A diagnostic model for sepsis-induced acute lung injury using a consensus machine learning approach and its therapeutic implications.

BACKGROUND: A significant proportion of septic patients with acute lung injury (ALI) are recognized late due to the absence of an efficient diagnostic test, leading to the postponed treatments and consequently higher mortality. Identifying diagnostic biomarkers may improve screening to identify septic patients at high risk of ALI earlier and provide the potential effective therapeutic drugs. Machine learning represents a powerful approach for making sense of complex gene expression data to find robust ALI diagnostic biomarkers. METHODS: The datasets were obtained from GEO and ArrayExpress databases. Following quality control and normalization, the datasets (GSE66890, GSE10474 and GSE32707) were merged as the training set, and four machine learning feature selection methods (Elastic net, SVM, random forest and XGBoost) were applied to construct the diagnostic model. The other datasets were considered as the validation sets. To further evaluate the performance and predictive value of diagnostic model, nomogram, Decision Curve Analysis (DCA) and Clinical Impact Curve (CIC) were constructed. Finally, the potential small molecular compounds interacting with selected features were explored from the CTD database. RESULTS: The results of GSEA showed that immune response and metabolism might play an important role in the pathogenesis of sepsis-induced ALI. Then, 52 genes were identified as putative biomarkers by consensus feature selection from all four methods. Among them, 5 genes (ARHGDIB, ALDH1A1, TACR3, TREM1 and PI3) were selected by all methods and used to predict ALI diagnosis with high accuracy. The external datasets (E-MTAB-5273 and E-MTAB-5274) demonstrated that the diagnostic model had great accuracy with AUC value of 0.725 and 0.833, respectively. In addition, the nomogram, DCA and CIC showed that the diagnostic model had great performance and predictive value. Finally, the small molecular compounds (Curcumin, Tretinoin, Acetaminophen, Estradiol and Dexamethasone) were screened as the potential therapeutic agents for sepsis-induced ALI. CONCLUSION: This consensus of multiple machine learning algorithms identified 5 genes that were able to distinguish ALI from septic patients. The diagnostic model could identify septic patients at high risk of ALI, and provide potential therapeutic targets for sepsis-induced ALI.

Patients with infectious diseases undergoing mechanical ventilation in the intensive care unit have better prognosis after receiving metagenomic next-generation sequencing assay.

OBJECTIVES: To evaluate the relation between metagenomic next-generation sequencing (mNGS) and the prognosis of patients with infectious diseases undergoing mechanical ventilation in the intensive care unit (ICU). METHODS: This is a single-center observational study, comparing nonrandomly assigned diagnostic approaches. We analyzed the medical records of 228 patients with suspected infectious diseases undergoing mechanical ventilation in the ICU from March 2018 to May 2020. The concordance of pathogen results was also assessed for the results of mNGS, culture, and polymerase chain reaction assays. RESULTS: The 28-day mortality of the patients in the mNGS group was lower after the baseline difference correction (19.23% (20/104) vs 29.03% (36/124) , P = 0.039). Subgroup analysis showed that mNGS assay was associated with improved 28-day mortality of patients who are not immunosuppressed (14.06% vs 29.82%, P = 0.018). Not performing mNGS assay, higher acute physiology and chronic health evaluation II score, and hypertension are independent risk factors for 28-day mortality. The mNGS assay presented an advantage in pathogen positivity (69.8% double-positive and 25.0% mNGS-positive only), and the concordance between these two assays was 79.0%. CONCLUSION: mNGS survey may be associated with a better prognosis by reducing 28-day mortality of patients with infectious diseases on mechanical ventilation in the ICU. This technique presented an advantage in pathogen positivity over traditional methods.

Independent risk factors of hypoxemia in patients after surgery with acute type A aortic dissection.

BACKGROUND: This study aimed to investigate independent risk factors of postoperative hypoxemia in patients with acute type A aortic dissection (ATAAD). METHODS: A single-center retrospective study was conducted with enrolled 75 ATAAD patients following surgery, which were stratified into three groups on the basis of the postoperative PaO2/FiO2 ratio: severe hypoxemia group (PaO2/FiO2 ratio ≤100 mmHg); moderate hypoxemia group (100 mmHg < PaO2/FiO2 ratio ≤200 mmHg); and non-hypoxemia group (PaO2/FiO2 ratio >200 mmHg). The patient's demography, perioperative laboratory results, operative details, clinical outcomes were collected and analyzed. Univariable and multivariable analyses were performed and logistic regression model was established. RESULTS: The incidence of postoperative severe hypoxemia and hypoxemia was 32% and 52%, respectively. Among the three groups, severe hypoxemia group exhibited a high significance of body mass index (BMI) and preoperative white blood cell (WBC) and main distribution of hypertension; meanwhile, Marfan syndrome was mainly distributed in non-hypoxemia group. On intensive care unit (ICU) admission, severe hypoxemia group exhibited a high significance of Acute Physiology and Chronic Health Evaluation (APACHE II) score of postoperative patients, and more patients would present shock. Moreover, severe hypoxemia group patients had a higher incidence of postoperative acute kidney injury (AKI) and usage of renal replacement therapy, longer length of stay (LOS) of ICU, and shorter 28 days ventilator-free days (VFDs). CONCLUSIONS: The incidence of postoperative hypoxemia was high in ATAAD patients owing to comprehensive high-risk factors. Besides, postoperative complications negatively impacted their clinical outcomes.

The Prevalence, Risk Factors, and Prognosis of Acute Kidney Injury After Lung Transplantation: A Single-Center Cohort Study in China.

PURPOSE: The aim of this study is to evaluate the incidence, risk factors, and prognosis of acute kidney injury (AKI) after lung transplantation (LTx). METHODS: Records of patients who underwent LTx in a single center were retrospectively reviewed. The prevalence of post-transplant AKI, the use of continuous renal replacement therapy (CRRT), and the risk factors for AKI were investigated. The effects of AKI and CRRT on short-term outcomes and long-term survival were measured. RESULTS: This study included 148 patients, 67 of which developed postoperative AKI. Of these, 31 patients underwent CRRT; the percentage of cases with no AKI was 6.2%, and the percentage of cases with stage 1, 2, and 3 who used CRRT was 0%, 10%, and 86.2%, respectively. Patients with AKI had significantly higher intensive care unit mortality and in-hospital mortality. The 1-year post-LTx survival rate of patients with AKI was 47.8%, significantly lower than those without AKI (74.1%). There was no difference in 1-year survival rate of those with stage 1 and stage 2 AKI, but patients with stage 3 AKI showed the worst survival. Patients who underwent CRRT had an inferior survival outcome (9.7% vs 76.1%, P < .05). We found that higher acute physiologic assessment and chronic health evaluation (APACHE) II scores (odds ratio [OR] 1.082, P = .009) and higher intraoperative fluid balance (OR 1.001, P = .012) were independent risk factors, and female sex (OR 2.539) and pulmonary hypertension (OR 2.869) were potential risk factors for post-LTx AKI. A prediction model integration of the above factors showed a good concordance with actual risks and had a concordance index (C-index) of 0.76 (95% confidence interval [CI], 0.66-0.87). CONCLUSION: Severe AKI requiring CRRT had a negative impact on the short-term and long-term outcomes of patients.

Effect of high-flow nasal cannula versus conventional oxygen therapy and non-invasive ventilation for preventing reintubation: a Bayesian network meta-analysis and systematic review.

BACKGROUND: Adequate respiratory support can improve clinical outcomes in patients who are ready for weaning from a ventilator. We aimed to investigate the efficacy of respiratory methods in adults undergoing planned extubation using a Bayesian network meta-analysis. METHODS: We searched PubMed, Embase, and ClinicalTrials.gov for unpublished and ongoing trials up to November 2019 for randomized controlled trials (RCTs) published in English that compared conventional oxygen therapy (COT), a high-flow nasal cannula (HFNC), and noninvasive ventilation (NIV) for post-extubation respiratory support. Screening of citations, study selection, data extraction, and assessment of risk were performed independently by two authors. The primary outcome was the reintubation rate. RESULTS: Twenty-two studies (4,218 patients) were included in our meta-analysis. Extubated patients supported with NIV had a significantly lower incidence of reintubation than those supported with COT [odds ratio (OR): 0.63, 95% confidence interval (CI): 0.42, 0.89]. However, there was no significant difference in the reintubation rate between the HFNC and NIV, and HFNC and COT groups (OR: 1.05, 95% CI: 0.60, 1.81; OR: 0.60, 95% CI: 0.33, 1.02, respectively). HFNC and NIV reduced the incidence of hospital-acquired pneumonia (HAP) (OR: 0.50, 95% CI: 0.25, 0.93; OR: 0.55, 95% CI: 0.27, 0.87, respectively) and post-extubation acute respiratory failure (ARF) (OR: 0.35, 95% CI: 0.14, 0.89; OR: 0.31, 95% CI: 0.14, 0.63, respectively) compared with COT. There was no significant difference in a decreased incidence of HAP (OR: 1.1, 95% CI: 0.56, 1.8) or post-extubation ARF (OR: 0.87, 95% CI: 0.33, 2.1) between NIV and HFNC. There were also no significant differences in improvements in other clinical outcomes, including intensive care unit (ICU) and hospital mortality and the length of stay (LOS) between NIV and HFNC. CONCLUSIONS: NIV reduces the reintubation rate in adult patients undergoing planned extubation compared with COT and HFNC.

Definition and Risks of Cytokine Release Syndrome in 11 Critically Ill COVID-19 Patients With Pneumonia: Analysis of Disease Characteristics.

Corona virus disease 2019 (COVID-19) patients with severe immune abnormalities are at risk of cytokine release syndrome (CRS). The definition, prevention, and treatment of symptoms of CRS in critically ill patients with COVID-19 are important problems. We report a single-center case series of 11 COVID-19 patients with acute respiratory distress syndrome from The First Affiliated Hospital of Guangzhou Medical University in China from 26 January 2020 to 18 February 2020. The termination date of follow-up was 19 February 2020. Eight patients were determined to have characteristics of CRS, including pulmonary inflammation, fever, and dysfunction of nonpulmonary organs. An increase in interleukin-6 in peripheral blood was the highest risk factor and an early indicator of CRS in COVID-19.

Factors associated with intraoperative extracorporeal membrane oxygenation support during lung transplantation.

BACKGROUND: Intraoperative Extracorporeal membrane oxygenation (ECMO) is increasingly being applied as life-support for lung transplantation patients. However, factors associated with this procedure in lung transplantation patients have not yet been characterized. The aim of this study was to identify preoperative factors of intraoperative ECMO support during lung transplantation and to evaluated the outcome of lung transplantation patients supported with ECMO. METHODS: Patients underwent lung transplantation treated with and without ECMO in Guangzhou Institute of Respiratory Diseases between January 2015 to August 2018 were retrospectively reviewed. Patient demographics and clinical variables were collected and analyzed. Multivariate logistic regression was performed to identify factors independently associated with intraoperative extracorporeal membrane oxygenation support during lung transplantation. RESULTS: During the study period, 138 patients underwent lung transplantation at our institution, the mean LAS was (56.63 ± 18.39) (range, 32.79 to 88.70). Fourty four patients were treated with veno-venous/veno-arterial ECMO. Among the patients, 32 patients wean successfully ECMO after operation, 12 patients remain ECMO after operation, and 32 patients (62.74%) survived to hospital discharge. In multiple analysis, the following factors were associated with intraoperative ECMO support: advanced age, high PAP before operation, duration of mechanical ventilation before operation, a higher APACHE II and primary diagnosis for transplantation. The overall survival rates at 1, 3, and 12 months were 90.91, 72.73, and 56.81% in the ECMO group, and 95.40, 82.76, and 73.56% in the non-ECMO group, respectively (log-rank P = 0.081). Patients who underwent single lung transplant had a lower survival rates in ECMO group as compared with non-ECMO group at 1, 3, and 12 months (90.47% vs 98.25, 71.43% vs 84.21, and 52.38% vs 75.44%) (log-rank P = 0.048). CONCLUSIONS: The preoperative factors of intraoperative ECMO support during lung transplantation included age, high PAP before operation, preoperative mechanical ventilation, a higher APACHE II and primary diagnosis for transplantation based on multivariate analysis.

Noninvasive ventilation support during fiberoptic bronchoscopy-guided nasotracheal intubation effectively prevents severe hypoxemia.

PURPOSE: This study investigated the feasibility and efficacy of continuous noninvasive ventilation (NIV) support with 100% oxygen using a specially designed face mask, for reducing desaturation during fiberoptic bronchoscopy (FOB)-guided intubation in critically ill patients with respiratory failure. MATERIALS AND METHODS: This was a single-center prospective randomized study. All patients undergoing FOB-guided nasal tracheal intubation were randomized to bag-valve-mask ventilation or NIV for preoxygenation followed by intubation. The NIV group were intubated through a sealed hole in a specially designed face mask during continuous NIV support with 100% oxygen. Control patients were intubated with removal of the mask and no ventilatory support. RESULTS: We enrolled 106 patients, including 53 in each group. Pulse oxygen saturation (SpO2) after preoxygenation (99% (96%-100%) vs. 96% (90%-99%), p = .001) and minimum SpO2 during intubation (95% (87%-100%) vs. 83% (74%-91%), p < .01) were both significantly higher in the NIV compared with the control group. Severe hypoxemic events (SpO2 < 80%) occurred less frequently in the NIV group than in controls (7.4% vs. 37.7%, respectively; p < .01). CONCLUSIONS: Continuous NIV support during FOB-guided nasal intubation can prevent severe desaturation during intubation in critically ill patients with respiratory failure. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02462668. Registered on 25 May 2015, https://www.clinicaltrials.gov/ct2/results?term=NCT02462668.

[Cause of massive hemoptysis in critical patients and the effect of bronchial artery embolization].

OBJECTIVE: To investigate the cause of massive hemoptysis in critical patients, and to evaluate the effect of bronchial artery embolization (BAE) on critical patients with massive hemoptysis. METHODS: A retrospective controlled analysis was conducted. The clinical data of 35 patients with life-threatening massive hemoptysis admitted to intensive care unit (ICU) of the First Hospital Affiliated to Guangzhou Medical University from January 2009 to December 2017 were analyzed. The patients were divided into BAE and non-BAE group according to whether receiving BAE or not. BAE patients were subdivided into subgroups: hemoptysis after ventilation and hemoptysis before ventilation subgroups, as well as survival and non-survival subgroups. The etiology of all massive hemoptysis was analyzed. The gender, age, acute physiology and chronic health evaluation II (APACHE II) score, amount of hemoptysis, whether presence of pleural thickening in chest CT, the length of ICU stay, total length of hospital stay, the duration of mechanical ventilation (MV), clinical effective and prognostic indicators of patients were recorded. The correlation between variables was analyzed by Spearman correlation analysis. RESULTS: All 35 patients were enrolled in the finally analysis. The main cause of critical patients with massive hemoptysis was fungal infection [37.1% (13/35)], followed by pneumonia and abnormal coagulation [17.1% (6/35)], bronchiectasis [11.4% (4/35)], tumor [8.6% (3/35)], etc. In all 35 patients, 27 were treated with BAE and 8 were treated without BAE. There was no difference in gender, age, the length of ICU stay, total length of hospital stay, the duration of MV, amount of hemoptysis, APACHE II score, whether use antiplatelet agents or anticoagulants, or whether presence of pleural thickening in chest CT between the two groups. The rate of hemoptysis remission in BAE group was significantly higher than that of non-BAE group [92.6% (25/27) vs. 25.0% (2/8), P < 0.01], but there was no statistically significant difference in hospital survival as compared with that of non-BAE group [48.1% (13/27) vs. 25.0% (2/8), P > 0.05]. Subgroup analysis showed that 64.3% (9/14) of patients with hemoptysis after ventilation was caused by pulmonary fungal infection, which was significantly higher than those with hemoptysis before ventilation [15.4% (2/13), P = 0.018]. Compared with hemoptysis after ventilation group, the length of ICU stay and the duration of MV in hemoptysis before ventilation group were significantly shortened [the length of ICU stay (days): 12.0 (14.0) vs. 30.0 (81.8), the duration of MV (days): 10.0 (16.0) vs. 25.0 (68.3)], the patients using antiplatelet drugs or anticoagulant drugs was decreased significantly (case: 1 vs. 9, all P < 0.05). However, there was no statistically significant difference in gender, age, total length of hospital stay, amount of hemoptysis, APACHE II score, whether presence of pleural thickening in chest CT, the rate of hemoptysis remission, the incidence of secondary BAE or hospital survival rate between the two groups. Compared with the survival subgroup (n = 13), more patients in the non-survival subgroup (n = 14) were treated with antiplatelet or anticoagulants (P < 0.05); and Spearman correlation analysis showed that the survival of the patients with BAE was negatively correlated with the use of antiplatelet or anticoagulants (r = -0.432, P = 0.024). There was no significant difference in the gender, age, the length of ICU day, total length of hospitalization, duration of MV, estimated hemoptysis, APACHE II score, or the proportion of pleural thickening between the two groups. CONCLUSIONS: The study indicated that the etiology of massive hemoptysis in critical patients was complicated. Fungal infection was the main cause in patients with hemoptysis after ventilation. BAE was effective in the control of massive hemoptysis in ICU, but it was not ideal for patients with abnormal coagulation function or abnormal platelet count or platelet dysfunction from antiplatelet or anticoagulant drugs, the overall survival rate was still low.

Prone position ventilation support for acute exacerbation of interstitial lung disease?

INTRODUCTION: Prone position ventilation (PPV) has been shown to improve oxygenation and decrease pulmonary vascular resistance and mortality in patients with severe acute respiratory distress syndrome (ARDS). Whether these benefits of PPV occur similarly in acute exacerbations of interstitial lung disease (ILD) is not clear. We retrospectively explored the use of PPV in acute exacerbation with ILD versus those with severe acute respiratory distress syndrome (severe ARDS). METHODS: Retrospective study of the application of PPV in 17 patients with acute exacerbations of ILD and in 19 patients with severe ARDS. Pre- and post-PPV hemodynamic parameters, respiratory mechanics, prognostic indicators, complications and mortality rates at 28, 60 and 90 days were compared. RESULTS: There was no difference in baseline characteristics between the two groups except for higher driving pressure and more diastolic dysfunction in ILD group than severe ARDS group Compared with pre-PPV, cardiac index and driving pressure remained unchanged post-PPV in both groups. PPV increased PaO2 /FiO2 [118.7 (92.0, 147.8) pre-PPV vs 132.0 (93.5, 172.0) post-PPV; P < 0.05] and central venous oxygenation in patients with ILD. In patients with severe ARDS, PPV significantly increased PaO2 /FiO2 [109.23 (89,135) pre- PPV vs 126.13 (100.93, 170) post-PPV; P < 0.05] and intrathorax blood volume index. However, mortality rates at 28, 60 and 90 days remained high in both groups (76.4%, 88.2% and 88.2% vs 36.8%, 57.9% and 57.9% in ILD and severe ARDS, respectively; P < 0.05). CONCLUSION: Our findings suggest that PPV may improve oxygenation and partially improve hemodynamic parameters during acute exacerbations of ILD.

Survival Predictors for Severe ARDS Patients Treated with Extracorporeal Membrane Oxygenation: A Retrospective Study in China.

Extracorporeal membrane oxygenation (ECMO) is increasingly being applied as life support for acute respiratory distress syndrome (ARDS) patients. However, the outcomes of this procedure have not yet been characterized in severe ARDS patients. The aim of this study was to evaluate the outcomes of severe ARDS patients supported with ECMO and to identify potential predictors of mortality in these patients. A total of 38 severe ARDS patients (aged 51.39±13.27 years, 32 males) who were treated with ECMO in the specialized medical intensive care unit of Guangzhou Institute of Respiratory Diseases from July 2009 to December 2014 were retrospectively reviewed. The clinical data of the patients on the day before ECMO initiation, on the first day of ECMO treatment and on the day of ECMO removal were collected and analyzed. All patients were treated with veno-venous ECMO after a median mechanical ventilation duration of 6.4±7.6 days. Among the 20 patients (52.6%) who were successfully weaned from ECMO, 16 patients (42.1%) survived to hospital discharge. Of the identified pre-ECMO factors, advanced age, a long duration of ventilation before ECMO, a higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score, underlying lung disease, and pulmonary barotrauma prior to ECMO were associated with unsuccessful weaning from ECMO. Furthermore, multiple logistic regression analysis indicated that both barotrauma pre-ECMO and underlying lung disease were independent predictors of hospital mortality. In conclusion, for severe ARDS patients treated with ECMO, barotrauma prior to ECMO and underlying lung disease may be major predictors of ARDS prognosis based on multivariate analysis.

A Multicenter Retrospective Review of Prone Position Ventilation (PPV) in Treatment of Severe Human H7N9 Avian Flu.

BACKGROUND: Patients with H7N9 avian flu concurrent with severe acute respiratory distress syndrome (ARDS) usually have a poor clinical outcome. Prone position ventilation (PPV) has been shown to improve the prognosis of patients with severe ARDS. This study explored the effects of PPV on the respiratory and circulatory mechanics of H7N9-infected patients with severe ARDS. METHODS: Individuals admitted to four hospitals designated for H7N9 patients in Guangdong province were treated with PPV, and their clinical data were recorded before and after receiving PPV. RESULTS: Six of 20 critically ill patients in the ICU received PPV. After treatment with 35 PPV sessions, the oxygenation index (OI) values of the six patients when measured post-PPV and post-supine position ventilation (SPV) were significantly higher than those measured pre-PPV (P < 0.05).The six patients showed no significant differences in their values for respiratory rate (RR), peak inspiratory pressure (PIP), tidal volume (TV) or arterial partial pressure of carbon dioxide (PaCO2) when compared pre-PPV, post-PPV, and post-SPV. Additionally, there were no significant differences in the mean values for arterial pressure (MAP), cardiac index (CI), central venous pressure (CVP), heart rate (HR), lactic acid (LAC) levels or the doses of norepinephrine (NE) administered when compared pre-PPV, post-PPV, and post-SPV. CONCLUSION: PPV provided improved oxygenation that was sustained after returning to a supine position, and resulted in decreased carbon dioxide retention. PPV can thus serve as an alternative lung protective ventilation strategy for use in patients with H7N9 avian flu concurrent with severe ARDS.

[Effect of prone position ventilation on respiratory mechanics and prognosis in patients with acute respiratory distress syndrome concurrent with interstitial lung disease].

OBJECTIVE: To explore the effect of prone position ventilation (PPV) on respiratory mechanics and prognosis in patients with acute respiratory distress syndrome (ARDS) concurrent with interstitial lung disease (ILD). METHODS: The data of 36 severe ARDS patients admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Guangzhou Medical University from February 2013 to January 2015, were retrospectively analyzed. They were then divided into two groups according to the presence of ILD or not. The changes in respiratory mechanics and oxygenation indexes were compared before and after PPV treatment in all the patients. Kaplan-Meier method was applied to draw the 60-day survival curves of both groups. RESULTS: There were 17 cases with ILD among these 36 severe ARDS patients. (1) No significant difference was found in baseline data between ILD group and non-ILD group. (2) Respiratory mechanics and oxygenation pre-PPV and post-PPV: compared with pre-PPV, oxygenation index (PaO2/FiO2, mmHg, 1 mmHg = 0.133 kPa) post-PPV was significantly increased in both groups [ILD group : 132.0 (93.5, 172.0) vs. 118.7 (92.0, 147.8); non-ILD group: 126.1 (100.9, 170.0) vs. 109.2 (89.0, 135.0), both P < 0.05]. Compared with pre-PPV, positive end-expiratory pressure (PEEP, cmH2O, 1 cmH2O = 0.098kPa) post-PPV was significantly higher in ILD group [10.0 (10.0, 12.0) vs. 10.0 (9.2, 12.0), P < 0.05], and respiratory rate (RR, times/min) was significantly lower in non-ILD group [24.5 (22.0, 27.0) vs. 25.5 (22.8, 28.0), P < 0.05]. The compliance of the respiratory system (Crs, mL/cmH2O) post-PPV in non-ILD group was significantly lower than that of the ILD group [19.7 (16.1, 28.6) vs. 23.0 (19.0, 29.7), P < 0.05]. (3) Respiratory mechanics and oxygenation pre-PPV and post-PPV in total: after all the PPV therapy, PaO2/FiO2 (mmHg) was significantly increased in non-ILD group [135.0 (86.0, 200.0) vs. 97.4 (69.2, 127.5), P < 0.05], PaO2/FiO2 after all the PPV therapy in non-ILD group was also higher than that in ILD group [135.0 (86.0, 200.0) vs. 78.7 (59.3, 114.9), P < 0.05]. No significant difference in Crs (mL/cmH2O) before PPV treatment was found between non-ILD and ILD groups [24.3 (15.9, 48.9) vs. 18.9 (12.7, 27.3), P > 0.05], and Crs was lower after PPV treatment in both groups, but without significant difference [non-ILD group: 22.7 (15.2, 27.1) vs. 24.3 (15.9, 48.9); ILD group: 16.2 (12.8, 25.6) vs. 18.9 (12.7, 27.3), both P > 0.05]. (4) The 60-day mortality in ILD group was significantly higher than that in non-ILD group [88.2% (15/17) vs. 57.9% (11/19), P = 0.047). It was shown by Kaplan-Meier curves that 60-day survival patients in ILD group was significantly lower than those in non-ILD group (χ2 = 5.658, P = 0.017). CONCLUSIONS: PPV can improve oxygenation in severe ARDS. Compared with non-ILD group, though the compliance of respiratory system in ILD group is increased during PPV, long-term effect is better in non-ILD group.

Compliance with severe sepsis bundles and its effect on patient outcomes of severe community-acquired pneumonia in a limited resources country.

INTRODUCTION: Validation of compliance with severe sepsis bundles is still needed. The purpose of this study was to determine compliance and its outcomes in severe community-acquired pneumonia (CAP) patients in a limited resources country. MATERIAL AND METHODS: A prospective cohort study of 212 severe CAP patients was carried out. The implementation programme was organized into two continuous phases. The primary outcomes were compliance and hospital mortality. RESULTS: Compliance with administration of antibiotics and vasopressors as well as plateau pressure on average < 30 cm H2O was high in both groups. In the bundles group, patients received more serum lactate monitoring (62.3% vs. 11.3%), more blood cultures (47.1% vs. 24.5%), more fluid resuscitation (63.2% vs. 26.4%) and volumes infused (1319.8 ±1107.4 ml vs. 461.9 ±799.3 ml), more inotropic dobutamine and/or packed red blood cells (21.7% vs. 10.0%), more low-dose steroids (56.5% vs. 15.0%), and more glucose control (51.9% vs. 6.6%) compared with such patients in the control group. The rates of total compliance with 6-hour, 24-hour, and 6/24-hour bundles in the prospective period were 47.1%, 51.9%, and 42.5%, respectively. Hospital mortality was reduced from 44.3% to 29.2% (p = 0.023) in the bundles group, and the compliant subgroup had a more than twofold decrease in mortality (17.8% vs. 37.7%, p = 0.003). Serum lactate measured, blood cultures, and fluid resuscitation showed independent relationships with decreased mortality. CONCLUSIONS: Total compliance was relatively low, but the implementation of severe sepsis bundles could clearly reduce mortality from severe CAP.

[Intrathoracic blood volume index as an indicator of fluid management in septic shock].

OBJECTIVE: To investigate the value of intrathoracic blood volume index (ITBVI) monitoring in fluid management strategy in septic shock patients. METHODS: In a prospective study, 33 patients who were diagnosed to be suffering from septic shock in the intensive care unit (ICU) were enrolled . Seventeen patients who received pulse indicator continuous cardiac output (PiCCO) monitoring, and ITBVI was used as indicator of fluid management, were enrolled into ITBVI group; 16 patients who received traditional fluid management strategy [directed by central venous pressure (CVP)] were enrolled into control group. Acute physiology and chronic health evaluation II (APACHEII) score, sepsis related organ failure assessment (SOFA) score and vasopressor score were compared between 1 day and 3 days of treatment. The characteristics of fluid management were recorded and compared within 72 hours. RESULTS: (1)In 3 days of treatment, APACHEII, SOFA and vasopressor score were significantly lower in ITBVI group compared with that of in 1 day of treatment[21.3±6.2 vs. 25.4±7.2, 6.1±3.4 vs. 9.0±3.5, 5 (0, 8.0) vs. 20.0 (8.0, 35.0), respectively, all P<0.01], whereas there were no changes in control group. (2)Although fluid output (ml) was higher in ITBVI group during 48-72 hours period (2 421± 868 vs. 1 721±934, P=0.039), there was no difference in fluid intake, fluid output or fluid balance (ml) within 0-72 hours between two groups (fluid intake: 9 918±137 vs. 10 529±1 331, fluid output : 6 035±1 739 vs. 5 827±2 897, fluid balance: 3 882±1 889 vs. 4 703±2 813, allP>0.05). (3)Comparing the fluid volume (ml) used for fluid replacement period, except that there was no significance in fluid challenge with colloid during 0-6 hours between two groups [ml: 250 (125, 500) vs. 250 (69,250), P>0.05], more fluid intake (ml) was found in ITBVI group [0-6 hours crystalloid: 250(150,250) vs. 125 (105,125), 6-72 hours crystalloid: 125 (125, 250) vs. 100 (56, 125), 0-72 hours crystalloid: 250(125, 250) vs. 125 (75, 125), 6-72 hours colloid: 125 (106, 250) vs. 75 (50, 125), 0-72 hours colloid: 200 (125, 250) vs. 100 (50, 125),all P<0.01]. CONCLUSION: Clinical picture in patients with septic shock is improved after 3 days of treatment than 1 day of treatment under fluid management directed by ITBVI, compared with by CVP. This improvement may be attributable to accurate assessment of preload and appropriate infusion rate in fluid challenge.

[Evaluation of compliance with bundle treatment in the management of severe infection].

OBJECTIVE: To evaluate compliance with bundle treatment in the management of severe infection in a tertiary hospital, aiming at analyzing clinical data in order to popularize guidelines for management of severe sepsis and septic shock. METHODS: A 14-month (from November 1, 2006 to December 31, 2007) prospective observational study of a group of 43 patients admitted to the respiratory intensive care unit in First Affiliated Hospital (tertiary hospital) of Guangzhou Medical College meeting the criteria for severe pneumonia and septic shock was carried out. Implementation of 6-hour and 24-hour bundle treatment for severe infection was divided into three phases consisting of education, trial, and application. A cohort of 43 patients with matched disease history admitted during January 1, 2004 to October 31, 2006 were enrolled as control group. RESULTS: (1) In 6-hour bundle treatment for severe infection, 20.9% (9/43) had serum lactate measured, blood culture was obtained prior to antibiotic administration in 7.0% (3/43) of patients, 100% (43/43) had empirical antibiotics administration within 1 hour, an infusion of an initial minimum of 20 ml/kg of crystalloid or colloid equivalent (1.1 ml/kg of 20% albumin or 4.8 ml/kg of 6% hydroxyethyl starch) was given in 44.2% (19/43), with infused fluid (converted into 6% hydroxyethyl starch) reaching (503.95+/-176.19) ml within 6 hours, in 94.7% (18/19) of patients had received vasopressors , and inotropic dobutamine and/or transfusion of packed red blood cells were administered in 7.0% (3/43). (2) In 24-hour bundle treatment for severe infection group, 31.6% (6/19) had received low-dose steroids, 34.9% (15/43) had their blood glucose controlled<8.3 mmol/L, mechanical ventilation with inspiratory plateau pressures maintained<30 cm H(2)O (1 cm H(2)O=0.098 kPa, 6 ml/kg tidal volume) was instituted in 97.6% (40/41) of patients. (3) The percentage of compliance with 6-hour and 24-hour bundle treatment for severe infection were 0 and 21.4% respectively, total compliance was also 0. (4) As compared with control group, a 23.30% absolute mortality reduction was found in bundle group (18.6% vs. 41.9%, P=0.019). CONCLUSION: Bundle treatment for severe infection is complied with partially in our hospital, suggesting that it is still quite arduous to popularize guidelines for management of severe sepsis and septic shock in our country.

[Severe respiratory failure after injection of botulinum toxin: case report and review of the literature].

OBJECTIVE: To describe the manifestations and management of respiratory failure caused by cosmetic injections of botulinum toxin type A (BTA). METHODS: A case of severe respiratory failure after cosmetic injections of BTA was reported and the literature was reviewed. RESULTS: A 24 year old female, seeking leg cosmetic therapy, received multiple point dorsal intramuscular injection of BTA (200 Units) in the legs. Two days later, 100 unit BTA was injected in the same sites. After the first injection, the patient felt no discomfort. But after the second injection, the patient developed diplopia and malaise but without breathlessness. Gradually, ptosis, dysphagia, and tetraparesis developed, and the patient felt difficult in raising her head, followed by systemic muscle paralysis and severe respiratory failure. After admission, the patient received mechanical ventilation, supportive therapies, active muscle functional exercise and she recovered slowly. The double proximal and distal upper limb strength were class III and V(-), and the double proximal and distal lower limb muscle strength were class IV and V(-). Cough reflex and deglutition reflex recovered gradually. The patient was successfully weaned off mechanical ventilation, and was able to walk on discharge. CONCLUSION: Even conventional doses of BTA injection could increase the risk of developing systemic muscle weakness and respiratory failure. Clinical application of botulinum toxin treatment should be strictly controlled.

[Severe acute respiratory syndrome in 78 patients: a retrospective study].

OBJECTIVE: To analyze the clinical features of severe acute respiratory syndrome (SARS) and the diagnosis and treatment of the disease. METHODS: Seventy-eight patients with SARS referred to the Guangzhou Institute of Respiratory Diseases (GIRD), China from December 22, 2002 to March 2003 were studied retrospectively. The data reviewed included those of clinical manifestations, laboratory investigation and roentgenology. RESULTS: The patients consisted of 42 men and 36 women, aged 20 - 75 years (mean 37.5 +/- 11.6 years), including 44 infected health-care professionals. Clinical symptoms of these patients were fever (100%), coughing (88%), and dyspnea (80%). Routine blood test revealed WBCs <4.0 x 10(9)/L in 12 patients (15%), (4.0 -10.0) x 10(9)/L in 49 (63%), and over 10.0 x 10(9)/L in 17 (22%) [average (7.6 +/- 5.0) x 10(9)/L]. The level of neutrophilic granulocyte was 0.75 +/- 0.13 and that of lymphocyte was 0.18 +/- 0.11. Chest X-ray and CT scanning revealed changes related to pneumonia. The transmission of the disease was likely via close contact with contagious droplets. The prevalences of acute lung injury (ALI,37 patients) and acute respiratory distress syndrome (ARDS, 21 of the 37 patients) were considerably high among the patients. Seven patients who developed ARDS complicated with MODS died. CONCLUSIONS: A history of close contact, fever, X-ray signs of pneumonia and normal or lowered WBC counts are favorable for the diagnosis of SARS. Recognition of ALI as the important index for critical SARS and comprehensive supportive management are of paramount importance in decreasing the mortality of patients with SARS.

[Effect of tumor necrosis factor-alpha and interleukin-1beta on bovine pulmonary arterial endothelial cell apoptosis].

OBJECTIVE: To investigate the effect of tumor necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta) on apoptosis of bovine pulmonary arterial endothelial cells (BPEC). METHODS: BPECs were incubated with TNF-alpha, IL-1beta or the combination of TNF-alpha and IL-1beta. BEPCs were also pretreated with TNF-alpha monoclonal antibody or Ac-DEVD-CHO (caspase-3 inhibitor), and followed by incubation with TNF-alpha. The apoptotic rate was measured by flow cytometry (Annexin V-FITC and PI staining). RESULTS: (1) TNF-alpha induced apoptosis in a dose-dependent manner after a 24 h incubation. With the increase of the TNF-alpha (500, 1,000, 2,000 U/ml respectively), the BPEC apoptotic rate [(8.21 +/- 0.70)%, (9.63 +/- 0.71)%, (17.43 +/- 1.99)%, respectively] was significantly higher than that of the control group [(3.09 +/- 0.08)%, P < 0.05]. (2) TNF-alpha induced apoptosis was time dependent. After incubated with TNF-alpha 2,000 U/ml, the BPEC apoptotic rate [(6.72 +/- 0.38)%, (7.72 +/- 1.66)%, (12.95 +/- 0.32)%, (17.70 +/- 1.79)%, P < 0.05] increased significantly with time [6, 12, 24, 36 h, respectively] of TNF-alpha incubation. (3) The BPEC apoptotic rate of anti-TNF-alpha monoclonal antibody group [(7.78 +/- 0.21)%] or the Ac-DEVD-CHO group [(7.32 +/- 0.11)%] was significantly higher than the TNF-alpha group alone [(10.59 +/- 0.49)%, P < 0.01], but the combination of TNF-alpha and IL-1beta group had no such significant effect (P > 0.05). CONCLUSIONS: It is TNF-alpha but not IL-1beta that induces pulmonary arterial endothelial cell apoptosis in acute lung injury (ALI). There is no synergistic effect between IL-1beta and TNF-alpha in the induction of BPEC apoptosis.