Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral Nutrition in ARDS Study Group.
OBJECTIVE
Recent studies in animal models of sepsis-induced acute respiratory distress syndrome (ARDS) have shown that a low-carbohydrate, high-fat diet combining the anti-inflammatory and vasodilatory properties of eicosapentaenoic acid (EPA; fish oil), gamma-linolenic acid (GLA; borage oil) (EPA+GLA), and antioxidants improves lung microvascular permeability, oxygenation, and cardiopulmonary function and reduces proinflammatory eicosanoid synthesis and lung inflammation. These findings suggest that enteral nutrition with EPA+GLA and antioxidants may reduce pulmonary inflammation and may improve oxygenation and clinical outcomes in patients with ARDS.


METHODS
Prospective, multicentered, double-blind, randomized controlled trial.


METHODS
Intensive care units of five academic and teaching hospitals in the United States.


METHODS
We enrolled 146 patients with ARDS (as defined by the American-European Consensus Conference) caused by sepsis/pneumonia, trauma, or aspiration injury in the study.


METHODS
Patients meeting entry criteria were randomized and continuously tube-fed either EPA+GLA or an isonitrogenous, isocaloric standard diet at a minimum caloric delivery of 75% of basal energy expenditure x 1.3 for at least 4-7 days.


RESULTS
Arterial blood gases were measured, and ventilator settings were recorded at baseline and study days 4 and 7 to enable calculation of PaO2/FIO2, a measure of gas exchange. Pulmonary neutrophil recruitment was assessed by measuring the number of neutrophils and the total cell count in bronchoalveolar lavage fluid at the same time points. Clinical outcomes were recorded. Baseline characteristics of 98 evaluable patients revealed that key demographic, physiologic, and ventilatory variables were similar at entry between both groups. Multiple bronchoalveolar lavages revealed significant decreases (approximately 2.5-fold) in the number of total cells and neutrophils per mL of recovered lavage fluid during the study with EPA+GLA compared with patients fed the control diet. Significant improvements in oxygenation (PaO2/FIO2) from baseline to study days 4 and 7 with lower ventilation variables (FIO2, positive end-expiratory pressure, and minute ventilation) occurred in patients fed EPA+GLA compared with controls. Patients fed EPA+GLA required significantly fewer days of ventilatory support (11 vs. 16.3 days; p = .011), and had a decreased length of stay in the intensive care unit (12.8 vs. 17.5 days; p = .016) compared with controls. Only four of 51 (8%) patients fed EPA+GLA vs. 13 of 47 (28%) control patients developed a new organ failure during the study (p = .015).


CONCLUSIONS
The beneficial effects of the EPA+GLA diet on pulmonary neutrophil recruitment, gas exchange, requirement for mechanical ventilation, length of intensive care unit stay, and the reduction of new organ failures suggest that this enteral nutrition formula would be a useful adjuvant therapy in the clinical management of patients with or at risk of developing ARDS.
Gadek
J E
JE
Pulmonary and Critical Care Division, Ohio State University Medical Center, Columbus 43210-1228, USA.
DeMichele
S J
SJ
Karlstad
M D
MD
Pacht
E R
ER
Donahoe
M
M
Albertson
T E
TE
Van Hoozen
C
C
Wennberg
A K
AK
Nelson
J L
JL
Noursalehi
M
M
D000975:Antioxidants / Q000627:therapeutic use*; D001784:Blood Gas Analysis; D001992:Bronchoalveolar Lavage Fluid / Q000166:cytology; D004311:Double-Blind Method; D015118:Eicosapentaenoic Acid / Q000627:therapeutic use*; D004750:Enteral Nutrition / Q000379:methods*; D005260:Female; D006801:Humans; D007249:Inflammation; D007902:Length of Stay / Q000706:statistics & numerical data; D007958:Leukocyte Count; D008297:Male; D008875:Middle Aged; D009504:Neutrophils / Q000276:immunology; D011446:Prospective Studies; D011659:Pulmonary Gas Exchange; D012123:Pulmonary Ventilation; D012121:Respiration, Artificial / Q000706:statistics & numerical data; D012128:Respiratory Distress Syndrome / Q000276:immunology / Q000378:metabolism / Q000628:therapy*; D017965:gamma-Linolenic Acid / Q000627:therapeutic use*
D000975:Antioxidants; D017965:gamma-Linolenic Acid; D015118:Eicosapentaenoic Acid