Teddy Hla Profile picture
Oct 24 10 tweets 6 min read
NEXT: Clinical question : ARDS and steroids-sensitive patterns by President-Elect @ElieAzoulay5
lots of questions: why? how ? phenotypes? timing? dose? are we missing "systemic vasculitis,etc" behind defn ARDS?
#LIVES2022
#ventilation
#steroids #ARDS @ESICM
@ElieAzoulay5 @ESICM Refreshing ARDS definition. Berlin definition needs further updates (more on this later). 🤓
Pathological : DAD : Diffuse Alveolar Damage" has many causes - most of them we wont discuss steroid use at all.
@ElieAzoulay5 @ESICM thus DAD pathological diagnosis is not helpful to ask clinical question of steroids.
Interesting finding in autopsy data in ARDS. #LIVES2022
1 year after ARDS - there are still changes in the lung but very few have "fibrosis" -- so fibrosis is EITHER completely reversible OR fibrosis patients dont survive to 1-year. We need to look at bio-markers in time-course of ARDS. #LIVES2022
#ventilation
#ards
#steroids @ESICM
in ARDS: want to reduce endothelial permeability, cytokine over-activation, neutrophil activity. Citing another classic DEXA-ARDS trial for established ARDS : 139 patients and DSMB stopped trial due to low recruitment. But data is interesting #LIVES2022
#ventilation
#steroids
in-depth on DEXA-ARDS. Open label with composite outcome (vent free day), 250 patients excluded because on steroids already. standard of care changed NMBA use 8.6% in dexa vs. 5.1% in control. 🧐🧐
summary, according to @ElieAzoulay5 not a routine use. Discussion regarding "phenotypes" & "endotypes". but Literature not conclusive. Limited data & low level of confidence. "enrichment" of trial recruitments m. #LIVES2022

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More from @teddyhla

Oct 25
Carolyn Calfee Clinical and Biological phenotypes of ARDS
- what do they have in common?

ARDS : subgrouping since the begining
- sepsis vs. non sepsis
- hyper vs. hypoinflamm
- reactive vs uninflamed
#ventilation #ards #phenotypes #LIVES2022
Are clinical phenotypes biologically distinct?
looking at Trauma vs. Non trauma

ICAM-1 , SP-D, vWF, sTNFr-1 are different.
What about in "Direct" vs. "indirect"
or "Diffuse" vs "focal" -- sRAGE comes up again.

pubmed.ncbi.nlm.nih.gov/17944012/
#ventilation #ARDS #LIVES2022
Image
Read 13 tweets
Oct 25
Mariangela PELLEGRINI
Uppsala- Sweden
"Do we Need a biological definition of ARDS"

- Berlin definition has NO Diffuse alveolar damage .
- the Berlin defn does not capture well
Frohlich - different definitions specificity of 0.63, 0.42, 0.31 even!
#ventilation #ards #LIVES2022
academic.oup.com/bja/article/11…
The BJA article by Frohlich.
Fibrosis only starts after 7 days
Thille article : atsjournals.org/doi/full/10.11…
In essence, different disease processes are happening to the lung at different times in the "ARDS"
pubmed.ncbi.nlm.nih.gov/24429204/
Read 14 tweets
Oct 25
ARDS - new definition or phenotypes by @GicoBellani refreshing with Kigali definition of ARDS - useful not just low resource but during pandemic in supposedly high income settings and only draw back is no PEEp requirement #ards #ventilation #LIVES2022 @ESICM
@GicoBellani @ESICM Resolved versus confirmed ARDS
- prospectively applying Berlin definition did work but if ya wait 24 hrs and re-measure P/F ratio, you end up stratifying much better.
- Better separation of groups

pubmed.ncbi.nlm.nih.gov/29632996/
#ventilation #LIVES2022
@GicoBellani @ESICM Whichever definition - american european consensus or Berlin or Kigali -- all goes back to Ashbaugh original paper in 1967

thelancet.com/journals/lance…

Why are we so confused when it comes to ARDS definition ?

#ards #ventilation #LIVES2022 @ESICM
Read 11 tweets
Oct 25
Next : Mypinder SEKHON on cardiac arrest in COVID-19 era.

Works in Vancouver
COVID 19 era cardiac arrest ARE a lot less sexy with all the PPE. #als #covid19 #resuscitation #LIVES2022
@ESICM
@ESICM Let's look at epidemiology. Northern Italy, Manhattan - COVID hit hard and has impact on other diseases.

e.g., OHCA in Italy during COVID 19 massive spike.
ImageImageImage
Read 9 tweets
Oct 25
NEXT Speaker : VA ecmo for which patients?
Alain COMBES

Severe cardiogenic shock has different phenotypes
1. medical cardiogenic shock(AMI, end stage dilated CM, myocarditis, septic shock)
2. Post cardiotomy refractory CS (post CABG)
#LIVES2022
@ESICM #ecmo #resuscitation #ALS
@ESICM 2022 what do the guidelines say
- ESC recommends short term MCS should be considred in cardiogenic shock.
IABP may be considered but not routinely recommended in post MI
#LIVES2022
Image
Read 18 tweets
Oct 25
what about in refractory cardiac arrest?
ERC - ESICM guidelines 2021
- timing of CAG if no evidence ofr ST segment evaluation.

which means we will end up treating a lot of patients with stent and anticoagulation
TOMAHAWK trial : delayed or early invasive angiography -- no effec.

#LIVES2022
- immediate catheterisation for non ST elevationrr
Read 4 tweets

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