Whether the use of inhaled or intravenous sedation affects outcomes differentially in mechanically ventilated adults with acute respiratory distress syndrome (ARDS) is unknown.

To determine the efficacy and safety of inhaled sevoflurane compared with intravenous propofol for sedation in patients with ARDS.

Phase 3 randomized, open-label, assessor-blinded clinical trial conducted from May 2020 to October 2023 with 90-day follow-up. Adults with early moderate to severe ARDS (defined by a ratio of Pao2 to the fraction of inspired oxygen of <150 mm Hg with a positive end-expiratory pressure of ≥8 cm H2O) were enrolled in 37 French intensive care units.

Patients were randomized to a strategy of inhaled sedation with sevoflurane (intervention group) or to a strategy of intravenous sedation with propofol (control group) for up to 7 days.

The primary end point was the number of ventilator-free days at 28 days; the key secondary end point was 90-day survival.

Of 687 patients enrolled (mean [SD] age, 65 [12] years; 30% female), 346 were randomized to sevoflurane and 341 to propofol. The median total duration of sedation was 7 days (IQR, 4 to 7) in both groups. The number of ventilator-free days through day 28 was 0.0 days (IQR, 0.0 to 11.9) in the sevoflurane group and 0.0 days (IQR, 0.0 to 18.7) in the propofol group (median difference, -2.1 [95% CI, -3.6 to -0.7]; standardized hazard ratio, 0.76 [95% CI, 0.50 to 0.97]). The 90-day survival rates were 47.1% and 55.7% in the sevoflurane and propofol groups, respectively (hazard ratio, 1.31 [95% CI, 1.05 to 1.62]). Among 4 secondary outcomes, sevoflurane was associated with higher 7-day mortality (19.4% vs 13.5%, respectively; relative risk, 1.44 [95% CI, 1.02 to 2.03]) and fewer intensive care unit-free days through day 28 (median, 0.0 [IQR, 0.0 to 6.0] vs 0.0 [IQR, 0.0 to 15.0]; median difference, -2.5 [95% CI, -3.7 to -1.4]) compared with propofol.

Among patients with moderate to severe ARDS, inhaled sedation with sevoflurane resulted in fewer ventilator-free days at day 28 and lower 90-day survival than sedation with propofol.

ClinicalTrials.gov Identifier: NCT04235608.

Prone positioning is commonly applied to improve gas exchange in mechanically ventilated patients with coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS). Whilst prone positioning is effective, specific complications may arise. We aimed to assess the prevalence of specific complications related to prone positioning in patients mechanically ventilated for COVID-19-related ARDS.

Multicentre, retrospective observational study.

Multi-centre observational study of mechanically ventilated patients with COVID-19-related ARDS admitted to intensive care units in Melbourne, Australia, from August to November 2021. Data on baseline characteristics, prone positioning, complications, and patient outcomes were collected.

We assessed 553 prone episodes in 220 patients across seven sites (mean ± standard deviation age: 54 ± 13 years, 61% male). Overall, 58% (127/220) of patients experienced at least one prone-positioning-related complication. Pressure injury was the most prevalent (n = 92/220, 42%) complication reported. Factors associated with increased risk of pressure injury were male sex (adjusted odds ratio = 1.15, 95% confidence interval: [1.02-1.31]) and the total number of prone episodes (adjusted odds ratio = 1.11, 95% confidence interval: [1.07-1.15]). Device dislodgement was the next most common complication, occurring in 28 of 220 (13%) patients. There were no nerve or retinal injuries reported.

Pressure injuries and line dislodgement were the most prevalent complications associated with prone positioning of patients mechanically ventilated for COVID-19. The risk of pressure injuries was associated with male sex and the number of prone positioning episodes.

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.

To conduct a Geospatial Information System analysis of extracorporeal membrane oxygenation (ECMO) centers in the United States utilizing data from the U.S. Census Bureau to better understand access to ECMO care and identify potential disparities.

A cross-sectional descriptive and statistical analysis of geospatial access to ECMO-capable centers in the United States, accounting for demographic variables.

The unit of analysis were U.S. Census block groups and demographic variables of interest obtained from the American Community Survey.

Patients accounted for in the U.S. Census data.

None.

Sixty-seven percent of the U.S. population had direct access to ECMO-capable centers. Disparities were present, with Puerto Rico, Wyoming, North Dakota, and Alaska having no access. Poverty, increased age, and lower population density consistently correlated with limited access. We identified significant racial and ethnic disparities in the Midwest and Northeast.

While 67% of the U.S. population had access to ECMO-capable centers by ground transportation, significant disparities in access exist. These findings emphasize the need for thoughtful implementation of ECMO systems of care to ensure equitable access. Future work should focus on developing novel systems of care that increase access utilizing advanced technology, such as aeromedical transport services.

Background: After the improvement of the initial phase of ARDS, when the patients begin spontaneous breathing and weaning from mechanical ventilation, some patients may present abnormal breathing patterns, whose evaluation of the repercussions were poorly studied. This study proposed to evaluate abnormal breathing patterns through the use of electrical impedance tomography (EIT), and clinical, respiratory mechanics, and ventilatory parameters according to the types of weaning from mechanical ventilation. Methods: This was a prospective cohort study of subjects with ARDS who were considered able to be weaned from mechanical ventilation in the clinical-surgical ICU. Weaning types were defined as simple, difficult, and prolonged weaning. EIT, ventilatory, lung mechanics, and clinical data were collected. Data were collected at baseline in a controlled ventilatory mode and, after neuromuscular blocker withdrawal, data were collected after 30 min, 2 h, and 24 h. EIT parameter analysis was performed for ventilation distribution in the lung regions, pendelluft, breath-stacking, reverse-trigger, double-trigger, and asynchrony index. Results: The study included 25 subjects who were divided into 3 groups (9/25 simple, 8/25 difficult, and 8/25 prolonged weaning). The prolonged weaning group showed more delirium, ICU-acquired weakness, stay in ICU, and hospital and ICU mortality. During the change from controlled to spontaneous mode, we observed increased tidal volumes and driving pressures, which were mainly found in the prolonged weaning group when compared with the simple weaning group. The prolonged weaning group showed a higher flow index, more asynchronies during volume-assisted ventilation, a higher incidence of pendelluft, and redistribution of ventilation to posterior regions visualized by EIT. Conclusions: The present study showed abnormal breathing patterns in the prolonged weaning group. The clinical occult findings of abnormal breathing patterns could be monitored, mainly through EIT and with better assessment of pulmonary mechanics.

Acute lung injury (ALI) is characterized by severe inflammation in lung tissue, excessive immune response and impaired lung function. In hospitalized high-risk patients and cases of secondary infection due to surgical contamination, it can lead to higher mortality rates and require immediate intervention. Currently, clinical treatments are limited in symptomatic therapy as mechanical ventilation and corticosteroids, having insufficient efficacy in mitigating the cause of progression to severe illness. Here we report a pulmonary targeting lung-homing nanoliposome (LHN) designed to attenuate excessive Neutrophil Extracellular Trap formation (NETosis) through sivelestat and DNase-1, coupled with an anti-inflammatory effect mediated by 25-hydroxycholesterol (25-HC), offering a promising intervention for the acute phase of ALI. Through intratracheal delivery, we intend prompt and constant action within the lungs to effectively prevent excessive NETosis. Isolated neutrophils from blood samples of severe ARDS patients demonstrated significant anti-NETosis effects, as well as reduced proinflammatory cytokine secretion. Furthermore, in a murine model of LPS-induced ALI, we confirmed improvements in lung histopathology, and early respiratory function. Also, attenuation of systemic inflammatory response syndrome (SIRS), with notable reductions in NETosis and neutrophil trafficking was investigated. This presents a targeted therapeutic approach that can be applied in early stages of high-risk patients to prevent severe pulmonary disease progression.

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.

In sepsis-induced cardiogenic shock, venoarterial extracorporeal membrane oxygenation (VA-ECMO) can improve survival. Simultaneous acute respiratory distress syndrome (ARDS) increases the risk of differential hypoxia (Harlequin syndrome). Due to desaturated blood ejected by the heart, the head becomes blue, whereas the lower body remains oxygenated by VA-ECMO. We report on an unusual cardiac manifestation, leading to electrical storm.

We present the clinical case of a 55-year-old man. During a minor viral pneumonia, superinfection led to severe ARDS and sepsis-induced refractory cardiogenic shock. Venoarterial extracorporeal membrane oxygenation support was initiated. In progressive respiratory failure, an electrocardiogram (ECG) revealed the onset of ST-segment elevations mirroring hypoxic coronary perfusion. As the mixing zone of blood from the heart and the VA-ECMO was in the ascending aorta, hypoxia was limited to the heart. Ventricular arrhythmias recurred, until ventricular fibrillation remained refractory to defibrillation. A second return cannula was inserted into the jugular vein, and veno-arteriovenous ECMO (V-AV-ECMO) was established. After the venous return was added to the circuit, ventricular fibrillation was defibrillated and sinus rhythm remained stable. Within an hour, ST-elevations receded. Systolic function recovered to normal within 26 days.

In severe sepsis-related cardiogenic shock, cardiac output is likely to recover. Venoarterial extracorporeal membrane oxygenation is a potential bridge to recovery. Apart from textbook knowledge, Harlequin syndrome can exclusively cause coronary ischaemia, leading to ST-segment elevations and electrical storm. ECGs reveal ST-elevations for early detection. Isolated cardiac Harlequin syndrome can be overlooked or misinterpreted as result of coronary artery disease, but needs immediate therapy to save the patient's life (e.g. V-AV-ECMO).

Background and Objectives: Acute respiratory distress syndrome (ARDS) is a severe form of acute lung injury with high mortality, characterized by hypoxemic respiratory failure and diffuse lung damage. Despite advancements in care, no definitive biomarkers have been established for ARDS diagnosis and prognostic stratification. Soluble receptor for advanced glycation end-products (sRAGE), a marker of alveolar epithelial injury, has shown promise as a prognostic indicator in ARDS. This study evaluates sRAGE's utility in predicting 28-day mortality. Materials and Methods: A retrospective cohort study was conducted at a tertiary care ICU in Serbia from January 2021 to June 2023. Adult patients meeting the Berlin definition of ARDS were included. Exclusion criteria included pre-existing chronic respiratory diseases and prolonged mechanical ventilation before diagnosis. Serum sRAGE levels were measured within 48 h of ARDS diagnosis using enzyme-linked immunosorbent assay (ELISA). Clinical severity scores, laboratory markers, and ventilatory parameters were recorded. Logistic regression and survival analyses were used to assess the prognostic value of sRAGE for 28-day mortality. Results: A cohort of 121 patients (mean age 55.5 years; 63.6% male) was analyzed. Non-survivors exhibited higher median sRAGE levels than survivors (5852 vs. 4479 pg/mL, p = 0.084). The optimal sRAGE cut-off for predicting mortality was >16,500 pg/mL (sensitivity 30.4%, specificity 86.9%). Elevated sRAGE levels were associated with greater disease severity and an increased risk of 28-day mortality in ARDS patients, highlighting its potential as a prognostic biomarker. The main findings, while indicative of a trend toward higher sRAGE levels in non-survivors, did not reach statistical significance. Conclusions: The main findings, while indicative of a trend toward higher sRAGE levels in non-survivors, did not reach statistical significance (p = 0.084). sRAGE demonstrates potential as a prognostic biomarker in ARDS and has moderate correlation with 28-day mortality. Integrating sRAGE with other biomarkers could enhance risk stratification and guide therapeutic decisions. The retrospective design limits the ability to establish causation, underscoring the need for multicenter prospective studies.

This study aimed to assess the knowledge, attitudes and practices (KAP) of intensive care unit (ICU) physicians in China towards acute respiratory distress syndrome (ARDS).

A cross-sectional study was conducted between September and November 2022.

A total of 497 ICU physicians participated, with 258 (51.91%) being male and the majority aged 30-40 years (56.74%).

Participants were surveyed to evaluate their KAP regarding ARDS, with mediation analysis employed to elucidate the association between demographic characteristics and KAP scores.

The mean scores for KAP were 11.89±2.64 (range: 0-17), 44.73±4.85 (range: 12-60) and 18.26±3.43 (range: 1-48), respectively. Pearson correlation analysis showed positive correlations between knowledge and attitude (0.367), knowledge and practice (0.582) and attitude and practice (0.314) (all p<0.001).

Mediation analysis indicated that attitude (β=0.07, p<0.001) and hospital type (β=-0.84, p=0.005) had direct effects on practice, while knowledge had significant direct (β=0.68, p<0.001) and indirect (β=0.03, p=0.019) effects. Additionally, education (β=0.47, p<0.001), work experience (β=0.25, p<0.001), hospital classification (β=-0.91, p<0.001), ICU type (β=-0.61, p=0.001) and ARDS experience (β=-1.57, p<0.001) showed various indirect effects on practice.

ICU physicians in China exhibited inadequate knowledge, moderate attitudes and suboptimal practices regarding ARDS management. Enhancing education and work experience is crucial, along with practical, scenario-based training, to improve KAP in ARDS management.

Sepsis is an uncontrolled inflammatory response to infection and is closely associated with the occurrence of acute respiratory distress syndrome (ARDS). Low tidal volume lung ventilation and permissive hypercapnia is a recognized therapy for ARDS. However, whether permissive hypercapnia aggravates sepsis-associated encephalopathy (SAE) remains unclear. The present study investigated whether hypercapnia contributed to the development of SAE through the purinergic 2X7 receptor (P2X7R) by activating the Nod-like receptor protein 3 (NLRP3) inflammasome in sepsis.

The SAE model was established by intracranial injection of lipopolysaccharide (LPS) (1 μg/ml, 5 μl) in C57BL/6 mice. Hypercapnia was induced by mechanical ventilation with a high concentration of CO2 (5 % CO2, 21 % O2 and 74 % N2) in vivo. Toll-like receptor 4 (TLR4) and P2X7R knockout (KO) mice were employed in the study, while in vitro, BV2 microglial cells were treated with LPS or a high concentration of CO2 (15 % CO2 + 20 % O2). Immunofluorescence and western blot analysis were used to assess the expression levels of TLR4, NF-κB, phosphorylated (p)-NF-κB, P2X7R, pro-caspase-1, caspase-1, pro-IL-1β, IL-1β, pro-IL-18 and IL-18. ATP levels in the cell culture medium were detected by fluorometric assay.

The results revealed that, compared with the sham group, the expression levels of TLR4, p-NF-κB, pro-IL-1β, pro-IL-18 and NLRP3 were significantly upregulated in the LPS and LPS + hypercapnia groups, but not in the hypercapnia group. Although the expression levels of caspase-1, IL-1β and IL-18 were increased slightly in the LPS group, their upregulation was more pronounced in the LPS + hypercapnia group, and it was suppressed when TLR4 was knocked out. Furthermore, P2X7R expression and ATP levels in the cell culture medium remained unchanged in the LPS group compared with the sham group but were remarkably increased both in the hypercapnia and LPS + hypercapnia groups. Additionally, P2X7R KO restrained the caspase-1, IL-1β and IL-18 increased induced by LPS injected intracranially and hypercapnia.

In conclusion, LPS induced the priming step of NLRP3 inflammasome activation, but had little effect on the activation step, while hypercapnia played an important role in the activation step through P2X7R, depending on the priming step stimulated by LPS.

Although current clinical practice guidelines have discordant conclusions, a judicious approach to using NMBA infusions may include reserving their use for patients with early severe ARDS who are already deeply sedated and for patients under light sedation who have significant ventilator dyssynchrony, despite attempts to adjust both ventilator settings and sedation requirements. Based on current evidence, the duration of NMBA use should be limited to 48 hours, whenever possible.

In patients with severe acute respiratory distress syndrome (ARDS), prolonged and inappropriate use of prone position ventilation (PPV) is a known risk factor for mortality. Hence, it is critical to monitor patients' response to PPV and accurately differentiate responders from non-responders at an early stage. The study aimed to investigate the relationship between oxygenation improvement after three rounds of PPV and survival rate in patients with pulmonary ARDS. Additionally, we sought to identify the earliest turning point for escalation from PPV to extracorporeal membrane oxygenation.

We performed a retrospective observational study from 2015 to 2023. We included adult patients who received invasive mechanical ventilation, underwent at least three periods of at least 6 h of PPV after admission to the Intensive Care Unit, and meet the ARDS criteria. The study collected data on each PPV session, including changes in PaCO2, PaO2, pH, FiO2, PaO2:FiO2 ratio, and clinical outcomes.

A total of 104 patients were enrolled in the study. The change in PaCO2 from baseline to the third PPV session (P3) had the highest area under the receiver operating characteristic curve (AUC) of 0.70 (95% CI 0.60-0.80; p < 0.001) for predicting hospital mortality, with an optimal cut-off point of 3.15 (sensitivity 75.9%, specificity 56.0%). The percentage change in PaO2:FiO2 ratio from baseline to P3 also had significant AUC of 0.71 (95% CI 0.61-0.81; p < 0.001) for predicting hospital mortality, with an optimal cut-off value of 99.465 (sensitivity 79.6%, specificity 62.0%). PaCO2 responders were defined as those with an increase in PaCO2 of ≤ 3.15% from baseline to P3, while PaO2:FiO2 responders were defined as those with an increase in PaO2:FiO2 ratio of ≥ 99.465% from baseline to P3. In the multivariable Cox analysis, PaO2:FiO2 responders had a significantly lower 60-day mortality risk (hazard ratio 0.369; 95% CI 0.171-0.798; p = 0.011).

The percentage change in PaO2:FiO2 ratio from baseline to P3 was a significant predictor of outcomes. The model fit and prediction accuracy were improved by including the variable of PaCO2 responders.

The dominant feature of COVID-19-associated ARDS is gas exchange impairment. Extravascular lung water index is a surrogate for lung edema and reflects the level of alveolocapillary disruption. The primary aim was the prediction of extravascular lung water index by the alveolar-arterial oxygen difference. The secondary aims were in determining the relationship between the extravascular lung water index and other oxygenation parameters, the [Formula: see text], end-tidal oxygen concentration, pulmonary oxygen gradient ([Formula: see text] minus end-tidal oxygen concentration), and [Formula: see text].

This observational prospective single-center study was performed at the Department of Anaesthesiology and Intensive Care, The University Hospital in Ostrava, The Czech Republic, during the COVID-19 pandemic, from March 20, 2020, until May 24, 2021.

The relationship between the extravascular lung water index and alveolar-arterial oxygen difference showed only a mild-to-moderate correlation (r = 0.33, P < .001). Other extravascular lung water index correlations were as follows: [Formula: see text] (r = 0.33, P < .001), end-tidal oxygen concentration (r = 0.26, P = .0032), [Formula: see text] minus end-tidal oxygen concentration (r = 0.15, P = .0624), and [Formula: see text] (r = -0.15, P = .01).

The alveolar-arterial oxygen difference does not reliably correlate with the extravascular lung water index and the degree of lung edema in COVID-19-associated ARDS.

Determining which patients with ARDS are most likely to benefit from lung recruitment maneuvers is challenging for physicians. The aim of this study was to assess whether the single-breath simplified decremental PEEP maneuver, which evaluates potential lung recruitment, may predict a subject's response to lung recruitment maneuvers, followed by PEEP titration.

We conducted a pilot prospective single-center cohort study with a 3-step protocol that defined sequential measurements. First, potential lung recruitment was assessed by the single-breath maneuver in the volume controlled mode. Second, the lung recruitment maneuver was performed in the pressure controlled mode, with a fixed driving pressure of 15 cm H2O and a maximum PEEP of 30 cm H2O. Third, the lung recruitment maneuver was followed by decremental PEEP titration to determine the optimal PEEP, defined as the lowest driving pressure. Responders to the lung recruitment maneuver were defined by an improvement in [Formula: see text]/[Formula: see text] > 20% between the baseline state and the end of the PEEP titration phase.

Forty-two subjects with moderate-to-severe ARDS were included. The mean ± SD lung recruitment was 149 ± 104 mL. A threshold lung recruitment of 195 mL (area under the receiver operator characteristic curve 0.62, 95% CI 0.43-0.80) predicted a positive response to the maximal lung recruitment maneuver. The lung recruitment maneuver, followed by PEEP titration, resulted in a modification of PEEP in 74% of the subjects. PEEP was increased in more than two thirds of the responders and decreased in almost half of the non-responders to the lung recruitment maneuver. In addition, a decrease in driving pressure and an increase in respiratory system compliance were reported in 62% and 67% of the subjects, respectively.

The single-breath maneuver for evaluating lung recruitability predicted, with poor accuracy, the subjects who responded to the lung recruitment maneuver based on [Formula: see text]/[Formula: see text] improvement. Nevertheless, the lung recruitment maneuver, followed by PEEP titration, improved ventilator settings and respiratory mechanics in a majority of subjects.

Over the past decade, numerous studies on potential factors contributing to ventilation-induced lung injury have been carried out. Mechanical power has been pointed out as the parameter that encloses all ventilation-induced lung injury-contributing factors. However, studies conducted to date provide data regarding mechanical power during the early hours of mechanical ventilation that may not accurately reflect the impact of power throughout the period of mechanical ventilatory support on intensive care unit mortality.

Retrospective observational study conducted at a single center in Spain. Patients admitted to the intensive care unit, > o = 18 years of age, and ventilated for over 24 h were included. We extracted the mechanical power values throughout the entire mechanical ventilation in controlled modes period from the clinical information system every 2 min. First, we calculate the cutoff-point for mechanical power beyond which there was a greater change in the probability of death. After, the sum of time values above the safe cut-off point was calculated to obtain the value in hours. We analyzed if the number of hours the patient was under ventilation with a mechanical power above the safe threshold was associated with intensive care unit mortality, invasive mechanical ventilation days, and intensive care unit length of stay. We repeated the analysis in different subgroups based on the degree of hypoxemia and in patients with SARS CoV-2 pneumonia.

The cut-off point of mechanical power at with there is a higher increase in intensive care unit mortality was 18 J/min. The greater the number of hours patients were under mechanical power > 18 J/min the higher the intensive care unit mortality in all the study population, in patients with SARS CoV-2 pneumonia and in mild to moderate hypoxemic respiratory failure. The risk of death in the intensive care unit increases 0.1% for each hour with mechanical power exceeding 18 J/min. The number of hours with mechanical power > 18 J/min also affected the days of invasive mechanical ventilation and intensive care unit length of stay.

The number of hours with mechanical power > 18 J/min is associated with mortality in the intensive care unit in critically ill patients. Continuous monitoring of mechanical power in controlled modes using an automated clinical information system could alert the clinician to this risk.

This overview addresses the pathophysiology of the acute respiratory distress syndrome (ARDS; conventional vs. COVID), the use of oxygen high flow (HFN) vs. noninvasive ventilation (NIV; conventional vs. helmet) and a multi-modal approach to avoid endotracheal intubation ("intubation"): low normal temperature, cooperative sedation, normalized systemic and microcirculation, anti-inflammation, reduced lung water, upright position, lowered intra-abdominal pressure. Increased ventilatory muscle activity ("respiratory drive") is observed in early ARDS, at variance with ventilatory fatigue observed in decompensated chronic obstructive pulmonary disease (COPD). This increased drive leads to impending then overt ventilatory failure. Therefore, muscle relaxation presents little rationale and should be replaced by lowering the excessive respiratory drive, increased work of breathing, continued or increased labored breathing, self-induced lung injury (SILI), i.e. preserving spontaneous breathing. As CMV is a lifesaver in the setting of failure but does not heal the lung, side-effects of intubation, controlled mechanical ventilation (CMV), paralysis and deep sedation are to be avoided. Additionally, critical care resources shortage requires practice changes. Therefore, NIV should be routine when addressing immune-compromised patients. The SARS-CoV2 pandemics extended this approach to most patients, which are immune-compromised: elderly, obese, diabetic, etc. The early COVID is a pulmonary vascular endothelial inflammatory disease requiring lower positive-end-expiratory pressure than the typical pulmonary alveolar epithelial inflammatory diffuse ARDS. This leads one to reassess a) the technique of NIV b) the sedation regimen facilitating continuous and extended NIV to avoid intubation. Autonomic, circulatory, respiratory, ventilatory physiology is hierarchized under HFN/NIV and cooperative sedation (dexmedetomidine, clonidine). A prospective randomized pilot trial, then a larger trial are required to ascertain our working hypotheses.

An association between driving pressure (∆P) and the outcomes of invasive mechanical ventilation (IMV) may exist. However, the effect of a sustained limitation of ∆P on mortality in patients with acute respiratory distress syndrome (ARDS), including patients with COVID-19 (COVID-19-related acute respiratory distress syndrome (C-ARDS)) undergoing IMV, has not been rigorously evaluated. The use of emulations of a target trial in intensive care unit research remains in its infancy. To inform future, large ARDS target trials, we explored using a target trial emulation approach to analyse data from a cohort of IMV adults with C-ARDS to determine whether maintaining daily ∆p<15 cm H2O (in addition to traditional low tidal volume ventilation (LTVV) (tidal volume 5-7 cc/PBW+plateau pressure (Pplat) ≤30 cm H2O), compared with LTVV alone, affects the 28-day mortality.

To emulate a target trial, adults with C-ARDS requiring >24 hours of IMV were considered to be assigned to limited ∆P or LTVV. Lung mechanics were measured twice daily after ventilator setting adjustments were made. To evaluate the effect of each lung-protective ventilation (LPV) strategy on the 28-day mortality, we fit a stabilised inverse probability weighted marginal structural model that adjusted for baseline and time-varying confounders known to affect protection strategy use/adherence or survival.

Among the 92 patients included, 27 (29.3%) followed limited ∆P ventilation, 23 (25.0%) the LTVV strategy and 42 (45.7%) received no LPV strategy. The adjusted estimated 28-day survival was 47.0% (95% CI 23%, 76%) in the limited ∆P group, 70.3% in the LTVV group (95% CI 37.6%, 100%) and 37.6% (95% CI 20.8%, 58.0%) in the no LPV strategy group.

Limiting ∆P may not provide additional survival benefits for patients with C-ARDS over LTVV. Our results help inform the development of future target trial emulations focused on evaluating LPV strategies, including reduced ∆P, in adults with ARDS.

Right ventricle impairment (RVI) is common during acute respiratory distress syndrome (ARDS) in adults and children, possibly mediated by the level of transpulmonary pressure (PL). We sought to investigate the impact of the level of PL on ARDS-associated right ventricle impairment (RVI).

Adults and children (> 72 h of life) were included in this two centers prospective study if they were ventilated for a new-onset ARDS or pediatric ARDS, without spontaneous breathing and contra-indication to esophageal catheter. Serial measures of static lung, chest wall, and respiratory mechanics were coupled to critical care echocardiography (CCE) for 3 days. Mixed-effect logistic regression models tested the impact of lung stress (ΔPL) along with age, lung injury severity, and carbon dioxide partial pressure, on RVI using two definitions: acute cor pulmonale (ACP), and RV dysfunction (RVD). ACP was defined as a dilated RV with septal dyskinesia; RVD was defined as a composite criterion using tricuspid annular plane systolic excursion, S wave velocity, and fractional area change.

46 patients were included (16 children, 30 adults) with 106 CCE (median of 2 CCE/patient). At day one, 19% of adults and 4/7 children > 1 year exhibited ACP, while 59% of adults and 44% of children exhibited RVD. In the entire population, ACP was present on 17/75 (23%) CCE. ACP was associated with an increased lung stress (mean ΔPL of 16.2 ± 6.6 cmH2O in ACP vs 11.3 ± 3.6 cmH2O, adjusted OR of 1.33, CI95% [1.11-1.59], p = 0.002) and being a child. RVD was present in 59/102 (58%) CCE and associated with lung stress. In children > 1 year, PEEP was significantly lower in case of ACP (9.3 [8.6; 10.0] cmH2O in ACP vs 15.0 [11.9; 16.3] cmH2O, p = 0.03).

Lung stress was associated with RVI in adults and children with ARDS, children being particularly susceptible to RVI. Trial registration Clinical trials identifier: NCT0418467.

Prone positioning (PP) has demonstrated its potential for improving outcomes in patients with ARDS who require invasive mechanical ventilation. However, the ability of prolonged proning to reduce mortality in patients with COVID-19 specifically, sessions lasting > 24 h remains uncertain.

In this retrospective cohort study, we examined 158 subjects with COVID-19 pneumonia who required mechanical ventilation due to moderate-to-severe ARDS. Seventy-six subjects were placed in standard PP and 82 in extended PP, defined as prone sessions lasting at least 32 h. Our primary aim was to evaluate the effect of EPP on 90-d survival in subjects with COVID-19 with acute severe respiratory failure. To ensure the reliability of our findings and to minimize bias, we applied 3 adjustment approaches: cardinality matching (CM), matching weighting (MW), and inverse probability of treatment weighting with stabilized and trimmed weights (SW). We used Kaplan-Meier curves and Cox proportional hazard models to analyze the effects of EPP on 90-d mortality and sensitivity analysis by calculating E-values.

The overall crude 90-d mortality rate was 31.7%. The unadjusted 90-d mortality rates were 19.5% in the EPP group and 44.7% in the SPP group (hazard ratio [HR] 0.35 [95% CI 0.19- 0.63], P < .001). After adjustment for confounding factors using CM, MW, and SW, baseline covariates were balanced between the 2 groups. Subjects in the EPP group exhibited lower 90-d mortality rates after adjustment using CM (HR 0.42 [95% CI 0.23-0.79], P = .007), MW (HR 0.45 [95% CI 0.21-0.95], P = .036), or SW (HR 0.29 [95% CI 0.15-0.56], P < .001).

Extended PP was associated with improved 90-d survival in subjects with COVID-19 undergoing mechanical ventilation for severe ARDS. These findings suggest the potential benefit of EPP in the management of COVID-19-related respiratory failure. Further research and prospective studies are warranted to confirm and elucidate the underlying mechanisms of this association.

Improvements in oxygenation and lung mechanics with prone position (PP) in patients with acute respiratory distress syndrome (ARDS) are inconstant. The objectives of the study were (i) to identify baseline variables, including the recruitment-to-inflation ratio (R/I), associated with a positive response to PP in terms of oxygenation (improvement of the ratio of arterial oxygen partial pressure over the inspired oxygen fraction (PaO2/FiO2) ≥ 20 mmHg) and lung mechanics; (ii) to evaluate whether the response to the previous PP session is associated with the response to the next session.

In this prospective, observational, single-center study in patients who underwent PP for ARDS due to COVID-19, respiratory variables were assessed just before PP and at the end of the session. Respiratory variables included mechanical ventilation settings and respiratory mechanics variables, including R/I, an estimate of the potential for lung recruitment compared to lung overinflation.

In 50 patients, 201 PP sessions lasting 19 ± 3 h were evaluated. Neuromuscular blockades were used in 116 (58%) sessions. The PaO2/FiO2 ratio increased from 109 ± 31 mmHg to 165 ± 65 mmHg, with an increase ≥ 20 mmHg in 142 (71%) sessions. In a mixed effect logistic regression, only pre-PP PaO2/FiO2 (OR 1.12 (95% CI [1.01-1.24])/every decrease of 10 mmHg, p = 0.034) in a first model and improvement in oxygenation at the previous PP session (OR 3.69 (95% CI [1.27-10.72]), p = 0.017) in a second model were associated with an improvement in oxygenation with PP. The R/I ratio (n = 156 sessions) was 0.53 (0.30-0.76), separating lower- and higher-recruiters. Whereas PaO2/FiO2 improved to the same level in both subgroups, driving pressure and respiratory system compliance improved only in higher-recruiters (from 14 ± 4 to 12 ± 4 cmH2O, p = 0.027, and from 34 ± 11 to 38 ± 13 mL/cmH2O, respectively, p = 0.014).

A lower PaO2/FiO2 at baseline and a positive O2-response at the previous PP session are associated with a PP-induced improvement in oxygenation. In higher-recruiters, lung mechanics improved along with oxygenation. Benefits of PP could thus be greater in these patients.

Severe viral infections often result in abnormal platelet function, affecting various stages of hemostasis. Activated platelets are often considered prothrombotic and more susceptible to further stimulation. However, emerging evidence suggests that initial hyperactivation is followed by platelet exhaustion and hypo-responsiveness, affecting platelet degranulation, activation, and aggregation. We examined early alterations in platelet aggregation among patients (N = 28) with acute respiratory distress syndrome and SARS-CoV-2 infection who were receiving mechanical ventilation and venovenous extracorporeal membrane oxygenation support. Blood samples were stimulated with four different activators: arachidonic acid, adenosine diphosphate, thrombin receptor-activating protein 6, and ristocetin. Our observations revealed that platelet aggregation was reduced in most patients upon admission (ranging from 61 to 89%, depending on the agonist used), and this trend intensified during the 5-day observation period. Concurrently, other coagulation parameters remained within normal ranges, except for elevated d-dimer and fibrinogen levels. Importantly, we found a significant association between platelet aggregation and patient mortality. Impaired platelet aggregation was more severe in patients who ultimately died, and reduced aggregation was associated with a significantly lower probability of survival, as confirmed by Kaplan-Meier analysis (p = 0.028). These findings underscore the potential of aggregometry as an early detection tool for identifying patients at higher risk of mortality within this specific cohort.

Invasive Mechanical Ventilation (IMV) in Intensive Care Units (ICU) significantly increases the risk of Ventilator-Induced Lung Injury (VILI), necessitating careful management of mechanical power (MP). This study aims to develop a real-time predictive model of MP utilizing Artificial Intelligence to mitigate VILI.

A retrospective observational study was conducted, extracting patient data from Clinical Information Systems from 2018 to 2022. Patients over 18 years old with more than 6 h of IMV were selected. Continuous data on IMV variables, laboratory data, monitoring, procedures, demographic data, type of admission, reason for admission, and APACHE II at admission were extracted. The variables with the highest correlation to MP were used for prediction and IMV data was grouped in 15-minute intervals using the mean. A mixed neural network model was developed to forecast MP 15 min in advance, using IMV data from 6 h before the prediction and current patient status. The model's ability to predict future MP was analyzed and compared to a baseline model predicting the future value of MP as equal to the current value.

The cohort consisted of 1967 patients after applying inclusion criteria, with a median age of 63 years and 66.9 % male. The deep learning model achieved a mean squared error of 2.79 in the test set, indicating a 20 % improvement over the baseline model. It demonstrated high accuracy (94 %) in predicting whether MP would exceed a critical threshold of 18 J/min, which correlates with increased mortality. The integration of this model into a web platform allows clinicians real-time access to MP predictions, facilitating timely adjustments to ventilation settings.

The study successfully developed and integrated in clinical practice a predictive model for MP. This model will assist clinicians allowing for the adjustment of ventilatory parameters before lung damage occurs.

Sepsis is a major cause of mortality worldwide and is the third-leading cause of death in the United States. Sepsis is resource-intensive and requires prompt recognition and treatment to reduce mortality. The impact of sepsis is not only on in-hospital survival but extends into post-discharge quality of life and risk of re-admission. As the understanding of sepsis physiology evolved, so have the recommended screening tools and treatment protocol which challenge prior standards of care. There have been noteworthy efforts by the Surviving Sepsis Campaign, the Third International Consensus Definitions for Sepsis and the Centers for Medicare and Medicaid Services to establish core measure bundles. This review highlights both the 2021 SSC International Guidelines and the 2015 CMS Severe Sepsis/Septic Shock Core Measure Bundle, or SEP-1. Notably, the SEP-1 bundle was implemented as a value-based purchasing program, linking care of sepsis patients to financial incentives. The objective is to explore the most current evidence-based data to inform clinical practice while utilizing the available guidelines as a roadmap.

Sepsis is a life-threatening organ dysfunction, and the most common and vulnerable organ is the lungs, with sepsis-related acute respiratory distress syndrome (ARDS) increasing mortality. In recent years, an increasing number of studies have improved our understanding of sepsis-related ARDS in terms of epidemiology, risk factors, pathophysiology, prognosis, and other aspects, as well as our ability to prevent, detect, and treat sepsis-related ARDS. However, sepsis-related lung injury remains an important issue and clinical burden. Therefore, a literature review was conducted on sepsis-related lung injury in order to further guide clinical practice in reducing the acute and chronic consequences of this condition.

This study conducted a search of the MEDLINE and PubMed databases, among others for literature published from 1991 to 2023 using the following keywords: definition of sepsis, acute lung injury, sepsis-related acute lung injury, epidemiology, risk factors, early diagnosis of sepsis-related acute lung injury, sepsis, ARDS, pathology and physiology, inflammatory imbalance caused by sepsis, congenital immune response, and treatment.

This review explored the risk factors of sepsis, sepsis-related ARDS, early screening and diagnosis, pathophysiology, and treatment and found that in view of the high mortality rate of ARDS associated with sepsis. In response to the high mortality rate of sepsis-related ARDS, some progress has been made, such as rapid identification of sepsis and effective antibiotic treatment, early fluid resuscitation, lung-protective ventilation, etc.

Sepsis remains a common and challenging critical illness to cure. In response to the high mortality rate of sepsis-related ARDS, progress has been made in rapid sepsis identification, effective antibiotic treatment, early fluid resuscitation, and lung-protective ventilation. However, further research is needed regarding long-term effects such as lung recruitment, prone ventilation, and the application of neuromuscular blocking agents and extracorporeal membrane oxygenation.

Nitric oxide (NO) is a strong vasodilator, selectively directed on pulmonary circulation through inhaled administration. In adult intensive care units (ICU), it is mainly used for refractory hypoxemia in mechanically ventilated patients. Several medical delivery devices have been developed to deliver inhaled nitric oxide (iNO). The main purpose of those devices is to guarantee an accurate inspiratory NO concentration, whatever the ventilator used, with NO2 concentrations lower than 0.3 ppm. We hypothesized that the performances of the different available iNO delivery systems could depend on their working principle and could be influenced by the ventilator settings. The objective of this study was to assess the accuracy of seven different iNO-devices combined with different ICU ventilators' flow-by to reach inspiratory NO concentration targets and to evaluate their potential risk of toxicity.

We tested seven iNO-devices on a test-lung connected to distinct ICU ventilators offering four different levels of flow-by. We measured the flow in the inspiratory limb of the patient circuit and the airway pressure. The nitric oxide/nitrogen (NO/N2) flow was measured on the administration line of the iNO-devices. NO and NO2 concentrations were measured in the test-lung using an electrochemical analyzer.

We identified three iNO-device generations based on the way they deliver NO flow: "Continuous", "Sequential to inspiratory phase" (I-Sequential) and "Proportional to inspiratory and expiratory ventilator flow" (Proportional). Median accuracy of iNO concentration measured in the test lung was 2% (interquartile range, IQR -19; 36), -23% (IQR -29; -17) and 0% (IQR -2; 0) with Continuous, I-Sequential and Proportional devices, respectively. Increased ventilator flow-by resulted in decreased iNO concentration in the test-lung with Continuous and I-Sequential devices, but not with Proportional ones. NO2 formation measured to assess potential risks of toxicity never exceeded the predefined safety target of 0.5 ppm. However, NO2 concentrations higher than or equal to 0.3 ppm, a concentration that can cause bronchoconstriction, were observed in 19% of the different configurations.

We identified three different generations of iNO-devices, based on their gas administration modalities, that were associated with highly variable iNO concentrations' accuracy. Ventilator's flow by significantly impacted iNO concentration. Only the Proportional devices permitted to accurately deliver iNO whatever the conditions and the ventilators tested.

A combination of prone positioning (PP) and venovenous extracorporeal membrane oxygenation (VV-ECMO) is safe, feasible, and associated with potentially improved survival for severe acute respiratory distress syndrome (ARDS). However, whether ARDS patients, especially non-COVID-19 patients, placed in PP before VV-ECMO should continue PP after a VV-ECMO connection is unknown. This study aimed to test the hypothesis that early use of PP during VV-ECMO could increase the proportion of patients successfully weaned from ECMO support in severe ARDS patients who received PP before ECMO.

In this prospective observational study, patients with severe ARDS who were treated with VV-ECMO were divided into two groups: the prone group and the supine group, based on whether early PP was combined with VV-ECMO. The proportion of patients successfully weaned from VV-ECMO and 60-day mortality were analyzed before and after propensity score matching.

A total of 165 patients were enrolled, 50 in the prone and 115 in the supine group. Thirty-two (64%) and 61 (53%) patients were successfully weaned from ECMO in the prone and the supine groups, respectively. The proportion of patients successfully weaned from VV-ECMO in the prone group tended to be higher, albeit not statistically significant. During PP, there was a significant increase in partial pressure of arterial oxygen (PaO2) without a change in ventilator or ECMO settings. Tidal impedance shifted significantly to the dorsal region, and lung ultrasound scores significantly decreased in the anterior and posterior regions. Forty-five propensity score-matched patients were included in each group. In this matched sample, the prone group had a higher proportion of patients successfully weaned from VV-ECMO (64.4% vs. 42.2%; P = 0.035) and lower 60-day mortality (37.8% vs. 60.0%; P = 0.035).

Patients with severe ARDS placed in PP before VV-ECMO should continue PP after VV-ECMO support. This approach could increase the probability of successful weaning from VV-ECMO.

ClinicalTrials.Gov: NCT04139733. Registered 23 October 2019.

Background: Acute respiratory distress syndrome (ARDS) is an acute inflammatory process in the lungs associated with high morbidity and mortality. Previous research has studied both nonpharmacologic and pharmacologic interventions aimed at targeting this inflammatory process and improving ventilation. Hypothesis: To date, only nonpharmacologic interventions including lung protective ventilation, prone positioning, and high positive end-expiratory pressure ventilation strategies have resulted in significant improvements in patient outcomes. Given the high mortality associated with ARDS despite these advancements, interest in subphenotyping has grown, aiming to improve diagnosis and develop personalized treatment approaches. Data Collection: Previous trials evaluating pharmacologic therapies in heterogeneous populations have primarily demonstrated no positive effect, but hope to show benefit when targeting specific subphenotypes, thus increasing their efficacy, while simultaneously decreasing adverse effects. Results: Although most studies evaluating pharmacologic therapies for ARDS have not demonstrated a mortality benefit, there is limited data evaluating pharmacologic therapies in ARDS subphenotypes, which have found promising results. Neuromuscular blocking agents, corticosteroids, and simvastatin have resulted in a mortality benefit when used in patients with the hyper-inflammatory ARDS subphenotype. Therapeutic Opinion: The use of subphenotyping could revolutionize the way ARDS therapies are applied and therefore improve outcomes while also limiting the adverse effects associated with their ineffective use. Future studies should evaluate ARDS subphenotypes and their response to pharmacologic intervention to advance this area of precision medicine.

Respiratory diseases pose a grave threat to human life. Therefore, understanding their pathogenesis and therapeutic strategy is important. Ferroptosis is a novel type of iron-dependent programmed cell death, distinct from apoptosis, necroptosis, and autophagy, characterised by iron, reactive oxygen species, and lipid peroxide accumulation, as well as glutathione (GSH) depletion and GSH peroxidase 4 (GPX4) inactivation. A close association between ferroptosis and the onset and progression of respiratory diseases, including chronic obstructive pulmonary disease, acute lung injury, bronchial asthma, pulmonary fibrosis, and lung cancer, has been reported. Recent studies have shown that traditional Chinese medicine (TCM) compounds exhibit unique advantages in the treatment of respiratory diseases owing to their natural properties and potential efficacy. These compounds can effectively regulate ferroptosis by modulating several key signalling pathways such as system Xc- -GSH-GPX4, NCOA4-mediated ferritinophagy, Nrf2-GPX4, and Nrf2/HO-1, thus playing a positive role in improving respiratory diseases.

This comprehensive review systematically outlines the regulatory role of ferroptosis in the onset and progression of respiratory diseases and provides evidence for treating respiratory diseases by targeting ferroptosis with TCM compounds. These insights aim to offer potential remedies for the clinical prevention and treatment of respiratory diseases.

We searched scientific databases PubMed, Web of Science, Scopus, and CNKI using keywords such as "ferroptosis","respiratory diseases","chronic obstructive pulmonary disease","bronchial asthma","acute lung injury","pulmonary fibrosis","lung cancer","traditional Chinese medicine","traditional Chinese medicine compound","monomer", and "natural product" to retrieve studies on the therapeutic potential of TCM compounds in ameliorating respiratory diseases by targeting ferroptosis. The retrieved data followed PRISMA criteria (preferred reporting items for systematic review).

TCM compounds possess unique advantages in treating respiratory diseases, stemming from their natural origins and proven clinical effectiveness. TCM compounds can exert therapeutic effects on respiratory diseases by regulating ferroptosis, which mainly involves modulation of pathways such as system Xc- -GSH-GPX4,NCOA4-mediated ferritinophagy, Nrf2-GPX4, and Nrf2/HO-1.

TCM compounds have demonstrated promising potential in improving respiratory diseases through the regulation of ferroptosis. The identification of specific TCM-related inducers and inhibitors of ferroptosis holds great significance in developing more effective strategies. However, current research remains confined to animal and cellular studies, emphasizing the imperative for further verifications through high-quality clinical data.

With the discovery of extracorporeal membrane oxygenation (ECMO), it is considered as a valuable tool for supporting the treatment of severe acute respiratory distress syndrome (ARDS). It has gained increasing attention, particularly during the COVID-19 epidemic. However, to date, no relevant bibliometric research on the association between ECMO and ARDS (ECMO-ARDS) has been reported. Our study aimed to summarize the knowledge structure and research focus of ECMO-ARDS through a bibliometric analysis.

Publications related to ECMO-ARDS from 2000 to 2022 were obtained from the Web of Science Core Collection (WoSCC). Research data underwent bibliometric and visual analysis by using CiteSpace, VOSviewer, and one online analysis platform. By analyzing the countries, institutions, journals, authors, the geographic distribution of research contributions as well as the leading institutions and researchers in this field were identified. Additionally, prominent journals and highly cited publications were highlighted, indicating their influence and significance in the field. Moreover, the co-citation references and co-occurring keywords provided valuable information on the major research topics, trends, and potential emerging frontiers.

A total of 1,565 publications from 60 countries/regions were retrieved. The annual publication number over time revealed exponential growth trends (R2 = 0.9511). The United States was dominant in ECMO-ARDS research, whereas the Univ Toronto was most productive institution. Prof Combes A published the most publications in this area. ASAIO Journal and Intensive Care Medicine were the most active and co-cited journals, respectively. Reference co-citation analysis showed that current research focus has shifted to COVID-related ARDS, multi-center studies, as well as prone positioning. Apart from the keywords "ECMO" and "ARDS", other keywords appearing at high frequency in the research field were "COVID-19", "mechanical ventilation", "extracorporeal life support", "respiratory failure", "veno-venous ECMO", "SARS-CoV-2", "outcome". Among them, keywords like "mortality", "veno-venous ECMO", "epidemiology", "obesity", "coagulopathy", "lung ultrasound", "inhalation injury", "noninvasive ventilation", "diagnosis", "heparin", "cytokine storm" has received growing interest in current research and also has the potential to continue to become research hotspots in the near future.

This bibliometric analysis offers a comprehensive understanding of the current state of ECMO-ARDS research and can serve as a valuable resource for researchers, policymakers, and stakeholders in exploring future research directions and fostering collaborations in this critical field.

Despite the significance and prevalence of acute respiratory distress syndrome (ARDS), its detection remains highly variable and inconsistent. In this work, we aim to develop an algorithm (ARDSFlag) to automate the diagnosis of ARDS based on the Berlin definition. We also aim to develop a visualization tool that helps clinicians efficiently assess ARDS criteria.

ARDSFlag applies machine learning (ML) and natural language processing (NLP) techniques to evaluate Berlin criteria by incorporating structured and unstructured data in an electronic health record (EHR) system. The study cohort includes 19,534 ICU admissions in the Medical Information Mart for Intensive Care III (MIMIC-III) database. The output is the ARDS diagnosis, onset time, and severity.

ARDSFlag includes separate text classifiers trained using large training sets to find evidence of bilateral infiltrates in radiology reports (accuracy of 91.9%±0.5%) and heart failure/fluid overload in radiology reports (accuracy 86.1%±0.5%) and echocardiogram notes (accuracy 98.4%±0.3%). A test set of 300 cases, which was blindly and independently labeled for ARDS by two groups of clinicians, shows that ARDSFlag generates an overall accuracy of 89.0% (specificity = 91.7%, recall = 80.3%, and precision = 75.0%) in detecting ARDS cases.

To our best knowledge, this is the first study to focus on developing a method to automate the detection of ARDS. Some studies have developed and used other methods to answer other research questions. Expectedly, ARDSFlag generates a significantly higher performance in all accuracy measures compared to those methods.

Conventional single indicators have low sensitivity and specificity for predicting weaning from mechanical ventilation in pediatric patients, necessitating the establishment of a combined prediction model for predicting weaning outcomes.

To explore the combined predictive value of PaO2/FiO2 Ratio (P/F ratio), diaphragm excursion-rapid shallow breathing index (DE-RSBI), diaphragm thickening fraction-rapid shallow breathing index (DTF-RSBI), and Pediatric Critical Illness Score (PCIS) in weaning from mechanical ventilation in pediatric patients.

Sixty critically ill pneumonia pediatric patients requiring mechanical ventilation treatment from July 2022 to June 2023 at the Second Affiliated Hospital of Jiaxing University were selected. They all underwent a spontaneous breathing trial (SBT) and were divided into the weaning success group (42 cases) and weaning failure group (18 cases) based on the weaning outcome. Parameters including total duration of illness, mechanical ventilation duration, heart rate (HR), P/F ratio, diaphragm excursion (DE), DE-RSBI, diaphragm thickening fraction (DTF), DTF-RSBI, and PCIS were included in univariate and multivariate logistic regression analyses to determine independent factors affecting pediatric weaning success. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive value of P/F ratio, DE-RSBI, DTF-RSBI, PCIS alone or in combination for weaning success.

Comparing P/F ratio, DE, DE-RSBI, DTF, DTF-RSBI and PCIS, there were statistically significant differences (P < 0.05). Through collinearity analysis and binary logistic regression analysis,P/F ratio [OR = 0.777, 95% CI (0.641,0.941)], DE-RSBI [OR = 1.694, 95% CI (1.172, 2.447)], DTF-RSBI [OR = 1.057, 95% CI (1.002, 1.114)], and PCIS [OR = 0.661, 95% CI (0.445, 0.982)] were identified as independent factors affecting successful weaning(P < 0.05).The regression equation was: LogitP = 73.299-0.253 P/F ratio + 0.525DE-RSBI + 0.055DTF-RSBI-0.43PCIS.The sensitivity of the combined indicator Logit(P) in predicting successful weaning from mechanical ventilation in pediatric patients was 88.9%, with a specificity of 95.2% (optimal cutoff value of 0.511), and the area under the ROC curve (AUC) was 0.960 [95% CI (0.915, 1.000)]. The AUC of the combined prediction model for predicting pediatric weaning was greater than that of P/F ratio, DE-RSBI, DTF-RSBI and PCIS alone (Z values = 9.129, 2.061, 2.075, 8.326, P < 0.05).

In mechanically ventilated pediatric patients, the combined prediction model has better predictive value for weaning success compared to using P/F ratio, DE-RSBI, DTF-RSBI, or PCIS alone.

Prone position (PP) has been widely used in the COVID-19 pandemic for ARDS management. However, the optimal length of a PP session is still controversial. This study aimed to evaluate the effects of prolonged versus standard PP duration in subjects with ARDS due to COVID-19.

This was a single-center, randomized controlled, parallel, and open pilot trial including adult subjects diagnosed with severe ARDS due to COVID-19 receiving invasive mechanical ventilation that met criteria for PP between March-September 2021. Subjects were randomized to the intervention group of prolonged PP (48 h) versus the standard of care PP (∼16 h). The primary outcome variable for the trial was ventilator-free days (VFDs) to day 28.

We enrolled 60 subjects. VFDs were not significantly different in the standard PP group (18 [interquartile range [IQR] 0-23] VFDs vs 7.5 [IQR 0-19.0] VFDs; difference, -10.5 (95% CI -3.5 to 19.0, P = .08). Prolonged PP was associated with longer time to successful extubation in survivors (13.00 [IQR 8.75-26.00] d vs 8.00 [IQR 5.00-10.25] d; difference, 5 [95% CI 0-15], P = .001). Prolonged PP was also significantly associated with longer ICU stay (18.5 [IQR 11.8-25.3] d vs 11.50 [IQR 7.75-25.00] d, P = .050) and extended administration of neuromuscular blockers (12.50 [IQR 5.75-20.00] d vs 5.0 [IQR 2.0-14.5] d, P = .005). Prolonged PP was associated with significant muscular impairment according to lower Medical Research Council values (59.6 [IQR 59.1-60.0] vs 56.5 [IQR 54.1-58.9], P = .02).

Among subjects with severe ARDS due to COVID-19, there was no difference in 28-d VFDs between prolonged and standard PP strategy. However, prolonged PP was associated with a longer ICU stay, increased use of neuromuscular blockers, and greater muscular impairment. This suggests that prolonged PP is not superior to the current recommended standard of care.