It wasn’t such a crazy idea, injecting beta-agonists continuously into the veins of people with acute respiratory distress syndrome (ARDS) for a week. After all, if you spray some albuterol on alveolar epithelial cells in a dish, it upregulates their cAMP production and doubles the rate at which they clear fluid across their basement membranes. [… read more]
Numerous small (n~100), single-center randomized trials have shown a benefit of omega-3 fatty acids in acute lung injury and ARDS (reduced mortality, length of stay, and organ failure; improved oxygenation and respiratory mechanics). A meta-analysis combining these studies suggested a stat.significant benefit in mortality (risk ratio 0.67), ventilator requirement (-5 days), and ICU stay (-4 [… read more]
Daniel Brodie and Matthew Bacchetta offer a nice review of extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) in adults, based on their experience at Columbia University in New York City. This general overview describes ECMO techniques and re-visits the CESAR trial results — the only major randomized controlled trial on ECMO in ARDS [… read more]
In the longest longitudinal study of acute respiratory distress syndrome (ARDS) yet, Herridge et al followed 109 young survivors of severe ARDS (medians: age 44; Lung Injury Score 3.7 out of 4) in Canada for 5 years, enrolling 1998-2001. Twelve died in the first year. At 5 years, the survivors remained below their pre-ARDS exercise tolerance; they [… read more]
Obesity may impose extra burdens on critical care staff (think turning, transport, intubation and central line placement), but reviews suggest people with “ordinary” obesity (BMI 30-39) with have the same mortality from critical illness as overweight or healthy-weight people. In fact, obese people may have a survival advantage, despite possible longer durations of mechanical ventilation and ICU stays. But what about extreme obesity (BMI > [… read more]
October’s Seminars in Respiratory & Critical Care Medicine brings you 110 pages and 11 articles on organ failure in the intensive care unit, with articles including: Organ failure scoring and predictive models Cardiac alterations due to organ failure The microcirculation as a therapeutic target in shock Immuologic derangements in organ failure Acute lung failure Cardiogenic [… read more]
The 2009 randomized CESAR trial in Lancet concluded that in severe ARDS in the U.K., referral to an ECMO center saved lives. However, patients in the control (non-ECMO) group didn’t consistently get low-tidal ventilation, and many patients randomized to ECMO never received it, creating skepticism of the findings. A case series from Australia/New Zealand (ANZ ECMO) in JAMA showed a 70% survival [… read more]
Adaptive support ventilation (ASV) has entered wide use based on its attractive premise: it’s patient-centered ventilation, adapting breath-by-breath to deliver precisely the right amount of pressure support to achieve a targeted minute ventilation. However, evidence for any superiority over conventional ventilator modes is limited to cardiac surgery patients who were extubated in ~6 hours regardless of [… read more]
Talc pleurodesis is 90-95% effective at prevention of recurrent primary spontaneous pneumothorax. However, there have been reports of ARDS occurring after talc pleurodesis, mostly in patients with malignant pleural effusions, raising concerns over its use. Bridevaux et al report results of talc pleurodesis on 418 patients with primary spontaneous pneumothorax (PSP) at nine centers in Europe and [… read more]
Perhaps the most contentious debate in critical care is whether and when to transfuse blood to patients, especially those with acute lung injury and/or septic shock. FACTT showed less fluids (which could include blood) are better for ALI/ARDS, but transfusion wasn’t controlled and its contribution to the outcomes is unknown. Practicing physicians vary widely in [… read more]
Stapleton et al report results of a phase II trial of 14 days of omega-3 fish oil vs. placebo in 90 people with acute lung injury or ARDS. There was no difference in the primary endpoint (inflammatory marker IL-8 in BAL fluid), nor in any clinical outcome. Crit Care Med 2011;39:1655-1662.
Masclans et al followed 38 patients with ARDS in 3 ICUs for 6 months. Health-related quality of life (Nottingham Test Profile) was lower than expected at 6 months, with 40% reporting limitations in daily activities mainly due to low energy, mobility and social functioning. Mild radiographic abnormalities and restrictive physiology were usually present on HRCT [… read more]
Acute lung injury & critical care update for 2010: Vadasz I, Sznajder J, AJRCCM 2011;183:1147-1152. ARDS review. Critical care review.
Prone positioning improves oxygenation in ARDS patients without improving outcome. Recruitment maneuvers do too. Rival et al prospectively tested the effects of both strategies together in 16 ARDS patients. Two extended sighs of 45 cm H2O in pressure control mode while lying prone improved PaO2/FiO2 from 98 to 166 mm Hg, without obvious adverse (or positive) effects. Critical [… read more]
Databases suggest that 60-70% of patients with severe respiratory failure due to H1N1 received steroids. Brun-Buisson et al looked back at a French registry including 208 patients with H1N1 and ARDS, 83 of whom received steroids. They found a hazard ratio of 2.4 for death associated with steroid administration, rising to 2.8 after applying their propensity scoring [… read more]
Those patients with severe acute lung injury due to pneumonia or aspiration who received the rSP-C surfactant product did no better on important outcomes (28-day survival, need for ventilation, organ-failure-free days) than those receiving usual care, report Spragg et al.(n=843). AJRCCM 2011;183:1055-1061.
In 1998, Dr. Cheryl Misak survived organ failure in the ICU; this month, she shares her story of a long and difficult recovery from debility. Although highly educated and motivated, and in top pre-admission physical shape, her struggle was formidable. Twelve years later, are we doing any better at adequately informing and preparing patients like [… read more]
ARDS and multi-organ failure: Curr Opin Crit Care 2011;17:1-6. Hemodynamic monitoring of ventilated patients: Ibid, pp. 36-42 The ‘ABCDE’ bundle for critical care: Ibid, pp. 43-49. Managing severely hypoxemic patients: Ibid.
Meade MO et al. (Lung open ventilation study investigators) Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2008; 299:637-45. Higher PEEP provided no benefit in 28-day mortality (28 vs 32%, p = 0.2), although it reduced refractory hypoxia (~5% [… read more]
Brower RG et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 2004;351:327-36. Randomized trial among 549 patients with ARDS/ALI conducted by NHLBI/ARDSNet. Compared high and low PEEP strategies, and found no significant difference in mortality, ventilator-free days, ICU-free days, or organ failure-free days between [… read more]