Criteria For Acute Lung Injury Research Articles

Definition of Acute Respiratory Distress Syndrome on the Plateau of Xining, Qinghai: A Verification of the Berlin Definition Altitude-PaO2/FiO2-Corrected Criteria.

BackgroundAcute respiratory distress syndrome (ARDS) is a common critical respiratory illness. Hypoxia at high altitude is a factor that influences the progression of ARDS. Currently, we lack clear diagnostic criteria for high-altitude ARDS. The purpose of this study was to determine the value of the application of the Berlin Definition altitude-PaO2/FiO2-corrected criteria for ARDS in Xining, Qinghai (2,261 m).MethodsWe retrospectively analyzed the clinical data of patients with ARDS admitted to the Department of Critical Care Medicine of the Affiliated Hospital of Qinghai University from January 2018 to December 2018. The severity of ARDS was categorized according to the Berlin Definition, Berlin Definition altitude-PaO2/FiO2-corrected criteria, and the diagnostic criteria for acute lung injury (ALI)/ARDS at high altitudes in Western China (Zhang criteria). In addition, the differences between the three criteria were compared.ResultsAmong 1,221 patients, 512 were treated with mechanical ventilation. In addition, 253 met the Berlin Definition, including 49 (19.77%) with mild ARDS, 148 (58.50%) with moderate ARDS, and 56 (22.13%) with severe ARDS. A total of 229 patients met the altitude-PaO2/FiO2-corrected criteria, including 107 with mild ARDS (46.72%), 84 with moderate ARDS (36.68%), and 38 (16.59%) with severe ARDS. Intensive care unit (ICU) mortality increased with the severity of ARDS (mild, 17.76%; moderate, 21.43%; and severe, 47.37%). Twenty-eight-day mortality increased with worsening ARDS (mild 23.36% vs. moderate 44.05% vs. severe 63.16%) (p < 0.001). There were 204 patients who met the Zhang criteria, including 87 (42.65%) with acute lung injury and 117 (57.35%) with ARDS. The area under receiver operating characteristics (AUROCs) of the Berlin Definition, the altitude-P/F-corrected criteria, and the Zhang criteria were 0.6675 (95% CI 0.5866–0.7484), 0.6216 (95% CI 0.5317–0.7116), and 0.6050 (95% CI 0.5084–0.7016), respectively. There were no statistically significant differences between the three diagnostic criteria.ConclusionFor Xining, Qinghai, the altitude-PaO2/FiO2-corrected criteria for ARDS can distinguish the severity of ARDS, but these results need to be confirmed in a larger sample and in multicenter clinical studies.Clinical Trial RegistrationClinicalTrials.gov, identifier: NCT04199650.

Non-Invasive Positive Pressure Ventilation (NIPPV) in the Pregnant Patient: A Case Series

Rationale: Acute respiratory failure is an uncommon complication of pregnancy. However, it is the most frequent organ dysfunction associated with obstetric admissions to an intensive care unit. The obstetric population is a different group due to its physiology and the presence of the fetus that lacks evidence in the literature within the subject of ventilatory support. Noninvasive positive pressure ventilation (NIPPV) is often avoided due to the lack of knowledge on the safety and efficacy of this modality. Currently, there are no guidelines for the management of respiratory failure in pregnancy. Objectives: To provide evidence in support of the use of NIPPV as a safe and reasonable modality for pregnant patients with respiratory failure. Methods: We retrospectively reviewed medical records of 29 pregnant patients of the Obstetric Critical Care Unit of a tertiary hospital in Panamá City who received NIPPV from 2013 to 2015. Failure to response was defined as the lack of increase in the paO2/FiO2 ratio or clinical deterioration 6 hours after initiating NIPPV. Demographics, indication for NIPPV, duration of treatment, as well as maternal and fetal outcomes were collected. Measurements and Main Results: Mean age was 28.4 ± 6 years, mean body mass index 27.4 ± 3.3, and mean gestational age at admission was 305/7 ± 5 weeks. Twenty-four patients (82.8%) met the criteria for acute lung injury (ALI) and an additional two (6.9%) for acute respiratory distress syndrome (ARDS). The mean duration of ventilation was 50.6 ± 17.27 hours. Statistically significant differences were noted between the paO2/FiO2 ratios in failure and successful patients within 2 hours of NIPPV therapy (P = 0.007) and paO2/FiO2 ratio within 6 hours of NIPPV therapy (P = 0.03). Success was defined when the patient was administered NIPPV, resulting in an improvement (increase in pa/FiO2 ratio) of her ventilatory parameters. Three patients (10.3%) failed to respond to NIPPV and needed to be converted to invasive mechanical ventilation. Patients who required intubation had a longer duration of ICU stay (P = 0.006) and overall hospital stay (P = 0.03). None of patients presented aspiration during NIPPV therapy. Conclusion: The current series is the largest report of pregnant patients requiring ventilatory support who received NIPPV as first line of therapy. This report shows the usefulness of this ventilation modality, avoiding intubation with its risks, of a significant number of patients, especially ventilator-associated pneumonia.

Challenges and perspectives in porcine model of acute lung injury using oleic acid

The oleic acid (OA) models of lung injury try to simulate the findings of human Acute Respiratory Distress Syndrome (ARDS). However, these models are difficult to replicate because they vary in terms of animals species, OA doses, time for establishment of lung injury, different observation periods and settings of mechanical ventilation. The objective of this study was to evaluate a protocol of administration of OA in lung injury model, challenges in its development and its effects on respiratory mechanics, hemodynamic changes, histology, gas exchange and mortality. We then submitted ten Large White pigs to acute lung injury through intravenous infusion of acid oleic in the pulmonary artery. The mortality of the model was 50%, due to an intense hemodynamic instability during OA administration, even with early use of vasoactive drugs. Three animals required additional doses of OA to achieve criteria for acute lung injury. Histology showed findings consistent with acute lung injury. However, more pulmonary edema was observed in lower segments than in upper segments of both lungs (p = 0.01). IL-6 and IL-8 were significantly increased compared to normal lungs (p < 0.05), and IL-6 showed higher levels in upper segments compared to lower segments (p = 0.03). Positive cells for Caspase 3 were present in all samples, localized mainly in respiratory epithelial cells and macrophages. In conclusion, this model shows histological findings of acute lung injury and inflammatory response similar to those of clinical ARDS, it presents high mortality, inconsistent reproducibility and hardly controlled hemodynamic instability.

Bronchoalveolar Lavage Cytokine Profiles Reflect Involvement in Pulmonary Recovery After Pulmonary Hypertension in a Pig Model of Endotoxin‐Induced Acute Lung Injury

We previously demonstrated in a pig model of acute lung injury (ALI) with endotoxin (ETX)‐induced pulmonary hypertension (PHN) that different cytokines in the circulation appear to mediate pulmonary vasoactivity vs alveolar gas exchange. Despite improvements in PHN and blood gas exchange, serum cytokine levels remain elevated several hours after ETX exposure. With prolonged elevated levels of cytokines, it would be logical that some would be involved in pulmonary recovery from ETX.We sought to further explore the relationship between cytokines and ALI by evaluating lung cytokine levels after ETX‐induced ALI. We tested the hypothesis that cytokine profiles in bronchoalveolar lavage (BAL) specimens several hours after ETX exposure would reflect a reparative response and be different from the blood cytokine profile seen at the initiation of inflammation.Anesthetized Yorkshire cross piglets (n = 17, 7.5 ± 0.2 kg body weight) were catheterized and baseline hemodynamics and blood gases were assessed. E. coli ETX was administered (up to 35,000 units i.v.) and titrated to achieve ALI criteria of PaO2/FiO2 less than 350 mmHg. Pulmonary to systemic vascular resistance ratios (PVR/SVR) were elevated in pigs receiving ETX (0.49 ± 0.04, n = 12) compared to controls (0.20 ± 0.01, n = 5). Blood was obtained every 2–4 hours for blood gases and cytokine profiles (Milliplex MAP for Luminex, MagPix). After 16 hours, BAL was performed for cytokine profiles. Hemodynamic measurements and cytokine levels remained constant in the control group.Compared to controls, blood TNF‐alpha levels remain elevated for 6–10 hours after ETX exposure (p &lt;0.05), while other cytokine levels returned to baseline levels within 2–6 hours. In contrast, BAL obtained 12–16 hours after ETX exposure, showed IL‐2 (0.97 ± 0.11 vs 0.58 ± 0.11 pg/ml, p&lt;0.057), IL‐4 (1.17 ± 0.13 vs 0.59 ± 0.05 pg/ml, p&lt;0.015), and IL‐8 (418 ± 62 vs 167 ± 40 pg/ml, p&lt;0.026) to remain elevated in ETX versus control pigs, respectively.Multiple regression analysis was performed to determine which BAL markers may be related to changes in pulmonary vasoconstriction versus gas exchange. BAL obtained 12–16 hours after ALI compared against PVR/SVR levels during the ALI period showed that PVR/SVR was negatively related to BAL IL‐1b and positively related to BAL IL‐8 and IL‐1a (r = 0.91, p&lt;0.0013). PaO2/FiO2 during early ALI was negatively related to IL‐8 and IL‐6, and positively correlated with IL‐1b, IL‐12, and TNF‐alpha (r = 0.940, p&lt;0.0001) in BAL specimens. The association of elevated BAL IL‐8 with more severe PHN and hypoxemia is consistent with IL‐8 functioning as a chemotactic factor to cause cell migration to inflamed regions of the lung. The prolonged elevation of BAL cytokines specific to regulation of tissue regeneration may serve as good markers for assessment of lung injury severity long after blood circulating cytokine levels have normalized.Support or Funding InformationThis project was funded by the US Army Medical Command. The views expressed in this abstract are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Seawater-drowning-induced acute lung injury: From molecular mechanisms to potential treatments.

Drowning is a crucial public safety problem and is the third leading cause of accidental fatality, claiming ~372,000 lives annually, worldwide. In near-drowning patients, acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) is one of the most common complications. Approximately 1/3 of near-drowning patients fulfill the criteria for ALI or ARDS. In the present article, the current literature of near-drowning, pathophysiologic changes and the molecular mechanisms of seawater-drowning-induced ALI and ARDS was reviewed. Seawater is three times more hyperosmolar than plasma, and following inhalation of seawater the hyperosmotic seawater may cause serious injury in the lung and alveoli. The perturbing effects of seawater may be primarily categorized into insufficiency of pulmonary surfactant, blood-air barrier disruption, formation of pulmonary edema, inflammation, oxidative stress, autophagy, apoptosis and various other hypertonic stimulation. Potential treatments for seawater-induced ALI/ARDS were also presented, in addition to suggestions for further studies. A total of nine therapeutic strategies had been tested and all had focused on modulating the over-activated immunoreactions. In conclusion, seawater drowning is a complex injury process and the exact mechanisms and potential treatments require further exploration.

Comparison of SpO2/FiO2 and PaO2/FiO2 ratios as markers of acute lung injury

Background One of the diagnostic criteria for acute lung injury (ALI) is the PaO2/FiO2 (P/F) ratio. This measurement is obtained by blood gas analysis, which involves an invasive procedure (arterial blood draw). In order to reduce invasive procedures on critically ill patients, an alternative non-invasive marker for ALI is needed. The SpO2/FiO2 (S/F) ratio attained by pulse oximetry may be a suitable alternative.Objective To investigate for a correlation between S/F ratio and P/F ratio, in order to find an alternative non-invasive marker of ALI.Methods A cross-sectional study was conducted in the pediatric intensive care unit (PICU) at Haji Adam Malik Hospital, Medan from August 2012 to June 2013. Subjects (children aged 1 month – 18 years) underwent blood gas analysis when their pulse oximetry showed saturation of 80-97% within 24 hours of ventilator use. We measured PaO2, SpO2, and FiO2 and calculated S/F and P/F ratios. Data were analyzed by Spearman’s correlation and linear regression tests.Results Of 69 PICU patients, 39 children fulfilled the criteria for ALI. The S/F ratio and P/F ratio had a weak correlation (r=0.2; P=0.18). The linear regression equation was S/F ratio = 129.67 + 0.11 (P/F), with S/F ratio values of 162.67 and 151.67 correlating to P/F ratio values of 300 and 200, respectively.Conclusion The S/F ratio has a weak correlation with P/F ratio for ALI in children.

The effect of ulinastatin on blood gas analysis in rabbits with acute lung injury following a blast

Objective To study the effect of ulinastatin (UTI) on blood gas analysis in rabbits with acute lung injury (ALI) after an explosion. Methods A total of 24 healthy New Zealand white rabbits were made to be ALI models by an explosion at a distance of 11 cm.The rabbits met the criteria of ALI, and were randomly(random number) divided into A and B groups. In group B, rabbits received UTI injected at 0.5 h, 6 h, 12 h, 24 h after modeling.In group A, an equal volume of saline was given to rabbits instead at the same intervals after modeling. Arterial blood pH, carbon dioxide partial pressure (PaCO2) and partial pressure of blood oxygen(PaO2) were determined by a portable blood gas analyzer before modeling and at given intervals after modeling. All rabbits were sacrificed after 48 h later. The pathological changes of lung tissue were observed with naked eye and extent of lung injury with HE staining. Results Compared with group A, pulmonary edema and infiltration of inflammatory cells in the lungs of rabbits in group B were less significant. The blood gas analysis showed there were significant difference in pH at 24 h after injury between group A(7.24 ± 0.07) and group B(7.35 ± 0.06), P<0.05.There was significant difference in PaO2 at 24 h after injury between group A(50.5±9.9)mmHg and group B (78.1±8.4)mmHg, P<0.05.And there was significant difference in PaCO2 at 24 h after injury between group A(52.4±5.5)mmHg and group B(42.8±4.5)mmHg, P<0.05. Conclusion UTI can significantly reduce acidosis, PaCO2 and increase PaO2 in rabbits with ALI following a blast, improving oxygenation and mitigating lung histopathological changes. Key words: Blast injuries; Acute lung injury; Ulinastatin; Blood gas analysis; Pathology

Validity of Spo2/Fio2 Ratio in Detection of Acute Lung Injury and Acute Respiratory Distress Syndrome

Introduction: One ofdiagnostic criteria for Acute Lung Injury and Acute Respiratory Distress Syndrome is pao2/fio2 (PF) ratio 300 for ALI or 200 for ARDS. This criteria requires invasive arterial sampling. Measurement of Spo2/Fio2 (SF) ratio by pulseoximetry may be a reliable non invasive alternative to the PF ratio. Methods and Materials: In a cross sectional study we enrolled 105 sample of patients with ALI or ARDS, to determine the Spo2/Fio2 (SF). Pao2 wasmeasured through arterial blood sampling and Spo2 measured with pulse oximetry and documented within 5 minutes of each other. Results The relationship between SF and PF ratio was described by the following equation: SF=57+0/61PF (P<0/001). Spo2/Fio2 (SF) ratios of 181 and 235 can be substituted pao2/fio2 (PF) ratio of 200 and 300 in ARDS and ALI respectively. The ALI SF cutoff of 235 had 57% sensitivity and 100% specificity, and ARDS, SF cutoff of 181 had 71% sensitivity and 82% specificity. Conclusion Spo2/Fio2 (SF) ratio is a reliable noninvasive marker to determine children with ALI or ARDS and can be used instead of it.

Comparison of the spo2/fio2 ratio and the pao2/fio2 ratio in patients with acute lung injury or acute respiratory distress syndrome.

Introduction: Diagnostic criteria for acute lung injury (ALI) and Acute Respiratory Distress syndrome (ARDS) includes acute onset of disease, chest radiograph demonstrating bilateral pulmonary infiltrates, lack of significant left ventricular dysfunction and Pao2/Fio2 (PF) ratio ≤300 for ALI or ≤200 for ARDS. Recent criteria require invasive arterial sampling. The pulse oximetric saturation Spo2/Fio2 (SF) ratio may be a reliable non-invasive alternative to the PF ratio. Methods: In this cross-sectional study, we enrolled 70 patients with ALI or ARDS who were admitted in Tabriz children’s hospital pediatrics intensive care unit (PICU). Spo2, Fio2, Pao2, charted within 5 minutes of each other and calculated SF and PF were recorded to determine the relationship between SF and PF ratio. SF values were examined as a substitute of PF ratio for diagnosis ARDS and ALI. Results: The relationship between SF and PF ratio was described by the following regression equation: SF=57+0.61 PF (P<0.001). SF ratios of 181 and 235 corresponded of PF ratio 300 and 200. The SF cutoff of 235 had 57% sensitivity and 100% specificity for diagnosis of ALI. The SF cutoff of 181 had 71% sensitivity and 82% specificity for diagnosis of ARDS. Conclusion: SF ratio is a reliable noninvasive surrogate for PF ratio to identify children with ALI or ARDS with the advantage of replacing invasive arterial blood sampling by non-invasive pulse oximetry.

Impact of Distinct Definitions of Acute Lung Injury on Its Incidence and Outcomes in Brazilian ICUs

Evaluation of prevalence and outcomes of acute lung injury in a large cohort of critically ill patients in Brazil and comparison of predictive receiver operating characteristic curve mortality of American European Consensus conference definition with new Berlin definition of acute respiratory distress syndrome. A 15-month prospective, multicenter, observational study. Fourteen medical ICUs in Espirito Santo, a state of Brazil. Mechanically ventilated patients who fulfilled American European Consensus conference criteria of acute lung injury or Berlin definition of acute respiratory distress syndrome. Clinical and respiratory data were collected for 7 consecutive days and on the 14 and 28 days. Twenty-eight day mortality, hospital mortality, and predictive receiver operating characteristic curve mortality were calculated. Of 7,133 patients, 130 patients (1.8%) fulfilled criteria for acute lung injury (American European Consensus conference) or acute respiratory distress syndrome (Berlin definition). Median time for diagnosis was 2 days (interquartile range, 0-3 d). Main risk factors were pneumonia (35.3%) and nonpulmonary sepsis (31.5%). Mean age was 44.2 ± 15.9 years, and 61.5% were men. Mean Acute Physiology and Chronic Health Evaluation II score was 20.7 ± 7.9. Mean PaO2/FIO2 was 206 ± 61.5, significantly lower in nonsurvivors on day 7 (p = 0.003). Mean mechanical ventilation time was 21 ± 15 days. Length of ICU stay was 26.4 ± 18.7 days. Twenty-eight-day mortality was 38.5% (95% CI, 30.1-46.8); hospital mortality was 49.2% (95% CI, 40.6-57.8). Predictive 28-day mortality area under the receiver operating characteristic curve for American European Consensus conference definition was 0.5625 (95% CI, 0.4783-0.6467) and for the Berlin definition 0.5664 (95% CI, 0.4759-0.6568; p = 0.9510). In our population, prevalence of acute lung injury was low, most cases were diagnosed 2 days after ICU admission, and Berlin definition was not different from American European Consensus conference definition in predicting mortality. There are still several problems with the global epidemiology, definition, and mortality predictive indices that should be added to the classification of this still lethal syndrome to improve its predictive mortality power in the future.

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Introduction: We compared the utility of the American-European Consensus Conference (AECC) and Berlin definitions in determining the prevalence of Acute Respiratory Distress Syndrome (ARDS) and its effect on mortality in consecutive burn patients on mechanical ventilation. Methods: A retrospective chart review included all patients with burns who were admitted to our burn intensive care unit (BICU) and required mechanical ventilation from January 1, 2003 to December 31, 2011. We identified all patients suffering from ARDS based on the AECC definition as well as the new Berlin definition. Various demographic data and outcomes were recorded. Logistical regression modeling with stepwise selection was performed to identify significant predictors of mortality. Results: 2071 patients were admitted to the BICU during the study period, of which 43% required mechanical ventilation (MV); of those, 37% developed ALI/ARDS as defined by the AECC vs. 34.0% by the Berlin definition. Patients with ALI/ARDS based on the AECC definition had a mortality of 41% compared to 43% in patients with ARDS classified under the Berlin definition. For the AECC defined categories of Acute Lung Injury (ALI) and ARDS the mortality rates were 15% and 46% respectively. For the Berlin defined categories of ARDS the mortality rates were: 17% for mild, 44% for moderate and 60% for severe. A subset of 22 patients met criteria for ALI or ARDS under AECC but not based on the Berlin definition due to the newly imposed requirement for PEEP support ≥ 5cm H20. On sub-analysis, the mortality rate for this group was 14%, which was not statistically different than for patients without ARDS. The following variables were found to be important predictors of the mortality in our cohort: age, injury severity score, size of burn, acute kidney injury, moderate and severe ARDS. Presence of inhalation injury or mild ARDS was not predictive of mortality (P > 0.05). Conclusions: Over a third of mechanically ventilated burn patients developed ARDS. The Berlin definition of ARDS, which incorporates more sensitive severity stratification and a minimum level of PEEP, better defines the contribution of lung injury to death in burns.

Anesthesia Literature Review

Anesthesia Literature Review

P145 S100A12 as a biomarker for neutrophil mediated inflammation in patients undergoing cardiac surgery necessitating cardiopulmonary bypass

Cardiac surgery necessitating cardiopulmonary bypass (snCPB) is often associated with the systemic inflammatory response syndrome (SIRS) and insufficient post-operative oxygenation, transiently fulfilling the criteria for acute lung injury (ALI); for...

Early Acute Lung Injury

Mortality associated with acute lung injury remains high. Early identification of acute lung injury prior to onset of respiratory failure may provide a therapeutic window to target in future clinical trials. The recently validated Lung Injury Prediction Score identifies patients at risk for acute lung injury but may be limited for routine clinical use. We sought to empirically derive clinical criteria for a pragmatic definition of early acute lung injury to identify patients with lung injury prior to the need for positive pressure ventilation. Prospective observational cohort study. Stanford University Hospital. We prospectively evaluated 256 patients admitted to Stanford University Hospital with bilateral opacities on chest radiograph without isolated left atrial hypertension. None. Of the 256 patients enrolled, 62 patients (25%) progressed to acute lung injury requiring positive pressure ventilation. Clinical variables (through first 72 hr or up to 6 hr prior to acute lung injury) associated with progression to acute lung injury were analyzed by backward regression. Oxygen requirement, maximal respiratory rate, and baseline immune suppression were independent predictors of progression to acute lung injury. A simple three-component early acute lung injury score (1 point for oxygen requirement > 2-6 L/min or 2 points for > 6 L/min; 1 point each for a respiratory rate ≥ 30 and immune suppression) accurately identified patients who progressed to acute lung injury requiring positive pressure ventilation (area under the receiver-operator characteristic curve, 0.86) and performed similarly to the Lung Injury Prediction Score. An early acute lung injury score greater than or equal to 2 identified patients who progressed to acute lung injury with 89% sensitivity and 75% specificity. Median time of progression from early acute lung injury criteria to acute lung injury requiring positive pressure ventilation was 20 hours. This pragmatic definition of early acute lung injury accurately identified patients who progressed to acute lung injury prior to requiring positive pressure ventilation. Pending further validation, these criteria could be useful for future clinical trials targeting early treatment of acute lung injury.

Alcohol screening scores and 90-day outcomes in patients with acute lung injury.

The effects of excess alcohol consumption (alcohol misuse) on outcomes in patients with acute lung injury have been inconsistent, and there are no studies examining this association in the era of low tidal volume ventilation and a fluid conservative strategy. We sought to determine whether validated scores on the Alcohol Use Disorders Identification Test that correspond to past-year abstinence (zone 1), low-risk drinking (zone 2), mild to moderate alcohol misuse (zone 3), and severe alcohol misuse (zone 4) are associated with poor outcomes in patients with acute lung injury. Secondary analysis. The Acute Respiratory Distress Syndrome Network, a consortium of 12 university centers (44 hospitals) dedicated to the conduct of multicenter clinical trials in patients with acute lung injury. Patients meeting consensus criteria for acute lung injury enrolled in one of three recent Acute Respiratory Distress Syndrome Network clinical trials. None. Of 1,133 patients enrolled in one of three Acute Respiratory Distress Syndrome Network studies, 1,037 patients had an Alcohol Use Disorders Identification Test score available for analysis. Alcohol misuse was common with 70 (7%) of patients having Alcohol Use Disorders Identification Test scores in zone 3 and 129 (12%) patients in zone 4. There was a U-shaped association between validated Alcohol Use Disorders Identification Test zones and death or persistent hospitalization at 90 days (34% in zone 1, 26% in zone 2, 27% in zone 3, 36% in zone 4; p < 0.05 for comparison of zone 1 to zone 2 and zone 4 to zone 2). In a multiple logistic regression model, there was a significantly higher odds of death or persistent hospitalization in patients having Alcohol Use Disorders Identification Test zone 4 compared with those in zone 2 (adjusted odds ratio 1.70; 95% confidence interval 1.00, 2.87; p = 0.048). Severe but not mild to moderate alcohol misuse is independently associated with an increased risk of death or persistent hospitalization at 90 days in acute lung injury patients.

The use of neutrophil elastase inhibitor in the treatment of acute lung injury after pneumonectomy

BackgroundThe prognosis of acute lung injury (ALI) after pneumonectomy is poor, with reported mortality rates of 30-100%. Neutrophil elastase inhibitor (NEI) is known to prevent lung injury caused by neutrophil elastase and improve lung function in ALI. We evaluated the effect of NEI on ALI after pneumonectomy.MethodsWe analyzed nine patients who required ventilator care due to ALI after pneumonectomy. Five of these patients underwent conventional ventilator care (group I), and four patients underwent ventilator care and were administrated NEI (group II). We retrospectively analyzed the lung injury score (LIS) for 10 days after intubation.ResultsThe LIS before intubation satisfied the diagnostic criteria of ALI or acute respiratory distress syndrome (ARDS) in all patients. After intubation, the LIS improved in both groups. But, as times went on, the mean value of the LIS in group II was lower compared to group I. In group I, only one patient underwent extubation. In group II, extubation was possible in three patients. Mortality rates were 80% in group I and 25% in group II.ConclusionsWe conclude that NEI may improve the lung function, shorten the duration of mechanical ventilation, and reduce mortality in patients with ALI after pneumonectomy.

Recruitment Maneuver in Prevention of Hypoxia During Percutaneous Dilational Tracheostomy: Randomized Trial

Percutaneous dilational tracheostomy (PDT) can potentially lead to hypoxia and alveolar derecruitment. The aim of this prospective study was to evaluate the efficacy of performing a recruitment maneuver (RM) before tracheostomy, in order to improve oxygenation. We enrolled 29 eligible trauma patients with acute lung injury criteria requiring tracheostomy in a university ICU. Subjects were ventilated on volume controlled mechanical ventilation (tidal volume of 6 mL/kg) and F(IO(2)) set at 1.0. Subjects were randomized into 2 groups: RM group (subjects who underwent RM 10 min before PDT, 15 subjects) and no-RM group (subjects without application of RM before PDT, 14 subjects). RM was performed by imposition of continuous positive airway pressure of 40 cm H(2)O for 40 seconds. We collected gas exchange, respiratory, and hemodynamic data 5 times: 1 hour before RM, 5 min after RM, 5 min after PDT, 30 min after PDT, and 6 hours after PDT. Subjects who underwent RM had a significant increase in P(aO(2)); 5 min after the maneuver, P(aO(2)) increased from 222.6 ± 33.4 mm Hg to 341.3 ± 33.1 mm Hg (P < .01) and was always significantly maintained throughout the following times of the study, compared to the no-RM group: in the RM and no-RM groups, respectively, 260.7 ± 35.4 mm Hg vs 108.5 ± 36.9 mm Hg 5 min after PDT; 285.6 ± 29.1 mm Hg vs 188.4 ± 21.4 mm Hg 30 min after PDT; and 226.3 ± 24.8 mm Hg vs 147.6 ± 42.8 mm Hg 6 h after PDT (P < .01). Our study suggests that application of RM before PDT could be useful to avoid hypoxemia following such procedure, by reducing fall in P(aO(2)) and preventing the decrease in oxygenation values below baseline at 6 hours.

A pilot, randomized, controlled clinical trial of lucinactant, a peptide-containing synthetic surfactant, in infants with acute hypoxemic respiratory failure

Inhibition of surfactant function and abnormal surfactant synthesis lead to surfactant dysfunction in children with acute hypoxemic respiratory failure. We evaluated whether intratracheal lucinactant, a synthetic, peptide-containing surfactant, was safe and well-tolerated in infants with acute hypoxemic respiratory failure, and assessed its effects on clinical outcomes. Infants ≤ 2 yrs of age with acute hypoxemic respiratory failure were enrolled in a phase II, double-blind, multinational, placebo-controlled randomized trial across 36 pediatric intensive care units. Infants requiring mechanical ventilation with persistent hypoxemia meeting acute lung injury criteria were randomized to receive intratracheal lucinactant (175 mg/kg) or air placebo. One retreatment was allowed 12-24 hrs after initial dosing if hypoxemia persisted. Peri-dosing tolerability of intratracheal lucinactant and adverse experiences were assessed. Mechanical ventilation duration was analyzed using analysis of variance. The Cochran-Mantel-Haenszel test was used for categorical variables.We enrolled 165 infants (84 lucinactant; 81 placebo) with acute hypoxemic respiratory failure. There were no significant differences in baseline subject characteristics, with the exception of a lower positive end-expiratory pressure and higher tidal volume in placebo subjects. The incidence of transient peri-dosing bradycardia and desaturation was significantly higher in the lucinactant treatment group. There were no statistical differences between groups for other adverse events or mortality. Oxygenation improved in infants randomized to receive lucinactant as indicated by fewer second treatments (67% lucinactant vs. 81% placebo, p = .02) and a trend in improvement in partial pressure of oxygen in arterial blood to fraction of inspired oxygen from eligibility to 48 hrs after dose (p = .06). There was no significant reduction in duration of mechanical ventilation with lucinactant (geometric least square means: 4.0 days lucinactant vs. 4.5 days placebo; p = .254). In a subset of infants (n = 22), the duration of mechanical ventilation in children with acute lung injury (partial pressure of oxygen in arterial blood to fraction of inspired oxygen >200) was significantly shorter with lucinactant (least square means: 2.4 days lucinactant vs. 4.3 days placebo; p = .006). In mechanically ventilated infants with acute hypoxemic respiratory failure, treatment with intratracheal lucinactant appeared to be generally safe. An improvement in oxygenation and a significantly reduced requirement for retreatment suggests that lucinactant might improve lung function in infants with acute hypoxemic respiratory failure.

Comparison of APACHE III, Charlson Comorbidity Index, and SOFA Score for Prediction of Mortality Following Acute Lung Injury

Abstract SESSION TYPE: New Insights into ARDS/Lung InjuryPRESENTED ON: Monday, October 22, 2012 at 04:00 PM - 05:30 PMPURPOSE: Severity of illness scores are used in predicting the ICU outcomes, however limited data is available on the performance of comorbidity scores in predicting the outcomes of acute lung injury (ALI). We assessed and compared the performance of three most commonly used prediction scores i.e. Charlson comorbidity index (CCI), APACHE III and SOFA score in predicting mortality as an outcome following ALI.METHODS: In a historical cohort design, from July 01, 2004 to December 31, 2010 all adults (≥ 18 years) admitted consecutively to Mayo Clinic hospital ICUs, from Olmsted County, Minnesota were included. ALI cases were ascertained during their hospital stay according to the American European Consensus Criteria (AECC) definition criteria. Patients who denied research authorization were excluded from the study. APACHE III, SOFA and CCI scores were computed from the patients' electronic medical records. The area under Receiver operating characteristic (ROC) curve was used to compare the performance of three scores in predicting hospital and one year mortality, the difference in AUC was analyzed using z-statistics by DeLong et al's method.RESULTS: Out of 7594 adults admitted to the ICUs, 555 met the AECC definition criteria for ALI. The median age was 70 yrs (IQR 54-81), 295 (53%) males and 481 (87%) were Caucasians. The median (IQR) scores for APACHE III, SOFA day one and CCI among ALI patients were 81 (61-103), 6 (4-9), and 5 (3-7) respectively. The AUC for predicting the hospital mortality for APACHE III, SOFA and CCI was 0.67 (0.63 - 0.71), 0.63 (0.59 - 0.67) and 0.61 (0.57 - 0.65) respectively. There was significant difference in the AUC for predicting hospital mortality between APACHE III and SOFA scores (P value = 0.039). The AUC for predicting the one year mortality for APACHE III, SOFA and CCI was 0.65 (0.60 - 0.69), 0.57 (0.53 - 0.61) and 0.69 (0.65 - 0.73) respectively. Both APACHE III and CCI significantly predicted the one year mortality as compared to SOFA (P value alt;0.001). However, there was marginal advantage for APACHE III as compared to CCI at hospital discharge (P value = 0.049), which was inconsequential at long term (P value = 0.12)CONCLUSIONS: All the three models moderately predicted hospital mortality for ALI patients; APACHE III was superior to SOFA in predicting hospital and one year mortality, whereas CCI was superior to SOFA only in predicting one year mortality.CLINICAL IMPLICATIONS: Need for combined or new models for better prediction of mortality for ALI patients.DISCLOSURE: The following authors have nothing to disclose: Balwinder Singh, Adil Ahmed, Michelle Biehl, Pablo Franco, Guangxi LiNo Product/Research Disclosure InformationMayo Clinic, Rochester, MN.

Prevalence of Acute Lung Injury Among Medical Patients in the Emergency Department

Acute lung injury (ALI) affects an estimated 190,000 persons per year in U.S. intensive care units (ICUs), but little is known about its prevalence in the emergency department (ED). The objective was to describe the prevalence of ALI among mechanically ventilated adult nontrauma patients in the ED. The hypothesis was that the prevalence of ALI in adult ED patients would be low. This was a retrospective cohort study of admitted nontrauma patients presenting to an academic ED. Two trained investigators abstracted data from patient records using a standardized form. The use of mechanical ventilation in the ED was identified in two phases. First, all ED patients were screened for the current procedural terminology (CPT) code for endotracheal intubation (CPT 31500) from January 1, 2003, to December 31, 2006. Second, each patient record was reviewed to verify the use of mechanical ventilation. ALI was defined in accordance with a modified version of the American-European Consensus Conference criteria as: 1) hypoxemia defined as PaO(2) /FiO(2) ratio ≤300 mm Hg on all arterial blood gases (ABGs) in the ED and the first 24 hours of admission, 2) the presence of bilateral infiltrates on chest radiograph, and 3) the absence of left atrial hypertension. Data are presented in absolute numbers and percentages. Interobserver agreement was evaluated using the kappa statistic. Of the 552 patients who received mechanical ventilation in the ED and were subsequently admitted, a total of 134 (24.3%, 95% confidence interval [CI] = 20.8% to 28.0%) met hypoxemia criteria. Of these, 34 had evidence of left atrial hypertension, 52 did not have chest radiograph findings consistent with ALI, and two did not have a chest radiograph performed; the remaining 46 met ALI criteria. An additional two patients who died in the ED had clinical evidence of ALI. Thus, 48 of 552, or 8.7% (95% CI = 6.6% to 11.3%), met criteria for ALI. The kappa value for determination of ALI was 0.84 (95% CI = 0.54 to 1.0). The prevalence of ALI was nearly 9% in adult nontrauma patients receiving mechanical ventilation in the ED. Further study is required to determine which types of patients present to the ED with ALI, the extent to which lung protective ventilation is used, and the need for ED ventilator management algorithms.