilitation Medicine, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, No.1279 Sanmen Road, Hongkou District, Shanghai, China
| | - Lize Xiong
- Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Translational Research Institute of Brain and Brain-Like Intelligence, School of Medicine, Shanghai Fourth People's Hospital, Tongji University, Shanghai, China
- Department of Anesthesiology and Perioperative Medicine, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Cai Jiang
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China.
- Rehabilitation Medicine Center, Fujian Provincial Hospital, No. 134, East Street, Gulou District, Fuzhou, Fujian, China.
| | - Anren Zhang
- Department of Rehabilitation Medicine, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, No.1279 Sanmen Road, Hongkou District, Shanghai, China.
| | - Xiaohua Ke
- Department of Rehabilitation Medicine, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, No.1279 Sanmen Road, Hongkou District, Shanghai, China.
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Zhou Y, Zou Y, Zhou L, Wei H, Zou YW, Guo XR, Ye YQ, Li N, Lu Y. Acute respiratory distress syndrome caused by Chlamydia psittaci: a case report and literature review. Front Med (Lausanne) 2024; 11:1418241. [PMID: 39697208 PMCID: PMC11653191 DOI: 10.3389/fmed.2024.1418241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 11/11/2024] [Indexed: 12/20/2024] Open
Abstract
Background Psittacosis is a zoonotic disease with a low incidence rate and a lack of specificity in clinical manifestations, making it prone to be missed, misdiagnosed, and even cause delayed treatment for patients. Metagenomic next-generation sequencing (mNGS) was successfully performed for the diagnosis of a young patient with psittacosis progressing to acute respiratory distress syndrome (ARDS), and precisely targeted antibiotic treatment was promptly administered. Additionally, a comprehensive review was conducted on 68 cases of psittacosis complicated with ARDS, with the goal of improving the clinical awareness of this disease. Case presentation This study reports a 37-year-old young female who was infected with Chlamydia psittaci (C. psittaci) after contact with parrots and eventually developed ARDS. The patient initially developed fever and sore throat, followed by cough and expectoration. Despite receiving empirical anti-infection treatment, the condition continued to progress rapidly, and severe dyspnea developed within a short period of time. She was subsequently transferred to the intensive care unit (ICU) and underwent tracheal intubation and mechanical ventilation due to acute respiratory failure. After the DNA sequence of C. psittaci in bronchoalveolar lavage fluid (BALF) was detected through mNGS, the patient received targeted antibiotic treatment with doxycycline and moxifloxacin, and her clinical symptoms gradually improved. Conclusion Epidemiological investigations and the application of mNGS are crucial for the early identification and diagnosis of psittacosis. For suspected psittacosis patients, the application of mNGS technology could promote early identification of pathogens and targeted antimicrobial therapy, which might improve patient prognosis. In addition, young psittacosis patients without underlying disease should also be vigilant about the possibility of developing severe cases.
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Affiliation(s)
- Yan Zhou
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Ya Zou
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Lu Zhou
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Hua Wei
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Yong-Wei Zou
- Department of Respiratory and Critical Care Medicine, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Xi-Rui Guo
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Yong-Qin Ye
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Na Li
- Department of Pharmacy, Central People’s Hospital of Zhanjiang, Zhanjiang, Guangdong, China
| | - Yun Lu
- Department of Pharmacy, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
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Goossen RL, Schultz MJ, van Meenen DMP, Horn J, Rocco PR, Robba C. Optimizing protective ventilation in adults with acute brain injury-challenging misconceptions and prioritizing neuromonitoring. Expert Rev Respir Med 2024; 18:929-933. [PMID: 39627018 DOI: 10.1080/17476348.2024.2438088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2024] [Revised: 11/29/2024] [Accepted: 12/02/2024] [Indexed: 12/11/2024]
Affiliation(s)
- Robin L Goossen
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Anaesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anaesthesia & Critical Care Medicine, Medical University of Vienna, Vienna, Austria
| | - David M P van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Janneke Horn
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Patricia R Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Science and Integrated Diagnostics, University of Genova, Genova, Italy
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Cucchi EW, Burzynski J, Marshall N, Greenberg B. A dynamic customized electronic health record rule based clinical decision support tool for standardized adult intensive care metrics. JAMIA Open 2024; 7:ooae143. [PMID: 39664648 PMCID: PMC11633943 DOI: 10.1093/jamiaopen/ooae143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 11/20/2024] [Accepted: 11/26/2024] [Indexed: 12/13/2024] Open
Abstract
Objectives Many routine patient care items should be reviewed at least daily for intensive care unit (ICU) patients. These items are often incompletely performed, and dynamic clinical decision support tools (CDSTs) may improve attention to these daily items. We sought to evaluate the accuracy of institutionalized electronic health record (EHR) based custom dynamic CDST to support 22 ICU rounding quality metrics across 7 categories (hypoglycemia, venothromboembolism prophylaxis, stress ulcer prophylaxis, mechanical ventilation, sedation, nutrition, and catheter removal). Design The dynamic CDST evaluates patient characteristics and patient orders, then identifies gaps between active interventions and conditions with recommendations of evidence based clinical practice guidelines across 22 areas of care for each patient. The results of the tool prompt clinicians to address any identified care gaps. We completed a confusion matrix to assess the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of the dynamic CDST and the individual metrics. Setting Tertiary academic medical center and community hospital ICUs. Subject Customized Clinical Decision Support Tool. Measurements and Main Results The metrics were evaluated 1421 times over 484 patients. The overall accuracy of the entire dynamic CDST is 0.979 with a sensitivity of 0.979, specificity of 0.978, PPV 0.969, and NPV 0.986. Conclusions A customized, EHR based dynamic CDST can be highly accurate. Integrating a comprehensive dynamic CDST into existing workflows could improve attention and actions related to routine ICU quality metrics.
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Affiliation(s)
- Eric W Cucchi
- University of Massachusetts Chan Medical School, Departments of Medicine, Worcester, MA 01655, United States
- UMass Memorial Health, UMass Memorial Medical Center, Worcester, MA 01655, United States
- University of Massachusetts Chan Medical School, Worcester, MA 01655, United States
- University of Massachusetts Chan Medical School, Digital Health Program, Worcester, MA 01655, United States
- University of Massachusetts Chan Medical School, Tan Chingfen Graduate School of Nursing, Worcester, MA 01655, United States
| | - Joseph Burzynski
- University of Massachusetts Chan Medical School, Worcester, MA 01655, United States
| | - Nicholas Marshall
- UMass Memorial Health, UMass Memorial Medical Center, Worcester, MA 01655, United States
| | - Bruce Greenberg
- University of Massachusetts Chan Medical School, Departments of Medicine, Worcester, MA 01655, United States
- UMass Memorial Health, UMass Memorial Medical Center, Worcester, MA 01655, United States
- University of Massachusetts Chan Medical School, Worcester, MA 01655, United States
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Paton M, Hodgson CL. Early Rehabilitation in Acute Respiratory Distress Syndrome. Clin Chest Med 2024; 45:895-904. [PMID: 39443006 DOI: 10.1016/j.ccm.2024.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2024]
Abstract
Providing early rehabilitation during critical illness is considered best practice; however, the respiratory compromise suffered by patients with ARDS often limits their capacity to participate in active exercise. This article outlines the current evidence regarding early rehabilitation in the ICU with a specific focus on the considerations for this cohort. It provides some practical recommendations to assist clinicians in the identification of appropriate early rehabilitation techniques, taking into account disease severity and medical management strategies. It outlines methods to ensure the safe implementation of early rehabilitation with the aim of improving the outcomes of ARDS survivors.
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Affiliation(s)
- Michelle Paton
- Physiotherapy Department, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia; Department of Epidemiology and Preventive Medicine, ANZIC-RC, Monash University, 553 St Kilda Road, Melbourne, Victoria 3004, Australia
| | - Carol L Hodgson
- Department of Epidemiology and Preventive Medicine, ANZIC-RC, Monash University, 553 St Kilda Road, Melbourne, Victoria 3004, Australia; Physiotherapy Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Australia.
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Bouteau A, Sarfati C, Cachanado M, Perrier J, Imbert A, Genty T, Stéphan F. Prone position in obese patients with acute respiratory distress syndrome after cardio-thoracic surgery. Eur J Cardiothorac Surg 2024; 66:ezae416. [PMID: 39565916 DOI: 10.1093/ejcts/ezae416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Revised: 10/25/2024] [Accepted: 11/18/2024] [Indexed: 11/22/2024] Open
Abstract
OBJECTIVES Prone positioning (PP) has benefits in patients with acute respiratory distress syndrome. The objective of this study was to compare the effects and complications of PP in obese versus non-obese patients with moderate-to-severe acute respiratory distress syndrome after cardiothoracic surgery. METHODS We retrospectively analysed a database established in 2014-2021 in an intensive care unit. The primary end point was the change in PaO2/FiO2 induced by PP. Secondary end points included pressure ulcers, mediastinitis and intensive care unit mortality. The groups with versus without obesity (body mass index >30 kg/m2) were compared, and a mixed linear model was built to identify factors associated with the PaO2/FiO2 change. RESULTS 81 patients with acute respiratory distress syndrome (36 with vs 45 without obesity) and 189 PP sessions were included. PP duration was 17.2 ± 4.5 h in obese and 18.0 ± 3.8 h in non-obese patients (P = 0.23). Mean number of sessions was 2.6 ± 1.4 in obese and 2.1 ± 1.3 in non-obese patients (P = 0.10). Median PaO2/FiO2 increase after the 1st PP session was 75.0% [14.5-123.0] and 72% [15.5-130.5] in the groups with versus without obesity (P = 0.67). Stage 3/4 pressure ulcers were more common in the obese group (44.4% vs 22.2%; P = 0.03) and occurred chiefly on the face. No significant differences between the obese and non-obese groups were found for mediastinitis (16.7% vs 8.9%, P = 0.33) or intensive care unit mortality (22% vs 20%, P = 0.81). CONCLUSIONS Improvement of oxygenation was not statistically different between patients with versus without obesity. Pressure ulcers were more common in the obese group, whereas mediastinitis was not. No patient experienced wound dehiscence.
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Affiliation(s)
- Astrid Bouteau
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Celine Sarfati
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Marine Cachanado
- Clinical Research Department, Paris Saint-Joseph Hospital Group, Paris, France
| | - Johann Perrier
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Audrey Imbert
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Thibaut Genty
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - François Stéphan
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
- School of Medicine, Paris Saclay University, Le Kremlin-Bicêtre, France
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Liang H, Deng Q, Ye W, Jiang Z, Zhang B, Zhang J, Jiang M, Xu Y. Prone position ventilation-induced oxygenation improvement as a valuable predictor of survival in patients with acute respiratory distress syndrome: a retrospective observational study. BMC Pulm Med 2024; 24:575. [PMID: 39567964 PMCID: PMC11577716 DOI: 10.1186/s12890-024-03349-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 10/17/2024] [Indexed: 11/22/2024] Open
Abstract
BACKGROUND In patients with severe acute respiratory distress syndrome (ARDS), prolonged and inappropriate use of prone position ventilation (PPV) is a known risk factor for mortality. Hence, it is critical to monitor patients' response to PPV and accurately differentiate responders from non-responders at an early stage. The study aimed to investigate the relationship between oxygenation improvement after three rounds of PPV and survival rate in patients with pulmonary ARDS. Additionally, we sought to identify the earliest turning point for escalation from PPV to extracorporeal membrane oxygenation. METHODS We performed a retrospective observational study from 2015 to 2023. We included adult patients who received invasive mechanical ventilation, underwent at least three periods of at least 6 h of PPV after admission to the Intensive Care Unit, and meet the ARDS criteria. The study collected data on each PPV session, including changes in PaCO2, PaO2, pH, FiO2, PaO2:FiO2 ratio, and clinical outcomes. RESULTS A total of 104 patients were enrolled in the study. The change in PaCO2 from baseline to the third PPV session (P3) had the highest area under the receiver operating characteristic curve (AUC) of 0.70 (95% CI 0.60-0.80; p < 0.001) for predicting hospital mortality, with an optimal cut-off point of 3.15 (sensitivity 75.9%, specificity 56.0%). The percentage change in PaO2:FiO2 ratio from baseline to P3 also had significant AUC of 0.71 (95% CI 0.61-0.81; p < 0.001) for predicting hospital mortality, with an optimal cut-off value of 99.465 (sensitivity 79.6%, specificity 62.0%). PaCO2 responders were defined as those with an increase in PaCO2 of ≤ 3.15% from baseline to P3, while PaO2:FiO2 responders were defined as those with an increase in PaO2:FiO2 ratio of ≥ 99.465% from baseline to P3. In the multivariable Cox analysis, PaO2:FiO2 responders had a significantly lower 60-day mortality risk (hazard ratio 0.369; 95% CI 0.171-0.798; p = 0.011). CONCLUSIONS The percentage change in PaO2:FiO2 ratio from baseline to P3 was a significant predictor of outcomes. The model fit and prediction accuracy were improved by including the variable of PaCO2 responders.
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Affiliation(s)
- Hanwen Liang
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Yuexiu District, Guangzhou, Guangdong, 510120, China
- Guangzhou Blood Center, 31 Luyuan Road, Yuexiu District, Guangzhou, Guangdong, 510095, China
| | - Qiuxue Deng
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Yuexiu District, Guangzhou, Guangdong, 510120, China
- Department of Critical Care Medicine, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Yuexiu District, Guangzhou, Guangdong, 510120, China
| | - Weiyan Ye
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Yuexiu District, Guangzhou, Guangdong, 510120, China
- Department of Critical Care Medicine, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Yuexiu District, Guangzhou, Guangdong, 510120, China
| | - Zhenjie Jiang
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Yuexiu District, Guangzhou, Guangdong, 510120, China
- Department of Critical Care Medicine, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Yuexiu District, Guangzhou, Guangdong, 510120, China
| | - Baozhu Zhang
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Yuexiu District, Guangzhou, Guangdong, 510120, China
- Department of Critical Care Medicine, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Yuexiu District, Guangzhou, Guangdong, 510120, China
| | - Jiesen Zhang
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Yuexiu District, Guangzhou, Guangdong, 510120, China
- Department of Critical Care Medicine, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Yuexiu District, Guangzhou, Guangdong, 510120, China
| | - Mei Jiang
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Yuexiu District, Guangzhou, Guangdong, 510120, China.
| | - Yuanda Xu
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Yuexiu District, Guangzhou, Guangdong, 510120, China.
- Department of Critical Care Medicine, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Yuexiu District, Guangzhou, Guangdong, 510120, China.
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Yamada N, Ueno M, Onishi K, Sugimoto K, Kakehi K, Fujita K, Matsumura K, Nakazawa G. Impact of inhaled nitric oxide therapy in patients with cardiogenic shock treated with veno-arterial extracorporeal membrane oxygenation combined with Impella: a retrospective cohort study. J Intensive Care 2024; 12:49. [PMID: 39558216 PMCID: PMC11572410 DOI: 10.1186/s40560-024-00761-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2024] [Accepted: 11/06/2024] [Indexed: 11/20/2024] Open
Abstract
BACKGROUND The mortality rate of patients with cardiogenic shock (CS) requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) combined with Impella (ECPELLA) support remains high. Inhaled nitric oxide (iNO) improves right ventricular (RV) function, resulting in increased Impella flow, which may facilitate early withdrawal of VA-ECMO and improve survival. This study investigated the prognostic impact of iNO therapy in ECPELLA patients. METHODS We retrospectively analyzed the data of consecutive patients with CS supported by ECPELLA from September 2019 to March 2024 at our hospital. Changes in pulmonary artery pulsatility index (PAPi) and Impella flow over time were evaluated, and VA-ECMO withdrawal rate, time to withdrawal, and 30-day survival were compared between ECPELLA patients with and without iNO therapy. RESULTS Of the 48 ECPELLA patients, 25 were treated with iNO. There were no significant differences between the groups in baseline characteristics or lactate levels at mechanical circulatory support induction. Patients with iNO therapy demonstrated significant improvements in the PAPi over time and a trend toward increased Impella flow, as well as a significantly higher VA-ECMO withdrawal rate (88% vs. 48%, P = 0.002) and a shorter time to VA-ECMO withdrawal (5 [3-6] days vs. 7 [6-13] days, P = 0.0008) than those without iNO therapy. Kaplan-Meier analysis demonstrated that the 30-day survival rate was significantly higher in patients with iNO than in those without (76% vs. 26%, P = 0.0002). CONCLUSIONS iNO therapy in patients with CS requiring ECPELLA was associated with short-term prognosis by improving RV function and facilitating weaning from VA-ECMO. Trial registration Retrospectively registered in UMIN-CTR (Reference No. R00006352).
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Affiliation(s)
- Nobuhiro Yamada
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Masafumi Ueno
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan.
| | - Kyohei Onishi
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Keishiro Sugimoto
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Kazuyoshi Kakehi
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Kosuke Fujita
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Koichiro Matsumura
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Gaku Nakazawa
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
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Yang S, Chen K, Yu J, Jin Z, Zhang M, Li Z, Yu Y, Xuan N, Tian B, Li N, Mao Z, Wang W, Chen T, Wu Y, Zhao Y, Zhang M, Fei X, Ying S, Li W, Yan F, Zhang X, Zhang G, Shen H, Chen Z. Inhibition of cathepsin L ameliorates inflammation through the A20/NF-κB pathway in endotoxin-induced acute lung injury. iScience 2024; 27:111024. [PMID: 39559762 PMCID: PMC11570319 DOI: 10.1016/j.isci.2024.111024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 08/07/2024] [Accepted: 09/20/2024] [Indexed: 11/20/2024] Open
Abstract
Acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is a severe inflammatory condition that remains refractory; however, its molecular mechanisms are largely unknown. Previous studies have shown numerous compounds containing 4-indolyl-2-aminopyrimidine that display strong anti-inflammatory properties. In our research, we identified that a 4-Indole-2-Arylaminopyrimidine derivative named "IAAP" suppressed lipopolysaccharide (LPS)-induced inflammation. Immunoprecipitation and liquid chromatography-tandem mass spectrometry (LC-MS/MS) identified that IAAP interacts with a lysosomal cysteine protease, cathepsin L (CTSL), and restrains its activity. The nuclear factor kappa B (NF-κB) family plays a central role in controlling innate immunity. Canonical NF-κB activation, such as stimulation with lipopolysaccharide (LPS), typically involves the degradation of A20. We observed that IAAP suppression of CTSL prevented the LPS-induced degradation of A20, thereby ameliorating NF-κB activation. This study identifies CTSL as a crucial regulator of A20/NF-κB signaling and suggests IAAP as a potential lead compound for developing drugs to treat ALI/ARDS.
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Affiliation(s)
- Shiyi Yang
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Kaijun Chen
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Jinkang Yu
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Zhangchu Jin
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Min Zhang
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Zhouyang Li
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Yang Yu
- Department of Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Nanxia Xuan
- Department of Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Baoping Tian
- Department of Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Na Li
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Zhengtong Mao
- College of Pharmaceutical Sciences, Zhejiang University of Technology, Hangzhou, Zhejiang 310014, China
| | - Wenbing Wang
- College of Pharmaceutical Sciences, Zhejiang University of Technology, Hangzhou, Zhejiang 310014, China
| | - Tianpeng Chen
- College of Pharmaceutical Sciences, Zhejiang University of Technology, Hangzhou, Zhejiang 310014, China
| | - Yinfang Wu
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Yun Zhao
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Min Zhang
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Xia Fei
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Songmin Ying
- International Institutes of Medicine, The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu 322000, China
- Department of Pharmacology & Department of Respiratory and Critical Care Medicine of the Second Affiliated Hospital, Zhejiang University School of Medicine, Key Laboratory of Respiratory Disease of Zhejiang Province, Hangzhou 310009, China
| | - Wen Li
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Fugui Yan
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Xingxian Zhang
- College of Pharmaceutical Sciences, Zhejiang University of Technology, Hangzhou, Zhejiang 310014, China
| | - Gensheng Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Huahao Shen
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
- State Key Lab of Respiratory Disease, Key Cite of National Clinical Research Center for Respiratory Disease, Guangzhou 510120, China
| | - Zhihua Chen
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
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Hannon DM, Syed JDA, McNicholas B, Madden M, Laffey JG. The development of a C5.0 machine learning model in a limited data set to predict early mortality in patients with ARDS undergoing an initial session of prone positioning. Intensive Care Med Exp 2024; 12:103. [PMID: 39540987 PMCID: PMC11564488 DOI: 10.1186/s40635-024-00682-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 10/06/2024] [Indexed: 11/16/2024] Open
Abstract
BACKGROUND Acute Respiratory Distress Syndrome (ARDS) has a high morbidity and mortality. One therapy that can decrease mortality is ventilation in the prone position (PP). Patients undergoing PP are amongst the sickest, and there is a need for early identification of patients at particularly high risk of death. These patients may benefit from an in-depth review of treatment or consideration of rescue therapies. We report the development of a machine learning model trained to predict early mortality in patients undergoing prone positioning as part of the management of their ARDS. METHODS Prospectively collected clinical data were analysed retrospectively from a single tertiary ICU. The records of patients who underwent an initial session of prone positioning whilst receiving invasive mechanical ventilation were identified (n = 131). The decision to perform prone positioning was based on the criteria in the PROSEVA study. A C5.0 classifier algorithm with adaptive boosting was trained on data gathered before, during, and after initial proning. Data was split between training (85% of data) and testing (15% of data). Hyperparameter tuning was achieved through a grid-search using a maximal entropy configuration. Predictions for 7-day mortality after initial proning session were made on the training and testing data. RESULTS The model demonstrated good performance in predicting 7-day mortality (AUROC: 0.89 training, 0.78 testing). Seven variables were used for prediction. Sensitivity was 0.80 and specificity was 0.67 on the testing data set. Patients predicted to survive had 13.3% mortality, while those predicted to die had 66.67% mortality. Among patients in whom the model predicted patient would survive to day 7 based on their response, mortality at day 7 was 13.3%. Conversely, if the model predicted the patient would not survive to day 7, mortality was 66.67%. CONCLUSIONS This proof-of-concept study shows that with a limited data set, a C5.0 classifier can predict 7-day mortality from a number of variables, including the response to initial proning, and identify a cohort at significantly higher risk of death. This can help identify patients failing conventional therapies who may benefit from a thorough review of their management, including consideration of rescue treatments, such as extracorporeal membrane oxygenation. This study shows the potential of a machine learning model to identify ARDS patients at high risk of early mortality following PP. This information can guide clinicians in tailoring treatment strategies and considering rescue therapies. Further validation in larger cohorts is needed.
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Affiliation(s)
- David M Hannon
- Department of Anaesthesia, Galway University Hospital, and School of Medicine, University of Galway, Galway, Ireland
- Anaesthesia and Intensive Care Medicine, School of Medicine, University of Galway, Galway, Ireland
| | - Jaffar David Abbas Syed
- Department of Anaesthesia, Galway University Hospital, and School of Medicine, University of Galway, Galway, Ireland
| | - Bairbre McNicholas
- Department of Anaesthesia, Galway University Hospital, and School of Medicine, University of Galway, Galway, Ireland
- Anaesthesia and Intensive Care Medicine, School of Medicine, University of Galway, Galway, Ireland
| | - Michael Madden
- School of Computer Science, University of Galway, Galway, Ireland
| | - John G Laffey
- Department of Anaesthesia, Galway University Hospital, and School of Medicine, University of Galway, Galway, Ireland.
- Anaesthesia and Intensive Care Medicine, School of Medicine, University of Galway, Galway, Ireland.
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Deinzer J, Philipp A, Kmiec L, Li J, Wiesner S, Blecha S, Petermichl W, Lubnow M, Camboni D, Schmid C, Stadlbauer A. Mortality on extracorporeal membrane oxygenation: Evaluation of independent risk factors and causes of death during venoarterial and venovenous support. Perfusion 2024; 39:1648-1656. [PMID: 37933793 PMCID: PMC11492568 DOI: 10.1177/02676591231212997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Most patients on extracorporeal membrane oxygenation (ECMO) decease during therapy on the system. However, the actual causes of death have not been studied sufficiently. This study analyses the etiology, prevalence, and risk factors for the outcome variable death during ongoing ECMO for all patients and divided according to venoarterial (VA) or venovenous (VV) support. METHODS We retrospectively analysed all patients receiving ECMO support at our institution between March 2006 to January 2021. Only the patients deceased during ongoing support were included. RESULTS 2016 patients were placed on VA (n = 1168; 58%) or VV (n = 848; 42%) ECMO; 759 patients (37.7%) deceased on support. The causes of death differed between the support types: VA ECMO patients mostly died from cerebral ischemia (34%), low-cardiac output (LCO; 24.1%) and multi-organ failure (MOF; 21.6%), whereas in VV ECMO cases, refractory respiratory failure (28.2%), and sepsis (20.4%) dominated. Multivariate regression analysis revealed cardiopulmonary resuscitation (CPR) and acidosis prior to ECMO as risk factors for dying on VA ECMO, while high inotropic doses pre-ECMO, a high fraction of inspired oxygen on day 1, elevated lactate dehydrogenase, and international normalized ratio levels lead to an unfavourable outcome in VV ECMO patients. CONCLUSION Even in highly experienced centers, ECMO mortality remains high and occurs mainly on support or 24 h after its termination. The causes of death differ between VV and VA ECMO, depending on the underlying diseases responsible for the need of extracorporeal support.
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Affiliation(s)
- Johannes Deinzer
- Department of Internal Medicine, University Medical Center Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Lukasz Kmiec
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Jing Li
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Sigrid Wiesner
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Sebastian Blecha
- Department of Anaesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Walter Petermichl
- Department of Anaesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine, University Medical Center Regensburg, Regensburg, Germany
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Andrea Stadlbauer
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Poole D, Pisa A, Fumagalli R. Prone position for acute respiratory distress syndrome and the hazards of meta-analysis. Pulmonology 2024; 30:529-536. [PMID: 36907814 PMCID: PMC9874051 DOI: 10.1016/j.pulmoe.2022.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 12/17/2022] [Accepted: 12/25/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Researchers have tried unsuccessfully for many years using randomized controlled trials to show the efficacy of prone ventilation in treating ARDS. These failed attempts were of use in designing the successful PROSEVA trial, published in 2013. However, the evidence provided by meta-analyses in support of prone ventilation for ARDS was too low to be conclusive. The present study shows that meta-analysis is indeed not the best approach for the assessment of evidence as to the efficacy of prone ventilation. METHODS We performed a cumulative meta-analysis to prove that only the PROSEVA trial, due to its strong protective effect, has substantially impacted on the outcome. We also replicated nine published meta-analyses including the PROSEVA trial. We performed leave-one-out analyses, removing one trial at a time from each meta-analysis, measuring p values for effect size, and also the Cochran's Q test for heterogeneity assessment. We represented these analyses in a scatter plot to identify outlier studies influencing heterogeneity or overall effect size. We used interaction tests to formally identify and evaluate differences with the PROSEVA trial. RESULTS The positive effect of the PROSEVA trial accounted for most of the heterogeneity and for the reduction of overall effect size in the meta-analyses. The interaction tests we conducted on the nine meta-analyses formally confirmed the difference in the effectiveness of prone ventilation between the PROSEVA trial the other studies. CONCLUSIONS The clinical lack of homogeneity between the PROSEVA trial design and the other studies should have discouraged the use of meta-analysis. Statistical considerations support this hypothesis, suggesting that the PROSEVA trial is an independent source of evidence.
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Affiliation(s)
- D Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy.
| | - A Pisa
- Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan, Italy
| | - R Fumagalli
- Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan, Italy; Department of Anesthesia and Intensive Care, Niguarda Hospital, Milan, Italy
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Abstract
The understanding of acute respiratory distress syndrome (ARDS) has evolved greatly since it was first described in a 1967 case series, with several subsequent updates to the definition of the syndrome. Basic science advances and clinical trials have provided insight into the mechanisms of lung injury in ARDS and led to reduced mortality through comprehensive critical care interventions. This review summarizes the current understanding of the epidemiology, pathophysiology, and management of ARDS. Key highlights include a recommended new global definition of ARDS and updated guidelines for managing ARDS on a backbone of established interventions such as low tidal volume ventilation, prone positioning, and a conservative fluid strategy. Future priorities for investigation of ARDS are also highlighted.
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Affiliation(s)
- Katherine D Wick
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA, USA
- Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
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48
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Tang R, Zhou M. How much tidal volume is sufficiently low to be called "protective lung ventilation". JOURNAL OF INTENSIVE MEDICINE 2024; 4:480-481. [PMID: 39310062 PMCID: PMC11411422 DOI: 10.1016/j.jointm.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/06/2024] [Accepted: 03/18/2024] [Indexed: 09/25/2024]
Abstract
Ultra-low tidal volume (ULT) is an appealing alternative for severe acute respiratory distress syndrome (ARDS) patients with the aim to alleviate excess lung stress and strain. A recent article showed that ULT without extracorporeal carbon dioxide removal did not improve prognosis in moderate-to-severe coronavirus disease 2019-related ARDS patients. However, several reasons should be considered before drawing the definite conclusion about the ULT strategy in severe ARDS.
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Affiliation(s)
- Rui Tang
- Critical Care Unit, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Min Zhou
- Critical Care Unit, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
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Siuba MT, Bulgarelli L, Duggal A, Cavalcanti AB, Zampieri FG, Rey DA, Lucena WDR, Maia IS, Paisani DM, Laranjeira LN, Neto AS, Deliberato RO. Differential Effect of Positive End-Expiratory Pressure Strategies in Patients With ARDS: A Bayesian Analysis of Clinical Subphenotypes. Chest 2024; 166:754-764. [PMID: 38768777 PMCID: PMC11489450 DOI: 10.1016/j.chest.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/22/2024] [Accepted: 04/06/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND ARDS is a heterogeneous condition with two subphenotypes identified by different methodologies. Our group similarly identified two ARDS subphenotypes using nine routinely available clinical variables. However, whether these are associated with differential response to treatment has yet to be explored. RESEARCH QUESTION Are there differential responses to positive end-expiratory pressure (PEEP) strategies on 28-day mortality according to subphenotypes in adult patients with ARDS? STUDY DESIGN AND METHODS We evaluated data from two prior ARDS trials (Higher vs Lower Positive End-Expiratory Pressures in Patients With the ARDS [ALVEOLI] and the Alveolar Recruitment in ARDS Trial [ART]) that compared different PEEP strategies. We classified patients into one of two subphenotypes as described previously. We assessed the differential effect of PEEP with a Bayesian hierarchical logistic model for the primary outcome of 28-day mortality. RESULTS We analyzed data from 1,559 patients with ARDS. Compared with lower PEEP, a higher PEEP strategy resulted in higher 28-day mortality in patients with subphenotype A disease in the ALVEOLI study (OR, 1.61; 95% credible interval [CrI], 0.90-2.94) and ART (OR, 1.73; 95% CrI, 1.01-2.98), with a probability of harm resulting from higher PEEP in this subphenotype of 94.3% and 97.7% in the ALVEOLI and ART studies, respectively. Higher PEEP was not associated with mortality in patients with subphenotype B disease in each trial (OR, 0.95 [95% CrI, 0.51-1.73] and 1.00 [95% CrI, 0.63-1.55], respectively), with probability of benefit of 56.4% and 50.7% in the ALVEOLI and ART studies, respectively. These effects were not modified by Pao2 to Fio2 ratio, driving pressure, or the severity of illness for the cohorts. INTERPRETATION We found evidence of differential response to PEEP strategies across two ARDS subphenotypes, suggesting possible harm with a higher PEEP strategy in one subphenotype. These observations may assist with predictive enrichment in future clinical trials.
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Affiliation(s)
- Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.
| | - Lucas Bulgarelli
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | | | | | | | | | | | | | | | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, VIC, Australia; Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Rodrigo Octávio Deliberato
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Biostatistics, Health Informatics and Data Science (BHIDS), University of Cincinnati College of Medicine, Cincinnati, OH
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50
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Wong JJM, Dang H, Gan CS, Phan PH, Kurosawa H, Aoki K, Lee SW, Ong JSM, Fan LJ, Tai CW, Chuah SL, Lee PC, Chor YK, Ngu L, Anantasit N, Liu C, Xu W, Wati DK, Gede SIB, Jayashree M, Liauw F, Pon KM, Huang L, Chong JY, Zhu X, Hon KLE, Leung KKY, Samransamruajkit R, Cheung YB, Lee JH. Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial. Crit Care Med 2024; 52:1602-1611. [PMID: 38920618 DOI: 10.1097/ccm.0000000000006357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
OBJECTIVES Despite the recommendation for lung-protective mechanical ventilation (LPMV) in pediatric acute respiratory distress syndrome (PARDS), there is a lack of robust supporting data and variable adherence in clinical practice. This study evaluates the impact of an LPMV protocol vs. standard care and adherence to LPMV elements on mortality. We hypothesized that LPMV strategies deployed as a pragmatic protocol reduces mortality in PARDS. DESIGN Multicenter prospective before-and-after comparison design study. SETTING Twenty-one PICUs. PATIENTS Patients fulfilled the Pediatric Acute Lung Injury Consensus Conference 2015 definition of PARDS and were on invasive mechanical ventilation. INTERVENTIONS The LPMV protocol included a limit on peak inspiratory pressure (PIP), delta/driving pressure (DP), tidal volume, positive end-expiratory pressure (PEEP) to F io2 combinations of the low PEEP acute respiratory distress syndrome network table, permissive hypercarbia, and conservative oxygen targets. MEASUREMENTS AND MAIN RESULTS There were 285 of 693 (41·1%) and 408 of 693 (58·9%) patients treated with and without the LPMV protocol, respectively. Median age and oxygenation index was 1.5 years (0.4-5.3 yr) and 10.9 years (7.0-18.6 yr), respectively. There was no difference in 60-day mortality between LPMV and non-LPMV protocol groups (65/285 [22.8%] vs. 115/406 [28.3%]; p = 0.104). However, total adherence score did improve in the LPMV compared to non-LPMV group (57.1 [40.0-66.7] vs. 47.6 [31.0-58.3]; p < 0·001). After adjusting for confounders, adherence to LPMV strategies (adjusted hazard ratio, 0.98; 95% CI, 0.97-0.99; p = 0.004) but not the LPMV protocol itself was associated with a reduced risk of 60-day mortality. Adherence to PIP, DP, and PEEP/F io2 combinations were associated with reduced mortality. CONCLUSIONS Adherence to LPMV elements over the first week of PARDS was associated with reduced mortality. Future work is needed to improve implementation of LPMV in order to improve adherence.
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Affiliation(s)
- Judith Ju Ming Wong
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Hongxing Dang
- Children's Hospital of Chongqing Medical University, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
| | - Chin Seng Gan
- Department of Paediatrics, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Phuc Huu Phan
- Vietnam National Children's Hospital, Hanoi, Vietnam
| | | | - Kazunori Aoki
- Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
| | - Siew Wah Lee
- Sultanah Aminah Hospital, Johor, Malaysia
- Hospital Tengku Ampuan Rahimah, Selangor, Malaysia
| | | | - Li Jia Fan
- Division of Paediatric Critical Care, National University Hospital, Singapore
| | - Chian Wern Tai
- Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
| | - Soo Lin Chuah
- Department of Paediatrics, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Pei Chuen Lee
- Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
| | | | - Louise Ngu
- Sarawak General Hospital, Sarawak, Malaysia
| | | | - Chunfeng Liu
- Shengjing Hospital of China Medical University, Liaoning, China
| | - Wei Xu
- Shengjing Hospital of China Medical University, Liaoning, China
| | - Dyah Kanya Wati
- Pediatric Emergency and Intensive Care Unit, Prof I.G.N.G Ngoerah Hospital, Bali, Indonesia
- Medical Faculty, Udayana University, Bali, Indonesia
| | - Suparyatha Ida Bagus Gede
- Pediatric Emergency and Intensive Care Unit, Prof I.G.N.G Ngoerah Hospital, Bali, Indonesia
- Medical Faculty, Udayana University, Bali, Indonesia
| | | | - Felix Liauw
- Harapan Kita National Women and Children Health Center, Jakarta, Indonesia
| | | | - Li Huang
- Guangzhou Women and Children's Medical Center, Guangdong, China
| | - Jia Yueh Chong
- Hospital Tunku Azizah Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Xuemei Zhu
- Children's Hospital of Fudan University, Shanghai, China
| | - Kam Lun Ellis Hon
- Paediatric Intensive Care Unit, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Karen Ka Yan Leung
- Paediatric Intensive Care Unit, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Rujipat Samransamruajkit
- Division of Pediatric Critical Care, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yin Bun Cheung
- Duke-NUS Medical School, Singapore
- Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University, Tampere, Finland
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
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