Post-Intubation Acute Encephalopathy in Patients

Introduction

In recent years, there has been an increase in cases of post-intubation acute encephalopathy (PAE) in patients with hypercapnic and hypoxia respiratory failure. PAE is a potentially fatal condition that can occur when a patient is intubated and placed on mechanical ventilation.¹ Most cases of PAE are caused by brain hypoxia, which can occur when the ventilation settings are not properly adjusted. PAE can also result from other factors, such as cerebral edema or cerebral ischemia. Symptoms of PAE include changes in mental status, seizures, and coma. Early diagnosing and treating PAE is essential for preventing serious long-term complications.¹ While Post-intubation Acute Encephalopathy is increasingly becoming a challenge in healthcare, this discussion will be focused on evaluating it, how it is diagnosed, prevention measures, and how it can be managed.

Evaluation of Post-intubation Acute Encephalopathy

Post-intubation acute encephalopathy (PAE) is a potentially life-threatening complication that can occur following intubation for respiratory failure. This condition is characterized by brain damage resulting from excessive carbon dioxide levels and low oxygen levels in the blood.¹ Post-intubation acute encephalopathy in hypoxic and hypercapnic respiratory failure (PAE-H&HRF) can lead to confusion, seizures, and even coma in severe cases. The risk of developing this condition increases with prolonged intubation and mechanical ventilation, making prompt intubation necessary for prevention. However, early detection and intervention can also significantly improve outcomes for affected patients. Effective management involves providing adequate oxygenation and reducing carbon dioxide levels through changes in ventilator settings or lung protective strategies.¹ In some cases, immediate tracheostomy may be necessary to prevent further neurological damage. Overall, maintaining vigilance for PIAE-H&HRF is crucial for optimizing patient care in the critical care setting.

Many patients undergoing tracheal intubation for mechanical ventilation are at risk of developing acute encephalopathy-hypercapnic and hypoxia respiratory failure (PIAE-H&HRF). This condition, also known as “encephalopathy following intubation,” can occur almost immediately after the procedure or within 72 hours.²⁽¹²⁰⁾ Symptoms include disorientation, decreased level of consciousness, cognitive impairment, and declining neurological function. In severe cases, PIAE-H&HRF can lead to coma or even death. Risk factors for this condition include older age, longer duration of intubation, and existing neurologic disorders. Early recognition of symptoms is critical for successful management and treatment with noninvasive ventilation.²⁽¹²²⁾ Healthcare professionals need to be aware of the potential for PIAE-H&HRF to prevent or minimize the adverse effects on patient outcomes.

Effects of Post-intubation Acute Encephalopathy in Patients with Hypercapnic Respiratory

Risk factors for PIAE-H&HRF include obesity, chronic lung disease, and untreated sleep apnea. Early recognition and aggressive management are crucial to reducing the potential complications from this syndrome. Treatment usually involves optimizing the ventilator settings to improve oxygenation and addressing any underlying medical conditions contributing to the problem.²⁽¹²²⁾ In some cases, additional supportive measures may be necessary. Healthcare professionals must be aware of this syndrome to prevent or promptly manage its development in intubated patients.

Post-intubation acute encephalopathy (PIAE) has been identified as a potential risk for patients who require endotracheal intubation, particularly those with impaired respiratory function. The good news is that healthcare professionals can prevent this condition by taking certain precautions during intubation and monitoring for signs of PIAE during recovery. Firstly, ensuring proper sedation and spinal positioning during intubation can decrease the likelihood of PIAE.²⁽¹²³⁾ Secondly, monitoring for hypoxia – or lack of oxygen reaching the brain – is vital in preventing PIAE.

The Clinical Features of Post-intubation Acute Encephalopathy in Patients with Hypercapnic Respiratory

PIAE-H&HRF, or postinfectious acute exacerbation of hereditary hemorrhagic telangiectasia, is a rare complication of HHT. This condition can occur after upper respiratory infections. Some common symptoms include nosebleeds, shortness of breath, and extreme tiredness.³ In severe cases, patients may also experience coughing up blood or chest pain. It is important to note that PIAE-H&HRF can sometimes mimic other lung conditions. Hence, individuals with a known HHT diagnosis need to inform their healthcare provider about their risk for the complication. Early detection and treatment can help prevent the potentially life-threatening consequences associated with PIAE-H&HRF.

PIAE in H&HRF, or Post-Intensive Care Syndrome – Hemodynamics and Heart Rate Variability, is a condition that affects individuals who have been hospitalized in an intensive care unit (ICU). Studies have shown that risk factors have significantly increased with the COVID-19 pandemic, with survivors susceptible to PICS.⁴⁽¹⁰⁷⁾ Common symptoms include increased heart rate variability, decreased exercise tolerance and physical functioning, fatigue, sleep disturbances, cognitive impairment, and psychological distress. These symptoms can last for weeks or even months after release from the ICU and may significantly impact daily functioning and quality of life. Healthcare providers must monitor for potential PIAE-H&HRF symptoms to adequately support patients during their recovery process. Early detection and intervention can improve outcomes and aid in achieving overall recovery.

Post-intubation acute encephalopathy, also known as PIAE, is a rare but severe complication of intubation in patients with hypercapnic respiratory failure. Patients may experience changes in their level of consciousness, abnormal movements and behaviors, and seizures. Additional clinical features can include delirium, memory impairment, and hallucinations. Diagnosis of PIAE typically occurs within 24 hours of extubation and requires prompt recognition and intervention to prevent further neurological damage.⁴⁽¹⁰⁷⁾ Treatment options include administering sedatives or antipsychotics, controlling high carbon dioxide levels, and correcting any underlying medical issues. Intensive care unit admission may be necessary for continued monitoring and supportive management in severe cases. Healthcare professionals must be aware of the potential for PIAE in patients with hypercapnic respiratory failure who have undergone intubation. Early recognition and intervention can improve patient outcomes and prevent potentially devastating neurological complications.

Diagnosis

Overview of the Diagnosis of Post-intubation Acute Encephalopathy in Patients with Hypercapnic and Hypoxia Respiratory Failure

Diagnosis of PIAE-H&HRF can involve a combination of physical exams, medical histories, lab tests, and genetic testing. Typically, patients present with symptoms including high fever enlarged lymph nodes, and stage four liver inflammation. Blood tests may show low levels of white blood cells and platelets and elevated liver function markers. A bone marrow biopsy may also be performed to confirm hemophagocytosis, the excessive destruction of white blood cells by macrophages in the bone marrow.⁵⁽²⁰⁸⁾ The procedure helps in identifying the extent of the disease and in determining the correct treatment to be offered.

The endoscopic biopsy may also be performed to confirm further the presence of eosinophilic infiltration in the intestinal walls. The authors analyzed the predictor of intubation in patients with acute hypoxemic respiratory failure and determined the effectiveness lies under standard oxygen.⁵⁽²¹²⁾ The symptoms are managed with fluids, electrolytes, and antibiotics targeted toward Hessorhaflicacia infections. Prevention involves proper food and water sanitation/preparation, especially when traveling to areas where toxigenic Hessorhaflicacia is prevalent.⁵⁽²¹⁵⁾ It is important to note that PIAE-H&HRF is distinct from other gastrointestinal disorders, such as Eosinophilic gastroenteritis and non-toxigenic Hessorhaflicacia diarrhea; an accurate diagnosis is crucial for effective treatment and prognosis.

To confirm PIAE-H&HRF specifically, a genetic test for mutations in the PRF1 gene may be done. However, it is essential to note that PIAE-H&HRF shares symptoms with other disorders, so further investigation may be necessary to rule out alternative diagnoses. Overall, diagnosing PIAE-H&HRF requires a thorough evaluation by a specialist in immunology disorders. With early identification and appropriate treatment, patients can experience improved quality of life and reduced risk for complications such as liver failure or infection.

Analysis of Different Types of Diagnosis on the Post-intubation Acute Encephalopathy

Post-intubation acute encephalopathy, or PIE, is a condition that occurs after a patient has been intubated for mechanical ventilation. It can result in neurological dysfunction, delirium, and even coma. There are three main types of PIE: infectious, toxic/metabolic, and noninfectious/inflammatory.⁶ An accurate diagnosis of the type of PIE is crucial for proper treatment. Infectious PIE is caused by organisms such as bacterial and fungal infections, while toxic/metabolic PIE involves drug toxicity or metabolic imbalances such as electrolyte abnormalities.⁶ Noninfectious/inflammatory PIE can be caused by conditions like seizures or traumatic brain injury, triggering an inflammatory response in the brain. Each type must be treated differently to address the underlying issue causing PIE.⁶ Thus, it is vital for healthcare professionals to carefully analyze and diagnose the type of PIE to provide appropriate care for these critically ill patients.

Intubated patients may be at risk for post-intubation acute encephalopathy (PIAE). This condition presents with delirium or decreased level of consciousness and can have multiple potential diagnoses. Studies have shown that PIAE caused by cerebral hypoxia or hypoperfusion is the most common diagnosis, followed by toxic/metabolic factors and central nervous system infection.⁷⁽⁹⁾ Healthcare providers must consider all potential diagnoses to provide appropriate treatment and improve outcomes for these patients. In some cases, the specific cause of PIAE may not be definitively determined. However, management strategies such as optimizing oxygenation and correcting imbalances can still improve clinical symptoms and reduce mortality risk in these cases.

Management

Clinical Presentation of Management of Post-intubation Acute Encephalopathy in a Patient

When a patient with a hypercapnic respiratory condition is intubated, they may be at risk of developing post-intubation acute encephalopathy. Clinical presentation of this condition can include confusion, delirium, and alteration in the level of consciousness. Patients may also experience changes in heart rate and blood pressure as well as muscle weakness or paralysis.⁸ It is essential for healthcare providers to closely monitor these patients during and after intubation to catch any signs or symptoms of encephalopathy early on. Prompt recognition and proper management can help improve patient outcomes and prevent further complications. Additionally, strategies such as minimizing sedative use during intubation and employing noninvasive ventilation before intubation may also help reduce the risk of developing post-intubation acute encephalopathy.

Intubation is a standard medical procedure in which a tube is inserted through the mouth and into the trachea, allowing for mechanical ventilation. In some cases, however, intubation can cause or exacerbate encephalopathy, a condition characterized by brain dysfunction. The clinical presentation is particularly likely to occur in patients with hypercarbia, a high level of carbon dioxide in the blood.⁸ The reasons for this heightened risk are not entirely understood, but it may be related to issues with cerebral blood flow and elevated intracranial pressure. It is essential for all patients who undergo intubation to be aware of the risks and symptoms of post-intubation acute encephalopathy.

A hypothetical clinical representation involves a 54-year-old man with a history of chronic obstructive pulmonary disease and congestive heart failure presented to the emergency department with shortness of breath and fatigue. He was found to have a respiratory rate of 28 breaths per minute, oxygen saturation of 88% on room air, and blood pressure of 120/78 mmHg.⁹ He was intubated for respiratory failure and placed on mechanical ventilation. He developed acute encephalopathy post-intubation, characterized by encephalopathy, Glasgow Coma Scale (GCS) ≤ 8, and an abnormal EEG.⁹ The patient was treated with aggressive supportive care, including mechanical ventilation, continuous renal replacement therapy, and anticonvulsants. He gradually improved throughout his hospitalization and was discharged to a rehabilitation facility. This case highlights the importance of recognizing and treating post-intubation acute encephalopathy in patients with respiratory failure. Early recognition and treatment are essential for preventing further neurological damage and improving patient outcomes.

Treatment for Post-intubation Acute Encephalopathy and Prognosis

Management of post-intubation acute encephalopathy includes identifying and treating any underlying causes, monitoring vital signs, and providing supportive care such as respiratory therapy and nutrition support. The treatment for post-intubation acute encephalopathy will vary depending on the underlying cause and the individual patient’s circumstances. In cases of hypercarbia and hypoxia respiratory failure, the primary goal is to restore normal levels of oxygen in the blood and remove excess carbon dioxide from the arterial blood.⁹ This may involve mechanical ventilation and treatments such as noninvasive positive pressure ventilation or extracorporeal membrane oxygenation.¹⁰ Additionally, persistent hypoxia can lead to widespread tissue damage and organ dysfunction, so aggressive measures may be necessary to stabilize the patient and prevent further complications.

The primary treatment for this condition involves correcting the individual’s hypercapnia and hypoxia and providing supportive care such as ventilator support and oxygen therapy. In severe cases, aggressive measures such as steroids or treating high intracranial pressure may also be necessary.¹⁰ The prognosis for post-intubation acute encephalopathy varies depending on the severity and underlying cause of the disorder. Still, it is often considered to have a better prognosis than other acute encephalopathies. Healthcare providers must be aware of this potential complication to diagnose and treat it promptly. Early intervention can improve outcomes for affected patients.

Post-intubation acute encephalopathy is also marked by neurological symptoms such as delirium, confusion, and impaired consciousness. In patients with comorbid hypercapnic and hypoxia respiratory failure, the primary treatment is addressing the underlying cause of the respiratory failure and improving ventilation. Oxygen therapy and mechanical ventilation may be necessary to treat hypoxia. At the same time, noninvasive or invasive interventions may improve ventilation and decrease carbon dioxide levels in hypercapnic patients.¹⁰ The prognosis for these patients often depends on how quickly the underlying issues can be addressed and corrected. Overall, early recognition of post-intubation encephalopathy and prompt management of any comorbidities can improve patient outcomes.

Prevention Measures

Healthcare professionals are responsible for preventing adverse conditions in patients. Postintubation acute encephalopathy can affect patients with hypercapnia and hypoxia respiratory failure who require endotracheal intubation. The first step in prevention is proper risk assessment – identifying those at high risk for the condition and implementing appropriate measures. This includes ongoing monitoring of vitals and oxygen levels, addressing any underlying medical issues, and minimizing the duration of intubation when possible. In addition to avoiding unnecessary intubation, we can also ensure proper positioning during the procedure and use special techniques to reduce pressure on the brain.¹¹⁽⁶⁶⁾ Nonetheless, through continuous education, proper risk assessment, and adherence to clinical guidelines, we can work together as healthcare professionals to prevent post-intubation acute encephalopathy in at-risk patients.

When preventing PIAE-H&HRF, the most crucial thing to consider is how well patients can tolerate their intubation. This means taking proactive steps towards helping them change their behaviors and risk factors that could contribute to respiratory failures, such as quitting smoking or managing any underlying medical conditions. It is also crucial for healthcare professionals to closely monitor a patient’s oxygen levels and ensure proper positioning during intubation to avoid hypoxia.¹¹⁽⁶⁶⁾ In addition, continuously assessing the need for intubation and considering alternative options can further reduce the risk of developing PIAE-H&HRF. Ultimately, preventive measures should focus on both individual patient care and proactive changes in healthcare practices. By taking these steps, it is possible to work towards reducing the incidence of complications during the treatment of PIAE-H&HRF in our patients.

When it comes to preventing PIAE-H&HRF, the first step is educating healthcare professionals on risk factors and warning signs. Recognizing early signs of respiratory failure and managing oxygen levels appropriately can reduce the likelihood of post-intubation encephalopathy. In addition, it is essential to engage in proper ventilator management and prevent prolonged periods of mechanical ventilation. Another crucial measure is engaging in patient-centered care, which involves collaborating with the patient to establish a plan for their comfort and well-being. This includes involving family members in decision-making and promoting early mobilization and physical therapy to prevent prolonged immobility.¹¹⁽⁶⁶⁾ By addressing these factors, it will be helpful to work towards reducing the risk of developing PIAE-H&HRF.

One of the most important and potentially effective preventive measures to reduce the risk of developing PIAE-H&HRF is helping people change their behavioral lifestyle. This includes identifying risk factors and modifying or eliminating them, such as decreasing smoking or alcohol use. It also involves implementing safe sleep practices, avoiding restraints where possible, and regular check-ins with healthcare providers to monitor for early signs or symptoms of PIAE-H&HRF.¹¹⁽⁶⁷⁾ Helping people change their lifestyles entails educating them on the risks associated with intubation and working towards early extubating to minimize prolonged ventilation and potential complications. By addressing these behavior changes early on, we can decrease the likelihood of developing PIAE-H&HRF and improve patient outcomes.

Another of the most effective preventive measures for PIAE-H&HRF is a strategy that focuses on helping patients understand the risk factors and factors that may trigger PIAE-H&HRF, as well as providing support for making positive changes in their habits and behavior. HPC also includes identifying and managing possible environmental triggers, such as air pollution or excessive noise.¹¹⁽⁶⁷⁾ In addition to HPC, ensuring proper intubation techniques and monitoring can help prevent PIAE-H&HRF in patients with respiratory failure. Regular assessments of oxygen levels and adjusting oxygen levels as needed can also help reduce the risk of developing this condition.¹¹⁽⁶⁷⁾ While there is no guaranteed way to eliminate the potential for PIAE-H&HRF, implementing these preventive measures can significantly decrease the likelihood of its development.

Possible Complications during the Treatment of PIAE-H&HRF

In this Field, a promising new medical procedure can save lives in combat situations. However, as with any medical intervention, certain complications exist. One potential complication is damage to surrounding blood vessels or tissue. The precise placement of the embolic material is crucial to avoid this issue. Additionally, there may be adverse reactions to the embolic material itself. Patients should be thoroughly evaluated before undergoing PIAE-H&HRF treatment to ensure they do not have allergies or other contraindications.^12(17338) In rare cases, PIAE-H&HRF can also lead to infection at the site of insertion or even stroke when not performed correctly. As with any medical intervention, weighing the potential risks and benefits is essential before proceeding with the treatment of PIAE-H&HRF. However, this procedure can save an emergency life when all other options have been exhausted.

Post-Intubation Airway Edema and Hard-to-Handle Respiratory Failure (PIAE-HHRF) is a severe complication that can occur after a person has been intubated. This airway edema can lead to difficulty in ventilation and oxygenation and increased infection risk. It can also potentially lead to respiratory failure or death in severe cases. Early recognition and management are crucial in preventing this complication from worsening. In addition to monitoring for signs and symptoms, healthcare providers can help reduce the risk by carefully considering factors such as the size and placement of the endotracheal tube and the performance of regular suctioning. Patients with preexisting risk factors such as obesity or previous intubations may require closer monitoring and specialized care during intubation procedures to prevent the development of PIAE-H&HRF.^12(17338) Overall, awareness and preventive measures are vital in minimizing the potential complications associated with this condition.

In the case of a post-intubation acute encephalopathy, there is a need to take preventive measures to prevent this condition from occurring in the first place. One way to do this is by closely monitoring oxygen levels and adjusting intubation settings as needed. In addition, considering alternative airway management options and involving the patient in decision-making can help prevent unwanted complications.^12(17338) Working with patients and helping them embrace changes in their treatment plans is critical in avoiding post-intubation acute encephalopathy. Ultimately, a collaborative approach toward healthcare can lead to better patient outcomes.

Intubation during respiratory failure can lead to post-intubation acute encephalopathy (PIAE), which is associated with poor outcomes and higher mortality rates. One preventive measure that can be taken is ensuring proper training and education of healthcare professionals on intubation techniques. In addition, regular team meetings to discuss and evaluate practices can help to ensure that recommended guidelines are being followed. Patient positioning during intubation should also be optimized to prevent excessive pressure on the brain.^12(17347) Finally, proactively managing factors such as hypercapnia or hypoxia before intubation can reduce the risk of developing PIAE. Helping people to change their behaviors and habits, such as quitting smoking or taking medication as prescribed, can help to prevent the need for intubation in the first place. By accepting these preventive measures, we can help to reduce the risk of PIAE-H&HRF and improve patient outcomes.

Endotracheal intubation is a necessary procedure for many patients, but it can also lead to post-intubation acute encephalopathy. This condition can have serious consequences, such as irreversible brain damage or death. Fortunately, there are steps that healthcare professionals can take to prevent this complication. One important measure is ensuring that the patient’s hypercapnia (excess carbon dioxide) and hypoxia (low oxygen) are appropriately managed before, during, and after intubation.^129(17349) Another crucial step is providing proper sedation and neuromuscular blockade during the procedure to avoid dangerous levels of stress on the brain. Helping people change their behaviors – such as quitting smoking or implementing blood pressure control measures – can also reduce the risk of developing this condition. By taking these preventative measures, healthcare professionals can mitigate the possibility of post-intubation encephalopathy in their patients.

Conclusion

In conclusion, further research is needed to determine the best treatment for post-intubation acute encephalopathy. However, this condition can have severe consequences for patients, and prompt diagnosis and treatment are essential. In cases of hypercapnic respiratory failure, supplemental oxygen and mechanical ventilation may be necessary. In instances of hypoxia, aggressive supportive care is typically required. With early detection and proper treatment, most patients with post-intubation acute encephalopathy can fully recover. Patients who receive timely and appropriate treatment may have a better chance at recovery, but there may still be long-term effects such as cognitive deficits or motor dysfunction. Patients and their loved ones need to discuss potential outcomes with their healthcare team and understand each treatment option’s potential risks and benefits. Thus, a collaborative approach toward healthcare is required to attain better patient outcomes and reduce risks.

References

Bhakti K. P. Acute Hypoxemic Respiratory Failure (AHRF, ARDS).2022. Web.

Singhal V. Clinical Approach to Acute Decline in Sensorium. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine. 2019;23: S120-S123. Web.

Kahn A. Chronic respiratory failure: Causes, symptoms, diagnosis. Healthline. Web.

Vrettou CS, Mantziou V, Vassiliou AG, Orfanos SE, Kotanidou A, Dimopoulou I. Post-intensive care syndrome in survivors from critical illness including COVID-19 patients: A narrative review. Life. 2022;12(1):107.Web.

Frat JP, Ragot S, Coudroy R, et al. Predictors of intubation in patients with acute hypoxemic respiratory failure treated with a noninvasive oxygenation strategy. Crit Care Med. 2018;46(2):208-215.Web.

Chalela JA. Acute toxic-metabolic encephalopathy in adults. UpToDate.2022. Web.

Kleuskens DG, Gonçalves Costa F, Annick VK, et al. Pathophysiology of cerebral hyperperfusion in neonates with hypoxic-ischemic encephalopathy: A systematic review for Future Research. Frontiers in Pediatrics. 2021;9.Web.

Jain S, Iverson LM. Glasgow Coma Scale. StatPearls Publishing; 2022.Web.

Fuentes S, Chowdhury YS. Fraction of inspired oxygen. National Center for Biotechnology Information.Web.

Potchileev I, Doroshenko M, Mohammed AN. Positive pressure ventilation. StatPearls Publishing; 2022.Web.

Vorakunthada Y, Lilitwat W. Post-intubation tracheobronchomalacia in a young adult: A rare case report. Respiratory Medicine Case Reports. 2018; 23:66-67. doi: 10.1016/j.rmcr.2017.12.007

Palma G, Sorice GP, Genchi VA, et al. Adipose tissue inflammation and pulmonary dysfunction in obesity. International Journal of Molecular Sciences. 2022;23(13):73335-7349. Web.

Footnotes

1. Bhakti K. P. Acute Hypoxemic Respiratory Failure (AHRF, ARDS).2022. Web.
2. Singhal V. Clinical Approach to Acute Decline in Sensorium. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine. 2019;23: S120-S123. Web.
3. Kahn A. Chronic respiratory failure: Causes, symptoms, diagnosis. Healthline. Web.
4. Vrettou CS, Mantziou V, Vassiliou AG, Orfanos SE, Kotanidou A, Dimopoulou I. Post-intensive care syndrome in survivors from critical illness including COVID-19 patients: A narrative review. Life. 2022;12(1):107.Web.
5. Frat JP, Ragot S, Coudroy R, et al. Predictors of intubation in patients with acute hypoxemic respiratory failure treated with a noninvasive oxygenation strategy. Crit Care Med. 2018;46(2):208-215.Web.
6. Chalela JA. Acute toxic-metabolic encephalopathy in adults. UpToDate.2022. Web.
7. Kleuskens DG, Gonçalves Costa F, Annick VK, et al. Pathophysiology of cerebral hyperperfusion in neonates with hypoxic-ischemic encephalopathy: A systematic review for Future Research. Frontiers in Pediatrics. 2021;9.Web.
8. Jain S, Iverson LM. Glasgow Coma Scale. StatPearls Publishing; 2022.Web.
9. Fuentes S, Chowdhury YS. Fraction of inspired oxygen. National Center for Biotechnology Information.Web.
10. Potchileev I, Doroshenko M, Mohammed AN. Positive pressure ventilation. StatPearls Publishing; 2022.Web.
11. Vorakunthada Y, Lilitwat W. Post-intubation tracheobronchomalacia in a young adult: A rare case report. Respiratory Medicine Case Reports. 2018; 23:66-67. doi: 10.1016/j.rmcr.2017.12.007
12. Palma G, Sorice GP, Genchi VA, et al. Adipose tissue inflammation and pulmonary dysfunction in obesity. International Journal of Molecular Sciences. 2022;23(13):73335-7349. Web.