Seminars in respiratory and critical care medicine
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Because acute lung injury (ALI) may arise from diverse and heterogeneous clinical insults, monitoring strategies for patients with ALI are heterogeneous as well. This review divides the monitoring strategies for ALI into three distinct phases. The "at-risk phase" is the period in which patients are at risk for ALI, and interventions may be applied to minimize or eliminate this risk. ⋯ The primary goals are to optimize fluid resuscitation to prevent organ dysfunction, including ALI, and if ALI occurs to additional optimize fluid balance vis-à-vis the lung. By judicious application of invasive hemodynamic monitoring, particularly in its more modern iterations, clinicians can optimize the ebb and flow phases common to critically ill patients. This is vitally important given our current and growing understanding of the relationship between fluid balance and important clinical outcomes, multiple organ dysfunction syndrome, and mortality.
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Semin Respir Crit Care Med · Aug 2013
ReviewEmerging pharmacological therapies for prevention and early treatment of acute lung injury.
Acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) are serious complications of acute illness and injury, associated with an inpatient mortality of up to 40%. Despite considerable basic science and clinical research, therapeutic options for established ALI are limited. Survivors of ARDS are often faced with poor health-related quality of life, depressive-anxiety disorders, cognitive deficits, and financial strain. ⋯ In addition to improving recognition of at-risk patients, it is necessary to identify novel treatments targeting the pathways that may prevent or ameliorate lung injury. The rationale and animal and clinical evidence for aspirin, systemic and inhaled steroids, β-agonists, renin-angiotensin axis blockers, statins, peroxisome proliferator agonist receptor ligands, curcumin, and inhaled heparin are included in this narrative review. Randomized, controlled trials are currently being designed and implemented to address their efficacy in populations at risk for ALI.
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Semin Respir Crit Care Med · Aug 2013
ReviewBiomarkers of ALI/ARDS: pathogenesis, discovery, and relevance to clinical trials.
Despite the high incidence and poor prognosis of acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS), it remains challenging to identify patients who are at highest risk of developing these syndromes, differentiate these syndromes from other causes of acute respiratory failure, and accurately prognosticate once the diagnosis is made. The identification and validation of biological markers of ALI has the potential to ameliorate these challenges by facilitating studies of therapies aimed at prevention, identifying patients more accurately that have ALI so they can benefit from evidence-based therapies and enrollment in clinical trials, and determining which patients are unlikely to have a positive outcome to guide therapeutic choices and trials of experimental rescue therapies. This article reviews the current state of biomarker research in ALI/ARDS. New methodologies for identification of novel biomarkers of ALI, including metabolomics, proteomics, gene expression, and genetic studies are also discussed.
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Semin Respir Crit Care Med · Aug 2013
ReviewTreatment of acute lung injury: current and emerging pharmacological therapies.
As a syndrome of injurious pulmonary inflammation resulting in deranged respiratory physiology, acute lung injury affords numerous potential therapeutic targets. Two main pharmacological treatment strategies have arisen-the attempted inhibition of excessive inflammation or the manipulation of the resulting physiological derangement causing respiratory failure. ⋯ An emerging approach is the use of cell-based therapy, which, rather than inhibiting the inflammatory process, seeks to convert it from an injurious process to a reparative one. This review outlines previous, current, and emerging pharmacological therapies for acute lung injury.
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Semin Respir Crit Care Med · Aug 2013
ReviewCost and health care utilization in ARDS--different from other critical illness?
Costs of care in the intensive care unit are a frequent target for concern in the current health care system. Utilization of critical care services in the United States is increasing and will continue to do so. Acute respiratory distress syndrome (ARDS) is a common and important complication of critical illness. ⋯ Limited reductions in ICU length of stay have benefits for the patient, but they do not lead to significant reductions in overall hospital costs. Early discharge to post-acute care facilities can reduce hospital costs but are unlikely to decrease costs for an entire episode of illness. Improved effectiveness of communication between clinicians and patients or their surrogates could help avoid costly interventions with poor expected outcomes.