WHAT WE ALREADY KNOW ABOUT THIS TOPICExtracorporeal membrane oxygenation is used in severe acute respiratory distress syndrome; whereas the long-term complications among survivors of acute ...respiratory distress syndrome treated without extracorporeal membrane oxygenation are well described, the status of extracorporeal membrane oxygenation survivors is poorly understood
WHAT THIS ARTICLE TELLS US THAT IS NEWIn a single-center cohort of acute respiratory distress syndrome survivors, management with (vs. without) extracorporeal membrane oxygenation resulted in similar survival at 1 yr, pulmonary function, and computed tomography lung imaging, but less impairment in quality of life
BACKGROUND:Survivors of acute respiratory distress syndrome (ARDS) have long-term impairment of pulmonary function and health-related quality of life, but little is known of outcomes of ARDS survivors treated with extracorporeal membrane oxygenation. The aim of this study was to compare long-term outcomes of ARDS patients treated with or without extracorporeal membrane oxygenation.
METHODS:A prospective, observational study of adults with ARDS (January 2013 to December 2015) was conducted at a single center. One year after discharge, survivors underwent pulmonary function tests, computed tomography of the chest, and health-related quality-of-life questionnaires.
RESULTS:Eighty-four patients (34 extracorporeal membrane oxygenation, 50 non–extracorporeal membrane oxygenation) were studied; both groups had similar characteristics at baseline, but comorbidity was more common in non–extracorporeal membrane oxygenation (23 of 50 vs. 4 of 34, 46% vs. 12%, P < 0.001), and severity of hypoxemia was greater in extracorporeal membrane oxygenation (median PaO2/FIO2 72 interquartile range, 50 to 103 vs. 114 87 to 133 mm Hg, P < 0.001) and respiratory compliance worse. At 1 yr, survival was similar (22/33 vs. 28/47, 66% vs. 59%; P = 0.52), and pulmonary function and computed tomography were almost normal in both groups. Non–extracorporeal membrane oxygenation patients had lower health-related quality-of-life scores and higher rates of posttraumatic stress disorder.
CONCLUSIONS:Despite more severe respiratory failure at admission, 1-yr survival of extracorporeal membrane oxygenation patients was not different from that of non–extracorporeal membrane oxygenation patients; each group had almost full recovery of lung function, but non–extracorporeal membrane oxygenation patients had greater impairment of health-related quality of life.
Objectives
To date, scarce evidence exists around the application of subgingival air polishing during treatment of severe periodontitis. The aim of this study was to evaluate the benefits of ...subgingival air polishing during non-surgical treatment of deep bleeding pockets in stages III–IV periodontitis patients
Materials and methods
Forty patients with stages III–IV periodontitis were selected, and pockets with probing depth (PD) 5–9 mm and bleeding on probing (BoP) were selected as experimental sites. All patients underwent a full-mouth session of erythritol powder supragingival air polishing and ultrasonic instrumentation. Test group received additional subgingival air polishing at experimental sites. The proportion of experimental sites shifting to PD ≤ 4 mm and no BoP at 3 months (i.e., non-bleeding closed pockets, NBCPs) was regarded as the primary outcome variable.
Results
The proportion of NBCP was comparable between test and control group (47.9 and 44.7%, respectively). Baseline PD of 7–9 mm, multi-rooted teeth and the presence of plaque negatively influenced the probability of obtaining NBCP.
Conclusions
The additional application of subgingival air polishing does not seem to provide any significant clinical advantage in achieving closure at moderate to deep bleeding pockets in treatment of stages III–IV periodontitis patients. The study was registered on Clinical
Trials.gov
(NCT04264624).
Clinical relevance
While air polishing can play a role in biofilm removal at supragingival and shallow sites, ultrasonic root surface debridement alone is still the choice for initial treatment of deep bleeding periodontal pockets.
Introduction:
Citric acid infusion in extracorporeal blood may allow concurrent regional anticoagulation and enhancement of extracorporeal CO2 removal. Effects of citric acid on human blood ...thromboelastography and aggregometry have never been tested before.
Methods:
In this in vitro study, citric acid, sodium citrate and lactic acid were added to venous blood from seven healthy donors, obtaining concentrations of 9 mEq/L, 12 mEq/L and 15 mEq/L. We measured gas analyses, ionized calcium (iCa++) concentration, activated clotting time (ACT), thromboelastography and multiplate aggregometry. Repeated measure analysis of variance was used to compare the acidifying and anticoagulant properties of the three compounds.
Results:
Sodium citrate did not affect the blood gas analysis. Increasing doses of citric and lactic acid progressively reduced pH and HCO3− and increased pCO2 (p<0.001). Sodium citrate and citric acid similarly reduced iCa++, from 0.39 (0.36-0.39) and 0.35 (0.33-0.36) mmol/L, respectively, at 9 mEq/L to 0.20 (0.20-0.21) and 0.21 (0.20-0.23) mmol/L at 15 mEq/L (p<0.001). Lactic acid did not affect iCa++ (p=0.07). Sodium citrate and citric acid similarly incremented the ACT, from 234 (208-296) and 202 (178-238) sec, respectively, at 9 mEq/L, to >600 sec at 15 mEq/L (p<0.001). Lactic acid did not affect the ACT values (p=0.486). Sodium citrate and citric acid similarly incremented R-time and reduced α-angle and maximum amplitude (MA) (p<0.001), leading to flat-line thromboelastograms at 15 mEq/L. Platelet aggregometry was not altered by any of the three compounds.
Conclusions:
Citric acid infusions determine acidification and anticoagulation of blood similar to lactic acid and sodium citrate, respectively.
Reducing the respiratory rate during extracorporeal membrane oxygenation (ECMO) decreases the mechanical power, but it might induce alveolar de-recruitment. Dissecting de-recruitment due to lung ...edema vs. the fraction due to hypoventilation may be challenging in injured lungs.
We characterized changes in lung physiology (primary endpoint: development of atelectasis) associated with progressive reduction of the respiratory rate in healthy animals on ECMO.
Six female pigs underwent general anesthesia and volume control ventilation (Baseline: PEEP 5 cmH
O, Vt 10 ml/kg, I:E = 1:2, FiO
0.5, rate 24 bpm). Veno-venous ECMO was started and respiratory rate was progressively reduced to 18, 12, and 6 breaths per minute (6-h steps), while all other settings remained unchanged. ECMO blood flow was kept constant while gas flow was increased to maintain stable PaCO
.
At Baseline (without ECMO) and toward the end of each step, data from quantitative CT scan, electrical impedance tomography, and gas exchange were collected. Increasing ECMO gas flow while lowering the respiratory rate was associated with an increase in the fraction of non-aerated tissue (i.e., atelectasis) and with a decrease of tidal ventilation reaching the gravitationally dependent lung regions (
= 0.009 and
= 0.018). Intrapulmonary shunt increased (
< 0.001) and arterial PaO
decreased (
< 0.001) at lower rates. The fraction of non-aerated lung was correlated with longer expiratory time spent at zero flow (
= 0.555,
= 0.011).
Progressive decrease of respiratory rate coupled with increasing CO
removal in mechanically ventilated healthy pigs is associated with development of lung atelectasis, higher shunt, and poorer oxygenation.
Abstract Purpose Partial pressure of carbon dioxide (P co2 ), strong ion difference (SID), and total amount of weak acids independently regulate pH. When blood passes through an extracorporeal ...membrane lung, P co2 decreases. Furthermore, changes in electrolytes, potentially affecting SID, were reported. We analyzed these phenomena according to Stewart's approach. Methods Couples of measurements of blood entering (venous) and leaving (arterial) the extracorporeal membrane lung were analyzed in 20 patients. Changes in SID, P co2 , and pH were computed and pH variations in the absence of measured SID variations calculated. Results Passing from venous to arterial blood, P co2 was reduced (46.5 ± 7.7 vs 34.8 ± 7.4 mm Hg, P < .001), and hemoglobin saturation increased (78 ± 8 vs 100% ± 2%, P < .001). Chloride increased, and sodium decreased causing a reduction in SID (38.7 ± 5.0 vs 36.4 ± 5.1 mEq/L, P < .001). Analysis of quartiles of ∆ P co2 revealed progressive increases in chloride ( P < .001), reductions in sodium ( P < .001), and decreases in SID ( P < .001), at constant hemoglobin saturation variation ( P = .12). Actual pH variation was lower than pH variations in the absence of measured SID variations (0.09 ± 0.03 vs 0.12 ± 0.04, P < .001). Conclusions When P co2 is reduced and oxygen added, several changes in electrolytes occur. These changes cause a P co2 -dependent SID reduction that, by acidifying plasma, limits pH correction caused by carbon dioxide removal. In this particular setting, P co2 and SID are interdependent.
Background
Noninvasive monitoring of maximal inspiratory and expiratory flows (MIF and MEF, respectively) by electrical impedance tomography (EIT) might enable early recognition of changes in the ...mechanical properties of the respiratory system due to new conditions or in response to treatments. We aimed to validate EIT-based measures of MIF and MEF against spirometry in intubated hypoxemic patients during controlled ventilation and spontaneous breathing. Moreover, regional distribution of maximal airflows might interact with lung pathology and increase the risk of additional ventilation injury. Thus, we also aimed to describe the effects of mechanical ventilation settings on regional MIF and MEF.
Methods
We performed a new analysis of data from two prospective, randomized, crossover studies. We included intubated patients admitted to the intensive care unit with acute hypoxemic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS) undergoing pressure support ventilation (PSV,
n
= 10) and volume-controlled ventilation (VCV,
n
= 20). We measured MIF and MEF by spirometry and EIT during six different combinations of ventilation settings: higher vs. lower support during PSV and higher vs. lower positive end-expiratory pressure (PEEP) during both PSV and VCV. Regional airflows were assessed by EIT in dependent and non-dependent lung regions, too.
Results
MIF and MEF measured by EIT were tightly correlated with those measured by spirometry during all conditions (range of
R
2
0.629–0.776 and
R
2
0.606–0.772, respectively,
p
< 0.05 for all), with clinically acceptable limits of agreement. Higher PEEP significantly improved homogeneity in the regional distribution of MIF and MEF during volume-controlled ventilation, by increasing airflows in the dependent lung regions and lowering them in the non-dependent ones.
Conclusions
EIT provides accurate noninvasive monitoring of MIF and MEF. The present study also generates the hypothesis that EIT could guide PSV and PEEP settings aimed to increase homogeneity of distending and deflating regional airflows.
Periodontitis is a disease that leads to serious functional and esthetic dysfunctions. Periodontitis exists in different forms, and its etiology is related to multiple component causes. Two key ...processes involved in the evolution of this pathology are angiogenesis and inflammatory infiltrate. The aim of this study was to understand if important factors such as smoking, gender, age, plaque, pus, and probing pocket depth could influence the histomorphological pattern of generalized stage III-IV, grade C periodontitis (GPIII-IVC), which is a particular form of periodontitis.
Eighteen subjects with GPIII-IVC were enrolled in this study. The percentage of inflammatory cells and the vascular area were measured and evaluated in relation to each periodontal disease-associated factor.
Females showed a significant increase in the percentage of inflammatory cells compared to males (6.29% vs. 2.28%,
-value = 0.020) and it was higher in non-smokers than in smokers (4.56% vs. 3.14%,
-value = 0.048). Young patients showed a significant increase in vascular area percentage compared to older patients (0.60% vs. 0.46%,
-value = 0.0006) and this percentage was also higher in non-smokers compared to smokers (0.41% vs. 0.55%,
-value = 0.0008). The vascular area was also more than halved in subjects with residual plaque on tooth surfaces (0.74% vs. 0.36%,
-value = 0.0005).
These results suggested that even if these factors are commonly related to the worsening of periodontal status, some of them (pus and periodontal probing depth (PPD)) do not affect the inflammatory and vascular patterns.
OBJECTIVES:Severe cases of coronavirus disease 2019 develop the acute respiratory distress syndrome, requiring admission to the ICU. This study aimed to describe specific pathophysiological ...characteristics of acute respiratory distress syndrome from coronavirus disease 2019.
DESIGN:Prospective crossover physiologic study.
SETTING:ICU of a university-affiliated hospital from northern Italy dedicated to care of patients with confirmed diagnosis of coronavirus disease 2019.
PATIENTS:Ten intubated patients with acute respiratory distress syndrome and confirmed diagnosis of coronavirus disease 2019.
INTERVENTIONS:We performed a two-step positive end-expiratory pressure trial with change of 10 cm H2O in random order.
MEASUREMENTS AND MAIN RESULTS:At each positive end-expiratory pressure level, we assessed arterial blood gases, respiratory mechanics, ventilation inhomogeneity, and potential for lung recruitment by electrical impedance tomography. Potential for lung recruitment was assessed by the recently described recruitment to inflation ratio. In a subgroup of seven paralyzed patients, we also measured ventilation-perfusion mismatch at lower positive end-expiratory pressure by electrical impedance tomography. At higher positive end-expiratory pressure, respiratory mechanics did not change significantlycompliance remained relatively high with low driving pressure. Oxygenation and ventilation inhomogeneity improved but arterial CO2 increased despite unchanged respiratory rate and tidal volume. The recruitment to inflation ratio presented median value higher than previously reported in acute respiratory distress syndrome patients but with large variability (median, 0.79 0.53–1.08; range, 0.16–1.40). The FIO2 needed to obtain viable oxygenation at lower positive end-expiratory pressure was significantly correlated with the recruitment to inflation ratio (r = 0.603; p = 0.05). The ventilation-perfusion mismatch was elevated (median, 34% 32–45% of lung units) and, in six out of seven patients, ventilated nonperfused units represented a much larger proportion than perfused nonventilated ones.
CONCLUSIONS:In patients with acute respiratory distress syndrome from coronavirus disease 2019, potential for lung recruitment presents large variability, while elevated dead space fraction may be a specific pathophysiological trait. These findings may guide selection of personalized mechanical ventilation settings.
Severe cases of coronavirus disease 2019 develop the acute respiratory distress syndrome, requiring admission to the ICU. This study aimed to describe specific pathophysiological characteristics of ...acute respiratory distress syndrome from coronavirus disease 2019.
Prospective crossover physiologic study.
ICU of a university-affiliated hospital from northern Italy dedicated to care of patients with confirmed diagnosis of coronavirus disease 2019.
Ten intubated patients with acute respiratory distress syndrome and confirmed diagnosis of coronavirus disease 2019.
We performed a two-step positive end-expiratory pressure trial with change of 10 cm H2O in random order.
At each positive end-expiratory pressure level, we assessed arterial blood gases, respiratory mechanics, ventilation inhomogeneity, and potential for lung recruitment by electrical impedance tomography. Potential for lung recruitment was assessed by the recently described recruitment to inflation ratio. In a subgroup of seven paralyzed patients, we also measured ventilation-perfusion mismatch at lower positive end-expiratory pressure by electrical impedance tomography. At higher positive end-expiratory pressure, respiratory mechanics did not change significantly: compliance remained relatively high with low driving pressure. Oxygenation and ventilation inhomogeneity improved but arterial CO2 increased despite unchanged respiratory rate and tidal volume. The recruitment to inflation ratio presented median value higher than previously reported in acute respiratory distress syndrome patients but with large variability (median, 0.79 0.53-1.08; range, 0.16-1.40). The FIO2 needed to obtain viable oxygenation at lower positive end-expiratory pressure was significantly correlated with the recruitment to inflation ratio (r = 0.603; p = 0.05). The ventilation-perfusion mismatch was elevated (median, 34% 32-45% of lung units) and, in six out of seven patients, ventilated nonperfused units represented a much larger proportion than perfused nonventilated ones.
In patients with acute respiratory distress syndrome from coronavirus disease 2019, potential for lung recruitment presents large variability, while elevated dead space fraction may be a specific pathophysiological trait. These findings may guide selection of personalized mechanical ventilation settings.
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