Cause Of Severe Respiratory Failure Research Articles

Long-term outcomes in patients who received veno-venous extracorporeal membrane oxygenation and renal replacement therapy: a retrospective cohort study

BackgroundAcute kidney injury (AKI) is a frequent complication in patients with severe respiratory failure receiving extracorporeal membrane oxygenation (ECMO). However, little is known of long-term kidney function in ECMO survivors. We aimed to assess the long-term mortality and kidney outcomes in adult patients treated with veno-venous ECMO (VV-ECMO).MethodsThis was a single-centre retrospective study of adult patients (≥ 18 years old) who were treated with VV-ECMO at a commissioned ECMO centre in the UK between 1st September 2010, and 30th November 2016. AKI was defined and staged using the serum creatinine and urine output criteria of the Kidney Diseases: Improving Global Outcomes (KDIGO) classification. The primary outcome was 1-year mortality. Secondary outcomes were long-term mortality (up to March 2020), 1-year incidence of end-stage kidney disease (ESKD) or chronic kidney disease (CKD) among AKI patients who received renal replacement therapy (AKI-RRT), AKI patients who did not receive RRT (AKI-no RRT) and patients without AKI (non-AKI).ResultsA total of 300 patients [57% male; median age 44.5; interquartile range (IQR) 34–54] were included in the final analysis. Past medical histories included diabetes (12%), hypertension (17%), and CKD (2.3%). The main cause of severe respiratory failure was pulmonary infection (72%). AKI occurred in 230 patients (76.7%) and 59.3% received renal replacement therapy (RRT). One-year mortality was 32% in AKI-RRT patients vs. 21.4% in non-AKI patients (p = 0.014). The median follow-up time was 4.35 years. Patients who received RRT had a higher risk of 1-year mortality than those who did not receive RRT (adjusted HR 1.80, 95% CI 1.06, 3.06; p = 0.029). ESKD occurred in 3 patients, all of whom were in the AKI-RRT group. At 1-year, 41.2% of survivors had serum creatinine results available. Among these, CKD was prevalent in 33.3% of AKI-RRT patients vs. 4.3% in non-AKI patients (p = 0.004).ConclusionsVV-EMCO patients with AKI-RRT had high long-term mortality. Monitoring of kidney function after hospital discharge was poor. In patients with follow-up creatinine results available, the CKD prevalence was high at 1 year, especially in AKI-RRT patients. More awareness about this serious long-term complication and appropriate follow-up interventions are required.

Muco-hematic plugs as a cause of severe respiratory failure in COVID-19 patients

We present 2 cases of COVID-19 patients with almost complete airway obstruction by muco-hematic plugs. The plugs were finally removed and the microscopic examination revealed a mixture of mucin, blood, neutrophils, bronchial epithelial cells and bacteria

A left shift in the oxyhaemoglobin dissociation curve in patients with severe coronavirus disease 2019 (COVID-19).

Critically ill patients with coronavirus disease 2019 (COVID‐19) present with hypoxaemia and are mechanically ventilated to support gas exchange. We performed a retrospective, observational study of blood gas analyses (n = 3518) obtained from patients with COVID‐19 to investigate changes in haemoglobin oxygen (Hb–O2) affinity. Calculated oxygen tension at half‐saturation (p50) was on average (±SD) 3·3 (3·13) mmHg lower than the normal p50 value (23·4 vs. 26·7 mmHg; P < 0·0001). Compared to an unmatched historic control of patients with other causes of severe respiratory failure, patients with COVID‐19 had a significantly higher Hb–O2 affinity (mean [SD] p50 23·4 [3·13] vs. 24·6 [5.4] mmHg; P < 0·0001). We hypothesise that, due to the long disease process, acclimatisation to hypoxaemia could play a role.

Effects of intravenous phosphodiesterase inhibitors and corticosteroids on severe meconium aspiration syndrome.

Meconium aspiration syndrome (MAS) is a major cause of severe respiratory failure in near- and full-term neonates. Alleviating inflammation is key to successfully treating severe MAS. Phosphodiesterase (PDE) inhibitors are known to play a role in airway smooth muscle relaxation and alveolar inflammation inhibition. This study aimed to investigate the effects of various intravenous (IV) PDE inhibitors and corticosteroids on MAS. MAS was induced in newborn piglets by instilling human meconium in them. The piglets were randomly divided into five groups (n = 5 in each group): (1) control (sham treatment); (2) dexamethasone (Dex) (IV 0.6 mg/kg of dexamethasone); (3) aminophylline (Ami) (IV 6 mg/kg of aminophylline, followed by continuous infusion of 0.5 mg/kg/h of aminophylline; (4) milrinone (Mil) (IV 50 μg/kg of milrinone, followed by continuous infusion of 0.75 μg/kg/h of milrinone); and (5) rolipram (Rol) (IV 0.8 mg/kg of rolipram). The duration of the experimental period was 4 hours. Compared to the control group, all the four treatment groups revealed better oxygenation 3 hours and more after the start of treatment. The Rol group had a significantly elevated heart beat (p < 0.05) and relatively lower blood pressure compared to the other groups during the first 2 hours of the experiment. The Dex group had significantly lower interleukin (IL)-1β levels in the lung tissue compared to the other groups (p < 0.05) and significantly lower IL-6 levels compared to the Ami and Mil groups (p < 0.05). Lung histology showed slightly less inflammation and atelectasis in the Dex group compared to the other groups, but lung injury scores showed no significant between-group differences. Using IV corticosteroids or any type of PDE inhibitors has some beneficial effects in improving oxygenation in MAS. PDE inhibitors are not superior to IV corticosteroids; in fact, adverse cardiovascular effects occur with the phosphodiesterase type 4 (PDE4) inhibitor. Further investigations are required before using IV corticosteroids and PDE inhibitors in future clinical application.

PO-0728 Lung Lavage With Dilute Porcine Surfactant For Meconium Aspiration Syndrome: A Randomised Controlled Study, A Preliminary Report

Background and aims Meconium aspiration syndrome (MAS) is an important cause of severe respiratory failure in newborn infants. The aim of this study was to evaluate the efficacy of lung lavage with dilute porcine surfactant in ventilated infants with MAS. Methods In this prospective randomised controlled study ventilated infants with MAS with a gestational age ≥36, birth weight ≥2000 g included. Enrolled infants randomised into two groups; in group 1, two sequential 15 mL/kg aliquots of dilute porcine surfactant (Curosurf, Chiesi Farmaceutici S.p. A., Parma, Italy) with a phospholipid concentration of 5 mg/ml were instilled into the lung. In group 2, 100 mg/kg of porcine surfactant were administered as a bolus. Infants in both groups were evaluated and compared with regard to efficacy, morbidity and mortality. Results Fourteen infants were randomised. There were no significant differences between two groups in term of demographic characteristics. Median duration of respiratory support was longer in bolus surfactant group, although the difference was not statistically significant (2.2 vs. 7.2 days, p = 0.18). Similarly, duration of oxygen therapy and hospital stay length were shorter in lung lavage group but the difference was statistically insignificant (8.0 vs. 12.7 days, p = 0.32, 11 vs. 18.5 days p = 0.15, respectively). There were no differences in requirement for high frequency ventilation and nitric oxide between the groups. Conclusion Although it is not statistically significant, preliminary results show that lung lavage with dilute surfactant therapy shortens the duration of respiratory support and hospital stay length.

Case report: Oseltamivir‐induced resistant pandemic influenza A (H1N1) Virus infection in a patient with AIDS and Pneumocystis jirovecii pneumonia

Pneumocystis jirovecii pneumonia is the main cause of severe respiratory failure in patients with advanced HIV disease who do not receive P. jirovecii prophylaxis. Other aetiological agents may contribute to the respiratory failure in these patients, which is highlighted by the case described below: A patient with advanced HIV disease was treated for a dual-infection with pandemic influenza A (H1N1) and P. jirovecii. Initially, his condition improved, but deteriorated after the emergence of oseltamivir-resistant influenza virus. This is the first documented case of emergence of drug-resistant influenza virus in a patient infected with HIV with a pandemic influenza A (H1N1) and P. jirovecii double infection.

Análisis de efectividad de la ventilación de alta frecuencia oscilatoria en pacientes pediátricos con insuficiencia respiratoria aguda en un centro de alta complejidad

Introduction. High frequency oscillatory ventilation (HFOV) is a rescue therapy for hypoxemic patients who deteriorate in conventional mechanical ventilation and/or for the air-leak syndrome treatment. A recent meta analysis showed that HFOV might have reduced mortality in pediatric and adult patients compared with conventional ventilation. In this context it's important to evaluate the effectiveness of this method in everyday use. Objectives. Main: To analize the effectiveness of HFOV in everyday practice in a center without extra corporeal membrane oxygenation (ECMO) capabilities. Secondary: To describe demographics and causes of severe respiratory failure of patients requiring HFOV. To assess the relationship between potential predictors and the occurrence of mortality. Population and methods. Retrospective study analyzing medical records of all patients that required HFOV in a tertiary care pediatric hospital pediatric intensive care units between march 1st 2008 and july 1st 2010. Results. Sixty-nine patients received 76 HFOV treatments. Eighty percent were diagnosed with acute lower respiratory infection or sepsis and 62.3% (n= 43) had preexisting chronic co-morbidities. The majority of HFOV treatments were because refractory hypoxemia (93.4%). Non survivors patients had worse clinical status at PICU admission, higher multiorgan failure, worse oxygenation and pulmonary condition. Conclusions. Everyday use of HFOV in a population with high incidence of chronic, oncologic and/or immunocompromised patients was associated with a survival of 33.4%. More prognostic studies are needed for a more effective selection of HFOV candidates.

A distinct influenza infection signature in the blood transcriptome of patients with severe community-acquired pneumonia

IntroductionDiagnosis of severe influenza pneumonia remains challenging because of a lack of correlation between the presence of influenza virus and clinical status. We conducted gene-expression profiling in the whole blood of critically ill patients to identify a gene signature that would allow clinicians to distinguish influenza infection from other causes of severe respiratory failure, such as bacterial pneumonia, and noninfective systemic inflammatory response syndrome.MethodsWhole-blood samples were collected from critically ill individuals and assayed on Illumina HT-12 gene-expression beadarrays. Differentially expressed genes were determined by linear mixed-model analysis and overrepresented biological pathways determined by using GeneGo MetaCore.ResultsThe gene-expression profile of H1N1 influenza A pneumonia was distinctly different from those of bacterial pneumonia and systemic inflammatory response syndrome. The influenza gene-expression profile is characterized by upregulation of genes from cell-cycle regulation, apoptosis, and DNA-damage-response pathways. In contrast, no distinctive gene-expression signature was found in patients with bacterial pneumonia or systemic inflammatory response syndrome. The gene-expression profile of influenza infection persisted through 5 days of follow-up. Furthermore, in patients with primary H1N1 influenza A infection in whom bacterial co-infection subsequently developed, the influenza gene-expression signature remained unaltered, despite the presence of a superimposed bacterial infection.ConclusionsThe whole-blood expression-profiling data indicate that the host response to influenza pneumonia is distinctly different from that caused by bacterial pathogens. This information may speed the identification of the cause of infection in patients presenting with severe respiratory failure, allowing appropriate patient care to be undertaken more rapidly.

Neonatal Respiratory Care

Acute respiratory failure caused by different origins continues to be the major etiology of morbidity and mortality in critical neonates. There has been much advancement in neonatal respiratory care, but a few neonates with severe respiratory failure continue to be candidates for extracorporeal membrane oxygenation or survive with chronic lung diseases (CLD). Therefore, searching for ideal respiratory care strategies to reduce the morbidity and mortality rates is crucial for caring critical neonates. The main aim of this special issue was focused on the existing and potential strategies or techniques in neonatal respiratory care. In this special issue, we have invited a few papers that address such issues. Meconium aspiration syndrome (MAS) is a common cause of severe respiratory failure in term infants. The associations of persistent pulmonary hypertension of newborn (PPHN), pulmonary air leaks, and other morbidities sometimes make the respiratory care a difficult challenge to neonatologists. Three papers address current respiratory care in MAS. In a paper by K. Swarnam et al. they have a detail review on the epidemiology, pathophysiology, and managements in many different views of MAS. In another paper, P. Dargaville focuses on the application of mechanical respiratory supports in MAS, as well as the role of adjunctive respiratory therapies. In a paper, by C. Fischer et al., they demonstrate the epidemiology of MAS in term neonates using a population-based retrospective study for all births from 2000 to 2007 in a French region (Burgundy). In addition, bronchopulmonary dysplasia (BPD)/chronic lung disease (CLD) continues to be a major cause of neonatal morbidity in spite of significant progress in the treatment of preterm neonates. We have two articles discussing the pharmacologic approaches for prevention and treatment of BPD/CLD. S. Gupta et al. focus on the use of corticosteroids in one paper, and K. Tropea reviews all possible medications and the future potential stem cell therapy in another one. Furthermore, research papers discussing other important clinical issues in neonatal respiratory care are included. In a paper by S. Rastogi et al., they report their analysis on the factors associated with the successful weaning from nasal continuous positive airway pressure (NCPAP). In a paper by A. Gentili et al., they report their analysis on the duration of preoperative stabilization in predicting outcome of congenital diaphragmatic hernia. In a paper by K. Hole et al., they report the impact of neonatal resuscitation training in neonatal mortality rates in Malawi, Africa. Mei-Jy Jeng Tsu F. Yeh Peter A. Dargaville Thomas H. Shaffer Jen-Tien Wung

Effective Lavage Volume of Diluted Surfactant Improves the Outcome of Meconium Aspiration Syndrome in Newborn Piglets

Meconium aspiration syndrome (MAS) is one of the top causes of severe respiratory failure in neonates. This study was designed to investigate the effective volume of therapeutic bronchoalveolar lavage (BAL) with diluted surfactant in the treatment of MAS in newborn piglets. Human meconium was instilled in 24 piglets to induce MAS, and the piglets were randomly divided into four groups: 1) control, no lavage; 2) lavage-10, BAL with diluted surfactant (5 mg/mL, Survanta) 10 mL/kg in two aliquots; 3) lavage-20, 20 mL/kg in two aliquots; 4) lavage-30, 30 mL/kg in two aliquots. Cardiopulmonary parameters were monitored, and the lung tissue was histologically examined after experiments. The changes in oxygenation and lung compliance of lavage-20 and lavage-30 groups were significantly better than control and lavage-10 groups (p < 0.05), but there was no significant difference between lavage-20 and lavage-30 groups. The lung injury scores were significantly lower in the dependent site of lavage-20 and lavage-30 groups than the other two groups. In conclusion, using 20 mL/kg diluted surfactant in two aliquots to perform therapeutic BAL was as effective as 30 mL/kg in improving the pathophysiological outcomes in MAS and may warrant consideration clinically in treating MAS.

A Series of Five Adult Cases of Respiratory Syncytial Virus-Related Acute Respiratory Distress Syndrome

Respiratory syncytial virus is a common cause of respiratory tract disease in children, predominantly presenting with mild symptoms. We present five cases of respiratory syncytial virus infection of the lower respiratory tract in immunocompromised adults suffering from severe respiratory insufficiency leading to bilateral pneumonia and fulfilling the criteria for acute respiratory distress syndrome. Respiratory syncytial virus was cultured as the only pathogen in the bronchoalveolar lavage fluid in four of these patients. Despite various therapeutic interventions, only one patient survived. Respiratory syncytial virus was implicated as a direct cause of respiratory failure. Respiratory syncytial virus may be an underestimated cause of severe respiratory failure and acute respiratory distress syndrome in the immunocompromised adult admitted to the intensive care unit.

Diffuse pulmonary opacification in infants undergoing extracorporeal membrane oxygenation: clinical and pathologic correlation.

Diffuse pulmonary opacification is commonly seen on chest radiographs from infants with severe respiratory failure treated with extracorporeal membrane oxygenation (ECMO). The chest radiographs and clinical records of 18 such infants were reviewed to determine the correlation among degree of abnormality on chest radiograph (as determined by a radiographic score), clinical severity of disease (as measured by ECMO requirements [ECMO flow rate]), and dynamic lung compliance determinations. Increasing lung compliance and decreasing ECMO flow rates correlated well with decreasing (improving) radiographic score. Pathologic changes were mainly those associated with intensive respiratory support and the underlying pulmonary condition. One patient had diffuse pulmonary hemorrhage. Other than bleeding, no distinctive pathologic features could be attributed to therapy with ECMO. We conclude that the degree of pulmonary opacification seen in infants undergoing ECMO therapy is an accurate reflection of markedly decreased lung compliance and lung volumes caused by hyaline membrane formation, pulmonary edema, and atelectasis associated with the various causes of severe respiratory failure.