Awake extracorporeal membrane oxygenation in patients with severe postoperative acute respiratory distress syndrome

Background

A clinical trial of extracorporeal membrane oxygenation (ECMO) as an alternative ventilator tool is being performed as a new indication for ECMO. The purpose of this study was to evaluate the feasibility of awake ECMO to increase the success rate of weaning patients from ECMO and ventilator care during treatment of postoperative severe acute respiratory distress syndrome (ARDS).

Methods

We retrospectively analyzed the clinical reports of 10 patients who underwent awake ECMO due to postoperative ARDS between August 2012 and May 2015. We analyzed patient history, the partial arterial pressure of oxygen (PaO₂)/fraction of inspired oxygen (FiO₂) ratio, and patient outcome.

Results

Seven patients (70%) were weaned from ECMO without difficulty; one patient failed to maintain awake ECMO, was re-intubated after 2 days of awake ECMO, and was re-tried on awake ECMO after 4 days of ventilator care. We weaned that patient from ECMO 2 days later. We weaned a total of eight patients (80%) from awake ECMO. The ECMO duration of surviving patients was 9.13±2.2 days (range, 6–12 days), and mean ventilator use duration was 6.8±4.7 days (range, 2–16 days). Two cases failed awake ECMO and died due to disease aggravation.

Conclusions

Awake ECMO was a useful weaning strategy after severe postoperative ARDS, as it avoids long-duration use of mechanical ventilation. Additionally, it is possible for patients to breathe spontaneously, which might prevents respiratory muscle dystrophy.     

Ventilation index and outcome in children with acute respiratory distress syndrome

The purpose of this investigation was to determine the predictive value of the ventilation index (VI) in children with acute respiratory distress syndrome (ARDS). We performed a 10-year retrospective chart review of children who were admitted to the Pediatric Intensive Care Unit with a diagnosis of ARDS. Acute respiratory distress syndrome was defined as acute onset of diffuse, bilateral pulmonary infiltrates of noncardiac origin, and severe hypoxemia, defined as the ratio of the arterial partial pressure of oxygen to the fraction of inspired oxygen of <200 and a positive end expiratory pressure of 6 cmH₂O or greater. Records of daily arterial blood gas results and ventilator settings were reviewed, and the ventilation index (VI = partial pressure of arterial CO₂ × peak airway pressure × respiratory rate/1,000) was calculated each time the measurements were made. These values were correlated with outcome (survival or nonsurvival). The VI was not different at the time of diagnosis of ARDS in the patients who lived, compared with those who subsequently died. However, by 3 to 5 days after study entry, the VI of nonsurvivors was significantly higher than for survivors (P < 0.05). The VI for survivors remained between 30 and 35 throughout the study period, whereas the VI of nonsurvivors continued to increase with time. A VI of >65 predicted death with a specificity and positive predictive value of >90% on days 3 through 9. We conclude that the VI provides a reliable prognostic marker in children with ARDS, and its increase above 65 indicates a need for orderly intervention with alternative modalities of care. Pediatr Pulmonol. 1998; 26:125–128. © 1998 Wiley-Liss, Inc.     

住院肺结核患者合并急性呼吸窘迫综合征的多因素分析

目的　探讨导致住院肺结核患者合并急性呼吸窘迫综合征(ARDS)的危险因素。方法 收集2006年1月—2007年10月内科收治的肺结核患者1931例,合并ARDS的患者91例作为观察组(ARDS组),非ARDS患者采用随机方法 选取病例作为对照组(非ARDS组),比较2组各项观察指标,行单因素分析,对有显著性差异的指标进行多因素分析,以发现肺结核患者导致ARDS的多种相关因素,单因素分析采用χ²检验,多因素分析采用Logistic回归分析。结果 1931例住院肺结核患者中,91例合并ARDS,占住院肺结核患者的4.71%(91/1931)。经多因素分析,复治肺结核患者、合并慢性阻塞性肺疾病(COPD)、合并休克、血常规示白细胞增加、中性粒细胞百分比增加与住院肺结核患者发生ARDS相关,且均为危险因素。结论 住院肺结核患者中,复治肺结核患者、合并COPD、休克、全身性感染者更易发生ARDS。     

S100A9 as a novel diagnostic and prognostic biomarker in human gastric cancer

Abstract

Objective: The morbidity and mortality of gastric cancer (GC) is high, but there are lack of the biomarkers for early diagnosis and progression of GC. We aimed to identify a novel biomarker for the growth and progression of GC.

Methods: The Cancer Genome Atlas (TCGA) database including 352 eligible patients was used to screen candidate genes related to the prognosis of GC. A proteomics analysis of Chinese Human Proteome Sketches (CHPS) including 84 eligible sample tissues was conducted to further identify candidate biomarkers. A series of in vitro assays were performed to investigate the functions of candidate proteins in GC. Next, to verify whether the candidate oncogene was associated with gastric carcinogenesis, we screened its expression levels using samples from 200 patients with chronic atrophic gastritis (CAG), intestinal metaplasia (IM), dysplasia, or GC and healthy controls.

Results: According to the analyses of the TCGA database and CHPS, we found that S100A9 may be associated with the prognosis of GC. The results of proliferation, wound-healing and invasion assays, immunohistochemistry (IHC) and western blot showed that high levels of S100A9 in tissues were significantly associated with GC aggressiveness and a poor prognosis (p?<?.05). Furthermore, we found that the expression of S100A9 increased gradually during the process of gastric carcinogenesis (p?<?.05). The diagnostic sensitivity and specificity of S100A9 as a biomarker for early GC were 61.4% and 81.3%, respectively.

Conclusions: This study reveals that S100A9 may be a novel biomarker for the early diagnosis and prognosis of GC patients.     

Efficacy of low-dose corticosteroids in patients with acute respiratory distress syndrome: a prospective observational study

BackgroundThere is still no agreement on whether corticosteroids can reduce mortality in patients with acute respiratory distress syndrome (ARDS). The aim of this study was to investigate the efficacy of low-dose corticosteroid administration in patients with ARDS.MethodsA prospective observational study of patients with ARDS in 17 hospitals in China was performed between March 2016 and February 2018. Propensity score matching was performed to adjust for differences in baseline characteristics between different groups. The effects of corticosteroids were assessed by using the Kaplan-Meier method and a multivariate Cox regression.ResultsA total of 527 ARDS patients were enrolled in the study. Sixty-five patients (12.3%) were administered low-dose (methylprednisolone ≤1 mg·kg⁻¹·d⁻¹) corticosteroids. The median dose was equivalent to 0.67 (0.57–0.81) mg/kg methylprednisolone for a median duration of 10 days. The control group included 224 patients (42.5%) who had never receive corticosteroids. In the matched sample, the hospital mortality rates in the low-dose (n=40) and control groups (n=80) were 27.5% and 42.5% (P=0.110), respectively. The length of hospital stay was significantly longer in the low-dose corticosteroid group than in the control group (24.0 vs. 17.0, P=0.002), and the multivariate Cox regression analysis suggested that the low-dose group had a significantly lower risk of death than the control group (HR: 0.48; 95% CI: 0.24–0.97; P=0.040).ConclusionsThe administration of low-dose corticosteroids may reduce mortality in patients with ARDS.     

不同病因导致急性呼吸窘迫综合征应用体外膜式氧合治疗体会

目的:观察不同病因引起急性呼吸窘迫综合征(ARDS)的患者,应用体外膜式氧合(ECMO)的治疗效果。方法:回顾性分析2007年6月至2008年8月我院3例ARDS应用ECMO病例。发生原因分别是重症肺炎、胸腹联合创伤后合并呼吸机相关性肺炎(VAP)、以及肺栓塞肺动脉内膜血栓剥脱术后灌注肺;观察应用ECMO前基础状态(Base)、用后8 h、24 h、48 h及72 h动脉血气分析、血压、脉搏和呼吸机调整参数。结果:应用ECMO后,例1重症肺炎患者8 h、24 h、48 h及72 h血压、脉搏及氧合等项指标平稳,但ECMO参数下调时,缺氧状态无缓解,最终ECMO辅助14 d后死亡;例2胸腹联合创伤后VAP合并ARDS患者和例3肺栓塞术后灌注肺患者,ECMO辅助8 h、24 h、48 h、72 h血压、脉搏、氧合等项指标明显改善,分别于ECMO辅助4 d后和24 h后停机。结论:不同病因导致的ARDS应用ECMO后可能结果有所不同。ECMO能改善ARDS患者氧合和气体交换,减轻肺部病理损伤,减轻机体因低氧血症带来的多器官损伤,为治疗原发病赢得时间。     

持续高水平PEEP治疗肺内源性ARDS的临床观察

目的探讨持续高水平PEEP治疗肺内源性ARDS的价值。方法前瞻性分析2003年1月-2007年12月21例于广东省佛山市顺德区第一人民医院等医院住院进行有创机械通气治疗的ARDS患者的临床资料。根据其PEEP是否〉12cmH2O,分为治疗组及对照组,采用χ2检验对两组患者的死亡率进行比较,采用重复测量数据的方差分析比较两种治疗方法对24 h内氧合指数、血压及心率等指标的影响变化。使用Mann-Whitney检验比较两组患者24 h血管活性药物的用量。结果两组患者的死亡率无显著性差异（P〉0.05）,两种不同治疗手段对肺内源性ARDS患者的氧合指数的影响无统计学显著性差异（P〉0.05）,治疗组患者在使用较大量的血管活性药物情况下两种不同治疗手段对肺内源性ARDS患者的血压、心率影响无统计学显著性差异（P〉0.05）,但两组患者在不同时间点的氧合指数、舒张血压等指标有统计学显著性差异（P〈0.05）。结论肺内源性ARDS患者使用持续高水平PEEP治疗并不可取。     

持续小剂量肝素治疗脓毒症患者急性肺损伤/急性呼吸窘迫综合症的临床研究

目的探讨持续小剂量肝素对脓毒症患者急性肺损伤/急性呼吸窘迫综合症的治疗作用。方法 119例脓毒症患者随机分为对照治疗组（61例）和肝素治疗组（58例）,对照组采用抗感染、呼吸支持等综合治疗,肝素组在对照治疗基础上加用持续小剂量肝素输注,比较两组患者治疗3天后氧合指数,APACHEⅡ积分,SOFA积分以及PLT、PT、APTT、FIB变化以及出血倾向。结果肝素组治疗后氧合指数明显好转,APACHEⅡ积分,SOFA积分明显低于对照组（P〈0.05）,PLT、PT、APTT、FIB两组治疗前后均无差异。结论持续小剂量肝素治疗严重脓毒症患者急性肺损伤/急性呼吸窘迫综合症可有效提高氧合指数,减轻患者炎症反应,且具有良好的安全性。     

应用小剂量肝素治疗急性呼吸窘迫综合症的临床疗效

目的探讨应用小剂量肝素治疗急性呼吸窘迫综合症(ARDS)患者的临床疗效。方法将我院重症医学科(ICU)住院治疗的明确诊断为ARDS的患者66人,随机分为试验组(34例)和对照组(32例),对照组给予常规治疗,试验组在常规治疗的基础上加用小剂量肝素(5～10 U/kg/h)持续泵入,测定两组间患者治疗前、治疗后第1天、第3天、第5天、第7天氧合指数(PaO2/FiO2)、呼吸频率(R)、血小板计数(PLT)、部分凝血酶原时间(APTT)、纤维蛋白原(FIB)、组织因子途径抑制物(TF-PI)。观察两组患者平均机械通气时间、平均ICU住院时间及28天病死率。结果与对照组相比,治疗后3、5、7天实验组PaO2/FiO2明显升高,R、TFPI含量明显下降,PLT、APTT、FIB含量无明显变化;对照组平均机械通气时间、ICU住院时间均显著低于对照组,28 d病死率较对照组有所降低。结论小剂量肝素治疗急性呼吸窘迫综合征疗效显著,临床应用安全。     

Effects of PMX-DHP treatment for patients with directly induced acute respiratory distress syndrome

Endotoxin-removal direct hemoperfusion column containing polymyxin B immobilized fibers (PMX-DHP) is an effective procedure for the treatment of sepsis-induced acute respiratory distress syndrome (ARDS). We investigated retrospectively the effects and appropriate timing of PMX-DHP induction for directly induced ARDS in 38 patients. PMX-DHP was carried out twice for two hours. Blood pressure, heart rate (HR) and PaO(2)/FIO(2) (PF) ratio, leukocytes, platelets, endotoxin, inflammatory cytokines and clusters of differentiated peripheral neutrophils and monocytes were measured before and after PMX-DHP. Acute Physiology and Chronic Health Evaluation (APACHE) II scores, Sequential Organ Failure Assessment (SOFA) scores and lung injury scores (LIS) were determined at the time of starting PMX-DHP. The underlying causes of ARDS were pneumonia in 29 patients and aspiration pneumonia in 9 patients. The patients were divided into Survivors (n = 21) and Nonsurvivors (n = 17). Mortality was 45% at 30 days after PMX-DHP. The APACHE II and SOFA scores and the LIS were not significantly different between the two groups. The time from the onset of ARDS to the start of PMX-DHP was significantly delayed between the two groups. PMX-DHP significantly improved the PF ratio, HR and systolic blood pressure in the Survivors compared to the Nonsurvivors. The function of active monocytes in the peripheral blood was significantly suppressed after PMX-DHP. This early induction of PMX-DHP is indicated for directly induced ARDS. In the Nonsurvivors, this delay could have led to undesirable responses to oxygenation and circulation after PMX-DHP.     

Plasma neurofilament light chain: A biomarker predicting severity in patients with acute ischemic stroke

Neurofilament light chain (NfL) levels have proved to be a good biomarker in cerebrospinal fluid (CSF) correlating with the degree of neuronal injury and neurodegeneration. However, little is known about the value of plasma neurofilament light chain (pNfL) levels in predicting the clinical prognosis of patients with acute cerebral infarction. This study aimed to explore whether pNfL could be used as a biomarker to predict the severity of the outcomes of acute ischemic stroke (AIS).Patients with AIS were included from the Department of Neurology of the First People’s Hospital of Bengbu City from January 2018 to May 2019, as well as health control (HC). The plasma levels of NfL in patients with AIS (n = 60) at 2 days, 7 days, and 6 months after stroke, as well as in HCs (n = 60) were measured by electrochemiluminescence immunoassay(ECL) on the Meso Scale Discovery platform. Stroke severity was analyzed at admission using the National Institutes of Health Stroke Scale score. Functional outcomes were assessed at different times using the modified Rankin Scale (mRS) and Barthel Index.The mean level of pNfL in patients with ischemic stroke (IS) at 2 days (225.86 pg/L) after stroke was significantly higher than that in HC (107.02 pg/L) and gradually increased 7 days after stroke (316.23 pg/L) (P < .0001). The mean level of pNfL in patients with IS at 6 months after stroke was 173.38 pg/L, which was still significantly higher than that of HC. The levels of pNfL at 7 days after stroke independently predicted modified Rankin Scale scores (mRS) (R = 0.621, P < .001), Barthel Index (R = –0.716, P < .001), and National Institutes of Health Stroke Scale (R = –0.736, P < .001). The diagnostic severity and prognosis were evaluated by ROC curve, an area under the receiver operator curve of 0.812 (P = .001, 95% CI: 0.69–0.93) at 7 days.Plasma NfL levels reflect neuronal injury after AIS. It changes with time and has a certain relationship with prognosis and may be a promising biomarker for predicting the severity of neuroaxonal injury in patients with acute IS.     

Vascular endothelial growth factor in epithelial lining fluid of patients with acute respiratory distress syndrome

Background and objective:   Vascular endothelial growth factor (VEGF) is known to contribute to the development of pulmonary oedema, and has been suggested to have a protective role against lung injury. To determine the role of VEGF in acute lung injury (ALI) and ARDS, VEGF levels were measured in lung epithelial lining fluid (ELF) collected from patients with ALI/ARDS.
Methods:   Forty patients with ALI/ARDS underwent bronchoscopic microsampling to collect ELF on days 0 (onset of ALI/ARDS), 1, 3, 5, 7 and 10, unless the patient was extubated or had died. Twelve patients, who underwent bronchoscopy for examination of small, peripheral pulmonary nodules, served as controls.
Results:   The initial (day 0) levels of VEGF in ELF of the ALI/ARDS patients who survived and those who did not were 5.5 ng/mL (IQR: 2.3–19.7) and 1.7 ng/mL (IQR: 0.0–6.4), respectively. On days 0, 5, 7 and 10, the VEGF levels in ELF were significantly greater in survivors than in non-survivors ( P  < 0.05). VEGF levels on days 1 and 3 did not differ between survivors and non-survivors. There was no significant difference in ELF VEGF levels between control subjects and patients with ALI/ARDS at any time point. Lung injury score was inversely correlated with VEGF concentration in ELF ( P  < 0.001).
Conclusions:   In patients with ALI/ARDS, elevated VEGF levels in ELF may predict a better outcome. Increased production of VEGF in the injured lung may contribute to resolution of inflammation in the lung.     

急性呼吸窘迫综合征患者单核细胞人类白细胞抗原DR表达及其与预后的关系

目的探讨急性呼吸窘迫综合征（ARDS）患者单核细胞人类白细胞抗原DR（HLA-DR）表达及其与预后的关系。方法2004年7月至2005年6月收住东南大学附属中大医院ICU的76例ARDS患者纳入观察。ARDS确诊当天（第1天）及确诊后第7天抽取外周血,应用流式细胞仪检测T淋巴细胞亚群占淋巴细胞百分比、单核细胞HLA-DR表达以及淋巴细胞凋亡。记录患者年龄、性别、导致ARDS的原因,及ARDS确诊当天急性生理和慢性健康（APACHE）Ⅱ评分、心率、呼吸频率、平均动脉压、氧合指数、动脉血pH、动脉血乳酸、外周血血红蛋白浓度、血小板和白细胞计数以及器官功能衰竭个数。以住院28d病死率为预后判定标准。结果与生存组比较,死亡组患者在ARDS第1天和第7天的单核细胞HLA-DR表达均无明显差异。死亡组患者ARDS第7天的单核细胞HLA-DR表达明显低于ARDS第1天。ARDS第1天HLA-DR≤30%的患者生存时间明显低于HLA-DR〉30%患者。ARDS第1天HLA-DR≤30%的患者的28d病死率为67%,有高于HLA-DR〉30%患者（42%）的趋势,但差异无统计学意义。以ARDS第1天HLA-DR≤30%作为判断患者死亡指标,其灵敏度为97%,但特异度仅为17%。以ARDS第1天单核细胞HLA-DR表达判断患者预后的ROC曲线下面积为0.553（P=0.618）,以患者第1天和第7天单核细胞HLA-DR表达变化判断预后的ROC曲线下面积为0.830（P〈0.01）。患者ARDS第1天及第7天HLA-DR表达与APACHEⅡ评分和器官功能衰竭数均无相关性。严重感染导致的ARDS患者的生存时间明显低于其他原因导致的ARDS患者。结论单核细胞HLA-DR≤30%可提示ARDS患者预后不良,HLA-DR表达动态下降对预后判断也具有一定价值。