Compliance versus dead space for optimum positive end expiratory pressure determination in acute respiratory distress syndrome

Objective:

To Compare compliance versus dead space (Vd) targeted positive end-expiratory pressure (PEEP) as regard its effect on lung mechanics and oxygenation.

Materials and Methods:

This study was carried out on 30 adult acute respiratory distress syndrome patients. The ventilator was initially set on volume controlled with tidal volume (Vt) 7 mL/kg predicted body weight (PBW), inspiratory plateau pressure (Ppl) <30 cm H₂ O. If the Ppl was >30 cm H₂ O with a TV of 6 mL/kg PBW, a step-wise Vt reduction of 1 mL/kg PBW to as low as 4 mL/kg/PBW was allowed. Respiratory rate adjusted to maintain pH 7.30-7.45. FiO₂ start at 100%. Best PEEP determined at 2 points, one by titrating PEEP until reaching the highest static compliance (Cst) (PEEP Cst) and the other one is at the lowest Vd/Vt (PEEP Vd/Vt). The following data measured before and 30 min after setting PEEP Cst and PEEP Vd/Vt. Cst, PaCO₂ - PetCO₂, Vd/Vt, PaO₂ /FiO₂, Ppl, heart rate, mean arterial pressure and oxygen saturation.

Results:

optimum PEEP determined by Vd/Vt was significantly (P < 0.05) lower than the optimum PEEP determined by Cst. Best PEEP Vd/Vt showed a significant decrease (P < 0.05) in Cst, PaCO₂ - PetCO₂, Vd/Vt and Ppl in comparison with best PEEP Cst. The PaO₂ /FiO₂ showed a significant increase (P < 0.05) with best PEEP Vd/Vt in comparison with best PEEP Cst.

Conclusion:

Vd guided PEEP improved compliance and oxygenation with less Ppl. Hence, its use as a guide for best PEEP determination may be useful.     

A comparison of clinical efficacy between high frequency oscillatory ventilation and conventional ventilation with lung volume recruitment in pediatric acute respiratory distress syndrome: A randomized controlled trial

Purpose:

To determine the efficacy of lung volume recruitment maneuver (LVRM) with high frequency oscillatory ventilation (HFOV) on oxygenation, hemodynamic alteration, and clinical outcomes when compared to conventional mechanical ventilation (CV) in children with severe acute respiratory distress syndrome (ARDS).

Materials:

We performed a randomized controlled trial and enrolled pediatric patients who were diagnosed to have severe ARDS upon pediatric intensive care unit (PICU) admission. LVRM protocol combined with HFOV or conventional mechanical ventilation was used. Baseline characteristic data, oxygenation, hemodynamic parameters, and clinical outcomes were recorded.

Results:

Eighteen children with severe ARDS were enrolled in our study. The primary cause of ARDS was pneumonia (91.7%). Their mean age was 47.7 ± 61.2 (m) and body weight was 25.3 ± 27.1 (kg). Their initial pediatric risk of mortality score 3 and pediatric logistic organ dysfunction were 12 ± 9.2 and 15.9 ± 12.8, respectively. The initial mean oxygen index was 24.5 ± 10.4, and mean PaO₂/FiO₂ was 80.6 ± 25. There was no difference in oxygen parameters at baseline the between two groups. There was a significant increase in PaO₂/FiO₂ (119.2 ± 41.1, 49.6 ± 30.6, P = 0.01*) response after 1 h of LVRM with HFOV compare to CV. Hemodynamic and serious complications were not significantly affected after LVRM. The overall PICU mortality of our severe ARDS at 28 days was 16.7%. Three patients in CV with LVRM group failed to wean oxygen requirement and were cross-over to HFOV group.

Conclusions:

HFOV combined with LVRM in severe pediatric ARDS had superior oxygenation and tended to have better clinical effect over CV. There is no significant effect on hemodynamic parameters. Moreover, no serious complication was noted.     

Efficacy of Veno-Venous Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Failure

Purpose

The objective of this study was to evaluate our institutional experience with veno-venous (VV) extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory failure (ARF).

Materials and Methods

From January 2007 to August 2013, 31 patients with severe ARF that was due to various causes and refractory to mechanical ventilation with conventional therapy were supported with VV ECMO. A partial pressure of arterial oxygen (PaO₂)/inspired fraction of oxygen (FiO₂) <100 mm Hg at an FiO₂ of 1.0 or a pH <7.25 due to CO₂ retention were set as criteria for VV ECMO.

Results

Overall, 68% of patients survived among those who had received VV ECMO with a mean PaO₂/FiO₂ of 56.8 mm Hg. Furthermore, in trauma patients, early use of ECMO had the best outcome with a 94% survival rate.

Conclusion

VV ECMO is an excellent, life-saving treatment option in patients suffering from acute and life-threatening respiratory failure due to various causes, especially trauma, and early use of VV ECMO therapy improved outcomes in these patients.     

Contractile reserve assessed by dobutamine test identifies super-responders to cardiac resynchronization therapy

Introduction

In this study, we sought to determine whether myocardial contractile reserve (CR) assessed by dobutamine stress echocardiography (DSE) can identify patients who experience nearly complete normalization of left ventricular (LV) function after the implantation of a cardiac resynchronization therapy (CRT) pacemaker.

Material and methods

The study group consisted of 55 consecutive patients with non-ischemic dilated cardiomyopathy, LV ejection fraction (LVEF) < 35%, and prolonged QRS complex duration, who were scheduled for CRT pacemaker implantation. The DSE (20 µg/kg/min) was performed in all patients. The CR assessment was based on a change in the wall motion score index (ΔWMSI) and ΔLVEF during DSE. Super-response was defined as an increase in LVEF to > 50% and reduction in left ventricular end-systolic dimension to < 40 mm 12 months following the CRT implantation.

Results

A total of 7 patients (12.7%) were identified as super-responders to CRT. When compared to non-super-responders, these patients had significantly higher values of the dobutamine-induced change in ΔWMSI (1.031 ±0.120 vs. 0.49 ±0.371, p < 0.01), and ΔEF (17.9 ±2.2 vs. 8.8 ±6.2, p < 0.01). Receiver operating characteristic analysis showed that dobutamine-induced changes in ΔWMSI ≥ 0.7 and ≥ 14% for ΔEF are the best discriminators for a super-response. Patients with ΔWMSI ≥ 0.7 and ΔEF ≥ 14% are significantly less often hospitalized (p < 0.01) for worsening of heart failure during 28.5 ±3.0 months of the follow-up.

Conclusions

Contractile reserve assessed by DSE can identify patients with dilated cardiomyopathy who are likely to experience near normalization of LV function following CRT.     

Preoperative pulmonary rehabilitation in patients with non-small cell lung cancer and chronic obstructive pulmonary disease

Introduction

The aim of this study was to assess the effects of preoperative pulmonary rehabilitation (PPR) on preoperative clinical status changes in patients with chronic obstructive pulmonary disease (COPD) and non-small cell lung cancer (NSCLC), and net effects of PPR and cancer resection on residual pulmonary function and functional capacity.

Material and methods

This prospective single group study included 83 COPD patients (62 ±8 years, 85% males, FEV₁ = 1844 ±618 ml, Tiffeneau index = 54 ±9%) with NSCLC, on 2–4-week PPR, before resection. Pulmonary function, and functional and symptom status were evaluated by spirometry, 6-minute walking distance (6MWD) and Borg scale, on admission, after PPR and after surgery.

Results

Following PPR significant improvement was registered in the majority of spirometry parameters (FEV₁ by 374 ml, p < 0.001; VLC by 407 ml, p < 0.001; FEF₅₀ by 3%, p = 0.003), 6MWD (for 56 m, p < 0.001) and dyspnoeal symptoms (by 1.0 Borg unit, p < 0.001). A positive correlation was identified between preoperative increments of FEV₁ and 6MWD (r _s = 0.503, p = 0.001). Negative correlations were found between basal FEV₁ and its percentage increment (r _s = –0.479, p = 0.001) and between basal 6MWD and its percentage change (r _s = –0.603, p < 0.001) during PPR. Compared to basal values, after resection a significant reduction of most spirometry parameters and 6MWD were recorded, while Tiffeneau index, FEF₂₅ and dyspnoea severity remained stable (p = NS).

Conclusions

Preoperative pulmonary rehabilitation significantly enhances clinical status of COPD patients before NSCLC resection. Preoperative increase of exercise tolerance was the result of pulmonary function improvement during PPR. The beneficial effects of PPR were most emphasized in patients with initially the worst pulmonary function and the weakest functional capacity.     

Influence of home-based telemonitored Nordic walking training on autonomic nervous system balance in heart failure patients

Introduction

Rehabilitation positively affects the modulation of the autonomic nervous system (ANS). There are no papers evaluating the influence of Nordic walking training (NW) on ANS activity among chronic heart failure (CHF) patients. The aim of study was to assess the influence of NW on ANS activity measured by heart rate variability (HRV) and heart rate turbulence (HRT) in CHF patients and its correlation with physical capacity improvement measured by peak oxygen consumption (peak VO₂ [ml/kg/min]) in the cardiopulmonary exercise treadmill test (CPET).

Material and methods

The study group comprised 111 CHF patients (NYHA class II–III; ejection fraction (EF) ≤ 40%). Patients were randomized (2 : 1) to 8-week NW (five times weekly) at 40–70% of maximal heart rate (training group – TG) (n = 77), or to a control group (CG) (n = 34). The effectiveness of NW was assessed by changes (delta (Δ)) in peak VO₂, HRV and HRT as a result of comparing these parameters from the beginning and the end of the programme.

Results

Eventually, 36 TG patients and 15 CG patients were eligible for HRV and HRT analysis. In the TG low/high frequency ratio (LF/HF) decreased (1.9 ±1.11 vs. 1.7 ±0.63, p = 0.0001) and peak VO₂ increased (16.98 ±4.02 vs. 19.70 ±4.36 ml/kg/min, p < 0.0001). Favourable results in CG were not observed. The differences between TG and CG were significant: Δpeak VO₂ (p = 0.0081); ΔLF/HF (p = 0.0038). An inverse correlation was found between the decrease in ΔLF/HF and the increase in Δpeak VO₂ (R = –0.3830, p = 0.0211) only in the TG. Heart rate variability did not change significantly in either group.

Conclusions

Nordic walking positively affects the parasympathetic-sympathetic balance in CHF patients, which correlates with the improvement in Δpeak VO₂. No significant influence of NW on HRT was observed.     

A study on the role of noninvasive ventilation in mild-to-moderate acute respiratory distress syndrome

Aim:There is sparse data on the role of noninvasive ventilation (NIV) in acute respiratory distress syndrome (ARDS) from India. Herein, we report our experience with the use of NIV in mild to moderate ARDS.Results:A total of 41 subjects (27 women, mean age: 30.9 years) were included in the study. Tropical infections followed by abdominal sepsis were the most common causes of ARDS. The use of NIV was successful in 18 (44%) subjects, while 23 subjects required intubation. The median time to intubation was 3 h. Overall, 19 (46.3%) deaths were encountered, all in those requiring invasive ventilation. The mean duration of ventilation was significantly higher in the intubated patients (7.1 vs. 2.6 days, P = 0.004). Univariate analysis revealed a lack of improvement in PaO₂/FiO₂ at 1 h and high baseline Acute Physiology and Chronic Health Evaluation II (APACHE II) as predictors of NIV failure.Conclusions:Use of NIV in mild to moderate ARDS helped in avoiding intubation in about 44% of the subjects. A baseline APACHE II score of >17 and a PaO₂/FiO₂ ratio <150 at 1 h predicts NIV failure.     

Correlation between central venous pressure and peripheral venous pressure with passive leg raise in patients on mechanical ventilation

Background:

Central venous pressure (CVP) assesses the volume status of patients. However, this technique is not without complications. We, therefore, measured peripheral venous pressure (PVP) to see whether it can replace CVP.

Aims:

To evaluate the correlation and agreement between CVP and PVP after passive leg raise (PLR) in critically ill patients on mechanical ventilation.

Setting and Design:

Prospective observational study in Intensive Care Unit.

Methods:

Fifty critically ill patients on mechanical ventilation were included in the study. CVP and PVP measurements were taken using a water column manometer. Measurements were taken in the supine position and subsequently after a PLR of 45°.

Statistical Analysis:

Pearson''s correlation and Bland–Altman''s analysis.

Results:

This study showed a fair correlation between CVP and PVP after a PLR of 45° (correlation coefficient, r = 0.479; P = 0.0004) when the CVP was <10 cmH₂O. However, the correlation was good when the CVP was >10 cmH₂O. Bland–Altman analysis showed 95% limits of agreement to be −2.912–9.472.

Conclusion:

PVP can replace CVP for guiding fluid therapy in critically ill patients.     

Efficacy and safety of parenteral omega 3 fatty acids in ventilated patients with acute lung injury

Objective:

To determine the effects of parenteral omega 3 fatty acids (10% fatty acids) on respiratory parameters and outcome in ventilated patients with acute lung injury.

Measurements and Main Results:

Patients were randomized into two groups – one receiving standard isonitrogenous isocaloric enteral diet and the second receiving standard diet supplemented with parenteral omega 3 fatty acids (Omegaven, Fresenius Kabi) for 14 days. Patients demographics, APACHE IV, Nutritional assessment and admission category was noted at the time of admission. No significant difference was found in nutritional variables (BMI, Albumin). Compared with baseline PaO²/FiO² ratio (control vs. drug group: 199 ± 124 vs. 145 ± 100; P = 0.06), by days 4, 7, and 14, patients receiving the drug did not show a significant improvement in oxygenation (PaO²/FiO²: 151.83 ± 80.19 vs. 177.19 ± 94.05; P = 0.26, 145.20 ± 109.5 vs. 159.48 ± 109.89; P = 0.61 and 95.97 ± 141.72 vs. 128.97 ± 140.35; P = 0.36). However, the change in oxygenation from baseline to day 14 was significantly better in the intervention as compared to control group (145/129 vs. 199/95; P < 0.0004). There was no significant difference in the length of ventilation (LOV) and length of ICU stay (LOS). There was no difference in survival at 28 days. Also, there was no significant difference in the length of ventilation and ICU stay in the survivors group as compared to the non survivors group.

Conclusions:

In ventilated patients with acute respiratory distress syndrome, intravenous Omega 3 fatty acids alone do not improve ventilation, length of ICU stay, or survival.     

Quercetin protects against lipopolysaccharide-induced acute lung injury in rats through suppression of inflammation and oxidative stress

Introduction

Acute lung injury (ALI) is an acute inflammatory disease characterized by excess production of inflammatory factors in lung tissue. Quercetin, a herbal flavonoid, exhibits anti-inflammatory and anti-oxidative properties. This study was performed to assess the effects of quercetin on lipopolysaccharide (LPS)-induced ALI.

Material and methods

Sprague-Dawley rats were randomly divided into 3 groups: the control group (saline alone), the LPS group challenged with LPS (Escherichia coli 026:B6; 100 µg/kg), and the quercetin group pretreated with quercetin (50 mg/kg, by gavage) 1 h before LPS challenge. Bronchoalveolar lavage fluid (BALF) samples and lung tissues were collected 6 h after LPS administration. Histopathological and biochemical parameters were measured.

Results

The LPS treatment led to increased alveolar wall thickening and cellular infiltration in the lung, which was markedly prevented by quercetin pretreatment. Moreover, quercetin significantly (p < 0.05) attenuated the increase in the BALF protein level and neutrophil count and lung wet/dry weight ratio and myeloperoxidase activity in LPS-challenged rats. The LPS exposure evoked a 4- to 5-fold rise in BALF levels of tumor necrosis factor-α and interleukin-6, which was significantly (p < 0.05) counteracted by quercetin pretreatment. Additionally, quercetin significantly (p < 0.05) suppressed the malondialdehyde level and increased the activities of superoxide dismutase, catalase, and glutathione peroxidase in the lung of LPS-treated rats.

Conclusions

Quercetin pretreatment effectively ameliorates LPS-induced ALI, largely through suppression of inflammation and oxidative stress, and may thus have therapeutic potential in the prevention of this disease.     

Critical illness associated with 2013-2014 influenza A (H1N1): Postpandemic characteristics,presentation and outcomes

Introduction:

The United States experienced a postpandemic outbreak of H1N1 influenza in 2013–2014. Unlike the pandemic in 2009 clinical course and outcomes associated with critical illness in this postpandemic outbreak has been only sparsely described.

Methods:

We conducted a retrospective analysis of all patients admitted to the Medical Intensive Care Unit with H1N1 influenza infection in 2009–2010 (pandemic) and 2013–2014 (postpandemic).

Results:

Patients admitted in the postpandemic period were older (55 ± 13 vs. 45 ± 12, P = 0.002), and had a higher incidence of underlying pulmonary (17 vs. 7, P = 0.0007) and cardiac (16 vs. 8, P = 0.005) disease. Mechanical ventilation was initiated in most patients in both groups (27 vs. 21, P = 1.00). The PaO₂/FiO₂ ratio was significantly higher in the pandemic group on days 1 (216 vs. 81, P = 0.0009), 3 (202 ± 99 vs. 100 ± 46, P = 0.002) and 7 (199 ± 103 vs. 113 ± 44, P = 0.019) but by day 14 no difference was seen between the groups. Rescue therapies were used in more patients in the postpandemic period (48% vs. 20%, P = 0.028), including more frequent use of prone ventilation (10 vs. 3, P = 0.015), inhaled vasodilator therapy (11 vs. 4, P = 0.015) and extracorporeal membrane oxygenation (ECMO) (4 vs. 2, P = NS). No significant differences in mortality were seen between the two cohorts.

Conclusions:

Compared to the 2009–2010 pandemic, the 2013–2014 H1N1 strain affected older patients with more underlying co-morbid cardio-pulmonary diseases. The patients had worse oxygenation indices and rescue modalities such as prone ventilation, inhaled epoprostenol and ECMO, were used more consistently as compared to the 2009 pandemic.     

Cystathionine-gamma-lyase inhibitor attenuates acute lung injury induced by acute pancreatitis in rats

Introduction

Acute pancreatitis (AP) is known to induce injuries to extrapancreatic organs. Because respiratory dysfunction is the main cause of death in patients with severe AP, acute pancreatitis-associated lung injury (APALI) is a great challenge for clinicians. This study aimed to investigate the potential role of hydrogen sulfide (H₂S) in the pathogenesis of APALI.

Material and methods

Fifty-four SD rats were randomly divided into three groups: the AP group of rats that received injection of sodium deoxycholate into the common bile duct, the control group that underwent a sham operation, and the treatment group made by intraperitoneal injection of propargylglycine (PAG), an inhibitor of cystathionine-γ-lyase (CSE), into rats with AP. Histopathology of the lung was examined and the expression of CSE and TNF-α mRNA in lung tissue was detected by real-time polymerase chain reaction. The H₂S level in the serum was detected spectrophotometrically.

Results

The serum concentration of H2S and CSE and TNF-α expression in the lung were increased in AP rats modeled after 3 h and 6 h than in control rats (p < 0.05). Intraperitoneal injection of PAG could reduce the serum concentration of H₂S, reduce CSE and TNF-α expression, and alleviate the lung pathology (p < 0.05).

Conclusions

Taken together, our findings suggest that the H₂S/CSE system is crucially involved in the pathological process of APALI and represents a novel target for the therapy of APALI.     

Goal-directed fluid optimization based on stroke volume variation and cardiac index during one-lung ventilation in patients undergoing thoracoscopy lobectomy operations: a pilot study

OBJECTIVES:

This pilot study was designed to utilize stroke volume variation and cardiac index to ensure fluid optimization during one-lung ventilation in patients undergoing thoracoscopic lobectomies.

METHODS:

Eighty patients undergoing thoracoscopic lobectomy were randomized into either a goal-directed therapy group or a control group. In the goal-directed therapy group, the stroke volume variation was controlled at 10%±1%, and the cardiac index was controlled at a minimum of 2.5 L.min^-1.m^-2. In the control group, the MAP was maintained at between 65 mm Hg and 90 mm Hg, heart rate was maintained at between 60 BPM and 100 BPM, and urinary output was greater than 0.5 mL/kg^-1/h^-1. The hemodynamic variables, arterial blood gas analyses, total administered fluid volume and side effects were recorded.

RESULTS:

The PaO₂/FiO₂-ratio before the end of one-lung ventilation in the goal-directed therapy group was significantly higher than that of the control group, but there were no differences between the goal-directed therapy group and the control group for the PaO₂/FiO₂-ratio or other arterial blood gas analysis indices prior to anesthesia. The extubation time was significantly earlier in the goal-directed therapy group, but there was no difference in the length of hospital stay. Patients in the control group had greater urine volumes, and they were given greater colloid and overall fluid volumes. Nausea and vomiting were significantly reduced in the goal-directed therapy group.

CONCLUSION:

The results of this study demonstrated that an optimization protocol, based on stroke volume variation and cardiac index obtained with a FloTrac/Vigileo device, increased the PaO₂/FiO₂-ratio and reduced the overall fluid volume, intubation time and postoperative complications (nausea and vomiting) in thoracic surgery patients requiring one-lung ventilation.     

Prevalence of occult adrenal insufficiency and the prognostic value of a short corticotropin stimulation test in patients with septic shock

Background:

Corticosteroid insufficiency in acute illness can be difficult to discern clinically. Occult adrenal insufficiency (i.e., Δmax ≤9 μg/dL) after corticotropin may be associated with a high mortality rate.

Objective:

To assess the prevalence of occult adrenal insufficiency and the prognostic value of short corticotropin stimulation test in patients with septic shock.

Materials and Methods:

A total of 30 consecutive patients admitted in the adult intensive care unit of the Sheri Kashmir Institute of Medical Sciences who met the clinical criteria for septic shock were prospectively enrolled in the study. A low dose (1 μg) short corticotropin stimulation test was performed; blood samples were taken before the injection (T0) and 30 (T30) and 60 (T60) minutes afterward.

Results:

The prevalence of occult adrenal insufficiency was 57%. The 28-day mortality rate was 60% and the median time to death was 12 days. The following seven variables remained independently associated with death: organ system failure scores, simplified acute physiology score II score, mean arterial pressure, low platelet count, PaO₂:FIO₂, random baseline cortisol (T0) >34 μg/dL, and maximum variation after test (Δmax) of ≤9 μg/dL. Three different mortality patterns were observed: (I) low (T0 ≤34 μg/dL and Δmax >9 μg/dL; a 28-day mortality rate of 33%),(II) intermediate (T0 >34 μg/dL and Δmax >9 μg/dL or T0 ≤34 μg/dL and Δmax ≤9 μg/dL; a 28-day mortality rate of 71%), and (III) high (T0 >34 μg/dL and Δmax ≤9 μg/dL; a 28-day mortality rate of 82%).

Conclusion:

A short corticotropin test using low-dose corticotropin (1 μg) has a good prognostic value. High basal cortisol and a low increase in cortisol on corticotropin stimulation test are predictors of a poor outcome in patients with septic shock.     

Predictors of mortality and length of stay in hospitalized cases of 2009 influenza A (H1N1): Experiences of a tertiary care center

Aim:

To study the clinical characteristics and outcome of admitted patients of H1N1 (hemagglutinin -H neuraminidase -N) influenza in a tertiary level hospital, from Oct 2009 to Dec 2010.

Materials and Methods:

A retrospective analysis of 77 confirmed patients admitted in this unit with H1N1 infection.

Results:

Of the 77 patients studied, 33 (42.8%) were female. Mean age was 40.88 ± 13.45 years, majority (70.13%) being less than 50 years. Thirty eight (49.3%) patients had at least one co-morbidity, diabetes mellitus being the most common (n = 15, 19.5%). The most common presenting symptom was fever in 75 (97.4%) patients, cough in 67 (87%) and dyspnoea in 59 (76.6%) patients. At admission, mean PaO2/FiO2 ratio was 213.16 ± 132.75 mmHg (n = 60) while mean PaCO₂ was 40.14 ± 14.86 mmHg. One or more organ failure was present in 45 (58.4%) patients. Nineteen (24.60%) patients required invasive mechanical ventilation. Circulatory failure was observed in 10 (13%) patients while 2 patients required hemodialysis. Overall, 13% mortality (n = 10) was observed. PaCO₂ level at admission (OR 1.093; 95% confidence interval: 1.002-1.193; P = 0.044) and number of organ failure (OR 8.089; 95% confidence interval: 1.133-57.778; P = 0.037) were identified as independent risk- factors for mortality.

Conclusion:

Increased duration of dyspnoea prior to admission, pneumonia, low PaO₂/FiO₂ ratio at admission and 24 hours later, higher PaCO₂ values on admission, higher O₂ requirement, number of organ failures and use of corticosteroids and delay in specialized treatment were associated with a poorer outcome.     

Evaluation of eicosanoids in nasal lavage as biomarkers of inflammation in patients with allergic rhinitis

Introduction

Cysteinyl leukotrienes (cys-LTs), 8-isoprostane and prostaglandin E2 (PGE₂) constitute fundamental mediators in allergic inflammation; therefore we wanted to determine the utility of PGE₂, 8-isoprostane and cys-LT levels in nasal lavage as biomarkers of allergic inflammation.

Material and methods

Twenty-one patients with allergic rhinitis (AR) were included on the basis of a positive history of AR symptoms and positive results of skin prick tests to grass pollen allergens. The main exclusion criteria were: uncontrolled asthma, nasal polyps, respiratory infection, tuberculosis, neoplastic and autoimmune diseases, current smoking and immunotherapy. Both outside the pollen season and at the height of the pollen season, total nasal symptom score (TNS-4) was evaluated and the levels of cys-LTs, 8-isoprostane and PGE₂ were measured in nasal lavage fluid (NALF).

Results

Natural allergen stimulation resulted in a significant increase of TNS-4 (p < 0.001) and nasal eosinophilia (p < 0.001). The concentration of PGE₂ dominated in the NALF outside the pollen season and decreased significantly at the height of natural exposure (p < 0.01). In contrast, lower baseline concentrations of cys-LTs and 8-isoprostane increased significantly upon allergen stimulation (p < 0.05). There was a significant correlation between mean concentration of PGE₂ and eosinophil number in NALF (r = 0.67, p = 0.0439).

Conclusions

The NALF concentrations of cys-LTs and 8-isoprostane change simultaneously with TNS-4 and nasal eosinophilia. However, due to the lack of any significant correlation, their utility as markers of allergic rhinitis should be warily considered. The decrease of PGE₂ concentration in NALF which correlated with nasal eosinophilia may participate in escalation of allergic inflammation and needs further evaluation.     

Neutrophil-to-lymphocyte ratio for the assessment of hospital mortality in patients with acute pulmonary embolism

Introduction

Neutrophil-to-lymphocyte ratio (NLR), which is an essential marker of inflammation, has been shown to be associated with adverse outcomes in various cardiovascular diseases in the literature. In this study we sought to evaluate the association between NLR and prognosis of acute pulmonary embolism (APE).

Material and methods

We retrospectively evaluated blood counts and clinical data of 142 patients with the diagnosis of pulmonary embolism (PE) from Ondokuz Mayis University Hospital between January 2006 and December 2012. The patients were divided into two groups according to NLR: NLR < 4.4 (low NLR group, n = 71) and NLR ≥ 4.4 (high NLR group, n = 71).

Results

Massive embolism (66.2% vs. 36.6%, p < 0.001) and in-hospital mortality (21.1%, 1.4%, p < 0.001) were higher in the high NLR group. In multivariate regression analysis NLR ≥ 5.7, systolic blood pressure (BP) < 90 mm Hg, serum glucose > 126 mg/dl, heart rate > 110 beats/min, and PCO₂ < 35 or > 50 mm Hg were predictors of in-hospital mortality. The optimal NLR cutoff value was 5.7 for mortality in receiver operating characteristic (ROC) analysis. Having an NLR value above 5.7 was found to be associated with a 10.8 times higher mortality rate than an NLR value below 5.7.

Conclusions

In patients presenting with APE, NLR value is an independent predictor of in-hospital mortality and may be used for clinical risk classification.     

PIRO concept: Staging of sepsis

Introduction:

Sepsis is common presenting illness to the emergency services and one of the leading causes of hospital mortality. Researchers and clinicians have realized that the systemic inflammatory response syndrome concept for defining sepsis is less useful and lacks specificity. The predisposition, infection (or insult), response and organ dysfunction (PIRO) staging of sepsis similar to malignant diseases (TNM staging) might give better information.

Materials and Methods:

A prospective observational study was conducted in emergency medical services attached to medicine department of a tertiary care hospital in Northern India. Patients with age 18 years or more with proven sepsis were included in the first 24 hours of the diagnosis. Two hundred patients were recruited. Multivariate logistic regression analysis was done to assess the factors that predicted in-hospital mortality.

Results:

Two hundred patients with proven sepsis, admitted to the emergency medical services were analysed. Male preponderance was noted (M: F ratio = 1.6:1). Mean age of study cohort was 50.50 ± 16.30 years. Out of 200 patients, 116 (58%) had in-hospital mortality. In multivariate logistic regression analysis, the factors independently associated with in-hospital mortality for predisposition component of PIRO staging were age >70 years, chronic obstructive pulmonary disease, chronic liver disease, cancer and presence of foley''s catheter; for infection/insult were pneumonia, urinary tract infection and meningitis/encephalitis; for response variable were tachypnea (respiratory rate >20/minute) and bandemia (band >5%). Organ dysfunction variables associated with hospital mortality were systolic blood pressure <90mm Hg, prolonged activated partial thromboplastin time, raised serum creatinine, partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO₂/FiO₂) ratio <300, decreased urine output in first two hours of emergency presentation and Glasgow coma scale ≤9. Each of the components of PIRO had good predictive capability for in-hospital mortality but the total score was more accurate than the individual score and increasing PIRO score was associated with higher in-hospital mortality. The area under receiver operating characteristic curve for cumulative PIRO staging system as a predictor of in-hospital mortality was 0.94.

Conclusion:

This study finds PIRO staging as an important tool to stratify and prognosticate hospitalised patients with sepsis at a tertiary care center. The simplicity of score makes it more practical to be used in busy emergencies as it is based on four easily assessable components.KEY WORDS: Emergency services, infection, organ dysfunction, predisposition, response, sepsis     

Renal vascular response to angiotensin II inhibition in intensive antihypertensive treatment of essential hypertension

Introduction

High blood pressure (BP) leads to target organ damage. It is suggested that regression of early organ lesions is possible on condition of BP normalization. The study objective was to assess whether permanent reduction of BP to the recommended values modifies renal vascular response to acute angiotensin II inhibition in the Doppler captopril test (DCT) in patients with essential hypertension (EH).

Material and methods

Twenty-nine persons (58 kidneys) were found eligible for the study: 18 patients with EH and 11 healthy volunteers constituting the control group. Glomerular filtration rate estimation (eGFR), 24-h ambulatory BP monitoring (ABPM) and DCT with evaluation of renal resistive index change (ΔRI) were performed before and after a 6-month period of intensive antihypertensive therapy (IAT). Additional ABPM was performed at the end of IAT.

Results

The mean IAT period was 8.5 ±2.4 months. The mean 24-h values of systolic and diastolic BP in the EH group were significantly lower in the IAT period than at the beginning and at the end of the study. Significantly lower systolic and diastolic BP (p < 0.05) and improvement of renal function (eGFR 121 ±38 vs. 139 ±40 ml/min, p < 0.001) were found after IAT as compared to initial values. Before IAT, ΔRI was significantly lower in the EH group as compared to the controls, but no such differences were found after IAT.

Conclusions

In EH patients, intensive BP lowering to the recommended values was associated with improvement of renal function and normalisation of renal vascular response to acute angiotensin II inhibition.     

Risk factors for hospital-acquired hypernatremia among critically ill medical patients in a setting utilizing a preventive free water protocol: Do we need to do more?

Context:

Hospital-acquired hypernatremia (HAH) is a frequent concern in critical care, which carries high mortality.

Aims:

To study the risk factors for HAH in settings that practice a preventive protocol.

Settings and Design:

Two tertiary-care hospitals. Prospective observational study design.

Materials and Methods:

Patients aged >18 years admitted for an acute medical illness with normal serum sodium and need for intensive care >48 h formed the study population. Details of the basic panel of investigations on admission, daily electrolytes and renal function test, sodium content of all intake, free water intake (oral, enteral and intravenous) and fluid balance every 24 h were recorded. Individuals with serum Na 140-142 meq/l received 500 ml of free water every 24 h, and those with 143-145 meq/l received 1000 ml free water every 24 h.

Statistical Analysis Used:

Risk factors associated with HAH was analysed by multiple logistic regression.

Results:

Among 670 study participants, 64 (9.5%) developed HAH. The median duration of hypernatremia was 3 days. A total 60 of 64 participants with HAH had features of renal concentrating defect during hypernatremia. Age >60 years (P = 0.02), acute kidney injury (AKI) on admission (P = 0.01), mechanical ventilation (P = 0.01), need for ionotropes (P = 0.03), worsening Sequential Organ Failure Assessment (SOFA) score after admission (P < 0.001), enteral tube feeds (P = 0.002), negative fluid balance (P = 0.02) and mannitol use (P < 0.001) were the risk factors for HAH. Mortality rate was 34.3% among hypernatremic patients.

Conclusions:

The study suggests that administration of free water to prevent HAH should be more meticulously complied with in patients who are elderly, present with AKI, suffer multi-organ dysfunction, require mechanical ventilation, receive enteral feeds and drugs like mannitol or ionotropes.