Incidence Of Acute Respiratory Distress Syndrome Research Articles

Real-life experience with antenatal glucocorticoid administration in premature pregnancies complicated by diabetes mellitus

Background: Diabetes mellitus (DM) in pregnancy is associated with an increased risk of premature birth, which therefore increases the risk of acute respiratory distress syndrome (ARDS) of the neonate and is associated with high morbidity and mortality of the newborn. The administration of glucocorticoids to the mother before premature birth decreases the risk of neonatal complications. However, the data regarding the administration of this therapy to mothers with DM is limited. Clinical guidelines recommend treating them in the same manner as the non-DM women, even if there is no recent data to support the benefit in this subpopulation. The aim of this study is to evaluate the real-life effects of glucocorticoid administration on the maternal and fetal prognosis of pregnancies complicated with DM. Material and methods: A retrospective study was conducted on 67 pregnant females who were admitted to the Obstetrics & Gynecology Department of The Emergency University Hospital of Bucharest between December 2016–March 2021, and who received corticosteroid before prematurely giving birth to 70 newborns. There was a group of 33 mothers with DM and a second group with 34 non-DM pregnant women selected for control of glucocorticoids’ real-life administration in the high risk for premature birth population. Results: The administration of glucocorticoids was not restricted by the presence of DM; 78% of the mothers with DM and 79.41% of the mothers without DM received one course of antenatal glucocorticoids for fetal lung maturation (p = 0.6). The incidence of ARDS differs between groups was statistically insignificant: 35.29% in the DM group versus 30.55% in the control group (p = 0.8). There were similar cases of maternal complications such as pregnancy-induced hypertension (PIH), or preeclampsia in the two groups. These findings suggest that glucocorticoid therapy is effective for premature newborns from pregnancies with DM and does not negatively impact the complication rate of the mothers, sustaining their administration in these cases. Conclusions: The administration of antenatal glucocorticoids before premature birth is not influenced by the presence of DM regarding Apgar score at 1 and 5 minutes, the incidence of ARDS, but there were differences such as more large for gestational age (LGA) newborns and neonatal hypoglycemia in the DM group. Considering the low number of patients enrolled from a single-center, future multicentric studies are needed. It is important to emphasize that this study’s findings reflect the local practice and cannot be generalized.

Acute Respiratory Distress Syndrome in Patients with Subarachnoid Hemorrhage: Incidence, Predictive Factors, and Impact on Mortality.

Acute respiratory distress syndrome (ARDS) is a known predictor of poor outcomes in critically ill patients. We sought to examine the role ARDS plays in outcomes in subarachnoid hemorrhage (SAH) patients. Prior studies investigating the incidence of ARDS in SAH patients did not control for SAH severity. Hence, we sought to determine the incidence ARDS in patients diagnosed with aneurysmal SAH and investigate the predisposing risk factors and impact upon outcomes. A retrospective cohort study was conducted using the National Inpatient Sample (NIS) database for the years 2008 to 2014. Multivariate stepwise regression analysis was performed to identify the risk factors and outcome associated with developing ARDS in the setting of SAH. We identified 170,869 patients with non-traumatic subarachnoid hemorrhage, of whom 6962 were diagnosed with ARDS and of those 4829 required mechanical ventilation. ARDS more frequently developed in high grade SAH patients (1.97 ± 0.05 vs. 1.15 ± 0.01; p < 0.0001). Neurologic predictors of ARDS included cerebral edema (OR 1.892, CI 1.180-3.034, p = 0.0035) and medical predictors included cardiac arrest (OR 4.642, CI 2.273-9.482, p < 0.0001) and cardiogenic shock (OR 2.984, CI 1.157-7.696, p = 0.0239). ARDS was associated with significantly worse outcomes (15.5% vs. 52.9% discharged home, 63.0% vs. 40.8% discharged to rehabilitation facility and 21.5% vs. 6.3% in-hospital mortality). Patients with SAH who developed ARDS were less likely to be discharged home, more likely to need rehabilitation and had a significantly higher risk of mortality. The identification of risk factors contributing to ARDS is helpful for improving outcomes and resource utilization.

SP-D and CC-16 Pneumoproteins' Kinetics and Their Predictive Role During SARS-CoV-2 Infection.

BackgroundSurfactant protein D (SP-D) and pulmonary club cell protein 16 (CC-16) are called “pneumoproteins” and are involved in host defense against oxidative stress, inflammation, and viral outbreak. This study aimed to determine the predictive value of these pneumoproteins on the incidence of acute respiratory distress syndrome (ARDS) or death in patients with coronavirus disease-2019 (COVID-19).MethodsThis retrospective study included 87 patients admitted to an emergency department. Blood samples were collected on three time points (days 1, 5, and 14 from hospital admission). SP-D and CC-16 serum levels were determined, and univariate and multivariate analyses considering confounding variables (age, body mass index, tobacco use, dyspnea, hypertension, diabetes mellitus, neutrophil-to-lymphocyte ratio) were performed.ResultsBased on the multivariate analysis, SP-D level on D1 was positively and slightly correlated with subsequent development of ARDS, independent of body mass index, dyspnea, and diabetes mellitus. CC-16 level on D1 was modestly and positively correlated with fatal outcome. A rise in SP-D between D1 and D5 and D1 and D14 had a strong negative association with incidence of ARDS. These associations were independent of tobacco use and neutrophil-to-lymphocyte ratio.ConclusionsOverall, our data reveal that increase in SP-D levels is a good prognostic factor for patients with COVID-19, and that initial CC-16 levels correlated with slightly higher risk of death. SP-D and CC-16 may prove useful to predict outcomes in patients with COVID-19.

Intraoperative High Tidal Volume Ventilation and Postoperative Acute Respiratory Distress Syndrome in Liver Transplant

Mechanical ventilation plays an important role in perioperative management and patient outcomes. Although mechanical ventilation with high tidal volume (HTV) is injurious in patients in the intensive care unit, the effects of HTV ventilation in patients undergoing liver transplant (LT) has not been reported. The aim of this study was to determine if intraoperative HTV ventilation was associated with the development of acute respiratory distress syndrome (ARDS). Patients undergoing LT between 2013 and 2018 at a tertiary medical center were reviewed. The tidal volume was recorded at 3 time points: after anesthesia induction, before liver reperfusion, and at the end of surgery. Patients were divided into 2 groups: HTV (>10 mL/kg predicted body weight [pBW]) and non-HTV (≤10 mL/kg pBW). The 2 groups were compared. Independent risk factors were identified by multivariable logistic models. Of 780 LT patients, 85 (10.9%) received HTV ventilation. Female sex and greater difference between actual body weight and pBW were independent risk factors for HTV ventilation. Patients who received HTV ventilation had a significantly higher incidence of ARDS (10.3% vs 3.9%; P=.01) than those who received non-HTV ventilation. In this retrospective study, we showed that HTV ventilation during LT was common and was associated with a higher incidence of ARDS. Therefore, tidal volume should be carefully selected during LT surgery. More studies using a prospective randomized controlled design are needed.

Risk Factors Analysis of Thoracic Trauma Complicated With Acute Respiratory Distress Syndrome and Observation of Curative Effect of Lung-Protective Ventilation.

PurposeTo explore the risk factors of acute respiratory distress syndrome (ARDS) secondary to thoracic trauma and the therapeutic effect of protective lung ventilation in patients with acute respiratory distress syndrome complicated with thoracic trauma.MethodsWe collected 206 patients with thoracic trauma admitted to our hospital from September 2017 to March 2021, counted the incidence of ARDS and analyzed the risk factors of ARDS. To observe the clinical efficacy of the application of lung-protective ventilation therapy in patients with thoracic trauma combined with ARDS.ResultsAmong 206 patients with thoracic trauma, there were 82 cases of combined ARDS, and its incidence was 39.81%. The 82 patients with ARDS were randomly divided into the control group and the observation group with 42 cases each, and different ventilation methods were used for treatment. The results showed that the mechanical ventilation time (MVT) was shorter in the observation group than in the control group, and the incidence of ventilator-associated lung injury (VALI) and case fatality rate (CFR) were lower than those in the control group (P < 0.05). Arterial partial pressure of oxygen (Pa02), arterial blood carbon dioxide partial pressure (PaCO2), and Oxygenation index (arterial partial pressure of oxygen/Fraction of inspiration O2, PaO2/FiO2) were significantly improved better in both groups after treatment; compared with the control group, patients in the observation group had higher Pa02 levels and lower PaCO2 levels at 8 h and 24 h after ventilation (P < 0.05). Multivariate analysis revealed that blunt trauma, massive blood transfusion, procalcitonin (PCT) level, tumor necrosis factor-α (TNF-α) level, and acute physiology and chronic health score (APACHE II) were all risk factors for Thoracic trauma with ARDS.ConclusionRisk factors for the development of ARDS after thoracic trauma are blunt injuries, massive blood transfusion, high PCT and TNF-α levels, and high APACHE II scores, which can be given active interventions in the early stage of clinical practice to improve patient prognosis. The use of protective lung ventilation therapy can improve the clinical outcome of patients with thoracic trauma combined with ARDS, which is important for improving the ventilation effect and respiratory function of patients.

Impact of early thoracic epidural analgesia in patients with severe acute pancreatitis.

This study was designed to assess the impact of thoracic epidural analgesia (TEA) in patients with severe acute pancreatitis (SAP). This is a single-centre retrospective study. In this study, the outcomes of SAP patients were compared between patients received TEA (TEA group) and without TEA (NTEA group). Early TEA was defined as TEA performed within 48hours after onset. The main outcome was the mortality at 30days after ICU admission, and secondary outcomes included the incidence of acute respiratory distress syndrome (ARDS), the acute renal injury (AKI) and sepsis, the hospital stay and hospitalization expenses. The mortality of SAP patients in TEA versus NTEA was 8.0% and 13.3% (p=.1520). Multivariate regression analysis showed significant difference in mortality between the TEA and NTEA groups (OR, 0.387; 95% CI, 0.168-0.892; p=.026). The incidence of ARDS in TEA versus NTEA was 46.0% and 62.4% (p=.0044); the proportion of patients requiring invasive ventilator assisted ventilation in TEA, and NTEA was 22.6% and 39.2% (p=.0016). The incidence of AKI in TEA versus NTEA was 27.7% and 45.3% (p=.0044); the proportion of patients needing for continuous renal replacement therapy (CRRT) in TEA and NTEA was 48.2% and 74.0% (p<.0001). The mortality of SAP patients in early TEA versus NTEA was 4.8% and 15.3% (p=.0263). TEA was associated with low incidence of ARDS and AKI in patients with SAP. Early TEA may benefit mortality in SAP patients and is a possible protective factor for the mortality of SAP patients.

Incidence and Outcomes of Respiratory Failure after Nonmyeloablative Related Haploidentical Blood or Marrow Transplantation

Respiratory failure is a devastating complication of allogenic blood or marrow transplantation (BMT). Prior data suggest that respiratory failure occurs in 20% of BMT recipients and acute respiratory distress syndrome (ARDS) occurs in 15%. Nonmyeloablative (NMA) haploidentical BMT allows donor pool expansion and may decrease complications. Incidence, outcomes, and risk factors for respiratory failure after NMA haploidentical BMT are unknown. This study aimed to determine the incidence of respiratory failure after NMA haploidentical BMT and explore outcomes and risk factors for respiratory failure. In this single-center, retrospective study of all patients age >18 years undergoing NMA haploidentical BMT between 2004 and 2016, the primary outcome was respiratory failure, marked by the use of high-flow nasal cannula oxygen, noninvasive ventilation (NIV), or invasive mechanical ventilation (IMV) within 2 years after BMT. Respiratory failure incidence is reported as incidence rate ratio (IRR) with 95% confidence interval (CI). Unadjusted and multivariable Cox proportional hazards models with adjustment for a priori identified patient-level characteristics were used. Results are presented as hazard ratio (HR) with 95% CI. A total of 520 patients underwent NMA haploidentical BMT, of whom 82 (15.8%) developed respiratory failure (IRR, 0.114/person-year) at a median of 0.34 year (interquartile range, 0.06 to 0.75 year) after BMT. Older age (HR, 1.04; 95% CI, 1.02 to 1.07), transplantation for myelodysplastic syndrome (MDS) (HR, 1.99; 95% CI, 1.07 to 3.72), and parent donor (HR, 3.49; 95% CI, 1.32 to 9.26) were associated with an increased risk of respiratory failure, whereas higher pretransplantation lung diffusion capacity of carbon monoxide (DLCO; % of predicted) was associated with lower risk (HR, 0.98; 95% CI, 0.77 to 0.99). Sixty-one patients (11.7%) required IMV, and 30 were successfully extubated. Only 37 patients (7%) had ARDS. Of the 82 patients with respiratory failure, 43 (52.4%) died during index hospitalization and 61 (77.2%) died by 2 years post-transplantation. Only 40 (49%) had nonrelapse mortality. The incidence of respiratory failure and ARDS after NMA haploidentical BMT is modest at 15% by 2 years post-transplantation. Despite successful extubation in >50% of patients, respiratory failure, regardless of cause, is associated with a high rate of death by 2 years from both relapse and nonrelapse causes. Age, BMT for MDS, parental donor, and pretransplantation DLCO are risk factors for respiratory failure.

Abstract 13658: Characterization of Acute Respiratory Distress Syndrome in Post-Cardiac Arrest Patients

Introduction: Acute respiratory distress syndrome (ARDS) may be precipitated by cardiac arrest, but the incidence and epidemiology of post-arrest ARDS is not well characterized in the in-hospital cardiac arrest (IHCA) setting. This study aimed to describe the incidence of ARDS after IHCA and ARDS-associated IHCA outcomes. Methods: This was a single-center retrospective study of adult patients admitted to the hospital between 2017-2018 who suffered IHCA, were resuscitated, and were intubated within 2 hours of arrest. Patients who died or were extubated on the day of resuscitation and those with pre-arrest ARDS were excluded. Post-IHCA ARDS was defined as meeting the Berlin criteria in the first 3 days after the cardiac arrest. Outcomes included hospital length-of-stay and hospital mortality. Results: Of the 105 patients included, 78 (74.3%) developed ARDS within 3 days of arrest. The mean PaO2:FiO2 ratio was 222 (SD 105). Of those with ARDS, most had mild (32%) or moderate (41%) disease. Patients with ARDS had a median hospital and ICU length of stay of 17 (IQR: 8, 31) and 7.5 (IQR: 3, 16) days compared to patients without ARDS, who had a median hospital and ICU length of stay of 10 (IQR: 7, 19) and 5 (IQR: 3, 11) days (p&gt;0.1 for both comparisons). There was a higher use of midazolam in patients with ARDS (18% vs 4%), but this was not statistically significant (p=0.1). Conclusion: There is a high incidence (74%) of post-arrest ARDS in IHCA patients. This compares to recent estimates suggesting a post-arrest ARDS incidence of approximately 50% in the out-of-hospital arrest population. While there was no statistically significant difference in outcomes, this study was limited by a small sample size. Future studies should further investigate these relationships in a larger cohort.

A Comparative Outcome Analysis of COVID-19 and Influenza Infection in Patients with Hematological Malignancies

A Comparative Outcome Analysis of COVID-19 and Influenza Infection in Patients with Hematological Malignancies

Impact of Platelet Transfusion on Pulmonary Function of Hematology Oncology Patients: The Piper Study

Background. Platelet transfusion is a critical therapy for hematology-oncology patients at risk of transfusion-transmitted infection (TTI) and pulmonary injury. Amotosalen-UVA pathogen reduction (PR) treatment of apheresis platelet components (PC) in plasma or additive solution (INTERCEPT Blood System for Platelets, Cerus, Concord, CA) is FDA approved to reduce risk of TTI and transfusion associated graft vs. host disease (TA-GVHD). PRPC meet the FDA bacteria risk reduction guidance, and approximately 50% of U.S. PC are PRPC. Amotosalen-UVA PR replaces bacteria screening, gamma irradiation, and CMV serology. PR is performed within 24 hours of collection enabling early release of PRPC with 5-day storage. We tested the hypothesis that PRPC were not inferior to conventional PC(CPC) for the incidence of pulmonary injury. Methods. An open-label sequential cohort study in platelet transfusion dependent hematology-oncology patients was conducted under routine practice conditions in 15 clinical centers. Each site enrolled a CPC cohort followed by a PRPC cohort using 4 primary therapy strata matched ± 10%: chemotherapy without hematopoietic cell transplant (HCT), HCT with myeloablation, HCT with non-myeloablative conditioning, and HCT with reduced intensity conditioning (RIC). Patients were supported with the assigned PC type for up to 21 days with 7 days of surveillance after the last PC exposure. Patients participated in only one cohort. The primary endpoint was treatment emergent assisted mechanical ventilation (TEAMV) by intubation or tight mask with positive end expiration pressure (5cm H 2O) after initiation of study PC. All endpoint patients were adjudicated by a blinded pulmonary expert panel (PEP) for diagnosis of acute respiratory distress syndrome (ARDS) by the Berlin Criteria. Secondary endpoints included: time to initiation of TEAMV, clinically significant pulmonary adverse events (CSPAE, CTCAE ≥ Grade 2), transfusion reactions, and mortality. The incidence of TEAMV by non-inferiority (margin = 2.3%), and secondary endpoints were analyzed by modified intention to treat (mITT) and per protocol (PP). Sensitivity analyses with propensity score matching for key variables were conducted for the primary endpoint. The associations between PC and categorical variables were tested by stratified Cochran-Mantel-Haenszel and continuous variables by ANOVA for two-sided significance p = 0.05. results. A total of 2291 pediatric and adult patients (1068 PRPC and 1223 CPC) were enrolled in the respective cohorts with transfusion of 5,277 PRPC and 5,491 CPC. PC assignment compliance and study completion were > 94%. For the mITT data set, the cumulative incidence of TEAMV was lower for the PRPC cohort (log rank p = 0.039) than the CPC cohort (2.9% versus 4.6%, HR = 0.633: 95% CI 0.408-0.982). PRPC by mITT were non-inferior to CPC for the incidence of TEAMV due to all indications, and for TEAMV with pulmonary dysfunction (PD) by PEP (Table). PP analyses were consistent with mITT. Relative risk (RR) of TEAMV showed significantly (p<0.05) decreased RR of PRPC respectively for baseline covariates: age < 65 (0.53), male (0.54), non-white (0.32), chemotherapy (0.40), prior pulmonary disease (0.55), and prior cardiac disease (0.58). Least squares (LS) mean days to initiation of TEAMV for patients with PD were longer for PRPC recipients. PEP adjudicated incidence of ARDS was not significantly different between cohorts (Table). Total and serious CSPAE were not different between the cohorts. There were no significant differences between cohorts in Respiratory, Thoracic, and Mediastinal Disorders, the most frequent system organ class event. Mortality was not different between cohorts. Multivariate analysis (mITT) for the probability of CSPAE or transfusion associated cardiac overload (TACO) showed PC type had no effect. The odds ratio (OR) of CSPAE or TACO during PC support was significantly increased (p< 0.05) in both cohorts for history of cardiac disease (1.35), history of pulmonary disease (2.57), diagnosis of Myelodysplasia (1.88), and diagnosis of Myelodysplasia/Myeloproliferative disease (2.27). There was a significant treatment interaction (p= 0.043) between PC type and acute myelogenous leukemia (AML), increased OR = 1.49 for CPC versus PRPC. Conclusions. PRPC did not potentiate pulmonary injury during PC support; and their use may decrease TEAMV risk with benefit of reduced TTI risk. [Display omitted] DisclosuresWheeler: Novo Nordisk A/S: Consultancy; Bayer: Consultancy; BioMarin: Consultancy; HEMA Biologics: Consultancy; Spark: Consultancy; Takeda: Consultancy; UniQure: Consultancy. Nooka: Janssen Oncology: Consultancy, Research Funding; Takeda: Consultancy, Research Funding; Sanofi: Consultancy; Oncopeptides: Consultancy; Amgen: Consultancy, Research Funding; Bristol-Myers Squibb: Consultancy; Adaptive technologies: Consultancy; GlaxoSmithKline: Consultancy, Other: Travel expenses; Karyopharm Therapeutics: Consultancy. Uhl: UpToDate: Patents & Royalties; Abbott: Consultancy, Speakers Bureau; Grifols: Consultancy, Speakers Bureau. Spinella: Secure Transfusion Services: Current Employment, Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company; Cerus Corporation: Consultancy, Research Funding. Liu: Cerus Corporation: Current Employment, Current equity holder in publicly-traded company. Benjamin: Cerus Corporation: Current Employment, Current equity holder in publicly-traded company. Corash: Cerus Corporation: Current Employment, Current equity holder in publicly-traded company.

Epidemiology and Outcomes of Critically Ill Children at Risk for Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study.

Interventional trials aimed at pediatric acute respiratory distress syndrome prevention require accurate identification of high-risk patients. In this study, we aimed to characterize the frequency and outcomes of children meeting "at risk for pediatric acute respiratory distress syndrome" criteria as defined by the Pediatric Acute Lung Injury Consensus Conference. Planned substudy of the prospective multicenter, international Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study conducted during 10 nonconsecutive weeks (May 2016-June 2017). Thirty-seven international PICUs. Three-hundred ten critically ill children meeting Pediatric Acute Lung Injury Consensus Conference "at-risk for pediatric acute respiratory distress syndrome" criteria. None. We evaluated the frequency of children at risk for pediatric acute respiratory distress syndrome and rate of subsequent pediatric acute respiratory distress syndrome diagnosis and used multivariable logistic regression to identify factors associated with subsequent pediatric acute respiratory distress syndrome. Frequency of at risk for pediatric acute respiratory distress syndrome was 3.8% (95% CI, 3.4-5.2%) among the 8,122 critically ill children who were screened and 5.8% (95% CI, 5.2-6.4%) among the 5,334 screened children on positive pressure ventilation or high-flow oxygen. Among the 310 at-risk children, median age was 2.1 years (interquartile range, 0.5-7.3 yr). Sixty-six children (21.3%) were subsequently diagnosed with pediatric acute respiratory distress syndrome, a median of 22.6 hours (interquartile range, 9.8-41.0 hr) later. Subsequent pediatric acute respiratory distress syndrome was associated with increased mortality (21.2% vs 3.3%; p < 0.001) and longer durations of invasive ventilation and PICU care. Subsequent pediatric acute respiratory distress syndrome rate did not differ by respiratory support modality at the time of meeting at risk criteria but was independently associated with lower initial saturation:Fio2 ratio, progressive tachycardia, and early diuretic administration. The Pediatric Acute Lung Injury Consensus Conference "at-risk for pediatric acute respiratory distress syndrome" criteria identify critically ill children at high risk of pediatric acute respiratory distress syndrome and poor outcomes. Interventional trials aimed at pediatric acute respiratory distress syndrome prevention should target patients early in their illness course and include patients on high-flow oxygen and positive pressure ventilation.

A Prospective Study of Specialized Coagulation Parameters in Admitted COVID-19 Patients and Their Correlation With Acute Respiratory Distress Syndrome and Outcome.

BackgroundAcute respiratory distress syndrome (ARDS) is a frequent complication of COVID-19 and is associated with a component of thrombo-inflammation and cytokine storm. COVID-19 also affects the hemostatic system causing multiple coagulation abnormalities that is a cause of concern and needs to be addressed. ObjectiveWe aimed to assess coagulation parameters of COVID-19 patients and identify whether they could be used as potential prognostic biomarkers to predict ARDS and immediate outcomes.MethodsThis was a prospective study done on 68 patients at four serial time points. Patients between 18-85 years admitted to the hospital as in-patients and ICU with a confirmed diagnosis of COVID-19 by RT-PCR were included. Exclusion criteria included pregnancy, patients below and above the mentioned age, previously known coagulopathy, systemic anticoagulants or anti-platelet therapy or vitamin K antagonists and moribund patients. Patients were divided into three categories based on SOFA score at admission, presence (group 1) or absence (group 2) of ARDS and outcome (dead or alive). Routine and specialized coagulation tests were performed on patients' platelet-poor plasma at the time of study inclusion (day 0), days 3, 7 and at discharge on STAR Max®3 (Diagnostica Stago France) automated coagulation analyzer and included prothrombin time (PT), international normalized ratio (INR) (STA® -NeoPTimal), activated partial thromboplastin time (APTT) (STA® -Cephascreen), fibrinogen (STA® Liquid Fib), D-dimer (STA® LiatestD- Dimer), Protein C (STA Stachrom® Protein C), Protein S (STA® Latest Free Protein S) and Antithrombin (STA® Chrom ATIII). ELISA did testing for tissue plasminogen activator (Asserachrom® tPA) as per the manufacturer's protocol.ResultsSixty-eight patients, including 43 (63%) males and 25 (37%) females, with a median age of 48 years (IQR 20-85), were recruited in this study. The incidence of ARDS was 34%, with a mortality of 13%. History of contact with a COVID-19 case was present in 71% (48/68) of the patients. Fever was the most common presenting symptom in 84% (57/68) of the patients. The most common comorbidities were hypertension and diabetes mellitus (DM) in 22% (15/68) and 21% (14/68) of the patients. DM (p=0.07) and chronic obstructive pulmonary disease (COPD) (p=0.03) were significantly associated with ARDS. DM (p=0.02), hypertension (p=0.01), and COPD (p=0.02) were also significantly associated with mortality. APTT was markedly prolonged among non-survivors at day 0 (D0) and D7 (p=0.03, p=0.02). D-Dimer was elevated in 38/68 (56%) patients at D0. D-Dimer levels were significantly higher in non-survivors (p<0.001), in ARDS patients (p=0.001) and patients with higher SOFA scores (p=0.001). ROC curve showed that D-dimer cut-off > 2.13 (AUC of 0.86) and >0.85 (AUC of 0.74) predicts mortality and ARDS, respectively. Among the natural anticoagulants, protein C was significantly associated with a high SOFA score at D0 and D3 (p=0.04). ConclusionDiabetes mellitus, hypertension and COPD were associated with poor outcomes. D-dimer levels must be monitored in COVID patients due to their association with ARDS and mortality. We observed that the levels of natural anticoagulants fell during the illness, making them prone to coagulopathies; however, none were seen in this study. Elevated tPA levels were also found in our patients; fibrinolytic therapy may benefit COVID-19 patients suffering from ARDS.

Study of Human Neutrophil Elastase Levels and the Correlation with ARDS Severity in Thoracic Trauma Patients

Introduction: Thoracic trauma is trauma that hits the thoracic wall or intra-thoracic organs, either due to blunt trauma or due to sharp trauma. In thoracic trauma often causes impaired ventilation perfusion due to damage to the lung parenchyma. This results in impaired tissue oxygenation, which is one of the causes of Acute respiratory distress Syndrome (ARDS). These changes are caused by the release of pro-inflammatory mediators, plasmatic proteins and proteases into the alveolar space associated with ongoing edema, as well as oxidative products that ultimately result in severe inhibition of the surfactant system. Method: This study will examine the relationship between plasma elastase levels as a predictor of the incidence of ARDS in thoracic trauma patients in Malang. This study is an observational cohort study. The research subjects were thoracic trauma patients who fit the criteria. Result: I t can be concluded that there is a significant relationship between elastase levels and BGA-3. The elastase level is below the value of 11.65 ±1.85, the patient is likely not to experience ARDS in the future. If the value of elastase levels is limited to 23.79 ±3.95, the patient will experience mild type ARDS. Meanwhile, if the value of elastase levels is limited to 57.68 ±18.55, in the future the patient will experience moderate type of ARDS. Meanwhile, if the elastase level is between 107.85 ± 5.04, the patient will likely experience severe ARDS. Conclusion: Based on the characteristic test of the sample characteristics, diagnosis and action, there are significant differences in the causes of ARDS. Neutophil elastase levels correlate with the degree of ARDS incidence.

Acute Respiratory Distress Syndrome (ARDS) after trauma: Improving incidence, but increasing mortality.

Acute Respiratory Distress Syndrome (ARDS) is an infrequent, yet morbid inflammatory complication in injury victims. With the current project we sought to estimate trends in incidence, determine outcomes, and identify risk factors for ARDS and related mortality. The national Trauma Quality Improvement Program dataset (2010-2014) was queried. Demographics, injury characteristics and outcomes were compared between patients who developed ARDS and those who did not. Logistic regression models were fitted for the development of ARDS and mortality respectively, adjusting for relevant confounders. In the studied 808,195 TQIP patients, incidence of ARDS decreased over the study years (3-1.1%, p < 0.001), but related mortality increased (18.-21%, p = 0.001). ARDS patients spent an additional 14.7 ± 10.3 days in the hospital, 9.7 ± 7.9 in the ICU, and 6.6 ± 9.4 on mechanical ventilation (all p < 0.001). Older age, male gender, African American race increased risk for ARDS. Age, male gender, lower GCS and higher ISS also increased mortality risk among ARDS patients. Several pre-existing comorbidities including chronic alcohol use, diabetes, smoking, and respiratory disease also increased risk. Although the incidence of ARDS after trauma appears to be declining, mortality is on the rise.

Adherence to Lung-Protective Ventilation Principles in Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study.

To describe mechanical ventilation management and factors associated with nonadherence to lung-protective ventilation principles in pediatric acute respiratory distress syndrome. A planned ancillary study to a prospective international observational study. Mechanical ventilation management (every 6 hr measurements) during pediatric acute respiratory distress syndrome days 0-3 was described and compared with Pediatric Acute Lung Injury Consensus Conference tidal volume recommendations (< 7 mL/kg in children with impaired respiratory system compliance, < 9 mL/kg in all other children) and the Acute Respiratory Distress Syndrome Network lower positive end-expiratory pressure/higher Fio2 grid recommendations. Seventy-one international PICUs. Children with pediatric acute respiratory distress syndrome. None. Analyses included 422 children. On pediatric acute respiratory distress syndrome day 0, median tidal volume was 7.6 mL/kg (interquartile range, 6.3-8.9 mL/kg) and did not differ by pediatric acute respiratory distress syndrome severity. Plateau pressure was not recorded in 97% of measurements. Using delta pressure (peak inspiratory pressure - positive end-expiratory pressure), median tidal volume increased over quartiles of median delta pressure (p = 0.007). Median delta pressure was greater than or equal to 18 cm H2O for all pediatric acute respiratory distress syndrome severity levels. In severe pediatric acute respiratory distress syndrome, tidal volume was greater than or equal to 7 mL/kg 62% of the time, and positive end-expiratory pressure was lower than recommended by the positive end-expiratory pressure/Fio2 grid 70% of the time. In multivariable analysis, tidal volume nonadherence was more common with severe pediatric acute respiratory distress syndrome, fewer PICU admissions/yr, non-European PICUs, higher delta pressure, corticosteroid use, and pressure control mode. Adherence was associated with underweight stature and cuffed endotracheal tubes. In multivariable analysis, positive end-expiratory pressure/Fio2 grid nonadherence was more common with higher pediatric acute respiratory distress syndrome severity, ventilator decisions made primarily by the attending physician, pre-ICU cardiopulmonary resuscitation, underweight stature, and age less than 2 years. Adherence was associated with respiratory therapist involvement in ventilator management and longer time from pediatric acute respiratory distress syndrome diagnosis. Higher nonadherence to tidal volume and positive end-expiratory pressure recommendations were independently associated with higher mortality and longer duration of ventilation after adjustment for confounding variables. In stratified analyses, these associations were primarily influenced by children with severe pediatric acute respiratory distress syndrome. Nonadherence to lung-protective ventilation principles is common in pediatric acute respiratory distress syndrome and may impact outcome. Modifiable factors exist that may improve adherence.

Supplemental oxygen therapy in trauma patients: An exploratory registry-based study.

Supplemental oxygen (SO) is one of the most commonly administered drugs in trauma patients and is recommended by guidelines. However, evidence supporting uniform administration is sparse, and excess oxygen use has been shown to be harmful in other patient populations. We hypothesized that SO may be harmful in patients with oxygen saturation>97%. Patients with available information on SO-therapy in the American Trauma Quality Improvement Program 2017 database were included. Patients were categorized into 3 groups according to Emergency Department (ED) oxygen saturation: (1) saturation<94%; (2) saturation 94%-97%; (3) saturation 98%-100%. Primary outcome was in-hospital mortality with comparisons made between patients who received SO or not. Secondary outcome was acute respiratory distress syndrome (ARDS). Patients were compared after propensity score matching. Overall, 864340 patients were identified. Mean age was 47.4±24.4years, and median injury severity score was 9. SO was associated with an increased risk of in-hospital mortality: (all patients: adjusted odds ratio [aOR] with 95% confidence interval [CI] 3.07 [2.92-3.22], ED saturation <94%: 2.63 [2.38-2.91], ED saturation 94%-97%: 2.71 [2.47-2.97], ED saturation >97%: 3.38 [3.16-3.61]. Same pattern was seen for in-hospital ARDS: (aOR 1.79, 95% CI [1.59-2.02], ED saturation <94%: aOR 1.75, 95% CI [1.37-2.24], ED saturation 94%-97%: aOR 1.81, 95% CI [1.43-2.29, ED saturation >97%: aOR 2.31, 95% CI [1.92-2.79]). Based on propensity matched, registry data for trauma patients, the administration of SO was associated with a higher incidence of in-hospital mortality and ARDS. The highest risk was found in patients with an ED saturation >97%.

Establishment of a predictive model for acute respiratory distress syndrome and analysis of its predictive value in critical burn patients

Objective: To establish a predictive model for acute respiratory distress syndrome (ARDS) in critical burn patients with the screened independent risk factors, and to validate its predictive value. Methods: Totally 131 critical burn patients (101 males and 30 females, aged 18-84 years) who met the inclusion criteria were admitted to the Department of Burns of the Second Affiliated Hospital of Zhejiang University School of Medicine from January 2018 to December 2019. A retrospective case-control study was conducted. The patients were divided into ARDS group (54 cases) and non-ARDS group (77 cases) according to whether ARDS occurred or not. The statistics of patients in the two groups were recorded including the gender, age, burn index, combination of inhalation injury, smoking history, delayed resuscitation, indwelling nasogastric tube, and complication of sepsis, and the data were statistically analyzed with independent sample t test, chi-square test, and Fisher's exact probability test. The multivariate logistic regression analysis was performed on the indicators with statistically significant differences between the two groups to screen the independent risk factors for developing ARDS in critical burn patients, and the corresponding nomograph prediction model for the risk of ARDS in critical burn patients was established. The risk scores for patients developing ARDS were therefore obtained based on the above-mentioned nomograph, and the corresponding receiver operating characteristic (ROC) curve was drawn to calculate the area under the curve. The internal validation of the above-mentioned ARDS prediction model was performed using the Bootstrap method, and the area under the ROC curve was calculated for modeling group (79 cases) and validation group (52 cases), respectively. A calibration curve was drawn to assess the predictive conformity of the above-mentioned ARDS prediction model for the occurrence of ARDS in critical burn patients. Results: The burn index, proportion of combination of inhalation injury, and proportion of complication of sepsis of patients were significantly higher in ARDS group than in non-ARDS group (t=0.36, χ2=33.78, 49.92, P<0.01). The gender, age, smoking history, delayed resuscitation, and indwelling nasogastric tube of patients in ARDS group were close to those in non-ARDS group (P>0.05). The multivariate logistic regression analysis showed that the burn index, combination of inhalation injury, and complication of sepsis were the independent risk factors for developing ARDS in critical burn patients (odds ratio=1.05, 15.33, 5.02, 95% confidence interval=1.01-1.10, 2.65-88.42, 1.28-19.71, P<0.05 or P<0.01). The overall area under the ROC curve of the above-mentioned ARDS prediction model was 0.92 (95% confidence interval=0.88-0.97), and the area under the ROC curve was 0.95 and 0.91 (95% confidence interval=0.90-1.00, 0.86-0.97) for validation group and modeling group, respectively. When applying the above-mentioned ARDS prediction model for ARDS incidence prediction, there might be some risk of overestimating ARDS incidence when the prediction probability was <35.0% or >85.0%, and some risk of underestimating ARDS incidence when the prediction probability was 35.0%-85.0%. Conclusions: The burn index, inhalation injury, and sepsis are the independent risk factors for the occurrence of ARDS in critical burn patients. The risk prediction model for ARDS based on these three indicators has good predictive ability for ARDS in critical burn patients.

A Review of Acute Respiratory Distress Syndrome Management and Treatment.

Acute respiratory distress syndrome (ARDS) was first described in 1967, but its definition has evolved considerably since then. ARDS is defined as the onset of hypoxemia, tachypnea, and loss of lung compliance due to some stimulus. In the United States, the incidence of ARDS has been growing because it is being increasingly recognized. The incidence of ARDS has also gone up recently due to the COVID-19 pandemic. To date, there is no known one treatment for ARDS. Multiple studies have looked into various causes of ARDS, pathophysiology, and ventilation and management strategies. However, there is still considerable variability in the treatment and management of these patients from institution to institution. A literature search was conducted through PubMed and Google Scholar. Publications describing the epidemiology, diagnostic criteria, pathophysiology, and treatment were included in this review. The definition of ARDS has evolved over the years. The most recent and agreed upon diagnostic criteria are based on the Berlin criteria for ARDS. Management of patients with ARDS includes low tidal volume ventilation, prone ventilation, paralysis in certain patient populations, and perhaps extracorporeal membrane oxygenation (ECMO). This also applies to patients with ARDS due to COVID-19. Patients with ARDS have a high mortality due to the incredibly complex disease process. Because of the complexity of ARDS, the management and treatment is equally as difficult. This article reviews some of the strategies used to date, including the role of ECMO, and includes some society recommendations. Further research must be done into which methods best guide lung ventilation in severe ARDS and patients on ECMO.

Clinical outcome with different doses of low-molecular-weight heparin in patients hospitalized for COVID-19

A pro-thrombotic milieu and a higher risk of thrombotic events were observed in patients with CoronaVirus disease-19 (COVID-19). Accordingly, recent data suggested a beneficial role of low molecular weight heparin (LMWH), but the optimal dosage of this treatment is unknown. We evaluated the association between prophylactic vs. intermediate-to-fully anticoagulant doses of enoxaparin and in-hospital adverse events in patients with COVID-19. We retrospectively included 436 consecutive patients admitted in three Italian hospitals. Outcome according to the use of prophylactic (4000 IU) vs. higher (> 4000 IU) daily dosage of enoxaparin was evaluated. The primary end-point was in-hospital death. Secondary outcome measures were in-hospital cardiovascular death, venous thromboembolism, new-onset acute respiratory distress syndrome (ARDS) and mechanical ventilation. A total of 287 patients (65.8%) were treated with the prophylactic enoxaparin regimen and 149 (34.2%) with a higher dosing regimen. The use of prophylactic enoxaparin dose was associated with a similar incidence of all-cause mortality (25.4% vs. 26.9% with the higher dose; OR at multivariable analysis, including the propensity score: 0.847, 95% CI 0.400–0.1.792; p = 0.664). In the prophylactic dose group, a significantly lower incidence of cardiovascular death (OR 0.165), venous thromboembolism (OR 0.067), new-onset ARDS (OR 0.454) and mechanical intubation (OR 0.150) was observed. In patients hospitalized for COVID-19, the use of a prophylactic dosage of enoxaparin appears to be associated with similar in-hospital overall mortality compared to higher doses. These findings require confirmation in a randomized, controlled study.

Bilateral femoral shaft fracture in polytrauma patients: Can intramedullary nailing be done on an emergency basis?

IntroductionWhether damage control orthopedics (DCO) or early total care (ETC) is the best way to treat polytrauma patients who have suffered a bilateral femoral shaft fracture remains unanswered. The aim of this study was to evaluate the morbidity of bilateral femur fractures treated by simultaneous intramedullary (IM) nailing according to ETC principles. Materials and methodsThis retrospective single-centre study included all polytrauma patients who had suffered a femoral shaft fracture and were treated at our level I trauma centre. Demographic data, associated lesions, injury severity score (ISS) and occurrence of acute respiratory distress syndrome (ARDS) were collected prospectively in our trauma database. Unilateral fractures (UF) were compared to bilateral fractures (BF). The risk of ARDS was evaluated by multivariate logistic regression. ResultsBetween 2010 and 2019, 176 UF (88%) and 25 BF (12%) were included. Patients with BF had a higher ISS (36 vs. 25, p<0.001) and more brain injuries (44% vs. 15%, p=0.001) than patients with a UF. More blood transfusions were done in BF than UF (4.0 vs. 1.6 units, p=0.002). The incidence of ARDS was higher in BF patients than UF (36% vs. 4%) with longer stay in intensive care (18 vs. 12 days, p=0.02) and in the hospital (32 vs. 23 days, p=0.006). There were no deaths in either group. The risk of ARDS was correlated to ISS, but not to bilaterality. DiscussionStudies on DCO and ETC report similar mortality and ARDS rates for BF. ISS appears to determine the postoperative morbidity irrespective of how the patients are managed. In contrast with DCO, perioperative intensive care has a predominant role in ETC, allowing early definitive fixation of fractures, even in severely injured patients. ConclusionBilateral femoral shaft fractures are a sign of severe trauma leading to high postoperative morbidity. The patient is likely to have concomitant severe injuries. Simultaneous ECM can be done emergently providing appropriate perioperative intensive care management. Level of evidenceIV; retrospective study.