Secondary Acute Respiratory Distress Syndrome Research Articles

Secondary ARDS Following Acute Pancreatitis: Is Extracorporeal Membrane Oxygenation Feasible or Futile?

Objective: To assess the feasibility of extracorporeal membrane oxygenation (ECMO) or life support (ECLS) as last resort life support therapy in patients with acute pancreatitis and subsequent secondary acute respiratory distress syndrome (ARDS). Methods: Retrospective analysis from January 2013, to April 2020, of ECMO patients with pancreatitis-induced ARDS at a German University Hospital. Demographics, hospital and ICU length of stay, duration of ECMO therapy, days on mechanical ventilation, fluid balance, need for decompressive laparotomy, amount of blood products, prognostic scores (CCI (Charlson Comorbidity Index), SOFA (Sequential Organ Failure Assessment), RESP(Respiratory ECMO Survival Prediction), SAVE (Survival after Veno-Arterial ECMO)), and the total known length of survival were assessed. Results: A total of n = 495 patients underwent ECMO. Eight patients with acute pancreatitis received ECLS (seven veno-venous, one veno-arterial). Five (71%) required decompressive laparotomy as salvage therapy due to abdominal hypertension. Two patients with acute pancreatitis (25%) survived to hospital discharge. The overall median length of survival was 22 days. Survivors required less fluid in the first 72 h of ECMO support and showed lower values for all prognostic scores. Conclusion: ECLS can be performed as a rescue therapy in patients with pancreatitis and secondary ARDS, but nevertheless mortality remains still high. Thus, this last-resort therapy may be best suited for patients with fewer pre-existing comorbidities and no other organ failure.

LATE DIAGNOSIS OF ANTI-MDA5 ANTIBODY-POSITIVE RAPIDLY PROGRESSIVE INTERSTITIAL LUNG DISEASE WITH CUTANEOUS MANIFESTATIONS

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody is associated with rapidly progressive interstitial lung disease (RP-ILD). This can be seen in patients with clinically amyopathic dermatomyositis or more typical dermatomyositis. Not only is MDA5-positive RP-ILD a rare cause of ILD, but the ILD often results in significant morbidity and mortality. Although there are several proposed treatment regimens, patients often succumb to the illness despite initiation of therapy. As such, early diagnosis and treatment in these patients is of paramount importance. CASE PRESENTATION: Herein we report a case of 37-year-old male diagnosed with anti-MDA5-associated RP-ILD late in his clinical course. He presented in October 2019. He initially presented with marked unintentional weight loss, preceding episodes of antimicrobial-refractory pneumonia, and an upper thigh abscess prior to his transfer to our hospital. He had a complicated hospital course with profound multi-organ system failure. Given an unclear underlying diagnosis, empiric antimicrobials and corticosteroids were started and intensified, without improvement. Furthermore, his secondary acute respiratory distress syndrome did not respond to standard evidence-based strategies. In the setting of chest imaging suggestive of underlying ILD with profound pneumomediastium and concomitant Gottron papules, rheumatologic work-up revealed a unifying diagnosis very late in his hospital course. Despite mechanical ventilation, venovenous extracorporeal membrane oxygenation (VV-ECMO), high-dose steroids, intravenous immunoglobulin, and tacrolimus, the patient had little clinical response to his disease which ultimately proved fatal. DISCUSSION: To the best of our knowledge, this is one of the first cases where VV-ECMO was used to treat anti-MDA5 positive RP-ILD. Unfortunately, this case demonstrates the futility of supporting patients with anti-MDA5 positive RP-ILD with VV-ECMO, particularly when that support is initiated late in their clinical course. His hospital and pre-hospital course highlight the barriers of a healthcare system that ultimately could not save him. Moreover, this case illustrates the importance of early diagnosis and expedited trials of therapy. In the future, early diagnosis of anti-MDA5 positive RP-ILD may support the utility of VV-ECMO as a bridge to lung transplant. CONCLUSIONS: In a case such as this one, where the diagnosis eludes while irreversible lung disease progresses, ECMO is a therapeutic modality best avoided. We would further recommend, should ECMO be utilized in such cases, where the diagnosis has yet to be made, it is important that all parties involved are clear on the overall treatment plan to include when extracorporeal support will be withdrawn. Reference #1: Gonzalez-Moreno et al. Rapidly progressive interstitial lung disease due to anti-MDA5 antibodies without skin involvement: a case report and literature review. Rheumatology International 2018. 38:1293-1296. Reference #2: LeClair et al. Successful lung transplantation in a case of rapidly progressive interstitial lung disease associated with antimelanoma differentiation-associated gene 5 antibodies. Journal of Rheumatology 2018. 45:581-583. Reference #3: So et al. Rituximab for refractory rapidly progressive interstitial lung disease related to anti-MDA5 antibody-positive amyopathic dermatomyositis. Clinical Rheumatology 2018. 37:1983-1989. DISCLOSURES: No relevant relationships by Erika Anderson, source=Web Response No relevant relationships by Cyrus Askin, source=Web Response No relevant relationships by Carl Kay, source=Web Response No relevant relationships by Whittney Warren, source=Web Response

Organ-protective effect of angiotensin-converting enzyme 2 and its effect on the prognosis of COVID-19.

This article reviews the correlation between angiotensin‐converting enzyme 2 (ACE2) and severe risk factors for coronavirus disease 2019 (COVID‐19) and the possible mechanisms. ACE2 is a crucial component of the renin‐angiotensin system (RAS). The classical RAS ACE‐Ang II‐AT1R regulatory axis and the ACE2‐Ang 1‐7‐MasR counter‐regulatory axis play an essential role in maintaining homeostasis in humans. ACE2 is widely distributed in the heart, kidneys, lungs, and testes. ACE2 antagonizes the activation of the classical RAS system and protects against organ damage, protecting against hypertension, diabetes, and cardiovascular disease. Similar to SARS‐CoV, SARS‐CoV‐2 also uses the ACE2 receptor to invade human alveolar epithelial cells. Acute respiratory distress syndrome (ARDS) is a clinical high‐mortality disease, and ACE2 has a protective effect on this type of acute lung injury. Current research shows that the poor prognosis of patients with COVID‐19 is related to factors such as sex (male), age (>60 years), underlying diseases (hypertension, diabetes, and cardiovascular disease), secondary ARDS, and other relevant factors. Because of these protective effects of ACE2 on chronic underlying diseases and ARDS, the development of spike protein‐based vaccine and drugs enhancing ACE2 activity may become one of the most promising approaches for the treatment of COVID‐19 in the future.

Extracorporeal membrane oxygenation in a child with traumatic ventricular septal defect

Abstract Traumatic ventricular septal defect is an uncommon event following blunt thoracic trauma. Within the pediatric trauma literature, extracorporeal membrane oxygenation is most commonly used for secondary acute respiratory distress syndrome. We present the first account of rescue extracorporeal membrane oxygenation to allow for safe transport and access to definitive operative repair in the setting of blunt cardiac injury.

A retrospective analysis of clinical features and risk factors of death in children with severe pneumonia treated with invasive mechanical ventilation

Objective To discuss the clinical features and risk factors of death in children with severe pneumonia treated with invasive mechanical ventilation. Methods Through a retrospective analysis of children with severe pneumonia treated with invasive mechanical ventilation, who were hospitalized in PICU of Tianjin Children′s Hospital from Jan 2011 to Dec 2014, we analyzed the distribution of age, etiologic characteristics, mechanical ventilation, complications and background diseases.The single factor analysis and multiple factors Logistic regression analysis were performed to evaluate the risk factors of death. Results A total of 214 pediatric patients were included, 134 were male, and 80 were female.The case fatality rate was 6.17%, the relevance ratio of pathogenic microorganism was 16.36%.The median age of death group was older than that of the survival group(4 mouths vs 2 mouths, P=0.039). The pediatric patients who were more than 1 year old in death group were more than the survival group(21.43% vs 15.8%, P<0.001). The common complications included dencephalopathy(11.68%) and electrolyte imbalance(8.41%). Anemia, cardiopathy and alloplasia of respiratory system were the top background diseases.The results of Logistic multivariate regression analysis showed that there were significant differences in the age above 1 year old(OR: 1.019, 95%CI: 1.003-1.030, P=0.019), secondary acute respiratory distress syndrome(OR: 7.254, 95%CI: 1.581-33.277, P=0.011) and accompanying cardiopathy(OR: 0.47, 95%CI: 0.273-0.81, P=0.007). Conclusion The risk factors of death in children with severe pneumonia treated with invasive mechanical ventilation are the following: the age above 1 year old, secondary acute respiratory distress syndrome or accompanying cardiopathy. Key words: Severe pneumonia; Invasive mechanical ventilation; Clinical feature; Risk factors of death,

初療室でECMOを導入し，救命し得た重症多発外傷の2症例(Two case of polytrauma patients with extracorporeal membrane oxygenation introduced in ER)

要旨平成22年人口動態統計によると，外傷死亡者の傷病部位として胸部外傷は頭部外傷に次いで多い 。胸部外傷を伴う多発外傷患者が，大量輸液・輸血や凝固障害により，他部位の止血処置中に著しい低酸素血症に陥ることは，重症例では稀ではない。これまで，胸部外傷によるsecondary ARDSに対するextracorporeal membrane oxygenation（以下，ECMO）導入の報告は散見されるが，病院到着から数時間以内の超急性期に初療室でECMOを導入することで，良好な経過をたどった2症例を経験したため報告する。症例1は，重症肺挫傷に対する下葉切除中の低酸素血症，低換気に対して術中にECMOを導入した。症例2は，重症骨盤骨折，腸管損傷に肺挫傷を合併し，腹部骨盤手術中に喀血し呼吸不全に陥ったため，ECMO実施下に止血を行った。2症例とも肺実質内に造影剤の血管外漏出像を認め，さらに他部位に複数箇所の止血を要する多発外傷例であり，ECMO導入により止血まで十分な酸素化が得られた。外傷症例に対して，来院から数時間以内に初療室においてECMO導入を速やかに行い，呼吸を担保しつつ止血術を行うことで救命し得た。外傷は，止血が得られれば引き続く集学的治療で十分可逆的な病態もあるため，救命手段の一つとして初療室でのECMO導入は有用な可能性がある。

The role of inhaled prostacyclin in treating acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is a syndrome of acute lung injury that is characterized by noncardiogenic pulmonary edema and severe hypoxemia second to a pathogenic impairment of gas exchange. Despite significant advances in the area, mortality remains high among ARDS patients. High mortality and a limited spectrum of therapeutic options have left clinicians searching for alternatives, spiking interest in selective pulmonary vasodilators (SPVs). Despite the lack of robust evidence, SPVs are commonly employed for their therapeutic role in improving oxygenation in patients who have developed refractory hypoxemia in ARDS. While inhaled epoprostenol (iEPO) also impacts arterial oxygenation by decreasing ventilation-perfusion (V/Q) mismatching and pulmonary shunt flow, this effect is not different from inhaled nitric oxide (iNO). The most effective and safest dose for yielding a clinically significant increase in PaO2 and reduction in pulmonary artery pressure (PAP) appears to be 20-30 ng/kg/min in adults and 30 ng/kg/min in pediatric patients. iEPO appears to have a ceiling effect above these doses in which no additional benefit may be derived. iNO and iEPO have shown similar efficacy profiles; however, they differ with respect to cost and ease of therapeutic administration. The most beneficial effects of iEPO have been seen in adult patients with secondary ARDS as compared with primary ARDS, most likely due to the difference in etiology of the two disease states, and in patients suffering from baseline right ventricular heart failure. Although iEPO has demonstrated improvements in hemodynamic parameters and oxygenation in ARDS patients, due to the limited number of randomized clinical trials and the lack of studies investigating mortality, the use of iEPO cannot be recommended as standard of care in ARDS. iEPO should be reserved for those refractory to traditional therapies.

Effects of early mechanical ventilation on oxygenation and hemodynamics in acute high altitude pulmonary edema patients complicated by acute respiratory distress syndrome

To investigate the effect of early mechanical ventilation on oxygenation and hemodynamic of acute high altitude pulmonary edema (HAPE) patients complicated by acute respiratory distress syndrome (ARDS). From May 2001 to December 2006, 8 HAPE patients with secondary ARDS admitted to Germud City People's Hospital were enrolled in the study. All the patients received early invasive mechanical ventilation within 24 hours of HAPE. Hemodynamics, cardiac output, arterial and mixed venous blood gas and oxygen dynamics parameters were determined before and after 96 hours of mechanical ventilation. Before treatment the right atrial pressure (RAP), mean pulmonary artery pressure (mPAP), pulmonary vascular resistance index (PVRI) and shunt (Qs/Qt) were above normal values. Oxygen delivery (DO2), oxygen extraction rate (O2ER), and oxygenation index (PaO2/FiO2) were lower than normal values. After treatment with mechanical ventilation, arterial partial pressure of oxygen (PaO2), PaO2/FiO2, arterial oxygen saturation (SaO2), partial pressure of oxygen of mixed venous blood (PVO2) and mixed venous oxygen saturation (SVO2) were increased significantly compared with those before treatment [PaO2: 70.3±2.9 mm Hg (1 mm Hg=0.133 kPa) vs. 49.9±3.5 mm Hg, t=15.292, P=0.001; PaO2/FiO2: 201.6 ± 4.8 mm Hg vs. 134.5±5.2 mm Hg, t=19.618, P=0.004; SaO2: 0.929±0.021 vs. 0.780±0.073, t=6.226, P=0.002; PVO2: 54.8±2.9 mm Hg vs. 44.9±2.6 mm Hg, t=6.767, P=0.002; SVO2: 0.726±0.017 vs. 0.663±0.053, t=3.262, P=0.008]. Heart rate (HR), RAP, mPAP, pulmonary wedge pressure (PAWP), PVRI, right ventricular stroke work index (RVSWI) and Qs/Qt were decreased significantly compared with those before mechanical ventilation [HR: 73±2 bpm vs. 102±13 bpm, t=6.228, P=0.000; RAP: 6.9±1.0 mm Hg vs. 13.9±1.5 mm Hg, t=3.609, P=0.008; mPAP: 18.5±2.9 mm Hg vs. 41.6±3.0 mm Hg, t=4.773, P=0.000; PAWP: 6.9±2.2 mm Hg vs. 14.0±4.2 mm Hg, t=2.747, P=0.030; PVRI: 26.3±1.7 kPa×s×L(-1) vs. 49.6±10.0 kPa×s×L(-1), t=9.861, P=0.000; RVSWI: 11.0±1.9 g×cm(-1)×min×m(2) vs. 22.0±1.5 g×cm(-1)×min×m(2), t=12.704, P=0.000; Qs/Qt: (26±18)% vs. (35±15)%, t=7.603, P=0.000], and cardiac index (CI), DO2, oxygen consumption (VO2) and O2ER were also increased [CI: 71.68±6.67 mL×s(-1)×m(-2) vs. 70.01±6.67 mL×s(-1)×m(-2), t=2.832, P=0.036; DO2 (L×min(-1)×m(-2)): 460.9±14.0 vs. 410.0±3.1, t=9.268, P=0.000; VO2 (L×min(-1)×m(-2)): 158.5±9.2 vs. 129.9±5.3, t=2.818, P=0.004; O2ER: (20±1)% vs. (18±1)%, t=7.652, P=0.000]. All of the 8 patients survived. Pulmonary circulation hemodynamic and oxygen dynamic disorders were found in HAPE patients with secondary ARDS. Treatment with early mechanical ventilation not only improved oxygenation but also reduced pulmonary hypertension and increased cardiac output and DO2.

Study on the clinicopathological correlation in the secondary acute respiratory distress syndrome

ObjectiveThis study has aimed to study the clinicopathological correlation of patients with secondary acute respiratory distress syndrome (ARDS), specifically having extrapulmonary causes. SettingA 22 beds intensive care unit. DesignAn observational study of case series. PatientsSeventeen patients whose death was caused by acute respiratory distress syndrome were included. InterventionA systematic histopathological study was made of all the pulmonary lobes of patients who died in our ICU with the clinical diagnosis of secondary ARDS, who had undergone an autopsy between 1999 and 2009. The Kappa analysis was used to analyze the grade of correlation between the clinical and the pathological diagnosis. ResultsThe autopsy confirmed to cases of false positive in 17 patients with ARDS (11%). The kappa value was 0.77, so that the concordance analysis was considered to be satisfactory. ConclusionsThe clinical criteria for ARDS correlate well with acute alveolar damage (AAD) in the autopsy study in patients with secondary ARDS, although some false positive cases can be observed.

Estudio sobre la correlación clínico-patológica en el síndrome de distrés respiratorio agudo secundario

Objective This study has aimed to study the clinicopathological correlation of patients with secondary acute respiratory distress syndrome (ARDS), specifically having extrapulmonary causes. Setting A 22 beds intensive care unit. Design An observational study of case series. Patients Seventeen patients whose death was caused by acute respiratory distress syndrome were included. Intervention A systematic histopathological study was made of all the pulmonary lobes of patients who died in our ICU with the clinical diagnosis of secondary ARDS, who had undergone an autopsy between 1999 and 2009. The Kappa analysis was used to analyze the grade of correlation between the clinical and the pathological diagnosis. Results The autopsy confirmed to cases of false positive in 17 patients with ARDS (11%). The kappa value was 0.77, so that the concordance analysis was considered to be satisfactory. Conclusions The clinical criteria for ARDS correlate well with acute alveolar damage (AAD) in the autopsy study in patients with secondary ARDS, although some false positive cases can be observed.

Impaired phospholipases A 2 production by stimulated macrophages from patients with acute respiratory distress syndrome

The aim of this study was to investigate whether early phase of acute respiratory distress syndrome (ARDS) is associated with changes in immune response, either systemic or localized to the lung. ARDS and control mechanically ventilated patients, as well as healthy volunteers were studied. Alveolar macrophages (AM Φ) and blood monocytes (BM) were treated ex vivo with lipopolysaccharide (LPS), interferon-γ (IFNγ), and surfactant. Phospholipase A 2 (PLA 2) activity and TLR4 expression were evaluated as markers of cell response. AM Φ from ARDS patients did not respond upon treatment with either LPS or IFN-γ by inducing PLA 2 production. On the contrary, upon stimulation, in control patients the intracellular PLA 2, (mainly cPLA 2) levels were increased, but secretion of PLA 2 (mainly sPLA 2-IIA) was observed only after treatment with LPS. Surfactant suppressed PLA 2 production in cells from both groups of patients. Increased relative changes of total PLA 2 activity and an upregulation of TLR4 expression upon stimulation was observed in BM from primary ARDS, control patients and healthy volunteers. In BM from secondary ARDS patients, however, no PLA 2 induction was observed, with a concomitant down-regulation of TLR4 expression. Cytosolic PLA 2, its activated form, p-cPLA 2, and sPLA 2-IIA were the predominant PLA 2 types within the cells, while extracellularly only sPLA 2-IIA was identified. These results support the concept of down-regulated innate immunity in early ARDS that is compartmentalized in primary and systemic in secondary ARDS. PLA 2 isoforms could serve as markers of the immunity status in ARDS. Finally, our data highlight the role of surfactant in controlling inflammation.

Complications respiratoires des noyades accidentelles chez l’enfant

Accidental drownings are severe and sometimes mortal events in children. Our study aims to better clarify the epidemiology and the respiratory complications of these accidents in our hospital. We led a retrospective study over 10 years concerning the children hospitalized for accidental drowning in our hospital centre. Age at the moment of the accident, sex, history of accident, hospitable care, thoracic imaging and neurological outcome of the children were studied. In total, 83 children were hospitalized (5 years on average, 70% being boys). The drowning especially took place in fresh water (71%), particularly in swimming pools (51.8%). Stages III and IV of drowning concerned 40.9% of the population. The coverage was the following one: admittance in ICU 57.8%, mechanical ventilation 34.9%, oxygen therapy 16.9%, antibiotics 87.9%. A normal chest x-ray was present in 45.7% of the cases. Drowning in fresh water, especially in contaminated fresh water (canal, WC, etc.), induced atelectasis (10.8%), whereas drowning in sea water induced diffuse infiltrates (8.4%). Aspiration pneumonia (33.7%) was present in both cases and a pulmonary oedema (6%) was only noticed during stage IV drowning. The secondary infections were rare (1 case was suspected and another probable). A child presented a secondary acute respiratory distress syndrome (1.2 %). Finally, 7 deaths (8.4%) and 1 case with severe neurological sequelae (1.2%) were noted. Accidental drowning causes important consequences in children. The long-term respiratory outcomes have not been properly studied. Prevention of such accidents is based on parental vigilance during their child's bathe.

Septic shock caused by Plesiomonas shigelloides in a patient with sickle beta-zero thalassemia

Invasive infection and extraintestinal complications are rarely caused by Plesiomonas shigelloides, a waterborne bacterium belonging to the Vibrionaceae family. We report a case of a 16-year-old female patient with sickle beta-zero thalassemia who survived septic shock caused by P. shigelloides associated with secondary acute respiratory distress syndrome and disseminated intravascular coagulation. Treatment with a carbapenem was successful, and the patient recovered without any sequelae. The previous reports of P. shigelloides sepsis are cited, and possible pathogenic mechanisms are discussed.

Hemodynamic profile in severe ARDS: results of the European Collaborative ARDS Study

Although the acute respiratory distress syndrome (ARDS) was identified as long as 30 years ago, potential therapeutic objectives have been defined from small series rather than large trials. Moreover, relationships between ARDS and hemodynamics are unclear. The European Collaborative ARDS Study was designed to identify factors influencing the pathogenesis, severity, and prognosis of ARDS. Analysis of the hemodynamic profiles collected during this study and of their contribution to the above-mentioned facets of ARDS is the focus of the present report. Prospective clinical study. 38 European intensive care units (ICUs). We collected 2758 sets of data from 586 patients, including baseline data, data on proven or suspected causes of ARDS differentiating direct and nondirect lung injury, and data on baseline status including multiple organ dysfunction (MOD) with differentiation of primary ARDS from ARDS secondary to severe systemic disorders. Events during follow-up were also recorded, including whether the acute respiratory failure did or did not improve after 24 h (groups A and B, respectively). When available, hemodynamic data were recorded at enrollment (day 0), on days 1-3, 7, 14, and 21, and at discharge or at the time of death in the ICU. Although the rate of pre-existing disease and the nature and rate of complications varied widely among etiologic categories, differences in the hemodynamic profile occurred only between primary and secondary ARDS. Both at inclusion and during the course of the illness, variables that were used to investigate Va/Q mismatch [arterial oxygen tension (PaO2, arterial oxygen saturation, right-to-left shunt, and the PaO2/fractional inspired oxygen (FIO2) ratio] predicted survival. High pulmonary artery pressure (PAP) and low systemic artery pressure (SAP) were also related to the prognosis. In the logistic regression model including hemodynamic and oxygen-related variables, however, the only independent predictors of survival were the ratio of right over left ventricular stroke work (RVSW/LVSW) and the PaO2/FIO2 ratio at admission. On day 2, the best prognostic model included: age [odds ratio (OR) = 1.04, p = 0.0004], opportunistic pneumonia as the cause of ARDS (OR = 3.2, p = 0.03), existence of MOD (OR = 1.9, p = 0.03), PaO2/FIO2 (OR = 0.96, p = 0.005), and RVSW/LVSW (OR = 25, p = 0.02). A high RVSW/LVSW ratio, high systolic PAP, low diastolic SAP, and low PaO2/FIO2, and increased right atrial pressure were negative prognostic indicators during follow-up. In addition to the cause of ARDS and the early time-course of lung function, a high systolic PAP and a low diastolic SAP were strong independent indicators of survival.