scholarly journals Pertinent clinical outcomes in pediatric survivors of pediatric acute respiratory distress syndrome (PARDS): a narrative review

2019 ◽  
Vol 7 (19) ◽  
pp. 513-513
Author(s):  
Siew Wah Lee ◽  
Sin Wee Loh ◽  
Chengsi Ong ◽  
Jan Hau Lee
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Clinical Outcomes ◽  
Distress Syndrome ◽  
Narrative Review

Acute respiratory distress syndrome phenotypes with distinct clinical outcomes in PHARLA trial cohort

2021 ◽  
Vol 23 (2) ◽  
pp. 163-170
Author(s):  
Shailesh Bihari ◽  
◽  
Andrew Bersten ◽  
Eldho Paul ◽  
Shay McGuinness ◽  
...  
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Clinical Outcomes ◽  
Distress Syndrome ◽  
Lung Ventilation ◽  
Tumour Necrosis Factor Receptor ◽  
Open Lung ◽  
Inflammatory Phenotype ◽  
Parsimonious Model

Background: The Permissive Hypercapnia, Alveolar Recruitment and Low Airway Pressure (PHARLAP) randomised controlled trial compared an open lung ventilation strategy with control ventilation, and found that open lung ventilation did not reduce the number of ventilator-free days (VFDs) or mortality in patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Parsimonious models can identify distinct phenotypes of ARDS (hypo-inflammatory and hyperinflammatory) which are associated with different outcomes and treatment responses. Objective: To test the hypothesis that a parsimonious model would identify patients with distinctly different clinical outcomes in the PHARLAP study. Design, setting and participants: Blood and lung lavage samples were collected in a subset of PHARLAP patients who were recruited in Australian and New Zealand centres. A previously validated parsimonious model (interleukin-8, soluble tumour necrosis factor receptor-1 and bicarbonate) was used to classify patients with blood samples into hypo-inflammatory and hyperinflammatory groups. Generalised linear modelling was used to examine the interaction between inflammatory phenotype and treatment group (intervention or control). Main outcome measure: The primary outcome was number of VFDs at Day 28. Results: Data for the parsimonious model were available for 56 of 115 patients (49%). Within this subset, 38 patients (68%) and 18 patients (32%) were classified as having hypo-inflammatory and hyperinflammatory phenotypes, respectively. Patients with the hypo-inflammatory phenotype had more VFDs at Day 28 when compared with those with the hyperinflammatory phenotype (median [IQR], 19.5 [11–24] versus 8 [0–21]; P = 0.03). Patients with the hyperinflammatory phenotype had numerically fewer VFDs when managed with an open lung strategy than when managed with control “protective” ventilation (median [IQR], 0 [0–19] versus 16 [8–22]). Conclusion: In the PHARLAP trial, ARDS patients classified as having a hyperinflammatory phenotype, with a parsimonious three-variable model, had fewer VFDs at Day 28 compared with patients classified as having a hypo-inflammatory phenotype. Future clinical studies of ventilatory strategies should consider incorporating distinct ARDS phenotypes into their trial design.

Alveolar MMP28 is Associated With Clinical Outcomes and Measures of Lung Injury in Acute Respiratory Distress Syndrome

2020 ◽  
Author(s):  
Eric Morrell ◽  
Carmen Mikacenic ◽  
Ke-Qin Gong ◽  
Susanna Kosamo ◽  
Renee D. Stapleton ◽  
...  
Keyword(s):  
Gene Expression ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Clinical Outcomes ◽  
Peripheral Blood ◽  
Distress Syndrome ◽  
Lavage Fluid ◽  
Peripheral Blood Monocyte ◽  
Omega 3

Abstract Background Excessive inflammation leading to increased alveolar-capillary barrier permeability remains the pathogenic model for acute respiratory distress syndrome (ARDS). Alveolar macrophage (AM) polarization has been shown to modify the activity of various matrix metalloproteinases (MMPs) that have downstream effects on key ARDS cytokines/chemokines, however the relationship between AMs, MMP28 (the newest member of the MMP family), and ARDS clinical outcomes is unknown.Methods We analyzed bronchoalveolar lavage fluid (BALF) and peripheral blood from subjects previously enrolled in a phase-II trial of omega-3 fatty acids for the treatment of ARDS ( n = 76). In a subset of these patients ( n = 25), we tested for assocations between AM- and peripheral blood monocyte (PBM)-specific MMP28 gene expression and clincal outcomes [ventilator-free days (VFDs), P a O 2 /F i O 2 ratio (P/F ratio), and sequential organ failure assessment score (SOFA)]. We tested for assocations between soluble BALF or plasma MMP28 concentrations and ARDS clinical outcomes and inflammatory mediator concentrations in the entire cohort.Results Increased AM MMP28 gene expression was significantly associated with worse VFDs and P/F ratio ( p < 0.05). Higher BALF MMP28 concentrations were associated with worse P/F, but not VFDs. Increased BALF MMP28 concentrations were associated with increased % neutrophils as well as BALF total protein, IL-6, IL-17A, and MCP-1 concentrations (all p < 0.05). Plasma MMP28 concentrations were not associated with any clinical outcome. Increased PBM MMP28 gene expression was associated with worse P/F ratio but not VFDs.Conclusions Higher AM MMP28 gene expression and BALF MMP28 concentrations are associated with poor clinical outcomes and with increased alveolar inflammatory mediators in patients with ARDS.

Moderate to Severe Acute Respiratory Distress Syndrome Management Strategies: A Narrative Review

2019 ◽  
Vol 32 (3) ◽  
pp. 347-360 ◽  
Author(s):  
Mitchell S. Buckley ◽  
Amy L. Dzierba ◽  
Justin Muir ◽  
Jeffrey P. Gonzales
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Clinical Evidence ◽  
Distress Syndrome ◽  
Fluid Management ◽  
Management Strategies ◽  
Neuromuscular Blocking ◽  
Narrative Review ◽  
Lung Protective Ventilation

Acute respiratory distress syndrome (ARDS) remains a common complication associated with significant negative outcomes in critically ill patients. Lung-protective mechanical ventilation strategies remain the cornerstone in the management of ARDS. Several therapeutic options are currently available including fluid management, neuromuscular blocking agents, prone positioning, extracorporeal membrane oxygenation, corticosteroids, and inhaled pulmonary vasodilating agents (prostacyclins and nitric oxide). Unfortunately, an evidence-based, standard-of-care approach in managing ARDS beyond lung-protective ventilation remains elusive, contributing to significant variability in clinical practice. Although the optimal therapeutic strategy for managing moderate to severe ARDS remains extremely controversial, therapies supported with more robust clinical evidence should be considered first. The purpose of this narrative review is to discuss the published clinical evidence for both pharmacologic and nonpharmacologic management strategies in adult patients with moderate to severe ARDS as well as to discuss practical considerations for implementation.

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