急性肺损伤（ALI）和急性呼吸窘迫综合征（ARDS）是指由心源性以外的各种肺内外致病因素所导致的急性进行性缺氧性呼吸衰竭，它们具有性质相同的病理生理改变，严重的ALI或ALI的最终严重阶段被定义为ARDS，临床表现以呼吸窘迫、顽固性低氧血症和非心源性肺水肿为特征，采用常规的治疗难以纠正其低氧血症，死亡率高达60%。目前，有关ALI/ARDS的研究取得较多进展，其中，能有效评估ALI病情和预测死亡率的临床参数和生化指标一直是研究热点。
Objective To explore the efficacy of prone positioning ventilation in patients with acute respiratory distress syndrome (ARDS) after acute Stanford type A aortic dissection (STAAD) surgery. Methods From November 2019 to September 2021, patients with ARDS who was placed prone position after STAAD surgery in the Xiamen Cardiovascular Hospital of Xiamen University were collected. Data such as the changes of blood gas, respiratory mechanics and hemodynamic indexes before and after prone positioning, complications and prognosis were collected for statistical analysis. ResultsA total of 264 STAAD patients had surgical treatment, of whom 40 patients with postoperative ARDS were placed prone position. There were 37 males and 3 females with an average age of 49.88±11.46 years. The oxygen partial pressure, oxygenation index and peripheral blood oxygen saturation 4 hours and 12 hours after the prone positioning, and 2 hours and 6 hours after the end of the prone positioning were significantly improved compared with those before prone positioning ventilation (P<0.05). The oxygenation index 2 hours after the end of prone positioning which was less than 131.42 mm Hg, indicated that the patient might need ventilation two or more times of prone position. Conclusion Prone position ventilation for patients with moderate to severe ARDS after STAAD surgery is a safe and effective way to improve the oxygenation.
Objective Exploring the correlation between intravesical pressure (IP) and diaphragm excursion (DE) in patients with severe acute pancreatitis (SAP) and acute respiratory distress syndrome (ARDS), and evaluating its predictive value for weaning outcomes. Methods A retrospective analysis was conducted on the clinical data of 144 SAP patients with ARDS admitted between 2020 and 2023. By collecting the outcome of weaning, collect data on gender, age, acute physiology and chronic health score II (APACHE II), oxygenation index, and IP and DE before weaning and extubation for all patients. Based on weaning outcomes, divide patients into successful and failed groups, and compare the differences in various indicators between the two groups; Use binary logistic regression to analyze whether IP and DE are risk factors affecting weaning in SAP patients with ARDS, and use Pearson correlation analysis to examine the correlation between IP and DE; Use receiver operating characteristic curve (ROC curve) to analyze the predictive value of IP and DE on weaning outcomes in SAP patients with ARDS. ResultsA total of 144 SAP patients with ARDS were included, of which 108 were successfully weaned and 36 were unsuccessful. There were no statistically significant differences in gender, age, and APACHE II scores between the successful and failed groups (males: 62.96% (68/108) compared to 69.44% (25/36), age (years): 41.91 ± 8.14 compared to 42.42 ± 6.22, APACHE II score (points): 18.28 ± 2.22 compared to 18.97 ± 1.83, P>0.05). The IP of the successful group was significantly lower than that of the failed group, and the DE was significantly higher than that of the failed group [IP (mmHg): 18.45 ± 3.76 compared to 23.92 ± 5.65, DE (mm): 16.18 ± 4.23 compared to 12.28 ± 4.44, all P<0.05]. All patients showed a significant negative correlation between IP and DE (r=–0.457, P<0.001). ROC curve analysis showed that the area under the curve (AUC) of IP predicting the withdrawal outcome of SAP patients with ARDS was 0.805, with a 95% confidence interval (95%CI) of 0.724-0.885 and P<0.001. When the cutoff value was 19.5 mmHg, the sensitivity was 91.57% and the specificity was 47.54%; The AUC for predicting the withdrawal outcome of SAP patients with ARDS by DE was 0.738, with a 95%CI of 0.641-0.834 and P<0.001. When the cutoff value was 11.5 points, the sensitivity was 84.82% and the specificity was 59.38%. Conclusions There is a significant negative correlation between IP and DE in SAP combined with ARDS patients, and both have certain predictive value for weaning outcomes.
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.
Acute respiratory distress syndrome (ARDS) is a serious threat to human life and health disease, with acute onset and high mortality. The current diagnosis of the disease depends on blood gas analysis results, while calculating the oxygenation index. However, blood gas analysis is an invasive operation, and can’t continuously monitor the development of the disease. In response to the above problems, in this study, we proposed a new algorithm for identifying the severity of ARDS disease. Based on a variety of non-invasive physiological parameters of patients, combined with feature selection techniques, this paper sorts the importance of various physiological parameters. The cross-validation technique was used to evaluate the identification performance. The classification results of four supervised learning algorithms using neural network, logistic regression, AdaBoost and Bagging were compared under different feature subsets. The optimal feature subset and classification algorithm are comprehensively selected by the sensitivity, specificity, accuracy and area under curve (AUC) of different algorithms under different feature subsets. We use four supervised learning algorithms to distinguish the severity of ARDS (P/F ≤ 300). The performance of the algorithm is evaluated according to AUC. When AdaBoost uses 20 features, AUC = 0.832 1, the accuracy is 74.82%, and the optimal AUC is obtained. The performance of the algorithm is evaluated according to the number of features. When using 2 features, Bagging has AUC = 0.819 4 and the accuracy is 73.01%. Compared with traditional methods, this method has the advantage of continuously monitoring the development of patients with ARDS and providing medical staff with auxiliary diagnosis suggestions.
As an extracorporeal life support technology, veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been demonstrated its role in the treatment of patients with severe respiratory failure. Its main advantages include the ability to maintain adequate oxygenation and remove excess CO2, increase oxygen delivery, improve tissue perfusion and metabolism, and implement lung protection strategies. Clinicians should accurately assess and identify the patient's condition, timely and accurately carry out VV-ECMO operation and management. This article will review the patient selection, cannulation strategy, anticoagulation, clinical management and weaning involved in the application of VV-ECMO.
Lung injury could be classified as acute and chronic injuries, such as acute respiratory distress syndrome and chronic obstructive pulmonary disease. Lung function recovery mainly depends on inflammation adjusting, lung and airway remodeling, endogenous stem cell proliferation and differentiation, and tissue repair. The principles of clinical therapy include inhibition of inflammation, balancing coagulation and fibrinolysis, and protective lung ventilation for acute lung injury; while reduction of hyper-secretion, bronchodilation, adjusting airway mucosal inflammation and immunity, as well as improving airway remodeling for chronic obstructive pulmonary disease. The functional recovery of lung and airway depends on endogenous stem cell proliferation and repair. The purpose of clinical treatment is to provide assistance for lung and airway repair besides pathophysiological improvement.
ObjectiveTo investigate the independent risk factors associated with postoperative acute respiratory distress syndrome in patients undergoing type A aortic dissection surgery.MethodsThe clinical data of 147 patients who underwent acute type A aortic dissection surgery in the First Affiliated Hospital of Anhui Medical University from 2015 to 2019 were retrospectively analyzed. There were 110 males at age of 51.9±10.1 years and 37 females at age of 54.3±11.1 years. According to whether the patients developed ARDS after surgery, all of the patients were divided into a ARDS group or a non-ARDS group. Logistic regress analysis was utilized to establish the predictive mode to identify the independent risk factors related to ARDS.ResultsOf the patients, 25 developed postoperative ARDS. Among them, 5 patients were mild ARDS, 13 patients were moderate, and 7 patients were severe ARDS. Multivariate logistic regression analysis showed that deep hypothermic circulatory arrest time [odds ratio (OR)=1.067, 95% confidence interval (CI) 1.014-1.124, P=0.013], cardiopulmonary bypass time (OR=1.012, 95%CI 1.001-1.022, P=0.027) and perioperative plasma input (OR=1.001, 95%CI 1.000-1.002, P=0.011) were independently associated with ARDS in patients undergoing acute A aortic dissection surgery. Receiver operating characteristic (ROC) curve analysis demonstrated a good discrimination ability of the logistic regression model, with an area under the curve of 0.835 (95%CI 0.740-0.929, P=0.000).ConclusionDuration of deep hypothermic circulatory arrest, cardiopulmonary bypass time and perioperative plasma are independent risk factors for postoperative ARDS in patients undergoing type A aortic dissection surgery.
Objective To evaluate the efficacy of pulmonary surfactant (PS) on severe acute respiratory distress syndrome (ARDS) in different age baby with congenital heart disease. Methods We divided 43 baby patients into two separate groups including a little baby group (12 patients with age less than 3 months) and an infants group (31 patients with age of 3 months to one year). Both groups of patients were treated with intratracheal PS at the same time. The clinical data were collected and analyzed. Results The little baby group had lower body weight. There was no statistical difference in the cardiopulmonary bypass (CPB) time, operation blocking time, mechanical ventilation time, ICU stay time between the two groups (P>0.05). Before treatment, arterial partial presurre of oxygen (PaO2), fractional oxygen concentration in inspire gas (FiO2), the ratio of arterial PO2 to the inspired oxygen fraction (P/F) and arterial-alveolar N2 difference or gradient (a/A) had no difference between the two groups (P>0.05). After treatment, PaO2 and P/F of both groups were significantly lower than before (P<0.05), and FiO2 and P/F were significantly higher than before (P<0.05). After 24 h of treatment, PaO2 and P/F of the little baby group was significantly higher than that of the infants group (P<0.05), and FiO2 and P/F were significantly lower than those of the infants group (P<0.05). Conclusion PS treating severe ARDS in little baby with congenital heart disease has better effect than infants.
Objective To investigate the titration of best positive end-expiratory pressure (Best PEEP) based on mechanical power (MP) and transpulmonary pressure monitoring during lung reexpansion in patients with acute respiratory distress syndrome (ARDS), and to analyze the value of both in evaluating the prognosis of ARDS patients.Methods ARDS patients treated in the intensive care Unit of the First Affiliated Hospital of Jinzhou Medical University from September 2021 to March 2023 were selected and divided into survival group and death group according to the 28-day mortality rate. After full sedation, esophageal pressure tube was inserted through the nasal passage, and lung recruitment maneuvers (RM) was performed by incremental PEEP method. The Best PEEP method was titrated based on MP and transpulmonary pressure. Pearson correlation analysis was used to analyze the correlation between MP at RM 30 min and 2 h and transpulmonary pressure. The changes of clinical indicators at 30 minutes and 2 hours after RM were compared between the two groups with different outcomes. Receiver operating characteristic (ROC) curve was used to analyze the predictive value of 2 h MP and transpulmonary pressure for 28-day mortality in ARDS patients. Results MP and transpulmonary pressure in the survival group decreased significantly at 30 min and 2 h, while MP and transpulmonary pressure in the death group showed a significant upward trend (P < 0.05). The Best PEEP and RR at 30 min and 2 h of the RM in the survival group were lower than those in the death group (P < 0.05). Pearson correlation analysis showed that MP at RM 30 min and 2 h was significantly correlated with transpulmonary pressure (r = 0.710 and 0.804, P < 0.05). The area under the ROC curve of MP and transpulmonary pressure were 0.812 and 0.795, respectively. 95% confidencial interval: 0.704 - 0.920 and 0.687 - 0.903 (P < 0.05); The sensitivity was 86.95% and 82.50%, respectively. The specificity were 76.67% and 59.40%; The positive predictive values were 0.851 and 0.688; The negative predictive values were 0.793 and 0.759; The optimal cut-off values were 15.5 and 17.5, respectively. RM 2 h MP and transpulmonary pressure have good predictive value for 28-day mortality in ARDS patients. Conclusion Monitoring MP and transpulmonary pressure during lung recruitment maneuver can effectively guide the titration of Best PEEP in ARDS patients, and both have good evaluation value for the prognosis of ARDS patients.