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1.
Medicina (Kaunas) ; 56(11)2020 Oct 29.
Artigo em Inglês | MEDLINE | ID: mdl-33137936

RESUMO

Coronavirus disease (COVID-19) started in Wuhan (China) at the end of 2019, and then increased rapidly. In patients with severe acute respiratory distress syndrome (ARDS) caused by COVID-19, venovenous extracorporeal membrane oxygenation (VV-ECMO) is considered a rescue therapy that provides adequate gas exchange. The way in which mechanical ventilation is applied during VV-ECMO is not clear, however it is associated with prognosis. Currently, the mortality rate of COVID-19 patients that receive VV-ECMO stands at approximately 50%. Here, we report three patients that successfully recovered from COVID-19-induced ARDS after VV-ECMO and implementation of an ultra-protective ventilation. This ventilation strategy involved maintaining a peak inspiratory pressure of ≤20 cmH2O and a positive end-expiratory pressure (PEEP) of ≤ 10 cmH2O, which are lower values than have been previously reported. Thus, we suggest that this ultra-protective ventilation be considered during VV-ECMO as it minimizes the ventilator-induced lung injury.


Assuntos
Infecções por Coronavirus/terapia , Oxigenação por Membrana Extracorpórea/métodos , Glucocorticoides/uso terapêutico , Pneumonia Viral/terapia , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório do Adulto/terapia , Lesão Pulmonar Induzida por Ventilação Mecânica/prevenção & controle , Idoso , Antibacterianos/uso terapêutico , Antivirais/uso terapêutico , Betacoronavirus , Infecções por Coronavirus/tratamento farmacológico , Feminino , Humanos , Imunização Passiva , Masculino , Pessoa de Meia-Idade , Pandemias
5.
Am J Respir Crit Care Med ; 202(8): 1081-1087, 2020 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-33054329

RESUMO

Protective ventilation strategies for the injured lung currently revolve around the use of low Vt, ostensibly to avoid volutrauma, together with positive end-expiratory pressure to increase the fraction of open lung and reduce atelectrauma. Protective ventilation is currently applied in a one-size-fits-all manner, and although this practical approach has reduced acute respiratory distress syndrome deaths, mortality is still high and improvements are at a standstill. Furthermore, how to minimize ventilator-induced lung injury (VILI) for any given lung remains controversial and poorly understood. Here we present a hypothesis of VILI pathogenesis that potentially serves as a basis upon which minimally injurious ventilation strategies might be developed. This hypothesis is based on evidence demonstrating that VILI begins in isolated lung regions manifesting a Permeability-Originated Obstruction Response (POOR) in which alveolar leak leads to surfactant dysfunction and increases local tissue stresses. VILI progresses topographically outward from these regions in a POOR-get-POORer fashion unless steps are taken to interrupt it. We propose that interrupting the POOR-get-POORer progression of lung injury relies on two principles: 1) open the lung to minimize the presence of heterogeneity-induced stress concentrators that are focused around the regions of atelectasis, and 2) ventilate in a patient-dependent manner that minimizes the number of lung units that close during each expiration so that they are not forced to rerecruit during the subsequent inspiration. These principles appear to be borne out in both patient and animal studies in which expiration is terminated before derecruitment of lung units has enough time to occur.


Assuntos
Prevenção Primária/métodos , Atelectasia Pulmonar/prevenção & controle , Edema Pulmonar/prevenção & controle , Síndrome do Desconforto Respiratório do Adulto/fisiopatologia , Lesão Pulmonar Induzida por Ventilação Mecânica/prevenção & controle , Lesão Pulmonar Induzida por Ventilação Mecânica/fisiopatologia , Doença Aguda , Fenômenos Biomecânicos , Doença Crônica , Feminino , Humanos , Masculino , Monitorização Fisiológica , Prognóstico , Atelectasia Pulmonar/etiologia , Edema Pulmonar/etiologia , Síndrome do Desconforto Respiratório do Adulto/terapia , Testes de Função Respiratória
6.
J Extra Corpor Technol ; 52(3): 191-195, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32981956

RESUMO

Although extracorporeal membrane oxygenation (ECMO) has been used in many different populations, its use in pregnant or postpartum patients has not been widely studied. This article reviews the ECMO experience in this population at a large urban hospital. Electronic medical records for all pregnant or postpartum patients who required ECMO between 2012 and 2019 were retrospectively reviewed. Data on clinical characteristics, outcomes, and complications were gathered. Comparisons between survivors and nonsurvivors were completed. Ten postpartum patients were identified. The patients presented as follows: four with cardiac arrest, one with a massive pulmonary embolism, three with acute respiratory distress syndrome (ARDS), one with combined ARDS and cardiogenic shock, and one with suspected amniotic embolism. Survival to decannulation was 70%, and survival to discharge was 60%. When comparing survivors vs. nonsurvivors, ECMO survivors tended to have shorter support times vs. nonsurvivors. Otherwise, no differences were noted in age, mechanical ventilation time, or length of stay. Disseminated intravascular coagulation was a common phenomenon in this patient cohort. After initiation of ECMO, elevated serum lactate levels, lower systolic blood pressure, and acute renal failure were predictors of mortality. In a single institution at a large metroplex, we present data regarding the use of ECMO in postpartum patients. ECMO can be successfully used in selected postpartum patients with severe cardiac or respiratory dysfunction. Multidisciplinary collaboration on a regular basis will streamline the ECMO referral in a timely manner. Furthermore, larger studies are indicated to understand the utility of ECMO in larger cohorts.


Assuntos
Oxigenação por Membrana Extracorpórea , Síndrome do Desconforto Respiratório do Adulto , Feminino , Humanos , Período Pós-Parto , Gravidez , Respiração Artificial , Síndrome do Desconforto Respiratório do Adulto/terapia , Estudos Retrospectivos , Resultado do Tratamento
7.
J Transl Med ; 18(1): 359, 2020 09 21.
Artigo em Inglês | MEDLINE | ID: mdl-32958009

RESUMO

More than seven months into the coronavirus disease -19 (COVID-19) pandemic, infection from the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has led to over 21.2 million cases and resulted in over 760,000 deaths worldwide so far. As a result, COVID-19 has changed all our lives as we battle to curtail the spread of the infection in the absence of specific therapies against coronaviruses and in anticipation of a proven safe and efficacious vaccine. Common with previous outbreaks of coronavirus infections, SARS and Middle East respiratory syndrome, COVID-19 can lead to acute respiratory distress syndrome (ARDS) that arises due to an imbalanced immune response. While several repurposed antiviral and host-response drugs are under examination as potential treatments, other novel therapeutics are also being explored to alleviate the effects on critically ill patients. The use of mesenchymal stromal cells (MSCs) for COVID-19 has become an attractive avenue down which almost 70 different clinical trial teams have ventured. Successfully trialled for the treatment of other conditions such as multiple sclerosis, osteoarthritis and graft versus host disease, MSCs possess both regenerative and immunomodulatory properties, the latter of which can be harnessed to reduce the severity and longevity of ARDS in patients under intensive care due to SARS-CoV-2 infection.


Assuntos
Betacoronavirus , Infecções por Coronavirus/terapia , Transplante de Células-Tronco Mesenquimais , Pneumonia Viral/terapia , Animais , Ensaios Clínicos como Assunto , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/imunologia , Humanos , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/imunologia , Síndrome do Desconforto Respiratório do Adulto/etiologia , Síndrome do Desconforto Respiratório do Adulto/imunologia , Síndrome do Desconforto Respiratório do Adulto/terapia , Pesquisa Médica Translacional
8.
J Med Case Rep ; 14(1): 161, 2020 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-32912329

RESUMO

BACKGROUND: In this case report, we describe the trajectory of recovery of a young, healthy patient diagnosed with coronavirus disease 2019 who developed acute respiratory distress syndrome. The purpose of this case report is to highlight the potential role of intensive care unit recovery or follow-up clinics for patients surviving acute hospitalization for coronavirus disease 2019. CASE PRESENTATION: Our patient was a 27-year-old Caucasian woman with a past medical history of asthma transferred from a community hospital to our medical intensive care unit for acute hypoxic respiratory failure due to bilateral pneumonia requiring mechanical ventilation (ratio of arterial oxygen partial pressure to fraction of inspired oxygen, 180). On day 2 of her intensive care unit admission, reverse transcription-polymerase chain reaction confirmed coronavirus disease 2019. Her clinical status gradually improved, and she was extubated on intensive care unit day 5. She had a negative test result for coronavirus disease 2019 twice with repeated reverse transcription-polymerase chain reaction before being discharged to home after 10 days in the intensive care unit. Two weeks after intensive care unit discharge, the patient returned to our outpatient intensive care unit recovery clinic. At follow-up, the patient endorsed significant fatigue and exhaustion with difficulty walking, minor issues with sleep disruption, and periods of memory loss. She scored 10/12 on the short performance physical battery, indicating good physical function. She did not have signs of anxiety, depression, or post-traumatic stress disorder through self-report questionnaires. Clinically, she was considered at low risk of developing post-intensive care syndrome, but she required follow-up services to assist in navigating the healthcare system, addressing remaining symptoms, and promoting return to her pre-coronavirus disease 2019 societal role. CONCLUSION: We present this case report to suggest that patients surviving coronavirus disease 2019 with subsequent development of acute respiratory distress syndrome will require more intense intensive care unit recovery follow-up. Patients with a higher degree of acute illness who also have pre-existing comorbidities and those of older age who survive mechanical ventilation for coronavirus disease 2019 will require substantial post-intensive care unit care to mitigate and treat post-intensive care syndrome, promote reintegration into the community, and improve quality of life.


Assuntos
Infecções por Coronavirus/terapia , Cuidados Críticos , Pneumonia Viral/terapia , Síndrome do Desconforto Respiratório do Adulto/virologia , Adulto , Betacoronavirus , Doença Crônica , Estado Terminal , Feminino , Humanos , Pandemias , Respiração Artificial , Síndrome do Desconforto Respiratório do Adulto/terapia
9.
J Card Surg ; 35(10): 2495-2499, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32939799

RESUMO

OBJECTIVE: Since the initiation of an adult extracorporeal membrane oxygenation (ECMO) program at our institution, the program has managed well over 200 patients with ECMO in a 3-year time frame. While there is a plethora of research evaluating ECMO for acute respiratory distress syndrome (ARDS), few studies have evaluated the impact that ventilator management after cannulation might have on outcomes. We hypothesized that failure to properly protect the lungs after cannulation would lead to higher mortality. MATERIALS AND METHODS: This was a retrospective observational study performed from 1 January 2014 to 8 July 2018. RESULTS: A total of 196 patients were treated with ECMO, 57 of whom were diagnosed with ARDS and treated with venovenous ECMO. The univariable analysis revealed a statistically higher total serum bilirubin and lower total days on ECMO in those who died vs those who lived. During ECMO, higher mean peak inspiratory pressures (PIP) and higher FiO2 were found in those who died vs those who lived. In multivariable analysis, increasing age (odds ratio [OR] = 1.2; confidence interval [CI] = 1.04-1.39, P = .02), increasing mean PIP, and increasing mean FiO2 concentration during ECMO (PIP: OR = 1.40, CI = 1.03-1.89, P = .03; FiO2 : OR = 1.16, CI = 1.02-1.32, P = .02) were all associated with increased mortality. CONCLUSION: Failing to protect the lungs with a lung protective strategy such as the EMPROVE protocol after ECMO cannulation was associated with mortality. For every 1 mm Hg increase in the mean PIP, the odds of dying increased 1.4 times, and for every 1% increase in the mean FiO2 , the odds of dying increased 1.16 times. For lung rest to truly be effective, the lungs must be relieved of the burden of gas exchange.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório do Adulto/terapia , Adulto , Cateterismo/métodos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Troca Gasosa Pulmonar , Síndrome do Desconforto Respiratório do Adulto/mortalidade , Síndrome do Desconforto Respiratório do Adulto/fisiopatologia , Resultado do Tratamento
10.
Rev Med Suisse ; 16(705): 1636-1644, 2020 Sep 09.
Artigo em Francês | MEDLINE | ID: mdl-32914595

RESUMO

Acute respiratory failure is a complex physiopathological process and the choice of the most appropriate therapy has to be made between standard oxygen therapy (SOT), high-flow oxygen therapy through nasal cannula (High-Flow Nasal Cannula (HFNC)), non- invasive ventilation (NIV) or invasive ventilation. HFNC can deliver a higher and consistent inspired fraction of oxygen than SOT, but has not clearly demonstrated a clinical advantage over other methods. NIV is a therapy of choice in the management of acute exacerbation of chronic obstructive pulmonary disease and acute cardiogenic pulmonary edema, but its effectiveness in other indications is questionable. In any case, early detection of treatment failure is essential to avoid late tracheal intubation, which is associated with increased mortality.


Assuntos
Ventilação não Invasiva , Oxigenoterapia , Síndrome do Desconforto Respiratório do Adulto/terapia , Humanos , Unidades de Terapia Intensiva , Síndrome do Desconforto Respiratório do Adulto/diagnóstico , Síndrome do Desconforto Respiratório do Adulto/mortalidade , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/terapia
11.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 32(8): 970-975, 2020 Aug.
Artigo em Chinês | MEDLINE | ID: mdl-32912412

RESUMO

OBJECTIVE: To systematically review the effect of Tongfu Xiefei method on prognosis and respiratory mechanics parameters in patients with acute respiratory distress syndrome (ARDS). METHODS: The randomized controlled trials (RCT) of Tongfu Xiefei method for ARDS published on PubMed, Web of Science, Embase, CNKI and Wanfang database from January 1st 2001 to June 30th 2019 were searched. Conventional treatment for ARDS that included mechanical ventilation, prone ventilation, anti-infection, organ function maintenance and nutritional therapy were used in the control group. While the Tongfu Xiefei method was applied in the experimental group based on the conventional treatment. The main outcome was in-hospital mortality, and the secondary outcomes included mechanic ventilation time, length of intensive care unit (ICU) stay and respiratory mechanics parameters. Two researchers independently searched the literature, collected data and assessed the risk of bias. The bias risk assessment was completed by RevMan 5.3 software. The Meta-analysis was completed by R software. The potential publication bias of main outcome was evaluation. RESULTS: A total of 27 RCTs were included. There were 1 763 patients, including 899 in the experimental group and 864 in the control group. Meta-analysis showed that, compared with the control group, the in-hospital mortality of the experimental group significantly decreased [relative risk (RR) = 0.46, 95% confidence interval (95%CI) was 0.36 to 0.59, P < 0.000 1], the mechanic ventilation time and the length of ICU stay were significantly shortened [mechanical ventilation time: standard mean difference (SMD) = -1.92, 95%CI was -2.56 to -1.29, P < 0.000 1; length of ICU stay: SMD = -1.84, 95%CI was -2.49 to -1.18, P < 0.000 1], oxygenation index was significantly improved (SMD = 2.26, 95%CI was 1.56 to 2.96, P < 0.000 1), airway peak pressure, airway platform pressure, mean airway pressure and airway resistance significantly decreased (airway peak pressure: SMD = -1.26, 95%CI was -2.35 to -0.18, P = 0.021 8; airway platform pressure: SMD = -0.61, 95%CI was -1.08 to -0.14, P = 0.010 7; mean airway pressure: SMD = - 1.67, 95%CI was - 2.93 to -0.42, P = 0.009 1; airway resistance: SMD = -0.88, 95%CI was -1.09 to -0.67, P < 0.000 1), while lung compliance increased (SMD = 1.57, 95%CI was 0.78 to 2.36, P < 0.000 1). The results of publication bias assessment showed that there was no potential publication bias (P = 0.499). CONCLUSIONS: Tongfu Xiefei method is capable of reducing the in-hospital mortality, shortening the mechanical ventilation time and the length of ICU stay, and improving respiratory mechanics parameters for patients with ARDS.


Assuntos
Medicina Tradicional Chinesa , Síndrome do Desconforto Respiratório do Adulto/terapia , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Complacência Pulmonar , Mecânica Respiratória
12.
Trials ; 21(1): 769, 2020 Sep 07.
Artigo em Inglês | MEDLINE | ID: mdl-32895056

RESUMO

OBJECTIVES: To assess the effect of anticoagulation with bivalirudin administered intravenously on gas-exchange in patients with COVID-19 and respiratory failure using invasive mechanical ventilation. TRIAL DESIGN: This is a single centre parallel group, superiority, randomized (1:1 allocation ratio) controlled trial. PARTICIPANTS: All patients admitted to the Hamad Medical Corporation -ICU in Qatar for COVID-19 associated respiratory distress and in need of mechanical ventilation are screened for eligibility. INCLUSION CRITERIA: all adult patients admitted to the ICU who test positive for COVID-19 by PCR-test and in need for mechanical ventilation are eligible for inclusion. Upon crossing the limit of D-dimers (1.2 mg/L) these patients are routinely treated with an increased dose of anticoagulant according to our local protocol. This will be the start of randomization. EXCLUSION CRITERIA: pregnancy, allergic to the drug, inherited coagulation abnormalities, no informed consent. INTERVENTION AND COMPARATOR: The intervention group will receive the anticoagulant bivalirudin intravenously with a target aPTT of 45-70 sec for three days while the control group will stay on the standard treatment with low-molecular-weight heparins /unfractionated heparin subcutaneously (see scheme in Additional file 1). All other treatment will be unchanged and left to the attending physicians. MAIN OUTCOMES: As a surrogate parameter for clinical improvement and primary outcome we will use the PaO2/FiO2 (P/F) ratio. RANDOMISATION: After inclusion, the patients will be randomized using a closed envelope method into the conventional treatment group, which uses the standard strategy and the experimental group which receives anticoagulation treatment with bivalirudin using an allocation ratio of 1:1. BLINDING (MASKING): Due to logistical and safety reasons (assessment of aPTT to titrate the study drug) only the data-analyst will be blinded to the groups. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): We performed a sample size calculation and assumed the data for P/F ratio (according to literature) is normally distributed and used the mean which would be: 160 and SD is 80. We expect the treatment will improve this by 30%. In order to reach a power of 80% we would need 44 patients per group (in total 88 patients). Taking approximately 10% of dropout into account we will include 100 patients (50 in each group). TRIAL STATUS: The local registration number is MRC-05-082 with the protocol version number 2. The date of approval is 18th June 2020. Recruitment started on 28th June and is expected to end in November 2020. TRIAL REGISTRATION: The protocol is registered before starting subject recruitment under the title: "Anticoagulation in patients suffering from COVID-19 disease. The ANTI-CO Trial" in ClinicalTrials.org with the registration number: NCT04445935 . Registered on 24 June 2020. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 2). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.


Assuntos
Antitrombinas/uso terapêutico , Infecções por Coronavirus/tratamento farmacológico , Fragmentos de Peptídeos/uso terapêutico , Pneumonia Viral/tratamento farmacológico , Respiração Artificial , Síndrome do Desconforto Respiratório do Adulto/terapia , Anticoagulantes/uso terapêutico , Betacoronavirus , Infecções por Coronavirus/sangue , Estado Terminal , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Heparina/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Hirudinas , Humanos , Pandemias , Tempo de Tromboplastina Parcial , Pneumonia Viral/sangue , Catar , Proteínas Recombinantes/uso terapêutico
13.
Anesthesiology ; 133(5): 1106-1117, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32898217

RESUMO

BACKGROUND: A lung rest strategy is recommended during extracorporeal membrane oxygenation in severe acute respiratory distress syndrome (ARDS). However, spontaneous breathing modes are frequently used in this context. The impact of this approach may depend on the intensity of breathing efforts. The authors aimed to determine whether a low spontaneous breathing effort strategy increases lung injury, compared to a controlled near-apneic ventilation, in a porcine severe ARDS model assisted by extracorporeal membrane oxygenation. METHODS: Twelve female pigs were subjected to lung injury by repeated lavages, followed by 2-h injurious ventilation. Thereafter, animals were connected to venovenous extracorporeal membrane oxygenation and during the first 3 h, ventilated with near-apneic ventilation (positive end-expiratory pressure, 10 cm H2O; driving pressure, 10 cm H2O; respiratory rate, 5/min). Then, animals were allocated into (1) near-apneic ventilation, which continued with the previous ventilatory settings; and (2) spontaneous breathing: neuromuscular blockers were stopped, sweep gas flow was decreased until regaining spontaneous efforts, and ventilation was switched to pressure support mode (pressure support, 10 cm H2O; positive end-expiratory pressure, 10 cm H2O). In both groups, sweep gas flow was adjusted to keep Paco2 between 30 and 50 mmHg. Respiratory and hemodynamic as well as electric impedance tomography data were collected. After 24 h, animals were euthanized and lungs extracted for histologic tissue analysis. RESULTS: Compared to near-apneic group, the spontaneous breathing group exhibited a higher respiratory rate (52 ± 17 vs. 5 ± 0 breaths/min; mean difference, 47; 95% CI, 34 to 59; P < 0.001), but similar tidal volume (2.3 ± 0.8 vs. 2.8 ± 0.4 ml/kg; mean difference, 0.6; 95% CI, -0.4 to 1.4; P = 0.983). Extracorporeal membrane oxygenation settings and gas exchange were similar between groups. Dorsal ventilation was higher in the spontaneous breathing group. No differences were observed regarding histologic lung injury. CONCLUSIONS: In an animal model of severe ARDS supported with extracorporeal membrane oxygenation, spontaneous breathing characterized by low-intensity efforts, high respiratory rates, and very low tidal volumes did not result in increased lung injury compared to controlled near-apneic ventilation.


Assuntos
Modelos Animais de Doenças , Oxigenação por Membrana Extracorpórea/métodos , Síndrome do Desconforto Respiratório do Adulto/fisiopatologia , Síndrome do Desconforto Respiratório do Adulto/terapia , Mecânica Respiratória/fisiologia , Índice de Gravidade de Doença , Animais , Feminino , Suínos
14.
Crit Care ; 24(1): 490, 2020 08 07.
Artigo em Inglês | MEDLINE | ID: mdl-32768001

RESUMO

BACKGROUND: With recent advances in technology, patients with acute respiratory distress syndrome (ARDS) and severe acute exacerbations of chronic obstructive pulmonary disease (ae-COPD) could benefit from extracorporeal CO2 removal (ECCO2R). However, current evidence in these indications is limited. A European ECCO2R Expert Round Table Meeting was convened to further explore the potential for this treatment approach. METHODS: A modified Delphi-based method was used to collate European experts' views to better understand how ECCO2R therapy is applied, identify how patients are selected and how treatment decisions are made, as well as to identify any points of consensus. RESULTS: Fourteen participants were selected based on known clinical expertise in critical care and in providing respiratory support with ECCO2R or extracorporeal membrane oxygenation. ARDS was considered the primary indication for ECCO2R therapy (n = 7), while 3 participants considered ae-COPD the primary indication. The group agreed that the primary treatment goal of ECCO2R therapy in patients with ARDS was to apply ultra-protective lung ventilation via managing CO2 levels. Driving pressure (≥ 14 cmH2O) followed by plateau pressure (Pplat; ≥ 25 cmH2O) was considered the most important criteria for ECCO2R initiation. Key treatment targets for patients with ARDS undergoing ECCO2R included pH (> 7.30), respiratory rate (< 25 or < 20 breaths/min), driving pressure (< 14 cmH2O) and Pplat (< 25 cmH2O). In ae-COPD, there was consensus that, in patients at risk of non-invasive ventilation (NIV) failure, no decrease in PaCO2 and no decrease in respiratory rate were key criteria for initiating ECCO2R therapy. Key treatment targets in ae-COPD were patient comfort, pH (> 7.30-7.35), respiratory rate (< 20-25 breaths/min), decrease of PaCO2 (by 10-20%), weaning from NIV, decrease in HCO3- and maintaining haemodynamic stability. Consensus was reached on weaning protocols for both indications. Anticoagulation with intravenous unfractionated heparin was the strategy preferred by the group. CONCLUSIONS: Insights from this group of experienced physicians suggest that ECCO2R therapy may be an effective supportive treatment for adults with ARDS or ae-COPD. Further evidence from randomised clinical trials and/or high-quality prospective studies is needed to better guide decision making.


Assuntos
Dióxido de Carbono/sangue , Circulação Extracorpórea/métodos , Unidades de Terapia Intensiva , Doença Pulmonar Obstrutiva Crônica/terapia , Síndrome do Desconforto Respiratório do Adulto/terapia , Consenso , Técnica Delfos , Europa (Continente) , Humanos
15.
ACS Chem Neurosci ; 11(16): 2391-2392, 2020 08 19.
Artigo em Inglês | MEDLINE | ID: mdl-32786329

RESUMO

The current outbreak has led to renewed interest in developing novel disinfectants/drugs to kill "a species" for the benefit of "another species." While the discovery of new antimicrobials will ensure our ability to counter such threats in the short term, the development of drug resistance through natural selection will lead to the evolution of more "superbugs." In this regard, there is a need to understand viral perspective and associated molecular mechanisms and whether we can regulate viral strategies for our benefit to coexist in the long term.


Assuntos
Betacoronavirus/imunologia , Infecções por Coronavirus/imunologia , Síndrome da Liberação de Citocina/imunologia , Pneumonia Viral/imunologia , Síndrome do Desconforto Respiratório do Adulto/imunologia , Antivirais/uso terapêutico , Evolução Biológica , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/prevenção & controle , Síndrome da Liberação de Citocina/tratamento farmacológico , Síndrome da Liberação de Citocina/prevenção & controle , Dexametasona/uso terapêutico , Desinfetantes/uso terapêutico , Glucocorticoides/uso terapêutico , Humanos , Pandemias/prevenção & controle , Pneumonia Viral/tratamento farmacológico , Pneumonia Viral/prevenção & controle , Síndrome do Desconforto Respiratório do Adulto/terapia
16.
Ann Am Thorac Soc ; 17(8): 918-921, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32735170

RESUMO

Amid efforts to care for the large number of patients with coronavirus disease (COVID-19), there has been considerable speculation about whether the lung injury seen in these patients is different than acute respiratory distress syndrome from other causes. One idea that has garnered considerable attention, particularly on social media and in free open-access medicine, is the notion that lung injury due to COVID-19 is more similar to high-altitude pulmonary edema (HAPE). Drawing on this concept, it has also been proposed that treatments typically employed in the management of HAPE and other forms of acute altitude illness-pulmonary vasodilators and acetazolamide-should be considered for COVID-19. Despite some similarities in clinical features between the two entities, such as hypoxemia, radiographic opacities, and altered lung compliance, the pathophysiological mechanisms of HAPE and lung injury due to COVID-19 are fundamentally different, and the entities cannot be viewed as equivalent. Although of high utility in the management of HAPE and acute mountain sickness, systemically delivered pulmonary vasodilators and acetazolamide should not be used in the treatment of COVID-19, as they carry the risk of multiple adverse consequences, including worsened ventilation-perfusion matching, impaired carbon dioxide transport, systemic hypotension, and increased work of breathing.


Assuntos
Doença da Altitude , Infecções por Coronavirus , Hipertensão Pulmonar , Pandemias , Pneumonia Viral , Síndrome do Desconforto Respiratório do Adulto , Acetazolamida/farmacologia , Doença da Altitude/fisiopatologia , Doença da Altitude/terapia , Betacoronavirus/isolamento & purificação , Inibidores da Anidrase Carbônica/farmacologia , Infecções por Coronavirus/complicações , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/fisiopatologia , Infecções por Coronavirus/terapia , Humanos , Hipertensão Pulmonar/fisiopatologia , Hipertensão Pulmonar/terapia , Lesão Pulmonar/etiologia , Lesão Pulmonar/fisiopatologia , Lesão Pulmonar/terapia , Nifedipino/farmacologia , Pneumonia Viral/fisiopatologia , Pneumonia Viral/terapia , Síndrome do Desconforto Respiratório do Adulto/etiologia , Síndrome do Desconforto Respiratório do Adulto/fisiopatologia , Síndrome do Desconforto Respiratório do Adulto/terapia , Vasodilatadores/farmacologia
17.
BMC Cardiovasc Disord ; 20(1): 389, 2020 08 26.
Artigo em Inglês | MEDLINE | ID: mdl-32842957

RESUMO

BACKGROUND: Fulminant (life-threatening) COVID-19 can be associated with acute respiratory failure (ARF), multi-system organ failure and cytokine release syndrome (CRS). We present a rare case of fulminant COVID-19 associated with reverse-takotsubo-cardiomyopathy (RTCC) that improved with therapeutic plasma exchange (TPE). CASE PRESENTATION: A 40 year old previous healthy male presented in the emergency room with 4 days of dry cough, chest pain, myalgias and fatigue. He progressed to ARF requiring high-flow-nasal-cannula (flow: 60 L/minute, fraction of inspired oxygen: 40%). Real-Time-Polymerase-Chain-Reaction (RT-PCR) assay confirmed COVID-19 and chest X-ray showed interstitial infiltrates. Biochemistry suggested CRS: increased C-reactive protein, lactate dehydrogenase, ferritin and interleukin-6. Renal function was normal but lactate levels were elevated. Electrocardiogram demonstrated non-specific changes and troponin-I levels were slightly elevated. Echocardiography revealed left ventricular (LV) basal and midventricular akinesia with apex sparing (LV ejection fraction: 30%) and depressed cardiac output (2.8 L/min) consistent with a rare variant of stress-related cardiomyopathy: RTCC. His ratio of partial arterial pressure of oxygen to fractional inspired concentration of oxygen was < 120. He was admitted to the intensive care unit (ICU) for mechanical ventilation and vasopressors, plus antivirals (lopinavir/ritonavir), and prophylactic anticoagulation. Infusion of milrinone failed to improve his cardiogenic shock (day-1). Thus, rescue TPE was performed using the Spectra Optia™ Apheresis System equipped with the Depuro D2000 Adsorption Cartridge (Terumo BCT Inc., USA) without protective antibodies. Over 5 days he received daily TPE (each lasting 4 hours). His lactate levels, oxygenation, and LV function normalized and he was weaned off vasopressors. His inflammation markers improved, and he was extubated on day-7. RT-PCR was negative on day-17. He was discharged to home isolation in good condition. CONCLUSION: Stress-cardiomyopathy may complicate the course of fulminant COVID-19 with associated CRS. If inotropic therapy fails, TPE without protective antibodies may help rescue the critically ill patient.


Assuntos
Antivirais/uso terapêutico , Cardiotônicos/uso terapêutico , Infecções por Coronavirus/terapia , Síndrome da Liberação de Citocina/terapia , Troca Plasmática , Pneumonia Viral/terapia , Síndrome do Desconforto Respiratório do Adulto/terapia , Choque Cardiogênico/terapia , Cardiomiopatia de Takotsubo/terapia , Adulto , Betacoronavirus , Infecções por Coronavirus/complicações , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/tratamento farmacológico , Síndrome da Liberação de Citocina/complicações , Síndrome da Liberação de Citocina/diagnóstico , Combinação de Medicamentos , Ecocardiografia , Humanos , Lopinavir/uso terapêutico , Masculino , Pandemias , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico , Respiração Artificial , Síndrome do Desconforto Respiratório do Adulto/etiologia , Ritonavir/uso terapêutico , Choque Cardiogênico/etiologia , Cardiomiopatia de Takotsubo/diagnóstico por imagem , Cardiomiopatia de Takotsubo/etiologia
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