Acute lung injury (ALI) is a critical condition marked by rapid-onset respiratory failure due to extensive inflammation and increased pulmonary vascular permeability, often progressing to acute respiratory distress syndrome (ARDS) with high mortality. Autophagy, a cellular degradation process essential for removing damaged organelles and proteins, plays a crucial role in regulating lung injury and repair. This review examines the protective role of autophagy in maintaining cellular function and reducing inflammation and oxidative stress in ALI. It underscores the necessity of precise regulation to fully harness the therapeutic potential of autophagy in this context. We summarize the mechanisms by which autophagy influences lung injury and repair, discuss the interplay between autophagy and apoptosis, and examine potential therapeutic strategies, including autophagy inducers, targeted autophagy signaling pathways, antioxidants, anti-inflammatory drugs, gene editing, and stem cell therapy. Understanding the role of autophagy in ALI could lead to novel interventions for improving patient outcomes and reducing mortality rates associated with this severe condition.

Pulmonary fibrosis is a major complication of the Acute Respiratory Distress Syndrome (ARDS). Pirfenidone is an approved treatment for idiopathic pulmonary fibrosis. It may attenuate ARDS-related fibrosis and decrease the need for prolonged ventilation. Accordingly, we aimed to evaluate the effect of pirfenidone on ventilator-free days in patients with ARDS.

In a multi-center, randomized, double-blind, placebo-controlled trial, we plan to randomly assign 130 adults invasively ventilated for ARDS to receive pirfenidone or placebo for up to 28 days. The primary outcome is days alive and ventilator free at 28 days. Secondary outcomes include ICU-free days, hospital free days all at 28 day, ICU mortality and hospital mortality. We will also assess fibroproliferative changes on high-resolution CT scans at ICU discharge and quality of life. Data analysis will be on an intention-to-treat basis.

The trial is ongoing and currently recruiting. It will be the first randomized controlled study to investigate whether, compared to placebo, pirfenidone increases the number of days alive and ventilator-free in patients with ARDS. Its double-blind multicenter design will provide internal validity, minimal bias, and a degree of external validity. If our hypothesis is confirmed, this treatment would justify larger trials of this intervention.

This trial was registered on ClinicalTrials.gov with the trial identification NCT05075161.

Prone positioning improves outcomes in patients with acute respiratory distress syndrome (ARDS), but the optimal duration in critical care settings remains uncertain. This study aims to evaluate the investigates the impact of prone ventilation duration on clinical outcomes.

This retrospective study was conducted on ARDS patients admitted to the intensive care unit (ICU), Nanfang hospital of Southern Medical University, who received prone positioning. Patients were categorized into two groups: the prolonged prone positioning (PPP) (≥ 16 h) group and the standard prone positioning (SPP) (< 16 h) group. Propensity score matching (PSM) was employed to balance baseline characteristics. Cox proportional hazards, regression models were utilized to evaluate the association between the prone duration and clinical outcomes. Kaplan-Meier survival curves were generated to compare 28-day mortality, with log-rank tests analyzing differences. Restricted cubic spline (RCS) were applied to investigate the time-response between prone duration, PaCO₂, PaO₂, positive end-expiratory pressure, response rate, and 28-day mortality. In addition, the incidence of prone position-related complications was assessed in both groups.

A total of 234 patients with ARDS were included, with an overall 28-day mortality of 49.1% (115/234). After PSM, 81 matched pairs were compared. The PPP group had lower 28-day mortality (46.9% vs. 53.1%; hazard ratios (HR): 0.53; 95% CI 0.32-0.85; P = 0.033) and improved prone positioning response rate [70.5% vs. 60.5%; odds ratio (OR): 1.46; 95% CI 1.23-1.89; P = 0.025]. RCS analysis suggested a reduction in mortality with prone durations ≥ 16 h, and longer durations correlated with better prone response. However, no significant association was found between PPP and reduced ICU or hospital length of stay. RCS analysis indicated a gradual decrease in 28-day mortality with increasing duration of prone positioning, and longer duration were associated with a higher likelihood of a prone response. There were no significant differences in prone ventilation-related complications between the two groups.

PPP (≥ 16 h) is associated with reduced 28-day mortality and improved response rates in ICU patients with ARDS, without increasing complication risks. Prospective studies are needed to further validate these results.

Up to 20% of patients with traumatic brain injury (TBI) develop acute respiratory distress syndrome (ARDS), which is associated with increased odds of mortality. Guideline-based treatment for ARDS includes "lung protective" ventilation strategies, some of which are in opposition to "brain protective" strategies used for ventilation with patients with TBI. We conducted a scoping review of ventilation management strategies with clinical outcomes among patients with TBI and ARDS.

We searched three databases (MEDLINE, Embase, Web of Science) using a systematic search strategy. We included any studies of patients with TBI and ARDS with ventilation strategies including PEEP, oxygenation, prone positioning, recruitment maneuvers, pulmonary vasodilators (e.g., nitric oxide), high frequency oscillatory ventilation (HFOV), and extracorporeal membrane oxygenation (ECMO). All clinical outcomes were included. Extracted data included details about sample (age, gender), study design, inclusion/exclusion criteria, intervention details, and outcomes.

The search returned 10,514 articles, 35 of which met final inclusion criteria. Interventions studied included ECMO (n = 13 articles), HFOV (n = 4), PEEP interventions (n = 3), prone positioning (n = 3), vasodilators (n = 4), and other lung recruitment maneuvers (n = 9). No randomized controlled trials were identified; studies were mostly case reports (n = 18/35, 51%) and series (n = 7/35, 20%), with some cohort studies (n = 5/35, 14%) and non-randomized experimental trials (n = 5/35, 14%), all at single institutions. Outcomes included physiologic changes (e.g., change in cerebrodynamics or hemodynamics with intervention) and clinical outcomes such as mortality, complications, or neurologic recovery. Five studies (14%) included pediatric patients.

In this scoping review of ventilatory strategies for patients with concurrent TBI and ARDS, we found variation in heterogeneity of study design, interventions, and outcomes. Studies were mostly case report/series and observational studies, seriously limiting our ability to draw conclusions about effectiveness of interventions. Targeted areas of further research are discussed.

Severe pneumonia is a leading cause of mortality and morbidity worldwide. Being a complex condition caused by a variety of microorganisms including bacteria, viruses, and fungi, it requires intensive care. A combination of early initiation of antimicrobial therapy and adjunctive nonantimicrobial interventions improve patient outcomes. This article reviews the most recent data on the epidemiology, microbiology, diagnosis, and management of severe pneumonia.

The evidence supporting the benefit on clinical outcomes of prone positioning during veno-venous extracorporeal membrane oxygenation (V-V ECMO) for acute hypoxemic respiratory failure remains inconclusive. We aimed to assess the association of prone positioning, compared to no prone positioning, with 28-day mortality and other clinical outcomes in different patient subgroups.

A systematic review and meta-analysis of randomized and non-randomized controlled trials (RCTs) using a random-effects model was conducted. An electronic database search up to September 1st, 2024 was performed (PROSPERO CRD42024517602). The RoB 2 and ROBINS-I tools were used for risk of bias assessments.

We analyzed two RCTs and 20 non-RCTs (3,465 patients). Compared to no prone positioning, the use of prone positioning was associated with lower 28-day (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.42-0.98, p = 0.040, I2 = 66%, low certainty of evidence [CoE]) and hospital mortality (OR 0.67, 95% CI 0.54-0.83, p < 0.001, I2 = 39%, low CoE), despite fewer 28-day ventilator-free days and longer ECMO duration. Younger age (p = 0.005), a higher sequential organ failure assessment (SOFA) score (p = 0.022), non-Covid-19 etiology (p = 0.003), and lower rates of prone positioning before cannulation (p = 0.049) were associated with a greater benefit from prone positioning.

In this analysis, among patients supported with V-V ECMO for acute hypoxemic respiratory failure, we observed improved 28-day and hospital mortality in those who received prone positioning, compared to those who did not. However, these findings do not imply causation. Further research is needed to clarify the role of prone positioning in this population.

To describe the epidemiology and outcome of children with acute hypoxemic respiratory failure (AHRF) and/or pediatric acute respiratory distress syndrome (PARDS).

Prospective, observational study in six nonconsecutive 2-month blocks form October 2019 to September 2021.

A network of 22 PICUs in Spain.

Consecutive children (7 d to 15 yr old) with a diagnosis of AHRF, defined by Pao2/Fio2 ratio less than or equal to 300 mm Hg, who needed invasive mechanical ventilation (IMV) using positive end-expiratory pressure (PEEP) greater than or equal to 5 cm H2O and Fio2 greater than or equal to 0.3.

None.

The primary outcomes were AHRF prevalence and PICU mortality. The secondary outcomes were the prevalence of IMV with PARDS (IMV-PARDS) and the use of adjunctive therapies. There were 6545 PICU admissions: 1374 (21%) underwent IMV and 181 (2.8%) had AHRF. Ninety-one patients (1.4% of PICU admissions, 6.6% of IMV cases, and 50.3% of AHRF cases) met the Second Pediatric Acute Lung Injury Consensus Conference IMV-PARDS criteria. At baseline, mean (± sd) tidal volume was 7.4 ± 1.8 mL/kg ideal body weight, PEEP 8.4 ± 3.1 cm H2O, Fio2 0.68 ± 0.23, and plateau pressure 25.7 ± 6.3 cm H2O. Unlike patients with PARDS, adjunctive therapies were used infrequently in non-PARDS AHRF patients. AHRF patients without PARDS had more ventilator-free days than PARDS patients (16.4 ± 9.4 vs. 11.2 ± 10.5; p = 0.002). All-cause PICU mortality in AHRF cases was higher in PARDS vs. non-PARDS patients (30.8% [95% CI, 21.5-41.3] vs. (14.4% [95% CI, 7.9-23.4]; p = 0.01).

In our 2019-2021 PICU population, the prevalence of AHRF is 2.8% of IMV cases. Of such patients, the prevalence of PARDS was 50.3%, and there was a 30.8% mortality, which was higher than in cases of AHRF without PARDS.

Acute Respiratory Distress Syndrome (ARDS) is a known and severe complication of thoracic trauma. Many patients, despite appropriate ventilator and medical support, continue to worsen requiring additional cardiopulmonary support with extracorporeal membrane oxygenation (ECMO). Additionally, obesity adds a layer of complexity in the management of trauma ARDS on ECMO. We describe the first U.S. Military air transportation mission via Critical Care Air Transport (CCAT) involving the cannulation and transportation of 2 obese trauma patients requiring ECMO support. We reviewed a cohort of 2 obese patients with ARDS secondary to trauma cannulated for venovenous ECMO and simultaneously transferred via Critical Care Air Transport to a DoD ECMO Center. We describe the logistics involved in the transport and management of obese trauma patients on ECMO. Both patients were safely cannulated and transported without complications, and survived their ECMO run and hospital stay. This is the first air transport of 2 obese ECMO patients simultaneously in U.S. Military history. This transport highlights the safety of cannulation and transportation of obese trauma patients, in addition to the flexibility and logistics needed to successfully complete an ECMO military transport.

This simulation is designed for critical care transport providers but can be easily adapted for the inpatient setting. It is applicable to an interdisciplinary team including nurses, respiratory therapists, medical students, emergency medicine residents, and emergency medicine attendings.

Cardiogenic shock carries an incredibly high burden of morbidity and mortality. Acute myocardial infarction accounts for 81% of cardiogenic shock patients and is a common indication for transfer to a tertiary care facility.1 Hypotension due to cardiogenic shock is often refractory to volume resuscitation and often requires pharmacologic intervention. Additionally, the resultant end organ dysfunction frequently requires advanced ventilatory support.1-6 This simulation aims to educate critical care transport providers on the best practices for management of the cardiogenic shock patients requiring resuscitation and intubation prior to transport.

By the end of this simulation session, learners will be able to: 1) recognize the need for intubation in an unstable patient in cardiogenic shock who requires transport, 2) appropriately titrate bi-Level non-invasive ventilatory support (BiPAP) to optimize oxygenation and ventilation in preparation for intubation, 3) choose appropriate vasoactive medications to support the hemodynamics of a patient in cardiogenic shock, 4) perform rapid sequence intubation using appropriate induction and paralytic agents and dosing for a patient in cardiogenic shock, 5) choose appropriate initial lung-protective ventilator settings, and 6) implement an adequate analgesia and sedation plan for transport of an intubated patient in cardiogenic shock.

This session was conducted using high-fidelity simulation, allowing learners to manage a patient in cardiogenic shock and respiratory distress requiring intubation. Each session was followed by a debriefing and discussion.

Qualitative feedback provided by participants during the discussion session was utilized to adjust the simulation between each session. In addition, participants were surveyed using a five-point Likert scale (strongly disagree to strongly agree) on if the simulation met their professional and educational needs, its efficacy and appropriateness for Level, and whether it would change future practice.

A total of 36 learners, including 20 physicians and 16 nurses, participated in the simulation over a total of nine sessions. Twenty out of the thirty-six participants completed the survey (both RNs and MDs) and 100% responded "strongly agree" to all four prompts (top response out of a five Likert scale). Feedback provided by participants was used after each session to adjust the simulation. Changes implemented included the addition of a nurse confederate, greater emphasis on management and titration of non-invasive ventilation for optimal preoxygenation, and initiation of post intubation sedation and analgesia.

Cardiogenic shock is a common cause of mortality, often requires transport, and is particularly challenging to manage. This simulation was overall effective at educating learners on the resuscitation of cardiogenic shock, including appropriate use of vasopressors and ventilatory support.

Cardiogenic shock, hypoxic respiratory failure, vasopressor management, airway management, intubation, non-invasive positive pressure ventilation management, ventilatory management, emergency medicine, critical care transport medicine.

Randomised controlled trials (RCTs) conducted early during the pandemic showed that awake prone positioning (APP) significantly reduced the risk of intubation among adults with COVID-19 acute respiratory distress syndrome (ARDS), but more recent studies have questioned this benefit. We hypothesise that the effects of APP may vary with the national Power Distance Index (PDI), a measure of hierarchy in local culture.

To conduct a meta-analysis examining the effects of APP in adults with COVID-19 ARDS and examine whether effects differ between nations with a PDI less than 80 versus at least 80 (low versus high deference to authority).

Systematic review and meta-analysis of RCTs.

Cumulated Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, Embase, Medline and Scopus were searched to November 2024.

All RCTs that compared APP with standard care in adults with COVID-19-related ARDS or Acute Hypoxaemic Respiratory Failure (AHRF) were included.

Twenty-two RCTs were identified with 3615 patients having valid data. APP reduced the risk of intubation [relative risk (RR) 0.80, 95% confidence interval (CI), 0.72 to 0.90]. Effects were greater in nations with a PDI at least 80 (RR 0.67, 95% CI, 0.54 to 0.82), and there was equipoise in nations with a PDI less than 80 (RR 0.89, 95% CI, 0.75 to 1.05). Intubation rates in the high PDI nations decreased from 32.3% (n = 512) with standard care to 21.2% (n = 508) with APP. The reduction in intubations with APP was less pronounced in nations with low PDI, from 20.1% (n = 1012) with standard care to 17.1% (n = 1084). The risk of mortality reduced with APP (RR 0.86, 95% CI, 0.74 to 0.99). Fidelity of APP, specifically, adherence to the recommended duration, was higher in nations with PDI at least 80 (P = 0.04).

APP reduces the risk of intubation and mortality, but the significance of this benefit varies with the cultural context. Effects are strong in nations with a higher PDI, where intubation rates are lower and adherence to APP higher.

The present protocol provides general recommendations based on the best evidence currently available for physiotherapists to use as a guide for the care of stroke patients during hospitalization. The Brazilian Early Stroke Rehabilitation Task Force, comprising physical therapy experts and researchers from different Brazilian states, was organized to develop this care protocol based on a bibliographical survey, including meta-analyses, systematic reviews, clinical trials, and other more recent and relevant scientific publications. Professionals working in stroke units were also included in the task force to ensure the practicality of the protocol in different contexts. This protocol provides guidance on assessment strategies, safety criteria for the mobilization of patients with stroke, recommendations for mobilization and proper positioning, as well as evidence-based practices for treatment during hospitalization, including preventive measures for shoulder pain and shoulder-hand syndrome. The protocol also provides information on the organization of the physiotherapy service at stroke units, guidelines for hospital discharge, and quality indicators for physiotherapy services. We have included detailed activities that can be performed during mobilization in the supplementary material, such as postural control training, sensory and perceptual stimulation, task-oriented training, and activities involving an enriched environment. The protocol was written in a user-friendly format to facilitate its application in different social and cultural contexts, utilizing resources readily available in most clinical settings.

N-acetylcysteine (NAC) can take part in the treatment of chronic respiratory diseases because of the potent mucolytic, antioxidant, and anti-inflammatory effects of NAC. However, less is known about its use in the treatment of acute lung injury. Nowadays, an increasing number of studies indicates that early administration of NAC may reduce markers of oxidative stress and alleviate inflammation in animal models of acute lung injury (ALI) and in patients suffering from distinct forms of acute respiratory distress syndrome (ARDS) or pulmonary infections including community-acquired pneumonia or Coronavirus Disease (COVID)-19. Besides low costs, easy accessibility, low toxicity, and rare side effects, NAC can also be combined with other drugs. This article provides a review of knowledge on the mechanisms of inflammation and oxidative stress in various forms of ALI/ARDS and critically discusses experience with the use of NAC in these disorders. For preparing the review, articles published in the English language from the PubMed database were used.

Background: Early prediction of ICU death in acute hypoxemic respiratory failure (AHRF) could inform clinicians for targeting therapies to reduce harm and increase survival. We sought to determine clinical modifiable and non-modifiable features during the first 24 h of AHRF associated with ICU death. Methods: This is a development, testing, and validation study using data from a prospective, multicenter, nation-based, observational cohort of 1241 patients with AHRF (defined as PaO2/FiO2 ≤ 300 mmHg on mechanical ventilation [MV] with positive end-expiratory pressure [PEEP] ≥ 5 cmH2O and FiO2 ≥ 0.3) from any etiology. Using relevant features captured at AHRF diagnosis and within 24 h, we developed a logistic regression model following variable selection by genetic algorithm and machine learning (ML) approaches. Results: We analyzed 1193 patients, after excluding 48 patients with no data at 24 h after AHRF diagnosis. Using repeated random sampling, we selected 75% (n = 900) for model development and testing, and 25% (n = 293) for final validation. Risk modeling identified six major predictors of ICU death, including patient's age, and values at 24 h of PEEP, FiO2, plateau pressure, tidal volume, and number of extrapulmonary organ failures. Performance with ML methods was similar to logistic regression and achieved a high area under the receiver operating characteristic curve (AUROC) of 0.88, 95%CI 0.86-0.90. Validation confirmed adequate model performance (AUROC 0.83, 95%CI 0.78-0.88). Conclusions: ML and traditional methods led to an encouraging model to predict ICU death in ventilated AHRF as early as 24 h after diagnosis. More research is needed to identify modifiable factors to prevent ICU deaths.

Evaluating the prognosis of ARDS patients using grading systems can enhance treatment decisions. This retrospective observational study evaluated the predictive accuracy of the SOFA score, APACHE II score, SpO2/FiO2 ratio, and PaO2/FiO2 ratio for mortality in ARDS patients in Vietnam. The study included 335 adult ARDS patients admitted to a central hospital from August 2015 to August 2023. Among them, 66.9% were male, the median age was 55 years, and 61.5% died in the hospital. The SOFA (AUROC: 0.651) and APACHE II scores (AUROC: 0.693) showed poor discriminatory ability for hospital mortality. The SpO2/FiO2 (AUROC: 0.595) and PaO2/FiO2 ratios (AUROC: 0.595) also displayed poor discriminatory ability. In multivariable analyses, after adjusting for the same set of confounding variables, the APACHE II score (adjusted OR: 1.152), SpO2/FiO2 ratio (adjusted OR: 0.985), and PaO2/FiO2 ratio (adjusted OR: 0.989) were independently associated with hospital mortality. Although the SOFA score (adjusted OR: 1.132) indicated a potential association with hospital mortality, it did not reach statistical significance (p = 0.081). However, a SOFA score of ≥ 10 emerged as an independent predictor (adjusted OR: 3.398) of hospital mortality. These findings emphasize the need for further studies to develop more accurate scoring systems for predicting outcomes in ARDS patients.

Background Acute respiratory distress syndrome (ARDS) affects a significant proportion of ICU patients and has a high mortality rate. The inflammation of the alveolar-capillary membrane is pathognomonic and characterized by increased capillary permeability and pulmonary edema. A safe, readily available anti-inflammatory agent delivered directly to the lungs could be a promising therapeutic approach. All these properties apply to nebulized furosemide. Objectives The primary objective of this study is to analyze 28-day all-cause ICU mortality while the secondary objectives include assessing hospital mortality, ICU and hospital length of stay (LOS), ventilator-free days at 28 days, successful extubation rate, and adverse events. Methods A double-blind, placebo-controlled, parallel-arm superiority RCT using an intention-to-treat (ITT) analysis to assess whether nebulized furosemide reduces mortality in adult mechanically ventilated ARDS patients will be employed. Results The results of descriptive and inferential analyses will be tabulated, and the significant results will be presented.

Acute-on-chronic liver failure (ACLF) is a complex syndrome defined by the existence of different organ failures (OFs) in patients with chronic liver disease, mainly cirrhosis. Several definitions have been proposed to define the syndrome, varying in the grade of the subjacent liver disease, the type of precipitants and the organs considered in the definition. Liver, coagulation, brain, kidney, circulatory and pulmonary are the six types of OFs proposed in the different classifications, with different prevalence worldwide. Irrespective of the definition used, patients who develop ACLF present a hyperactive immune system, profound haemodynamic disturbances and several metabolic alterations that finally lead to organ dysfunction. These disturbances are triggered by different factors such as bacterial infections, alcoholic hepatitis, gastrointestinal bleeding or hepatitis B virus flare, among others. Because patients with ACLF present high short-term mortality, a prompt recognition is needed to start treatment of the trigger event and specific organ support. Liver transplantation is also feasible in carefully selected patients and should be evaluated.

Intensive care unit (ICU) admissions can be traumatic for critically ill, ventilated acute respiratory distress syndrome (ARDS) patients due to fear of death, an inability to verbally communicate, reliance on health care professionals, and invasive medical interventions. Adult ARDS patients hospitalized during the COVID-19 pandemic were strictly isolated and had limited to no visitation from loved ones, impacting their access to support systems.

To explore the memories and sensory triggers for them (if applicable) of adult ARDS survivors hospitalized during the COVID-19 pandemic.

This study used a phenomenological design with an interpretative descriptive approach. Semistructured interviews with open-ended questions were conducted with survivors. Thematic analysis of 16 ARDS survivors' responses to ICU memories and sensory triggers questions was completed to identify the most prevalent themes.

Major themes for vivid memories included (1) altered reality, (2) vivid nonsense dreams, (3) medical treatment/procedures, and (4) feeling lonely/isolated. Themes for triggers included (1) seeing doctors/nurses/hospitals and medical equipment or seeing/hearing media depictions of them, (2) hearing ringtones and beeping/alarms, (3) seeing/hearing helicopters, (4) smelling cleaning products, and (5) seeing/touching scars.

Fifteen of the 16 ARDS survivors reported traumatic vivid memories, often triggered by sensory stimuli they encountered in their everyday lives. It is important for acute care and outpatient nurses to understand the impact of an ICU admission on ARDS survivors' mental health, so they can adopt evidence-based interventions to prevent or limit these effects.

Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.

Background: Prone positioning in mechanically ventilated patients with severe ARDS is associated with reduced mortality. COVID-19 causes variable pulmonary involvement in some patients suffering from severe respiratory failure and ARDS. Although proning in the COVID-19 patient population is increasingly common, more data are needed to fully understand its utility in those with ARDS due to COVID-19. Methods: We conducted a single-center retrospective study, inclusive of 100 consecutive subjects intubated for ARDS from COVID-19, admitted to the ICU from September 2020 to December 2020. Data were collected daily from time of intubation for 7 d along with 30-d outcomes. Results: The study included a total of 53 subjects proned and 47 nonproned during their hospitalization. Proned subjects had a mean age of 61.8 years and 56.6% were male, compared with a mean age of 66.3 years and 57.4% male in the nonproned group. Age, sex, other baseline characteristics, and treatments were similar between groups, except that proned subjects had a higher body mass index than nonproned subjects (34.1 ± 7.5 vs 30.5 ± 7.4, kg/m2 P = .02) and lower initial P/F ratios (119.1 ± 54.5 vs 154.0 ± 92.7 mm Hg, P = .047). Proned subjects received more neuromuscular blockade (OR 6.63, 95% CI 3.25-13.12, P < .001) and higher sedation levels (two sedatives: OR = 3.00, 95% CI 1.77-5.08; ≥3 sedatives: OR = 7.13, 95% CI 3.96-12.81) with similar ICU stays, ventilator days, newly initiated renal replacement therapy, and 30-d outcomes including being alive, out of the ICU, or discharged from the hospital when compared with nonproned subjects. There were a total of 15 (28.3%) complications related to proning. Proned subjects were reintubated significantly less than the nonproned group (1.9% vs 19.1%, P = .006). Conclusions: Proning mechanically ventilated COVID-19 subjects was associated with more frequent use of neuromuscular blockade and sedation, and lower rates of re-intubation, for respiratory failure when compared with nonproned subjects.

Mechanical ventilation can be a life-saving intervention, but its implementation requires a multidisciplinary approach, with an understanding of its indications and contraindications due to the potential for complications. The management of mechanical ventilation should be part of the curricula during clinical training; however, trainees and practicing professionals frequently report low confidence in managing mechanical ventilation, often seeking additional sources of knowledge. Review articles, consensus statements and clinical practice guidelines have become important sources of guidance in mechanical ventilation, and although clinical practice guidelines offer rigorously developed recommendations, they take a long time to develop and can address only a limited number of clinical questions. The Associação de Medicina Intensiva Brasileira and the Sociedade Brasileira de Pneumologia e Tisiologia sponsored the development of a joint statement addressing all aspects of mechanical ventilation, which was divided into 38 topics. Seventy-five experts from all regions of Brazil worked in pairs to perform scoping reviews, searching for publications on their specific topic of mechanical ventilation in the last 20 years in the highest impact factor journals in the areas of intensive care, pulmonology, and anesthesiology. Each pair produced suggestions and considerations on their topics, which were presented to the entire group in a plenary session for modification when necessary and approval. The result was a comprehensive document encompassing all aspects of mechanical ventilation to provide guidance at the bedside. In this article, we report the methodology used to produce the document and highlight the most important suggestions and considerations of the document, which has been made available to the public in Portuguese.

We investigated the occurrence and outcome of respiratory failure and ARDS in critically ill patients with liver cirrhosis. This is a retrospective analysis of patients with liver cirrhosis at an ICU during an 8-Year period. An assessment of acute on chronic liver failure as well as the presence and grade of ARDS within the first 72 h of admission to the ICU was performed. A total of 735 patients during the study period. Median age was 58 (50-69) years and 61% (n = 447) were male. 57% (n = 421) of the patients received mechanical ventilation (MV). Liver specific as well as ICU scores on admission were significantly higher in patients with MV. Necessity of vasopressor support (86%vs.25%, p < 0.001) and RRT (50%vs.11%, p < 0.001) was more frequent in patients with MV. The incidence of ARDS within the first 72 h of admission was 8% (n = 61). We observed a 28-day mortality or liver transplantation rate of 54% (n = 196) and 66% (n = 66%) in patients with MV and ARDS, respectively. After 90-days 63% (n = 226) with MV and 70% (n = 43) with ARDS were dead or received liver transplantation. ARDS is a prognostic factor for mortality in patients with liver cirrhosis admitted to the ICU. One out of ten critically ill cirrhotic patients develop ARDS within 72 h after admission. Although mortality rates are high initially critical care therapy should not be withheld and must be reevaluated regularly.

Mechanical ventilation can be a life-saving intervention, but its implementation requires a multidisciplinary approach, with an understanding of its indications and contraindications due to the potential for complications. The management of mechanical ventilation should be part of the curricula during clinical training; however, trainees and practicing professionals frequently report low confidence in managing mechanical ventilation, often seeking additional sources of knowledge. Review articles, consensus statements and clinical practice guidelines have become important sources of guidance in mechanical ventilation, and although clinical practice guidelines offer rigorously developed recommendations, they take a long time to develop and can address only a limited number of clinical questions. The Associação de Medicina Intensiva Brasileira and the Sociedade Brasileira de Pneumologia e Tisiologia sponsored the development of a joint statement addressing all aspects of mechanical ventilation, which was divided into 38 topics. Seventy-five experts from all regions of Brazil worked in pairs to perform scoping reviews, searching for publications on their specific topic of mechanical ventilation in the last 20 years in the highest impact factor journals in the areas of intensive care, pulmonology, and anesthesiology. Each pair produced suggestions and considerations on their topics, which were presented to the entire group in a plenary session for modification when necessary and approval. The result was a comprehensive document encompassing all aspects of mechanical ventilation to provide guidance at the bedside. In this article, we report the methodology used to produce the document and highlight the most important suggestions and considerations of the document, which has been made available to the public in Portuguese.

This study aimed to assess the impact of a bundle of care strategy on the duration of awake prone positioning (AW-PP) and other key clinical outcomes in patients with acute respiratory failure (ARF) who require high-flow nasal oxygen (HFNO).

In this secondary analysis of a prospective, multicenter cohort study, we included patients admitted with COVID-19-related ARF who required HFNO. The protocol encouraged AW-PP for as long as possible. The main exposure was a bundle of care including light sedation, monitoring, and information to patients about the strategy (bundle) compared to no bundle (control). The primary outcome was the duration of AW-PP (hours/day), while secondary outcomes included endotracheal intubation and in-hospital mortality. Directed acyclic graphs (DAGs) were employed to identify variables related to both exposure and outcomes. Four models were used to evaluate exposure-outcome associations: inverse probability of treatment weighting (IPTW), "double-robust" approximation (DR), traditional regression (TR), and mixed-effects model (MEM).

Out of 499 patients, 197 were exposed to bundle, and 302 did not. The exposure group had a median (IQR) AW-PP duration of 16 (10-18) hours/day, compared to 10 (7-14) hours/day in the control group. Regression coefficients (95% CI) were 3.39 (1.67-5.11), 3.35 (1.55-5.14), 3.95 (2.63-5.28), and 3.72 (2.5-4.94) for IPTW, DR, TR and MEM, respectively. The odds ratios (95% CI) for intubation were 0.34 (0.15-0.76), 0.23 (0.10-0.50), 0.42 (0.23-0.77), and 0.48 (0.16-0.49), and for in-hospital mortality were 0.38 (0.11-1.27), 0.43 (0.14-1.26), 0.47 (0.22-0.91), and 0.46 (0.12-1.43) in the respective models.

In the evaluated population of patients with COVID-19-related ARF, implementing a bundle-of-care strategy was associated with a longer AW-PP exposure and a reduced risk of endotracheal intubation.

ClinicalTrials.gov. Identifier NCT05178212. Date of registration: January 5th, 2022.

Observational.

The novel coronavirus disease (COVID-19) has revived the debate on the optimal tidal volume during acute respiratory distress syndrome (ARDS). Some experts recommend 6 mL/kg of predicted body weight (PBW) for all patients, while others suggest 7-9 mL/kg PBW for those with compliance >50 mL/cmH2O. We investigated whether a tidal volume ≥ 7 ml/kg PBW may be safe in COVID-19 patients, particularly those with compliance >50 mL/cmH2O.

This secondary analysis of a multicenter study compares the Intensive Care Unit (ICU) mortality among 600 patients ventilated with <7 or ≥ 7 mL/kg PBW. Compliance was categorized as <40, 40-50, or > 50 mL/cmH2O.

346 patients were ventilated with <7 (6.2 ± 0.5) mL/kg PBW and 254 with ≥7 (7.9 ± 0.9) mL/kg PBW. ICU mortality was 33 % and 29 % in the two groups (p = 0.272). At multivariable regression analysis, tidal volume ≥ 7 mL/kg PBW was associated with lower ICU mortality in the overall population (odds ratio: 0.62 [95 %-confidence interval: 0.40-0.95]) and in each compliance category.

A tidal volume ≥ 7 (up to 9) mL/kg PBW was associated with lower ICU mortality in these COVID-19 patients, including those with compliance <40 mL/cmH2O. This finding should be interpreted cautiously due to the retrospective study design.

ClinicalTrails.govNCT04388670.

In the initial phases of veno-venous extracorporeal membrane oxygenation (VV ECMO) support for severe acute respiratory distress syndrome (ARDS), ultraprotective controlled mechanical ventilation (CMV) is typically employed to limit the progression of lung injury. As patients recover, transitioning to assisted mechanical ventilation can be considered to reduce the need for prolonged sedation and paralysis. This study aimed to evaluate the feasibility of transitioning to pressure support ventilation (PSV) during VV ECMO and to explore variations in respiratory mechanics and oxygenation parameters following the transition to PSV. This retrospective monocentric study included 191 adult ARDS patients treated with VV ECMO between 2009 and 2022. Within this population, 131 (69%) patients were successfully switched to PSV during ECMO. Pressure support ventilation was associated with an increase in respiratory system compliance ( p = 0.02) and a reduction in pulmonary shunt fraction ( p < 0.001). Additionally, improvements in the cardiovascular Sequential Organ Failure Assessment score and a reduction in pulmonary arterial pressures ( p < 0.05) were recorded. Ninety-four percent of patients who successfully transitioned to PSV were weaned from ECMO, and 118 (90%) were discharged alive from the intensive care unit (ICU). Of those who did not reach PSV, 74% died on ECMO, whereas the remaining patients were successfully weaned from extracorporeal support. In conclusion, PSV is feasible during VV ECMO and potentially correlates with improvements in respiratory function and hemodynamics.

This study aimed to develop a reliable and effective nomogram model to identify high-risk populations with non-response to prone position ventilation (PPV) in acute respiratory distress syndrome (ARDS) patients.

This retrospective cohort study included 175 patients with ARDS undergoing PPV. An improvement of ≥ 20 mmHg in the PaO2/FiO2 after the first PPV was defined as a 'response'. For the construction of the model, all patients were randomly assigned to the train and validation cohort according to 2:1. Multivariate logistic regression was useed to develop the nomogram. The area under the receiver operating characteristic curve (AUC), decision curve and calibration curve were assessed to evaluate the efficiency, clinical utility and calibration of the model.

The overall rate of non-response to PPV in ARDS patients was approximately 32.6 %. In the training cohort and validation cohort, the rate are 29.9 % and 34.5 % respectively. Murray score ≥ 2.5 (OR: 4.29), procalcitonin (PCT) ≥ 2 ng/mL (OR: 2.52), N-terminal pro-B-type natriuretic peptide (Nt-proBNP) ≥ 2000 pg/ml (OR: 2.44), and hemoglobin ≤ 90 g/L (OR: 2.39) were independently associated with the rate of non-response to PPV and combined in prediction model. The model demonstrated good predictive value with AUC of 0.817 and 0.828 in the train and validation cohort. Calibration curve showed good calibration and decision curve analysis indicated favorable clinical utility.

This study constructed a risk prediction model for non-response to PPV, which demonstrated good predictive value and clinical utility.

Early identification of prone position response in ARDS is essential for timely alternative treatments, improving patient prognosis and healthcare efficiency. The predictive model included representative indicators of patients with ARDS, encompassing parameters such as the acute lung injury (Murray score), cardiac function (Nt-proBNP), infectious status (PCT), and hemoglobin levels.

Prone position has been diffusely applied in mechanically ventilated COVID-19 patients. Our aim is ascertaining the association between the physiologic response and the length of the first cycle of prone position and intensive care unit (ICU) mortality.

International registry including COVID-19 adult patients who underwent prone positioning. We measured the difference for arterial partial pressure of oxygen to inspired fraction of oxygen ratio (PaO2/FiO2), ventilatory ratio, and respiratory system compliance (Crs) between baseline supine position and at either the end of the first cycle of prone position (Delta-PP) or re-supination (Delta-PostPP).

We enrolled 1816 patients from 53 centers. Delta-PP and Delta-PostPP for PaO2/FiO2 were both associated with ICU mortality [OR (95% CI) 0.48 (0.38, 0.59), and OR (95% CI) 0.60 (0.52, 0.68), respectively]. Ventilatory ratio had a non-linear relationship with ICU mortality for Delta-PP (p = 0.022) and Delta-PostPP (p = 0.004). Delta-PP, while not Delta-PostPP, for Crs was associated with ICU mortality [OR (95% CI) 0.80 (0.65, 0.98)]. The length of the first cycle of prone position showed an inverse relationship with ICU mortality [OR (95% CI) 0.82 (0.73, 0.91)]. At the multivariable analysis, the duration of the first cycle of prone position, Delta-PP and Delta-PostPP for PaO2/FiO2, and Delta-PostPP for ventilatory ratio were independently associated with ICU mortality.

In COVID-19 patients with acute respiratory failure receiving invasive mechanical ventilation and prone positioning, the physiological response to prone position is associated with ICU mortality. Prolonging the duration of the first cycle of prone position is associated with improved survival.

Prone positioning is an intervention used for patients with acute respiratory distress syndrome (ARDS) whose hypoxia is worsening despite conventional treatment. Previously used infrequently, it became an important treatment escalation strategy for hypoxia during the COVID-19 pandemic. Current evidence for prone positioning suggests increased survivability in intubated patients with moderate to severe ARDS who are prone for >12 hours a day. As a relatively low-cost, low-tech intervention with a growing evidence base, the viability of prone positioning in the deployed land environment is considered in this article. The practical technique of prone positioning is easy to teach to healthcare staff experienced in manual handling. However, it requires significant resources, in particular staff numbers, and time to execute and maintain, and necessitates a pressure-minimising mattress. Additionally, staff are placed at increased risk of musculoskeletal injuries and potential exposure to aerosolised microbes if there is a disconnection of the breathing system. We conclude that in the deployed 2/1/2/12 facility (or larger), with access to higher staff numbers and high-specification mattresses, prone positioning is a valid escalation technique for intubated hypoxic patients with ARDS. However, in smaller facilities where resources are constrained, its implementation is unlikely to be achievable.

Sepsis is a life-threatening condition involving organ dysfunction characterized by a generalized inflammatory syndrome, and the associated mortality rate is high. Electroacupuncture (EA) exerts benefits in endotoxemia-induced lung injury, mainly through lung inflammation reduction and cellular homeostasis, although the anti-inflammatory mechanisms underlying these benefits remain to be completely understood.

Mice were pretreated with EA or sham EA therapy 5 days prior to the induction of endotoxemia through the administration of lipopolysaccharide (LPS) and cecal ligation and puncture (CLP). Histopathological changes, systemic inflammation and cell death in the lungs were assessed. Transmission electron microscopy was employed to visually identify the structure of the Golgi complex. We examined proteins involved in maintaining the structural integrity of the Golgi apparatus and proteins associated with Golgi stress. The potential molecular mechanisms were investigated through overexpression of CREB3.

EA pretreatment effectively rescued the lung from pathological changes, lung edema, cell apoptosis, and survival rate in septic mice, along with the improvement of physiological parameters. Endotoxemia strongly induces fragmented Golgi stacks, leading to fragmentation and disintegration of its shape, inducing cell apoptosis, and causing the outbreak of a large amount of inflammation in the lungs. EA therapy can significantly inhibit the fragmented process of Golgi stress to rescue the morphological changes and exert anti-inflammatory effects. And this protective effect may be related to downregulation of cAMP responsive element binding protein 3 (CREB3) and ADP-Ribosylation Factor 4 (ARF4), one of the key pathways involved in Golgi stress response. However, Sham EA (SEA) treatment did not substantially improve the fragmentation, stacking, and separation of Golgi organization, and inflammatory damage induced by endotoxin remains. This study discovered that overexpression of CREB3 may diminish the protective efficacy of EA.

Administering EA pretreatment at precisely selected acupoints notably improves the survival rate in mice challenged with endotoxemia and concurrently exerts a protective effect against inflammatory lung injury. This salutary impact is speculated to be mediated through the augmentation of the Golgi apparatus's stress response.

The association between bedside ventilatory parameters-specifically arterial carbon dioxide pressure (PaCO2) and ventilatory ratio (VR)-and mortality in patients with acute respiratory distress syndrome (ARDS) remains a topic of debate. Additionally, the persistence of this association over time is unclear. This study aims to investigate the relationship between 28-day mortality in ARDS patients and their longitudinal exposure to ventilatory inefficiency, as reflected by serial measurements of PaCO2 and VR.

We conducted a secondary analysis of four randomized controlled trials (FACTT, ALTA, EDEN, and SAILS) from the ARDS Network. All included patients were intubated and received mechanical ventilation. Patients were excluded if they underwent extracorporeal life support or were on mechanical ventilation for less than one day. The primary outcome was 28-day mortality. Bayesian joint models were employed to estimate the strength of associations over time.

A total of 2,851 patients were included in our analysis. The overall 28-day mortality rate was 21.3%, with a median duration of invasive mechanical ventilation of 9 days (IQR: 4-28 days). After adjustment, each daily increment in PaCO2 (HR 1.008, 95% CI 0.997-1.018) was not associated with mortality, while a daily increment in VR (HR 1.548, 95% CI 1.309-1.835) was associated with increased mortality. This association persisted during the prolonged stages (Days 0-23) of mechanical ventilation. Furthermore, a significant increase in the risk of death was related to daily exposure to VR > 2 (HR 1.088 per day, 95% CI 1.034-1.147) and its cumulative effect (HR 1.085 per area, 95% CI 1.050-1.122), whereas PaCO2 was found to be insignificant.

VR, which reflects ventilatory inefficiency, should be closely monitored during invasive mechanical ventilation. Cumulative exposure to high intensities of VR may be associated with increased mortality in patients with ARDS.

This systematic review aims to evaluate the optimal management of acute respiratory distress syndrome (ARDS) in critically ill surgical patients, specifically focusing on positioning, extracorporeal membrane oxygenation (ECMO) use, ventilation, fluid resuscitation, and pharmacological treatments.

A systematic review was conducted utilizing four databases including PubMed, Google Scholar, EMBASE, and ProQuest. This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with The International Prospective Register of Systematic Reviews. Studies published until May 20, 2024, that assessed the management of ARDS in critically ill surgical adult populations were included in our review. The primary outcome of interest was mortality, with secondary outcomes like intensive care unit (ICU) length of stay (LOS), ventilator days, and oxygenation also being considered.

A total of fifteen studies met inclusion criteria; four studies assessed positional interventions, four assessed treatments with ECMO, three assessed mechanical ventilation settings, and four assessed fluid resuscitation and medications. Prone position was found to decrease mortality, ICU LOS, ventilator days, and increased oxygenation (P < 0.001). ECMO utilization decreased the overall mortality rate when compared to patients without ECMO (36.4% versus 43.9%, P < 0.001). Maintaining a tidal volume ≤8 mL/kg body weight and plateau pressure ≤35 cm H2O on mechanical ventilation also decreased patient mortality (P < 0.001). Finally, conservative fluid management decreased ICU LOS, whereas methylprednisolone use demonstrated decreased mortality.

Prone positioning, ECMO utilization, lung protective ventilation settings, and methylprednisolone reduced mortality among surgical patients with ARDS. In addition, prone positioning and conservative fluid management were associated with decreased ICU LOS, ventilator days, and improved oxygenation status.