Effect of lung recruitment maneuver on oxygenation, physiological parameters and mortality in acute respiratory distress syndrome patients: a systematic review and meta-analysis
Joris PensierAudrey De JongZied HajjejNicolas MolinariJulie CarrFouad BelafiaGérald ChanquesEmmanuel FutierÉlie AzoulaySamir Jaber
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2019-20 coronavirus outbreak
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Since its inception, the neonatal mechanical ventilator has been considered an essential tool for managing preterm neonates with Respiratory Distress Syndrome (RDS) and is still regarded as an integral component in the neonatal respiratory care continuum. Mechanical ventilation of newborn has been practiced for several years with several advances made in the way. This clinical intervention study was done to analyze immediate outcome of preterm neonates with RDS required mechanical ventilation and conducted on preterm neonates with RDS required mechanical ventilation from July 2014 to June 2015. Total of 31 preterm neonates with RDS were mechanically ventilated during the study period, of which 77.42% (N=24) survived. The survival rate was highest among 30- <34 weeks (100%) gestational age (GA) group and lowest in 27- <30 weeks (56%) GA, (p=0.0036). The neonates with Birth Weight (BW) 1500gm -1800gm were higher rate of recovery which was 100% and gradually declined in 1000-1499gm (93.75%) and 800-999gm (33.33%) BW groups (p=0.00083). In this study most of the neonates were male (61.29%) but recovery rate was relatively better among baby girls (83.33%) than baby boys (73.68%) (p=0.53). RDS with surfactant therapy was better outcome than non surfactant group & survival of neonates who got surfactant were 93.33% & non surfactant neonates were 62.50%, (p=0.040). Majority (71.43%) of RDS with surfactant therapy recovered earlier <7 days than non surfactant therapy neonates (30.00%) and most of non surfactant neonates (70.00%) required prolonged ventilator support >7days (p=0.045). During the period of ventilation a total 17(54.84%) neonates developed different complications, of which ventilator associated pneumonia was (16.13%), sepsis (16.13%), pneumothorax (9.68%), pulmonary hemorrhage (6.45%) and intraventricular hemorrhage (6.45%) and among them 10 neonates recovered. No complications encountered in 14(45.16%) neonates, all of them survived, (p=0.0064). All (N=31) preterm neonates were candidate for surfactant therapy but only 15 neonates got surfactant therapy, remaining (N=16) did not get for their financial issue. As mechanical ventilation with surfactant therapy reduces the neonatal mortality; hence, facilities for neonatal ventilation and cost effective surfactant therapy should be included in the regional and central hospitals providing intensive care for neonates.
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Fifteen years have passed since lung protective strategy to the patients with acute respiratory distress syndrome (ARDS) established. Recently, the new Berlin Definition of ARDS has been developed and this classified ARDS into three stages (mild, moderate, and severe ARDS), depending on the PaO2/FiO2. After this new definition of ARDS, each treatment to the patients with ARDS should be considered, depending on the severity of lung injury, such as prone position to the patients with severe ARDS, muscle paralysis to the patients with severe ARDS. In this review article, we review the history of lung protective strategy and ARDS definition, discuss the novel physiological approaches to minimizing ventilator-induced lung injury, and highlight a numbers of experimental/clinical studies to support these concepts.
Prone position
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Objective To explore the clinical value of serum Ang-1,Ang-2 and IL-8 in ARDS prediction.Methods Totally 283 critically ill patients admitted in EICU of the Hunan Provincial People's Hospital from January 2012 to July 2013 were enrolled in this study and divided into the non-ARDS group (n =251) and ARDS group (n =32) depending on the development of ARDS.According to the occurrence of death in the following 60 days,the non-ARDS group and the ARDS group were further subdivided into the non-ARDS survival group,the non-ARDS death group,thc ARDS survival group and the ARDS death group.The differences in serum Ang-1,Ang-2 and IL-8 concentrations between these four groups measured by ELISA on admission were analyzed by statistical methods and ROC curve.Results The EICU stays,duration of mechanical ventilation,APACHE Ⅱ score、serum Ang-2 and IL-8 levels in the ARDS group were significantly higher than those in the non-ARDS group,while the Ang-1 level in the ARDS group was significantly lower than that in the non-ARDS group.The serum Ang-2 and IL-8 concentrations in the ARDS death group were significantly higher than those in the non-ARDS survival group and the non-ARDS death group,and the serum Ang-2 concentrations in the ARDS death group were also significantly higher than those in the ARDS survival group.Further ROC curve analysis showed that the area under the curve of Ang-2 for ARDS diagnosis and ARDS death prediction were 0.907 and 0.899 respectively and their diagnostic sensitivity and specificity were 0.969 and 0.725,0.907 and 0.882 respectively,illustrating that Ang-2 possess the best diagnostic efficiency.Conclusions Ang-2 functions as a valuable biomarker for early diagnosis and prognosis of ARDS.
Key words:
Acute respiratory distress syndrome; Angiopoietin-1; Angiopoietin-2; Interleukin-8
Angiopoietin 2
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Poisoning induced by inhalation of hydrogen chloride has significant effects on the respiratory system. It can cause severe pulmonary edema and acute respiratory distress syndrome (ARDS) in the early stage, and even death in critical cases. As a novel treatment for ARDS, the efficacy of sivelestat sodium in infection-induced ARDS has been widely verified, but its application in ARDS caused by chemical poisoning is still scarce in literature. Here we report a case of ARDS induced by hydrogen chloride inhalation which was successfully treated with sivelestat sodium and conventional treatment.
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Introduction: It is uncertain whether ventilation management in patients with COVID-19 ARDS differs from that in patients with ARDS from another origin. Aim: To compare ventilation management in published cohorts of COVID-19 patients vs patients with ARDS from another origin. Methods: Two literature searches in PubMed were performed to identify observational studies reporting on ventilation management–one for COVID-19 ARDS, and one for ARDS from another origin. Results: The two searches identified 14 studies in COVID–19 ARDS patients, and 8 studies in patients with ARDS from another origin. In patients with COVID-19 ARDS, ventilation with a lower VT (median from 5.8 to 7.0 ml/kg PBW) was applied more rigorously than in patients with ARDS from another origin (median from 6.7 to 8.4 ml/kg PBW), albeit that Pplat was comparable between patients with COVID-19 ARDS (median from 24 to 27 cm H2O) and patients with ARDS from another origin (median from 19 to 26 cm H2O). PEEP and FiO2 were higher in patients with COVID-19 ARDS (median from 10 to 15 cm H2O, and from 60 to 80%) than in patients with ARDS from another origin (median from 7.5 to 10 cm H2O, and from 45 to 50%). Prone positioning was used more often in patients with COVID-19 ARDS (17 to 76%) than in patients with ARDS from another origin (1%, 6% and 16% in mild, moderate and severe ARDS). Conclusions: Remarkable differences exist in ventilation management of patients with COVID-19 ARDS vs patients with ARDS from another origin. Differences may, at least in part originate from disparities in oxygenation problems, that are more severe in COVID-19 ARDS patients.
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Abstract Background: Prone positioning is recommended for patients with moderate-to-severe acute respiratory distress syndrome (ARDS) receiving mechanical ventilation. While the debate continues as to whether COVID-19 ARDS is clinically different from non-COVID ARDS, there is little data on whether the physiological effects of prone positioning differ between the two conditions. We aimed to compare the physiological effect of prone positioning between patients with COVID-19 ARDS and those with non-COVID ARDS. Methods: We retrospectively compared 23 patients with COVID-19 ARDS and 145 patients with non-COVID ARDS treated using prone positioning while on mechanical ventilation. Changes in PaO 2 /FiO 2 ratio and static respiratory system compliance (Crs) after the first session of prone positioning were compared between the two groups: first, using all patients with non-COVID ARDS, and second, using subgroups of patients with non-COVID ARDS matched 1:1 with patients with COVID-19 ARDS for baseline PaO 2 /FiO 2 ratio and static Crs. We also evaluated whether the response to the first prone positioning session was associated with the clinical outcome. Results: When compared with the entire group of patients with non-COVID ARDS, patients with COVID-19 ARDS showed more pronounced improvement in the PaO 2 /FiO 2 ratio (adjusted difference 39.3 [95% CI 5.2–73.5] mmHg) and static Crs (adjusted difference 3.4 [95% CI 1.1–5.6] mL/cmH 2 O). However, these between-group differences were not significant when the matched samples (either PaO 2 /FiO 2 -matched or compliance-matched) were analyzed. The improvements in PaO 2 /FiO 2 ratio (subdistribution hazard ratio 1.19, 95% CI 1.08–1.30) and static Crs (subdistribution hazard ratio 1.57, 95% CI 1.29–1.91) after the first prone positioning session were associated with successful discontinuation of mechanical ventilation in patients with COVID-19 ARDS. Conclusions: In patients with COVID-19 ARDS, prone positioning was as effective in improving respiratory physiology as in patients with non-COVID ARDS. Thus, it should be actively considered as a therapeutic option. The physiological response to the first session of prone positioning was predictive of the clinical outcome of patients with COVID-19 ARDS.
Prone position
Pulmonary compliance
Respiratory physiology
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Pain medicine
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Mechanical ventilator
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Acute respiratory distress syndrome (ARDS) is an actual problem of the modern medicine. Despite current progress in management of such patients, an all-cause mortality is still very high. Mandatory approach to all ARDS patients is mechanical ventilation (MV). There are several additional ways to increase oxygenation rate in ARDS; inhaled nitric oxide (iNO) is one of them. Aims: The aim of our study was to determine a role of iNO in therapy of ARDS. Methods. We involved 30 patients with moderate to severe ARDS, PaO 2 / FiO 2 , 113.3 ± 33.7; Qs / Qt, 40.5 ± 12.9 %; APACHE II score, 20.3 ± 1.9; Lung Injury Score, 2.7 ± 0.7. iNO was administered to all patients in a starting dose of 5 ppm titrated to get positive response with PaO2 / FiO2 increase > 20 % from baseline. Results. 62 % of patients positively responded to the therapy. We observed an increase in PaO 2 / FiO 2 from 107.5 to 172.5 (p < 0.05) and a decrease in Qs / Qt from 39.3 to 27.9 (p < 0.05). Responders had statistically significantly worse oxygenation and better hemodynamics (cardiac output) parameters comparing to non-responders. iNO did not alter survival rate; patients treated with iNO had median survival time 3 days longer but this difference was not statistically significant. Conclusions. iNO is an effective way to improve oxygenation in ARDS patients. Better response was seen in patients with severe ARDS and stable central hemodynamics.
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