Effect of Mechanical Ventilation on Inflammatory Mediators in Patients With Acute Respiratory Distress Syndrome

Ranieri, V. Marco; Suter, Peter M.; Tortorella, Cosimo; Tullio, Renato De; Dayer, J.-M.; Brienza, A; Bruno, Francesco; Slutsky, Arthur S.

doi:10.1001/jama.282.1.54

Cited by 1,621 publications

(356 citation statements)

References 44 publications

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“…99 Confirming that these strategies may target an important source of continued inflammation in the injured lung, both the pulmonary and systemic cytokine responses were reduced in a recent study of a protective ventilatory strategy. 100 Coagulation Pathway Dysregulation of the coagulation and fibrinolytic cascades has been well described in ALI/ARDS. [101][102][103] A variety of markers of activation of coagulation have been measured in the plasma, bronchoalveolar lavage fluid, or pulmonary edema fluid of patients at risk for 104 or with established ARDS 105,106 including tissue factor, a highly thrombogenic mediator in the extrinsic coagulation pathway.…”

Section: Oxidant-mediated Injurymentioning

confidence: 99%

Pathophysiology of Acute Lung Injury and the Acute Respiratory Distress Syndrome

Ware¹

2006

Semin Respir Crit Care Med

430

324

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Since the adult respiratory distress syndrome was first described substantial progress has been made in understanding the pathogenesis of this complex syndrome. This review summarizes our current understanding of the pathophysiology of what is now termed the acute respiratory distress syndrome (ARDS) and its less severe form acute lung injury (ALI), with an emphasis on cellular and molecular mechanisms of injury that may represent potential therapeutic targets. Although it is difficult to synthesize all of these abnormalities into a single, unified, pathogenetic pathway, a theme that emerges repeatedly is that of imbalance, be it between pro-and anti-inflammatory cytokines, oxidants and antioxidants, procoagulants and anticoagulants, neutrophil recruitment and activation and mechanisms of neutrophil clearance, or proteases and protease inhibitors. Future therapies aimed at restoring the overall balance of cytokines, oxidants, coagulants, and proteases may ultimately be successful where therapies that target individual cytokines or other mediators have not.

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Section: Oxidant-mediated Injurymentioning

confidence: 99%

Pathophysiology of Acute Lung Injury and the Acute Respiratory Distress Syndrome

Ware¹

2006

Semin Respir Crit Care Med

430

324

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“…Excessive volumes lead to high transpulmonary pressures with consequent stretch of the pulmonary tissues [29]. Recently, greater attention has been focused on intratidal collapse and reinflation, which can generate shear forces that increase capillary permeability and induce activation of inflammatory factors, leading to local and systemic inflammatory response ("biotrauma") [30].…”

Section: Ventilator-associated Lung Injury and The Prone Positionmentioning

confidence: 99%

Prone position in acute respiratory distress syndrome

Pelosi¹,

Brazzi²,

Gattinoni³

2002

European Respiratory Journal

271

167

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In the last few years prone positioning has been used increasingly in the treatment of patients with acute respiratory distress syndrome (ARDS) and this manoeuvre is now considered a simple and safe method to improve oxygenation. However, the physiological mechanisms causing respiratory function improvement as well as the real clinical benefit are not yet fully understood. The aim of this review is to discuss the physiological and clinical effects of prone positioning in patients with ARDS.The main physiological aims of prone positioning are: 1) to improve oxygenation; 2) to improve respiratory mechanics; 3) to homogenise the pleural pressure gradient, the alveolar inflation and the ventilation distribution; 4) to increase lung volume and reduce the amount of atelectatic regions; 5) to facilitate the drainage of secretions; and 6) to reduce ventilator-associated lung injury.According to the available data, the authors conclude that: 1) oxygenation improves iny70-80% of patients with early acute respiratory distress syndrome; 2) the beneficial effects of oxygenation reduce after 1 week of mechanical ventilation; 3) the aetiology of acute respiratory distress syndrome may markedly affect the response to prone positioning; 4) extreme care is necessary when the manoeuvre is performed; 5) pressure sores are frequent and related to the number of pronations; 6) the supports used to prone and during positioning are different and nonstandardised among centres; and 7) intensive care unit and hospital stay and mortality still remain high despite prone positioning. Eur Respir J 2002; 20: 1017-1028. Acute respiratory distress syndrome (ARDS) is characterised by radiographical diffuse bilateral infiltrates, decreased respiratory compliance, small lung volumes and severe hypoxaemia. Correction of lifethreatening hypoxia and improvement of respiratory mechanics and lung volumes are the main treatment goals. To achieve these ends, it is important to select the most appropriate means of ventilatory support, thereby minimising the damaging effects of mechanical ventilation. Currently, ventilatory support using small tidal volumes and low plateau pressures and respiratory rate, to control arterial carbon dioxide tension (Pa,CO 2 ) and pH, are considered optimal [1]. Moreover, the application of relatively high levels of positive end-expiratory pressure (PEEP) seems to be beneficial in reducing ventilator-associated lung injury (VALI) and improving survival [2]. In 1974, BRYAN [3] suggested that anaesthetised and paralysed patients in the prone position should exhibit better expansion of the dorsal lung regions with a consequent improvement in oxygenation. In 1976, PIEHL and BROWN [4] showed, in a retrospective study, that the prone position improved oxygenation in five patients with ARDS without deleterious effects. One year later, DOUGLAS et al. [5] demonstrated, in a prospective study with a limited group of ARDS patients, that prone positioning could effectively improve oxygenation in ARDS. Starting from these repor...

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“…The clinical implications of these changes suggest that patients with IAH may develop a secondary ARDS pattern with a cytokine profile and bacterial translocation propensity which creates a ventilatorinduced lung change resembling primary ARDS. 78,79 The ventilator strategy in these patients is specific and distinct from that of an ARDS case where the reduction in FRC and the trend towards pulmonary oedema suggests a role for a greater utilization of muscle relaxation and higher PEEP values despite its risk for barotrauma, 80 keeping alveoli recruited and open with permissive hypercapnia, a restricted tidal volume and peak inspiratory pressure that more readily permits weaning. 81,82 In summary the pulmonary effects of IAH are complex with diaphragmatic elevation increasing intra-thoracic and pleural pressure causing a reduction in FRC and all lung volumes commensurate with a restrictive lung deficit combined with basal compression atelectasis, with increases in mean, plateau and peak airway pressures and pulmonary vascular resistance.…”

Section: Respiratory System Dynamicsmentioning

confidence: 99%

Primary Intra-Abdominal Hypertension and Abdominal Compartment Syndrome: Pathophysiology and Treatment

Ap¹,

Wun²,

Chiappa³

et al. 2015

Emerg Med Open J

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Abdominal Compartment Syndrome (ACS) is a potentially lethal condition caused by various events that produce intra-abdominal hypertension. The most common cause is blunt abdominal trauma. Increasing intra-abdominal pressure causes progressive hypoperfusion and ischemia of the intestines and other peritoneal and retroperitoneal structures. Pathophysiological effects include release of cytokines, production of oxygen free radicals, and decreased cellular formation of adenosine triphosphate. These processes may lead to translocation of bacteria from the gut and intestinal edema, predisposing patients to multiorgan dysfunction syndrome. The consequences of abdominal compartment syndrome are profound and affect many vital body systems. Respiratory, hemodynamic, cardiovascular, renal, and neurological abnormalities are signs of abdominal compartment syndrome. Medical management of critically ill patients with raised intra-abdominal pressure should be instigated early to prevent further organ dysfunction and to avoid progression to ACS. Many treatment options are available and are often part of routine daily management in the ICU (nasogastric, rectal tube, prokinetics, enema, sedation, body position). Some of the newer treatments are very promising options in specific patient populations with raised IAP. Nursing care involves vigilant monitoring for early detection, including serial measurements of intra-abdominal pressure.KEYWORDS: Intra-abdominal hypertension; Abdominal compartment syndrome; Damage control laparotomy; Laparostomy; Open abdomen. DEFINITIONS, INCIDENCE AND MEASUREMENT STRATEGIES IN INTRA-ABDOMINAL HY-PERTENSION (IAH) AND ABDOMINAL COMPARTMENT SYNDROME (ACS)The concept of the Abdominal Compartment Syndrome (ACS) has been rediscovered as a final common pathway of the physiologic sequelae of increased Intra-Abdominal Pressure In each case if the graph shifts to the right, higher IAP and lower APP values may not be associated with significant end-organ dysfunction creating a degree of "ACS-resistance." Shifts to the left would create "ACS-sensitivity" where lower values of IAP (higher APP values) may still be associated with organ dysfunction which might not occur normally. This results in difficulty for broader acceptance of critical IAP and APP levels for individual cases. ACS-sensitivity may potentially occur in patients where there is pre-existing partial end-organ failure, morbid obesity or following fluid hyper-resuscitation in patients with severe burns, haemorrhagic pancreatitis, massive blood loss, widespread intra-peritoneal sepsis and high-output intestinal fistulae. 6-8There is no strict definition of what represents abnormal IAP, but there is a general acceptance that measured pressures >12 mmHg when recorded 1-6 hours apart are considered to represent IAH, where Sugrue, et al. have shown that this represents up to 40% of cases admitted to a surgical Intensive Care Unit (ICU). 9 Although there are biases in the prospective assessment of a selective population admitted to an ICU who ...

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Effect of Mechanical Ventilation on Inflammatory Mediators in Patients With Acute Respiratory Distress Syndrome

Cited by 1,621 publications

References 44 publications

Pathophysiology of Acute Lung Injury and the Acute Respiratory Distress Syndrome

Pathophysiology of Acute Lung Injury and the Acute Respiratory Distress Syndrome

Prone position in acute respiratory distress syndrome

Primary Intra-Abdominal Hypertension and Abdominal Compartment Syndrome: Pathophysiology and Treatment

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