Recently Published Documents
AbstractAcute respiratory distress syndrome (ARDS) has high mortality and multiple therapeutic strategies have been used to improve the outcome. Inhaled nitric oxide (INO), a pulmonary vasodilator, is used to improve oxygenation. This study was conducted to determine the role of sildenafil, an oral vasodilator, to improve oxygenation and mortality in pediatric ARDS (PARDS). The prevalence of pulmonary hypertension in PARDS was studied as well. Inclusion criteria included children (1–18 years) with ARDS requiring invasive ventilation admitted to the pediatric intensive care unit of a teaching hospital in Northern India over a 1-year period of time. Thirty-five patients met the inclusion criteria. Cardiologist performed a detailed echocardiogram to determine pulmonary arterial pressure (PAP). Patients with persistent hypoxemia were started on oral sildenafil. The majority (77%) patients had a primary pulmonary etiology of PARDS. Elevated PAP (>25 mm Hg) was detected in 54.3% patients at admission. Sildenafil was given to 20 patients who had severe and persistent hypoxemia. Oxygenation improved in most patients after the first dose with statistically significant improvement in PaO2/FiO2 ratios at both 12 and 24 hours following initiation of therapeutic dosing of sildenafil. Improvement in oxygenation occurred irrespective of initial PAP. Outcomes included a total of 57.1% patients discharged, 28.6% discharged against medical advice (DAMA), and a 14.3% mortality rate. Mortality was related to the severity of PARDS and not the use of sildenafil. This is the first study to determine the effect of sildenafil in PARDS. Sildenafil led to improvement in oxygenation in nearly all the cases without affecting mortality. Due to unavailability of INO in most centers of developing countries, sildenafil may be considered as an inexpensive alternative in cases of persistent hypoxemia in PARDS. We recommend additional randomized controlled trials to confirm the effect of sildenafil in PARDS as determined in this study.
Is the Pao 2:Fio 2 Ratio the Best Marker to Monitor the Blood-Air Barrier Function in Acute Respiratory Distress Syndrome?
Sedation and Neuromuscular Blockade in Acute Respiratory Distress Syndrome: A Step Toward Disentangling Best Practices*
Role of DAMPs in respiratory virus-induced acute respiratory distress syndrome—with a preliminary reference to SARS-CoV-2 pneumonia
Acute lung injury and acute respiratory distress syndrome are characterized by rapid-onset respiratory failure following a variety of direct and indirect insults to the parenchyma or vasculature of the lungs. Extracorporeal membrane oxygenation is a form of extracorporeal life support where an external artificial circulator carries venous blood from the patient to a gas exchange device (oxygenator) where blood becomes enriched with oxygen and has carbon dioxide removed. This blood then re-enters the patients circulation. The potential advantages of ECMO over conventional manajement may extend beyond its role in supporting patients with ARDS. ECMO may facilitate and enhance the application of lung-protective ventilation by minimizing ventilator-induced lung injury.
Autotaxin levels in serum and bronchoalveolar lavage fluid are associated with inflammatory and fibrotic biomarkers and the clinical outcome in patients with acute respiratory distress syndrome
Abstract Background Autotaxin (ATX) is a secreted glycoprotein that is widely present in extracellular biological fluids and has been implicated in many inflammatory and fibrotic diseases. However, the clinical impact of the release of ATX in patients with acute respiratory distress syndrome (ARDS) remains unclear. Methods Serum and bronchoalveolar lavage fluid (BALF) levels of ATX, interleukin (IL)-6, IL-8, tumor necrosis factor (TNF)-α, matrix metalloproteinase (MMP)-7, fibronectin, oncostatin M (OSM), and SPARC (secreted protein acidic and rich in cysteine) were collected from 52 patients with ARDS within 24 h of diagnosis. All cytokines were measured by Magnetic Luminex Assay. BALF albumin (BA) and serum albumin (SA) were measured by enzyme-linked immunosorbent assay. Results Serum ATX, MMP-7, and BALF IL-8 levels were significantly higher in patients who did not survive than in those who survived up to 28 days after diagnosis of ARDS (P < 0.05). BALF and serum ATX levels were correlated with IL-6, IL-8, and MMP-7 levels in BALF and serum, respectively. In addition, BALF ATX was positively correlated with BALF TNF-α, fibronectin, OSM, and SPARC as well as the BA/SA ratio, while serum ATX was correlated with severity of illness based on the SOFA score and PaO2/FIO2 ratio. Furthermore, serum ATX was better able to predict 28-day ARDS-related mortality (area under the curve 0.744, P < 0.01) than the SOFA score, APACHE II score, or PaO2/FIO2 ratio. Serum ATX independently predicted mortality in a univariate Cox regression model (P < 0.0001). Conclusion The serum ATX level is a potential prognostic biomarker in patients with ARDS. BALF ATX is associated with pulmonary biomarkers of inflammation and fibrosis, suggesting a role of ATX in the pathogenesis of ARDS.
ECMO induces early alterations in coagulation and fibrinolysis profiles in COVID-19 patients with acute respiratory distress syndrome.
Hemostatic changes induced by extracorporeal membrane oxygenation (ECMO) support have been yet poorly documented in COVID-19 patients who have a baseline complex hypercoagulable state. In this prospective monocentric study of patients with severe acute respiratory distress syndrome (ARDS) rescued by ECMO, we performed longitudinal measurements of coagulation and fibrinolysis markers throughout the course of ECMO support in 20 COVID-19 and 10 non-COVID-19 patients. Blood was sampled before and then 24 hours, 7 and 14 days after ECMO implantation. Clinical outcomes were prospectively assessed until discharge from the intensive care unit or death. The median age of participants was 47 (35-56) years, with a median body mass index of 30 (27-35) kg/m², and a SOFA score of 12 (8-16). Baseline levels of von Willebrand factor, fibrinogen, factor VIII, prothrombin F1+2, thrombin-antithrombin, D-Dimers and PAI-1 were elevated in both COVID-19 and non-COVID-19 ARDS patients, indicating that endothelial activation, endogenous thrombin generation and fibrinolysis shut-down occur in all ARDS patients before ECMO implantation. From baseline to day 7, thrombin generation (prothrombin F1+2, p<0.01) and fibrin formation markers (fibrin monomers, p<0.001) significantly increased, further resulting in significant decreases in platelet count (p<0.0001) and fibrinogen level (p<0.001). PAI-1 levels significantly decreased from baseline to day 7 (p<0.0001) in all ARDS patients. These changes were more marked in COVID-19 patients, resulting in 14 non-fatal and 3 fatal bleeding. Additional studies are warranted to determine whether monitoring of thrombin generation and fibrinolysis markers might help to early predict bleeding complications in COVID-19 patients supported by ECMO.
Introduction Venovenous extracorporeal membrane oxygenation has been recommended as an effective rescue therapy for select critically ill patients with COVID-19. This case report describes a first experience caring for a patient with COVID-19 who received venovenous extracorporeal membrane oxygenation and expands the literature by discussing relevant nursing management and operational considerations. Clinical Findings A 46-year-old man presented to a hospital emergency department with pleuritic chest pain, dyspnea, anorexia, and chills. The patient was intubated for pneumonia-associated acute respiratory distress syndrome. Diagnosis A nasopharyngeal swab specimen was positive for SARS-CoV-2, and chest radiography confirmed a diagnosis of COVID-19 with acute respiratory distress syndrome. Interventions After no improvement with mechanical ventilation and prone positioning, the patient began receiving venovenous extracorporeal membrane oxygenation and was transferred to an extracorporeal membrane oxygenation center. Frontline critical care nurses played a vital role in coordinating patient care activities, monitoring changes in the patient’s condition, and detecting complications early. Outcomes The patient was decannulated on day 15 and extubated on day 17. The patient was successfully discharged home on hospital day 24. Conclusion Caring for a patient with COVID-19 receiving venovenous extracorporeal membrane oxygenation posed unprecedented challenges that required deviations from standards of care to optimize infection control measures and staff safety while providing quality care. This case report may inform, prepare, and guide other critical care nurses who will be caring for similar patients during this pandemic.