Teddy Hla Profile picture
Oct 25 14 tweets 8 min read
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/
For example potential groups
Single Biomarkers
- Meduri looked at cytokines
- patients with higher TNF-a, IL1b,IL6,IL8 on day 1 of ARDS died more.
pubmed.ncbi.nlm.nih.gov/7587434/
#ventilation #biomarker #ards #LIVES2022
How about looking at Biomarkers for specific injury mechanisms ?
- RAGE :marker of alveolar type 1 injury
pubmed.ncbi.nlm.nih.gov/24156650/

Five best pefroming biomaekres
SP - D , RAGE (i missed the other 3)
#ventilation #ards #biomarker #LIVES2022
How about panel of biomarkers?
pubmed.ncbi.nlm.nih.gov/28450529/

good correlate with outcome
IL6
IFN gamma
Angiopoietin 2
plasminogen activator inibitor 1

better than APACHE , age , lactate, albumin, bicarb
Looking at single centre vs. multi centre

Epithelial injury including RAGE and vWF

pubmed.ncbi.nlm.nih.gov/26033126/
Now in COVID
angiopoietin
atsjournals.org/doi/10.1164/rc…
see image
So, Do we need a biological definition of ARDS?

Ans : NO
- true biological defn ARDS is out of reach
- limited mechanistic understanding of ARDS
- limited plasma biomarkers
- more markers may help
- not associated with Rx response.
- sampling huge variation.
So what can we do ?
BEST ANS : is to basically do stratification and sub-grouping for now.

Laurent Brochard : i dont think you can differentiate ARDS from Ventilator induced lung injury.

#ards #ventilation #biomarker #LIVES2022
panel john laffey : exhumed bodies in spanish flu has Diffuse alveolar damage in their lungs (this is before invention of ventilator!)

This is fascinating!!
i found this paper!
pnas.org/doi/10.1073/pn…

#ards before #ventilation @Jopo_dr thought ya might like this! :P

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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
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 12 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.
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
Oct 25
Updates on Advanced life supprot by Theresa OLASVEENGEN

Vasopressors and Drugs : recent trial outcomes.
#LIVES2022
@ESICM #als #resuscitation
@ESICM 2020 ILCOR consensus : strong recommendation to use "ADRENALINE" in cardiac arrest, if you dont have it "LIDOCAINE".

Adrenaline to placebo comparison is mainly 1 older trial with latest PARAMEDIC 2

pubmed.ncbi.nlm.nih.gov/30980877/
@ESICM PARAMEDIC 2 - big study
8007 pts, adrenaline 4000, placebo 3999
- a lot of discussion post trial
- need a nuanced interpretation.
- 19 "more good" survivors and 5 "more bad" survivors in adrenaline arm.

nejm.org/doi/full/10.10…
Read 19 tweets

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