Objective To analyze different characteristics of extra-vascular lung water ( EVLW) in the patients with acute respiratory distress syndrome( ARDS) , and examine its prognostic value. Methods 23 patients with ARDS admitted between November 2010 and December 2011 were divided into a survival group( n=13) and a dead group( n =10) according to the outcome. The hemodynamic status including extravascular lung water index( EVLWI) was measured in 3 consecutive days, and the relationship between EVLWI and the prognosis of patients was analyzed. Results On the first day of diagnosis, the EVLWI was higher in both groups in comparison with normal value. It was ( 13. 9 ±3. 45) mL/kg in the survival group and ( 14. 87 ±5. 75) mL/kg in the dead group( P gt;0. 05) . However, on the second day, the EVLWI in the survival group dropped significantly after intensive intervention, but the patients in the dead group did not respond well to the treatment and the EVLWI declined slightly. The EVLWI of both groups began to diverge significantly fromeach other, showing average value of ( 11. 07 ±2. 51) mL/kg and ( 15.63 ±5. 05) mL/kg, respectively( P lt; 0. 05) . On the third day, this difference between two groups was still more remarkable, resulting in ( 10.32 ±1.57) mL/kg vs. ( 16. 6 ±4. 33) mL/kg( P lt; 0. 01) . Conclusions The changes of EVLWI can be used to evaluate the effectiveness of treatment and predict the prognosis of patients with ARDS. EVLWI would likely be an indicator to evaluate the pulmonary capillary leakage.
Objective To investigate the role of angiotensin-II type 1 receptor ( AT1) antagonist in treatment of acute lung injury/acute respiratory distress syndrome ( ALI/ARDS) . Methods Animal model of ALI/ARDS was induced by cecal ligation and perforation ( CLP) . ALI/ARDS animals received a separate intraperitoneal injection of several concentrations( 5, 10, 15, 20, 25 mg/kg) of AT1 inhibitor losartan after CLP, then the changes of lung injury and 7-day survival were measured. Results Oxygenation index and lung wet to dry weight ratio ( W/D) showed an improving trend when losartan was administered at doses of 5 to 15 mg/kg in ALI/ARDS rats, but aggravated above the dose of 15 mg/kg. Losartan ( 15 mg/kg) treatment significantly alleviated pulmonary edema after CLP operation, and decreased serumlevels of TNF-α, IL-6, andIL-1β [ TNF-α: ( 554. 1 ±62. 7 ) pg/mL vs. ( 759. 2 ±21. 5 ) pg/mL, P lt; 0. 01; IL-6: ( 1227. 3 ±130. 0) pg/mL vs. ( 2670. 4 ±174. 1) pg/mL, P lt; 0. 01; IL-1β: ( 444. 0 ±38. 6) pg/mL vs. ( 486. 6 ±61. 7)pg/mL, P lt; 0. 05] . 7-day survival rate also increased in losartan treatment group at a dose of 15 mg/kg( 6. 7% vs. 0 ) . Conclusions The AT1 inhibitor, losartan, can significantly prevent lung injury in ALI/ARDS after CLP, and improve the 7-day survival rate.
Objective To explore the effects of different humidification and heating strategies during non-invasive positive pressure ventilation( NIPPV) in patients with ALI/ARDS. Methods A total of 45 patients with ALI/ARDS were randomly divided into three groups to receive NIPPV with different humidification and heating strategies, ie. Group A ( humidification with a 370 Humidifier without heating) ,group B ( humidification with a 370 Humidifier along with a MR410 Heater) , and group C ( humidification and heating with aMR850 Humidifier, and a RT308 circuit heater) . The changes of air temperature, absolute humidity, relative humidity, sputum thickness and patient comfort were compared between the three groups. Sputum thickness was evaluated with AWSS scoring system. Results After humidification and heating, the air temperature, absolute humidity and AWSS score improved significantly in group B [ elevated from ( 23. 9 ±1. 0) ℃, (9.8 ±1. 3) mg/L and 2. 0 ±0. 7 respectively to ( 30. 3 ±1. 7) ℃, ( 31. 0 ±2. 3)mg/L and ( 3. 0 ±0. 9) respectively, P lt; 0. 001] and group C [ elevated from( 23. 8 ±1. 0) , ( 9. 8 ±1. 5)mg/L and ( 2. 1 ±0. 7) respectively to ( 34. 0 ±1. 1) ℃, ( 43.8 ±2. 5) mg /L and 3. 5 ±1. 0 respectively,P lt; 0. 001] . Air temperature and absolute humidity were significantly higher in group C than those in group B( P lt; 0. 001) . Of all the parameters, only absolute humidity showed a significant improvment in group A [ elevated from( 9. 9 ±1. 6) mg/L to ( 11. 9 ±0. 9) mg/L, P lt; 0. 001] . The degree of comfort in group C was significantly higher than that in group A and B [ 8. 0 ±1. 7 vs 5. 0 ±1. 2 and 3. 0 ±0. 4, respectively, P lt;0. 001] . In group A seven patients were switched to group C because of discomfort, four accepted NIPPV continuously, and two avoided invasive mechanical ventilation eventually. In group B three patients were switched to group C because of intolerance of too much condensed water in the breathing circuit, all of them accepted NIPPV continuously, and one avoided invasive mechanical ventilation eventually. Conclusions Compared with mere humidification or humidification with heating humidifier, humidification with heating humidifier and circuit heating during NIPPV can improve the absolute humidity, air temperature and patient comfort,meanwhile decreasing the sputumthickness of patients with ALI/ARDS.
ObjectiveTo summarize and analyze the clinical characteristics of patients with acute diffuse lung changes and respiratory failure.MethodsThe clinical data of patients in the Department of Critical Care Medicine, Dazhou Central Hospital between January 2016 and December 2018 were retrospectively collected, whose main clinical manifestation was acute respiratory distress syndrome with acute onset (<3 weeks) and main imaging manifestation was diffuse changes in both lungs. The clinical characteristics of patients were summarized, and the causes of the disease were explored.ResultsA total of 65 patients with acute diffuse lung changes and respiratory failure were enrolled, including 42 males (64.6%) and 23 females (35.4%). The average age was (57.1±18.4) years, the average time from onset to treatment was (7.5±5.9) d, and the average length of stay in the intensive care unit was (8.9±4.1) d. A total of 23 cases died, with a case-fatality rate of 35.4%. Among the 65 patients, there were 50 case (76.9%) of infectious diseases, including 36 cases of bacterial infections (including 4 cases of tuberculosis), 8 cases of viral infections (all were H1N1 infections), and 6 cases of fungal infections (including 1 case of pneumocystis infection); and there were 15 cases (23.1%) of non-infectious diseases, including 4 cases of acute left heart failure, 2 cases of interstitial pneumonia, 2 cases of vasculitis, 1 case of myositis dermatomyositis, 1 case of aspiration pneumonia, 1 case of acute pulmonary embolism, 1 case of acute drug lung injury, 1 case of neurogenic pulmonary edema, 1 case of drowning, and 1 case of unknown origin.ConclusionsInfectious diseases are the main cause of acute diffuse lung changes and respiratory failure, while among non-infectious diseases, acute heart failure and immune system diseases are common causes.
Objective To investigate the guiding value of bedside lung ultrasound and lung stretch index for optimal positive end-expiratory pressure (PEEP) in lung recruitment of patients with acute respiratory distress syndrome (ARDS). Methods From February 2020 to October 2023, 90 patients with ARDS requiring invasive mechanical ventilation were selected from the Department of Critical Care Medicine, the Second Affiliated Hospital of Zhengzhou University. According to the setting method of PEEP after lung recruitment, they were randomly divided into an ultrasound group (45 cases) and a stretch group (45 cases). Both groups were treated with PEEP incremental method for lung recruitment, and the ultrasound group was treated with bedside ultrasound-guided method to set PEEP after lung recruitment. PEEP was set by lung stretch index method in the stretch group. The dynamic changes of oxygenation index (PaO2/FiO2), dynamic compliance (Cdyn), mean airway pressure and peak airway pressure were monitored before lung recruitment and 15 min, 1 h, 6 h and 24 h after lung recruitment. Heart rate, mean arterial pressure and central venous pressure were monitored before and 24 h after lung recruitment in the two groups. The optimal PEEP value and the corresponding volume at the end of recruitment were explored. The mechanical ventilation time, ICU hospitalization time, incidence of barotrauma, incidence of extrapulmonary organ failure, and 28-day mortality were recorded as well. Results After lung recruitment, the oxygenation index, Cdyn, mean airway pressure, and peak airway pressure in the ultrasound group were higher than those in the stretch group at 15 min, 1 h, 6 h, and 24 h after recruitment (all P<0.05). There was no significant difference in heart rate, mean arterial pressure or central venous pressure between the two groups at 24 h after lung recruitment (all P>0.05). After lung recruitment, the optimal PEEP value and the corresponding volume at the end of recruitment in the ultrasound group were higher than those in the distraction group (both P<0.05). The mechanical ventilation time and ICU stay in the ultrasound group were shorter than those in the stretch group (both P<0.05). There was no significant difference in the incidence of barotrauma, extrapulmonary organ failure rate or 28-day mortality between the two groups (all P>0.05). Conclusions Both bedside lung ultrasound-guided PEEP and lung stretch index-guided PEEP can improve oxygenation and respiratory compliance, and have no adverse effects on hemodynamics. Bedside lung ultrasound-guided PEEP can make the alveoli fully expand, which is more conducive to improving patients’ oxygenation and respiratory compliance, and the guiding value is higher than the lung stretch index.
ObjectiveTo improve clinicians' understanding of severe cytokine release syndrome (CRS) through reporting the clinical manifestation, diagnosis, treatment, and prognosis of CRS after chimeric antigen receptor T (CAR-T) cell therapy in a patient with solid tumor. Methods A patient with ovarian cancer who suffered severe CRS after CAR-T cell therapy in the Department of Critical Care Medicine, the First Affiliated Hospital of Nanjing Medical University was reviewed. Relevant studies were searched for literature review. Results The patient, a 55-year-old woman, was diagnosed with ovarian cancer in early 2016 and continued to progress despite multiple lines of treatment, so she received CAR-T cell therapy on September 16, 2022. The patient developed a fever 2 days after infusion, and developed dyspnea and shortness of breath with oxygen desaturation 2 days later. Her condition kept deteriorating with respiratory distress and severe hypoxia 6 days after infusion, and the level of interleukin-6 and interferon-gamma continued to be elevated. Chest CT showed pleural effusion and massive exudation of both lungs. Considered to have acute respiratory distress syndrome (ARDS) due to severe CRS, she was transferred to the intensive care unit (ICU). The patient was treated with tocilizumab, high-dose intravenous glucocorticoid pulses, mechanical ventilation, and sivelestat sodium for ARDS. Her symptoms were gradually relieved, and the results of laboratory tests were gradually stabilized. The patient was extubated 6 days after ICU admission and discharged from ICU a week later. Six patients were screened out with ARDS or acute respiratory failure caused by CRS after CAR-T cell therapy, whose treatments were mainly anticytokine agents combined with high-flow oxygen therapy or invasive mechanical ventilation. One of them died. ConclusionsClinicians should be alert to severe CRS during the administration of CAR-T cell. Rapid interruption of the inflammation development is the key to all treatments. If respiratory and/or circulatory dysfunction occurs, patients should be transferred to ICU in time for organ support therapy.
Objective To evaluate the effects of neuromuscular blocking agents( NMBAs) in acute respiratory distress syndrome( ARDS) . Methods Randomized controlled trials( RCTs) and non-RCTs were recruited fromPubMed( 1966. 1-2012. 3) , EMBASE( all the years) , Cochrane Library( all the years) and CNKI Database( 1979-2012) . Related published studies and attached references were hand searched. All the RCTs and non-RCTs ( including prospective and retrospective studies) about NMBAs for the patients with ARDS were included. Then a meta-analysis and statistic descriptions for RCTs( using RevMan5. 0 software) and non-RCTs were performed. Jadad and NEWCASTLE-OTTAWA QUALITY ASSESSMENT SCALE were used to assess the methodological quality of the included RCTs and non-RCTs. Results Three eligible RCTs and four non-RCTs were enrolled. The quality of the included trials was high. Pooled analysis for three RCTs showed that NMBAs significantly reduced 28-day mortality [ OR 0. 58, 95% CI( 0. 39, 0. 86) , P = 0. 007] and increased ventilator-free days within 28 days [ WMD 1. 91 d, 95% CI( 0. 28,3. 55) , P =0. 02] in ARDS compared with the control group. Conclusion The present meta-analysis indicates that NMBAs reduce the 28-day mortality and increase ventilator-free days within 28 days in ARDS.
ObjectiveTo investigate the clinical characteristics and contribution factors in severe coronavirus disease 2019 (COVID-19).MethodsThe clinical symptoms, laboratory findings, radiologic data, treatment strategies, and outcomes of 110 COVID-19 patients were retrospectively analyzed in these hospitals from Jan 20, 2020 to Feb 28, 2020. All patients were confirmed by fluorescence reverse transcription polymerase chain reaction. They were classified into a non-severe group and a severe group based on their symptoms, laboratory and radiologic findings. All patients were given antivirus, oxygen therapy, and support treatments. The severe patients received high-flow oxygen therapy, non-invasive mechanical ventilation, invasive mechanical ventilation or extracorporeal membrane oxygenation. The outcomes of patients were followed up until March 15, 2020. Contribution factors of severe patients were summarized from these clinical data.ResultsThe median age was 50 years old, including 66 males (60.0%) and 44 females (40.0%). Among them, 45 cases (40.9%) had underlying diseases, and 108 cases (98.2%) had different degrees of fever. The common clinical manifestations were cough (80.0%, 88/110), expectoration (33.6%, 37/110), fatigue (50.0%, 55/110), and chest tightness (41.8%, 46/110). Based on classification criteria, 78 (70.9%) non-severe patients and 32 (29.1%) severe patients were identified. Significant difference of the following parameters was found between two groups (P<0.05): age was 47 (45, 50) years vs. 55 (50, 59) years (Z=–2.493); proportion of patients with underlying diseases was 27 (34.6%) vs. 18 (56.3%) (χ2=4.393); lymphocyte count was 1.2 (0.9, 1.5)×109/L vs. 0.6 (0.4, 0.7)×109/L (Z=–7.26); C reactive protein (CRP) was 16.2 (6.5, 24.0) mg/L vs. 45.3 (21.8, 69.4) mg/L (Z=–4.894); prothrombin time (PT) was 15 (12, 19) seconds vs. 18 (17, 19) seconds (Z=–2.532); D-dimer was 0.67 (0.51, 0.82) mg/L vs. 0.98 (0.80, 1.57) mg/L (Z=–5.06); erythrocyte sedimentation rate (ESR) was 38.0 (20.8, 59.3) mm/1 h vs. 75.5 (39.8, 96.8) mm/1 h (Z=–3.851); lactate dehydrogenase (LDH) was 218.0 (175.0, 252.3) U/L vs. 325.0 (276.5, 413.5) U/L (Z=–5.539); neutrophil count was 3.1 (2.1, 4.5)×109/L vs. 5.5 (3.7, 9.1)×109/L (Z=–4.077). Multivariable logistic analysis showed that there was positive correlation in elevated LDH, CRP, PT, and neutrophil count with the severity of the disease. Currently, 107 patients were discharged and 3 patients died. Total mortality was 2.7%.ConclusionsOld age, underlying diseases, low lymphocyte count, elevated CPR, high D-dimer and ESR are relevant to the severity of COVID-19. LDH, CPR, PT and neutrophil count are independent risk factors for the prognosis of COVID-19.