Ming-Cheng Chan

Effects of Prone Position on Inflammatory Markers in Patients with ARDS Due to Community-acquired Pneumonia

BACKGROUND/PURPOSE Acute respiratory distress syndrome (ARDS) is a serious disorder of intensive care unit patients. We evaluated the safety of continuous prone position ventilation (PRONE) and its effects on oxygenation and plasma cytokine concentrations in patients with ARDS caused by severe community-acquired pneumonia (CAP). METHODS This was a prospective observational clinical study conducted in a respiratory intensive care unit of a 1200-bed medical center in central Taiwan. Twenty-two patients with severe CAP and ARDS were included. They were treated by traditional supine ventilation (SUPINE, n = 11) or PRONE (n = 11) if they met the criteria for ARDS. Patients in the PRONE group were ventilated in prone position continuously for at least 72 hours. Plasma cytokines were collected and analyzed at baseline, 24 hours and 72 hours after enrolment. Serial PaO2/FiO2 and complications were evaluated. RESULTS Complications associated with PRONE were minor and self-limited. PRONE had higher PaO2/FiO2 ratio than SUPINE did at 48 hours after enrolment. The levels of plasma IL-6 concentration declined significantly with time in the PRONE group (p = 0.011). The levels of plasma IL-6 concentration at enrolment, 24 hours and 72 hours after enrolment also predicted the 14th day mortality of all patients. CONCLUSION PRONE was a safe and effective maneuver for improving oxygenation in patients with severe CAP and ARDS. PRONE also influenced IL-6 expression in patients with severe CAP.

Circadian rhythms: From basic mechanisms to the intensive care unit

Objective:Circadian rhythms are intrinsic timekeeping mechanisms that allow for adaptation to cyclic environmental changes. Increasing evidence suggests that circadian rhythms may influence progression of a variety of diseases as well as effectiveness and toxicity of drugs commonly used in the intensive care unit. In this perspective, we provide a brief review of the molecular mechanisms of circadian rhythms and its relevance to critical care. Data Sources, Study Selection, Data Extraction, and Data Synthesis:Articles related to circadian rhythms and organ systems in normal and disease conditions were searched through the PubMed library with the goal of providing a concise review. Conclusions:Critically ill patients may be highly vulnerable to disruption of circadian rhythms as a result of the severity of their underlying diseases as well as the intensive care unit environment where noise and frequent therapeutic/diagnostic interventions take place. Further basic and clinical research addressing the importance of circadian rhythms in the context of critical care is warranted to develop a better understanding of the complex pathophysiology of critically ill patients as well as to identify novel therapeutic approaches for these patients.

Procalcitonin is a valuable prognostic marker in ARDS caused by community-acquired pneumonia

Background and objective:  ARDS is life‐threatening acute respiratory failure, and pneumonia is one of the most common causes of direct ARDS. Procalcitonin (PCT) has been evaluated for its utility in determining the aetiology of community‐acquired pneumonia (CAP), choice of antibiotics and prediction of outcome. This study evaluated the role of PCT in predicting the outcome of patients with ARDS caused by severe CAP.

Evaluation of a new inflammatory molecule (triggering receptor expressed on myeloid cells-1) in the diagnosis of pleural effusion

Background and objective:  The triggering receptor expressed on myeloid cell‐1 (TREM‐1) is a newly discovered molecule that is associated with the inflammatory response to microorganisms. We investigated the role of surface and soluble TREM‐1 in differentiating different disease entities in pleural effusion formation.

Etiology and cytokine expression in patients requiring mechanical ventilation due to severe community-acquired pneumonia.

BACKGROUND The relationship between bacterial etiology and serum cytokine levels in patients with severe community-acquired pneumonia (CAP) without response to initial empiric treatment remains unclear. This study investigated the bacterial etiology, outcomes, and bronchoalveolar and systemic cytokines (interleukin [IL]-1beta, IL-8, IL-10) in these patients. METHODS This hospital-based study enrolled 47 consecutive patients without response to initial empiric treatment and requiring mechanical ventilation due to severe CAP between July 1, 2000 and October 31, 2001, in a respiratory intensive care unit of a 1200-bed teaching hospital in central Taiwan. Bronchoalveolar lavage (BAL) was performed within 3 days after hospitalization. BAL fluid was processed for quantitative bacterial cultures. Blood samples were taken just before BAL, and the levels of both BAL and serum cytokines were measured. RESULTS The most common pathogens isolated were Pseudomonas aeruginosa (22.5%) and Klebsiella pneumoniae (25%). Patients with a K. pneumoniae isolate (n = 10) had significantly higher levels of IL-1beta in BAL fluid and significantly higher levels of IL-10 in serum and BAL fluid than patients with other etiologies. Non-survivors had higher levels of serum IL-8 (p = 0.001), serum IL-10 (p < 0.001) and BAL IL-10 (p = 0.039) than survivors. Marked increases in local and systemic cytokine expression (IL-8 and IL-10) were noted in rapidly fatal cases. CONCLUSION P. aeruginosa and K. pneumoniae are the most common causes of CAP requiring mechanical ventilation in Taiwan. Cytokine patterns in the BAL fluid and serum of patients with severe CAP due to K. pneumoniae showed significant elevations compared to other pathogens. Bronchoalveolar and systemic cytokine levels (especially IL-10) predicted mortality. These findings suggest the need for a clinical trial to determine how immunomodulating therapy might affect cytokine profiles and clinical outcome.

Predictive value of serial measurements of sTREM-1 in the treatment response of patients with community-acquired pneumonia.

BACKGROUND/PURPOSE To evaluate the roles of plasma sTREM-1 (soluble triggering receptor expressed on myeloid cells-1) and C-reactive protein (CRP) in predicting treatment response in patients with community-acquired pneumonia (CAP). METHODS Patients with CAP were enrolled prospectively at a medical center in central Taiwan from September 1, 2004 to July 31, 2005. They were treated according to the guidelines proposed by the American Thoracic Society. Patients were noted as nonresponsive to initial treatment if they had one of the following: persistent fever for more than 3 days, progression on chest radiograph, switching to other antibiotics, or need of mechanical ventilation and/or chest tube drainage. RESULTS Fifty-eight patients (43 males/15 females; mean age, 67 +/- 21 years) with CAP were enrolled. Twelve (12/58, 21%) were nonresponsive. In the response group, CRP was reduced up to 58% from day 1 to day 3 (from 18.8 to 7.8 mg/dL), whereas sTREM-1 was reduced by only 15% (from 32.8 to 28.1 pg/mL). In the nonresponse group, CRP still declined 20% (from 22.2 to 17.7 mg/dL), whereas sTREM-1 was persistently high (from 61.7 to 63.7 pg/mL). Using multivariate logistic regression analysis, both CRP (p = 0.006) and sTREM-1 (p = 0.046) on day 3 predicted treatment response significantly, but CRP on day 3 had stronger statistic power. CONCLUSION Both CRP and sTREM-1 on day 3 could be useful in predicting nonresponsive CAP patients. Differential trends between sTREM-1 and CRP in nonresponsive CAP suggest that sTREM-1 could be an adjuvant biomarker to CRP in predicting CAP patients without response to empiric treatment.

Reply to Friedrich et al

©2008 Elsevier & Formosan Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divisions of 1Chest Medicine and 6Critical Care and Respiratory Therapy, Department of Internal Medicine, and 3Department of Nursing, Taichung Veterans General Hospital, 2Central Taiwan University of Science and Technology, 4Department of Medical Technology, Chung Shan Medical University, Taichung, 5Laboratory of Epidemiology and Biostatistics, Taipei Veterans General Hospital, Taipei, and 7Department of Life Sciences, National Chung-Hsing University, Taichung, Taiwan.

Association of day 4 cumulative fluid balance with mortality in critically ill patients with influenza: A multicenter retrospective cohort study in Taiwan

Background Fluid balance is a fundamental management of patients with sepsis, and this study aimed to investigate the impact of cumulative fluid balance on critically ill patients with influenza admitted to an intensive care unit (ICU). Methods This multicenter retrospective cohort study was conducted by the Taiwan Severe Influenza Research Consortium (TSIRC) which includes eight medical centers. Patients with virology-proven influenza infection admitted to ICUs between October 2015 and March 2016 were included for analysis. Results A total of 296 patients were enrolled (mean age: 61.4±15.6 years; 62.8% men), and 92.2% (273/296) of them required mechanical ventilation. In the survivors, the daily fluid balance was positive from day 1 to day 3, and then gradually became negative from day 4 to day 7, whereas daily fluid balance was continuously positive in the non-survivors. Using the cumulative fluid balance from day 1–4 as a cut-off point, we found that a negative cumulative day 1–4 fluid balance was associated with a lower 30-day mortality rate (log-rank test, P = 0.003). To evaluate the impact of shock on this association, we divided the patients into shock and non-shock groups. The positive correlation between negative day 1–4 fluid balance and mortality was significant in the non-shock group (log-rank test, P = 0.008), but not in the shock group (log-rank test, P = 0.396). In a multivariate Cox proportional hazard regression model adjusted for age, sex, cerebrovascular disease, and PaO2/FiO2, day 1–4 fluid balance was independently associated with a higher 30-day mortality rate (aHR 1.088, 95% CI: 1.007–1.174). Conclusions A negative day 1–4 cumulative fluid balance was associated with a lower mortality rate in critically ill patients with influenza. Our findings indicate the critical role of conservative fluid strategy in the management of patients with complicated influenza.

Using Objective Fluid Balance Data to Identify Pulmonary Edema in Subjects With Ventilator-Associated Events

BACKGROUND: A ventilator-associated events (VAEs) algorithm was developed to detect events in mechanically ventilated subjects using objective parameters, and we aimed to use objective data of fluid balance to identify pulmonary edema-associated VAEs. METHODS: This single-center retrospective cohort study was conducted in a medical ICU and enrolled all mechanically ventilated patients between July 2016 and June 2017. Electronic medical records were reviewed to obtain data regarding ventilator-associated conditions (VACs), infection-related ventilator-associated complications (IVACs), possible ventilator-associated pneumonia (VAP), and traditionally defined VAP. RESULTS: Of the 1,158 mechanically ventilated subjects, 85 (7.3%) subjects developed VAEs with a corresponding incidence rate of 7.7 events per 1,000 ventilator days. Among the 85 subjects with VAEs, 52 (61.2%) were classified as IVACs, while 23 (27.1%) had possible VAP. Notably, pulmonary edema was the main etiology (29.0%) for VAEs in the 62 subjects with non-possible VAP VAEs. Compared with those without pulmonary edema, subjects with pulmonary edema had a higher positive fluid balance 2 d before (+1,228 vs +173.5 mL, P = .005) and 1 d before (+1,622 vs +313 mL, P = .002) the diagnosis of VAE. In the multivariate logistic regression analysis (adjusted odds ratio [OR]) adjusted for potential confounders, an older age (adjusted OR 1.072, 95% CI 1.001–1.147), receiving renal replacement therapy (adjusted OR 8.906, 95% CI 1.454–54.558), and a positive cumulative difference between fluid balance 2 d and 1 d before VAE indexing (adjusted OR 1.527 per L positive, 95% CI 1.153–2.023) were independently associated with pulmonary edema in subjects with VAEs. CONCLUSION: These findings provide epidemiological evidence of VAEs in a medical ICU and showed that fluid balance may be used to identify pulmonary edema-associated VAEs. Further studies are warranted to validate and translate these findings into an automated surveillance system for VAEs.

Assessment of Asthma Control by Correlation of Asthma Control Test and GINA Criteria

Background and objective: The GINA asthma guidelines indicate that the rating of asthma control should include the daytime and nocturnal symptoms, limitations of activities, need for rescue treatment, frequency of exacerbations, and measurement of spirometry or peak flow rates. The Asthma Control Test (ACT(superscript TM)), a recently devised tool, evaluates asthma control simply, using a 5-item, self-administered questionnaire. To ensure the clinical applicability of the ACT, we evaluated the correlation of the ACT and the GINA rating criteria in assessing asthma control in our asthmatic patients. Methods: Asthmatic patients with regular outpatient follow-up at our clinic who completed the ACT were enrolled into this study. The patients were classified according to their ACT questionnaire score: 25 as total control, 20 to 24 as well controlled, and less than 20 as not well controlled. Results: Among the 116 patients, who accounted for a total of 233 visits, there was a significant correlation between the ACT control level and the GINA rating criteria in assessing asthma control. Complete agreement was observed in 71.7% (kappa agreement=.524). There was a 15.5% and 12.9% over- and underestimation, respectively, of asthma control status by the patients themselves. Sub-group analysis showed a better kappa agreement value in the non-smoking patients. Conclusions: The ACT correlates well with the GINA rating criteria in assessing asthma control, although some disagreements may still persist. The results of this study confirm that the ACT is a convenient alternative screening tool for use in outpatient follow-up.