Management Of Acute Respiratory Distress Syndrome Research Articles

Effectiveness of Lung Ultrasound for Diagnosis of Acute Respiratory Distress Syndrome in Mechanically Ventilated Patients

Background: Acute respiratory distress syndrome (ARDS) requires rapid diagnosis for early intervention and improved outcomes. Lung ultrasound may be a reasonable alternative to chest X-ray for the identification of ARDS but the effectiveness of lung ultrasound in ARDS diagnosis is still uncertain. The objective of the study is to explore the efficacy of lung ultrasound (LUS) for diagnosis of ARDS in mechanically ventilated patients. Methods: A cross sectional study was conducted among 75 patients in Critical Care Centre, Combined Military Hospital, Dhaka from September 2021 to January 2022. The study was approved by the ethical committee in the hospital. In this study, the Bedside Lung Ultrasound in Emergency (BLUE) protocol for the immediate diagnosis of acute respiratory failure was followed. Purposive sampling technique was used. Data were analyzed by using Statistical Package For Social Sciences (SPSS) version 25.0. Results: A total of 75 patients were assessed. Among them male were 42(56%) and female 33(44%). The median age of patients was 48 years (Interquartile range 30-60). Primary diagnoses were pneumonia (22.67%), pulmonary oedema (20%), sepsis (20%) and trauma (17.33%). A total of 34(45.33%) patients fulfilled ‘CXR-based Berlin Definition’ and a total of 36(48%) patients were diagnosed as ARDS by ‘LUS-based Berlin Definition’. Considering the ‘CXR-based Berlin Definition’ as reference standard, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of lung ultrasound were 85.29%, 82.92%, 80.55%, 87.18% and 84% respectively. Conclusion: Lung ultrasound can be an effective tool for the diagnosis & management of ARDS in the intensive care unit. Bangladesh Armed Forces Med J Vol 56 No (2) December 2023, pp 51-57

Temporal and regional trends of case-fatality in patients hospitalized with acute respiratory distress syndrome in Germany

Abstract Funding Acknowledgements None. Aims Significant progress has been made in understanding the pathophysiology of acute respiratory distress syndrome (ARDS). However, ARDS it is still a life-threatening medical condition with a high mortality rate. Little is known about temporal trends and regional variations in Germany. Methods We analyzed data on the characteristics, comorbidities and in-hospital outcomes for all hospitalized patients with ARDS in Germany between 2005 and 2019. Diagnoses were coded according to the International Classification of Diseases and Related Health Problems, 10th Revision with German Modification (ICD-10-GM), and diagnostic, surgical or interventional procedures according to the German Procedure Classification (OPS, surgery and procedures codes. The computed study analyses were performed on our behalf by the Research Data Center of the Federal Statistical Office and the Statistical Offices of the federal states in Wiesbaden, Germany. Results Overall, 8,369,723 inpatients aged ≥18 years were included in this analysis; among these, 155,872 (1.9%) were codes with the diagnosis of ARDS. The annual number of ARDS cases increased from 7,286 in 2005 to 13,722 in 2019 in parallel with a significant decrease of in-hospital mortality. Overall, 74,751 (48.0%) patients with ARDS died during the in-hospital stay and in-hospital case-fatality grew exponentially with age. Independent predictors of in-hospital fatality with an OR >2 were age ≥70 years, necessity of ECMO, severe liver disease, acute renal failure, dialysis, shock and cardio-pulmonary resuscitation. Most patients with ARDS were treated in hospitals in urban areas (n=56,582) with a high case-fatality rate (49.7%), but also with concomitant high proportion rate of mechanical ventilation (23.7%) compared to hospitals in suburban or rural areas. Conclusion The number of patients with ARDS increased markedly in Germany between 2005 and 2019, in parallel with a decrease of in-hospital fatality. Our findings may suggest that general management of ARDS have improved over time and might draw more attention to predictors for in-hospital fatality in patients hospitalized with ARDS. The need for mechanical ventilation and a poor outcome was more likely in urban areas – this might be accentuated by patient transfer to specialized high care centers usually located in urban settings.

A scale-free model of acute and ventilator-induced lung injury: a network theory approach inspired by seismology.

Acute respiratory distress syndrome (ARDS) presents a significant clinical challenge, with ventilator-induced lung injury (VILI) being a critical complication arising from life-saving mechanical ventilation. Understanding the spatial and temporal dynamics of VILI can inform therapeutic strategies to mitigate lung damage and improve outcomes. Histological sections from initially healthy mice and pulmonary lavage-injured mice subjected to a second hit of VILI were segmented with Ilastik to define regions of lung injury. A scale-free network approach was applied to assess the correlation between injury regions, with regions of injury represented as 'nodes' in the network and 'edges' quantifying the degree of correlation between nodes. A simulated time series analysis was conducted to emulate the temporal sequence of injury events. Automated segmentation identified different lung regions in good agreement with manual scoring, achieving a sensitivity of 78% and a specificity of 85% across 'injury' pixels. Overall accuracy across 'injury', 'air', and 'other' pixels was 81%. The size of injured regions followed a power-law distribution, suggesting a 'rich-get-richer' phenomenon in the distribution of lung injury. Network analysis revealed a scale-free distribution of injury correlations, highlighting hubs of injury that could serve as focal points for therapeutic intervention. Simulated time series analysis further supported the concept of secondary injury events following an initial insult, with patterns resembling those observed in seismological studies of aftershocks. The size distribution of injured regions underscores the spatially heterogeneous nature of acute and ventilator-induced lung injury. The application of network theory demonstrates the emergence of injury 'hubs' that are consistent with a 'rich-get-richer' dynamic. Simulated time series analysis demonstrates that the progression of injury events in the lung could follow spatiotemporal patterns similar to the progression of aftershocks in seismology, providing new insights into the mechanisms of injury distribution and propagation. Both phenomena suggest a potential for interventions targeting these injury 'hubs' to reduce the impact of VILI in ARDS management.

The value of point-of-care ultrasound in the diagnosis and management of acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) continues to cause significant morbidity and mortality worldwide. However, there are currently no corresponding specific medications. Lung, right heart, and diaphragm protective therapy is the cornerstone of ARDS management. Non-invasive, radiation-free, and transportation-free point-of-care ultrasound enables for real-time dynamic evaluation of the lung, right heart, and diaphragm. It is an essential tool for the diagnosis, monitoring, and clinical decision-making of ARDS patients. However, ultrasound has several limitations, and its clinical application must be carefully evaluated in conjunction with clinical symptoms and other monitoring techniques. Further research is needed to determine whether clinical decision-making based on point-of-care ultrasound examination can improve the prognosis of ARDS patients.

Use of inhaled vasodilators in ARDS patients

Abstract:
 Acute Respiratory Distress Syndrome (ARDS) is a severe lung injury leading to bilateral lung opacities and severe hypoxemic respiratory failure. It results from acute inflammation, endothelial dysfunction, and disruption of the alveolar-capillary membrane. ARDS management encompasses lung-protective supportive care such as lung-protective ventilation strategies. Inhaled pulmonary vasodilators show potential as adjunctive therapies for refractory hypoxemia and hold promise in improving oxygenation and reducing pulmonary vascular resistance in severe ARDS. However, their impact on mortality remains uncertain and current evidence supports their role as rescue therapies. Prudent consideration and assessment of potential benefits and risks are crucial when integrating these agents into clinical practice.

Respiratory extracorporeal membrane oxygenation : From rescue therapy to standard tool for treatment of acute respiratory distress syndrome?

The use of extracorporeal membrane oxygenation (ECMO) for patients with acute respiratory distress syndrome (ARDS) has increased substantially. With modern trials supporting its efficacy, ECMO has become an important tool in the management of severe ARDS. The objectives of this paper are to discuss ECMO physiology and configurations used for patients with ARDS, review evidence supporting the use of ECMO for ARDS, and discuss aspects of management during ECMO. Current evidence supports the use of ECMO, combined with an ultra-lung-protective approach to mechanical ventilation, in patients with ARDS who have refractory hypoxemia or hypercapnia with severe respiratory acidosis. Furthermore, data suggest that center volume and experience are important factors in the care of patients receiving ECMO. The use of extracorporeal technologies in expanded patient populations and the optimal management of patients during ECMO remain areas of investigation. This article is freely available.

MANAGEMENT OF ARDS IN DROWNING PATIENT IN INTENSIVE CARE UNIT

Acute Respiratory Distress Syndrome (ARDS) occured in drowning patients in both fresh or salt water. This is a consequence of aspiration of fluid into the lungs. This condition can be made worse by the possibility of hypothermia, arrhythmia, or neurological impacts as a result of anoxia. A male, 16 years old, 60 kg without comorbid was drowned in a well, came on referral from a another hospital, he was admitted to the ward for 2 days. The patient arrived in emergency room and the patient is in respiratory failure state and ARDS. This patient was given intubation in the emergency room, after this patient is stable he was transfered to ICU. In the ICU, the patient was given mechanical ventilation therapy on 4th day and then he was given weaning gradually, on 7th day the patient was given extubation. In general, treatment outcome of drowned patient really depends on how effective and fast the maangement of the respiratory distress in the incident location and until taken to hospital. Mechanical ventilation therapy follows the general ARDS management pattern, using PEEP and lung protection strategies. Monitoring and caution is needed during the weaning process to prevent recurrence of pulmonary edema and re-intubation.

Is Prone Positioning Worth the Turn in Pediatrics? Unraveling the Oxygenation Mystery in Ventilated Patients with Acute Respiratory Distress Syndrome: An Observational Study Introducing a Novel SF Ratio Method for Non-Invasive Monitoring in Children

Background: Respiratory illnesses are prevalent among children, attributed to factors such as immature immune systems, anatomical variations, and increased susceptibility to infections. Acute respiratory distress syndrome (ARDS) is a significant cause of morbidity and mortality, necessitating various forms of respiratory support in pediatric intensive care units (PICUs). Prone positioning has emerged as a strategy to improve oxygenation in ARDS, but its effectiveness and correlation with non-invasive monitoring parameters remain underexplored.
 Subjects and Methods: This prospective observational study, conducted in the PICU of Dr. B.C Roy PGIPS, Kolkata, aimed to assess the impact of prone ventilation on oxygenation in children diagnosed with ARDS. The study, spanning 18 months, included 40 patients aged 3 months to 12 years requiring mechanical ventilation. Parameters such as oxygenation index (OI), oxygen saturation index (OSI), PF ratio, and SF ratio were monitored at different time points during supine and prone ventilation. Prone positioning's effectiveness was evaluated based on improvements in these parameters.
 Results: The study revealed a significant improvement in oxygenation status after four hours of prone ventilation compared to supine ventilation. Oxygenation index, OSI, SF ratio, and PF ratio showed statistically significant changes favoring prone positioning. A strong positive correlation between SF ratio and PF ratio was observed at various time points, emphasizing the potential of SF ratio as a non-invasive alternative. Responders and non-responders to prone positioning were identified based on predefined criteria, highlighting individual variability in treatment response.
 Conclusion: Prone ventilation demonstrated significant improvements in oxygenation parameters in children with ARDS. The study supports the use of non-invasive SF ratio as a reliable substitute for PF ratio, simplifying monitoring without invasive arterial sampling. This finding has implications for improving ARDS management strategies in pediatric patients, offering a less cumbersome alternative for assessing oxygenation status.

Effect of piperacillin sodium and sulbactam sodium on respiratory function in patients with acute respiratory distress syndrome

Purpose: To investigate the effect of the combination of piperacillin sodium and sulbactam sodium on respiratory function in patients with acute respiratory distress syndrome (ARDS).
 Methods: The clinical data for 151 ARDS patients admitted in Tianjin Hospital of ITCWM Nankai Hospital, Tianjin China from January 2020 to January 2021 were analyzed in this retrospective study. The patients were assigned to two groups based on different treatment regimens. Control group (COG) comprised 77 patients who received basic treatment (mechanical ventilation and drug treatment using oxazolidinones), while 74 patients who received basic treatment together with a combination of piperacillin sodium and sulbactam sodium (4 g of piperacillin and 0.5 g of sulbactam (for adults) through intravenous injection for 2 weeks continuously) were in study group (STG). Respiratory function was assessed in the two groups post-treatment using the basic dyspnea index (BDI) measurement. Mechanical ventilation time, intensive care unit (ICU) stay time and 28-day mortality rate after treatment, were also recorded.
 Results: Following treatment, patients in STG had significantly higher levels of partial pressure of arterial oxygen (PaO2) and oxygenation index (PaO2/FiO2), significantly lower partial pressure of carbon dioxide (PaCO2), markedly lower levels of pentraxin-3 (PTX-3) and procalcitonin (PCT), significantly higher score on BDI scale, and overtly lower mechanical ventilation time and ICU stay time, than COG (p < 0.05).
 Conclusion: Piperacillin sodium and sulbactam sodium combination significantly relieves clinical symptoms of ARDS such as breathlessness and chest discomfort in patients, resulting in improved respiratory function. The effectiveness of this combination makes it a potential first-line treatment for further large-scale investigation in ARDS management.

Insuficiencia respiratoria en paciente con dengue en la unidad de cuidados intensivos. Reporte de un caso

The dengue epidemic currently affecting the Lambayeque department has set a historic record in terms of the number of diagnosed dengue patients compared to previous years. Additionally, numerous complications such as hemorrhages, multiorgan failure, and acute respiratory distress syndrome (ARDS) have been observed. This is why the case of a 60-year-old patient with sensory impairment and ARDS as the main complication is presented. Initially, she was treated at a private clinic and later referred to the Lambayeque Regional Hospital, where she was immediately assisted in the emergency department. After a few days, she showed mild recovery. However, after 10 days of symptoms with warning signs, she was admitted to the intensive care unit of the hospital for ARDS management.

Lactobacillus rhamnosus (LR) ameliorates pulmonary and extrapulmonary acute respiratory distress syndrome (ARDS) via targeting neutrophils

Pulmonary and extrapulmonary acute respiratory distress syndrome (ARDS) is a life-threatening respiratory failure associated with high mortality. Despite progress in our understanding of the pathological mechanism causing the crippling illness, there are currently no targeted pharmaceutical treatments available for it. Recent discoveries have emphasized the existence of a potential nexus between gut and lung health fueling novel approaches including probiotics for the treatment of ARDS. We thus investigated the prophylactic-potential of Lactobacillus rhamnosus-(LR) in lipopolysaccharide (LPS)-induced pulmonary and cecal ligation puncture (CLP) induced extrapulmonary ARDS mice. Our in-vivo findings revealed that pretreatment with LR significantly ameliorated vascular-permeability (edema) of the lungs via modulating the neutrophils along with significantly reducing the expression of inflammatory-cytokines in the BALF, lungs and serum in both pulmonary and extrapulmonary mice-models. Interestingly, our ex-vivo immunofluorescence and flow cytometric data suggested that mechanistically LR via short chain fatty acids (butyrate being the most potent and efficient in ameliorating the pathophysiology of both pulmonary and extra-pulmonary ARDS) targets the phagocytic and neutrophils extracellular traps (NETs) releasing potential of neutrophils. Moreover, our in-vivo data further corroborated our ex-vivo findings and suggested that butyrate exhibits enhanced potential in ameliorating the pathophysiology of ARDS via reducing the infiltration of neutrophils into the lungs. Altogether, our study establishes the prophylactic role of LR and its associated metabolites in the prevention and management of both pulmonary and extrapulmonary ARDS via targeting neutrophils.

Ventilatory Management of Patients with Acute Respiratory Distress Syndrome Due to SARS-CoV-2.

The emergence of the new SARS-CoV-2 in December 2019 caused a worldwide pandemic of the resultant disease, COVID-19. There was a massive surge in admissions to intensive care units (ICU), notably of patients with hypoxaemic acute respiratory failure. In these patients, optimal oxygen therapy was crucial. In this article, we discuss tracheal intubation to provide mechanical ventilation in patients with hypoxaemic acute respiratory failure due to SARS-CoV-2. We first describe the pathophysiology of respiratory anomalies leading to acute respiratory distress syndrome (ARDS) due to infection with SARS-CoV-2, and then briefly review management, focusing particularly on the ventilation strategy. Overall, the ventilatory management of ARDS due to SARS-CoV-2 infection is largely the same as that applied in ARDS from other causes, and lung-protective ventilation is recommended. The difference lies in the initial clinical presentation, with profound hypoxaemia often observed concomitantly with near-normal pulmonary compliance.

An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline.

Background: This document updates previously published Clinical Practice Guidelines for the management of patients with acute respiratory distress syndrome (ARDS), incorporating new evidence addressing the use of corticosteroids, venovenous extracorporeal membrane oxygenation, neuromuscular blocking agents, and positive end-expiratory pressure (PEEP). Methods: We summarized evidence addressing four "PICO questions" (patient, intervention, comparison, and outcome). A multidisciplinary panel with expertise in ARDS used the Grading of Recommendations, Assessment, Development, and Evaluation framework to develop clinical recommendations. Results: We suggest the use of: 1) corticosteroids for patients with ARDS (conditional recommendation, moderate certainty of evidence), 2) venovenous extracorporeal membrane oxygenation in selected patients with severe ARDS (conditional recommendation, low certainty of evidence), 3) neuromuscular blockers in patients with early severe ARDS (conditional recommendation, low certainty of evidence), and 4) higher PEEP without lung recruitment maneuvers as opposed to lower PEEP in patients with moderate to severe ARDS (conditional recommendation, low to moderate certainty), and 5) we recommend against using prolonged lung recruitment maneuvers in patients with moderate to severe ARDS (strong recommendation, moderate certainty). Conclusions: We provide updated evidence-based recommendations for the management of ARDS. Individual patient and illness characteristics should be factored into clinical decision making and implementation of these recommendations while additional evidence is generated from much-needed clinical trials.

Efficacy of Pulse Methylprednisolone in Treatment of Acute Respiratory Distress Syndrome due to Malaria: A Randomized Controlled Clinical Trial.

Objective: To study the efficacy of pulse methylprednisolone (MPS) therapy in patients with malaria-associated acute respiratory distress syndrome (ARDS). Materials and methods: The study was a randomized, single-blind, placebo-controlled trial with a total sample size of 44 patients. The total random number table was used on a computer for randomization. The sample size was divided into either the study group that received pulse MPS therapy along with the standard therapy to manage acute lung injury (ALI)/ARDS or the control group that received a placebo in the form of 100 mL of normal saline with the standard therapy to manage ALI/ARDS. The primary outcome was defined as either death of the patient or discharge from the hospital. The sequential organ failure assessment (SOFA) score, the lung injury score (LIS), duration of stay in the medical intensive care unit (MICU), number of days for which mechanical ventilation was required, and the rate of secondary infections between the study and the control groups were also calculated. Statistically significant differences among continuous variables were analyzed by t-test, and differences between categorical variables were assessed by Chi-squared test. Results: A total of 30 patients passed initial screening, out of which 60% were males and 40% were females. About 73.3% of the patients fell between the age groups of 36-45 years. A total of 20 patients (66.7%) were discharged from the hospital, while the remaining 10 patients succumbed to death in the intensive care unit (ICU) (33.3%). The outcome of death or discharge was found to be independent of the use of pulse MPS therapy (p = 0.44). No statistically significant difference was found between the partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio, SOFA score, and LIS between the two groups. Furthermore, the differences between the mean duration of stay in the MICU, the mean duration for the provision of mechanical ventilation (p = 0.41), and the rate of secondary infections (p = 0.46) remained unaffected with the use of pulse MPS therapy. Conclusion: Pulse MPS therapy has not shown any clear-cut benefit in the management of malaria-associated ARDS, and in fact, the continuous use of this treatment in hospitals may lead to worsened outcomes. A novel, effective therapy for this grave complication needs to be developed to reduce the morbidity and mortality in such patients, which is frequently encountered. The development of a robust surveillance system is required for adequate monitoring and early diagnosis of this complication, along with larger multicentric randomized clinical trials. Disclosures: Approval was granted by the Institutional Ethics Committee (IEC). All participants were only selected after taking their written informed consent. The authors have no conflicts of interest or acknowledgments to report. How to cite this article: Tiwari S, Kursange S, Goyal A, et al. Efficacy of Pulse Methylprednisolone in Treatment of Acute Respiratory Distress Syndrome due to Malaria: A Randomized Controlled Clinical Trial. J Assoc Physicians India 2023;71(11):36-39.

Outcomes and time trends of acute respiratory distress syndrome patients with and without liver cirrhosis: an observational cohort

BackgroundIn studies prior to lung-protective ventilation, liver cirrhosis in acute respiratory distress syndrome (ARDS) was associated with high mortality rates. Since patients with cirrhosis have been excluded from many trials on ARDS, their outcome when treated with lung-protective ventilation is unclear. The objectives were to assess whether cirrhosis is associated with mortality in ARDS and trends over time in mortality and severity.MethodsWe conducted a retrospective analysis of a prospective observational cohort conducted in a 20-bed tertiary ICU from October 2003 to December 2021. All consecutive adult critically ill patients with ARDS were included. ARDS was defined by the Berlin criteria. The primary outcome was 90 day mortality, assessed with Kaplan–Meier curves and multivariate Cox analysis. Time trends were assessed on 90 day mortality, Sequential Organ-Function Assessment score (SOFA) and non-hepatic SOFA. Ventilation settings were compared between patients with and without cirrhosis.ResultsOf the 7155 patients screened, 863 had a diagnosis of ARDS. Among these ARDS patients, 157(18%) had cirrhosis. The overall 90 day mortality was of 43% (378/863), 57% (90/157) in patients with cirrhosis and 41% (288/706) in patients without cirrhosis (p < 0.001). On survival curves, cirrhosis was associated with 90 day mortality (p < 0.001). Cirrhosis was independently associated with 90 day mortality in multivariate analysis (hazard ratio = 1.56, 95% confidence interval 1.20–2.02). There was no change in mortality over time in ARDS patients with and without cirrhosis. SOFA (p = 0.04) and non-hepatic SOFA (p = 0.02) increased over time in ARDS patients without cirrhosis, and remained stable in ARDS patients with cirrhosis. Tidal volume, positive end-expiratory pressure, plateau pressure and driving pressure were not different between ARDS patients with and without cirrhosis.ConclusionsAlthough ARDS management improved over the last decades, the 90 day mortality remained high and stable over time for both ARDS patients with (57%) and without cirrhosis (41%). Nevertheless, the severity of patients without cirrhosis has increased over time, while the severity of patients with cirrhosis has remained stable.Graphical

The Use of High-Flow Nasal Cannula and Non-Invasive Mechanical Ventilation in the Management of COVID-19 Patients: A Prospective Study.

High-flow nasal cannula (HFNC) and ventilator-delivered non-invasive mechanical ventilation (NIV) were used to treat acute respiratory distress syndrome (ARDS) due to COVID-19 pneumonia, especially in low- and middle-income countries (LMICs), due to lack of ventilators and manpower resources despite the paucity of data regarding their efficacy. This prospective study aimed to analyse the efficacy of HFNC versus NIV in the management of COVID-19 ARDS. A total of 88 RT-PCR-confirmed COVID-19 patients with moderate ARDS were recruited. Linear regression and generalized estimating equations (GEEs) were used for trends in vital parameters over time. A total of 37 patients were on HFNC, and 51 were on NIV. Patients in the HFNC group stayed slightly but not significantly longer in the ICU as compared to their NIV counterparts (HFNC vs. NIV: 8.00 (4.0-12.0) days vs. 7.00 (2.0-12.0) days; p = 0.055). Intubation rates, complications, and mortality were similar in both groups. The switch to HFNC from NIV was 5.8%, while 37.8% required a switch to NIV from HFNC. The resolution of respiratory alkalosis was better with NIV. We conclude that in patients with COVID-19 pneumonia with moderate ARDS, the duration of treatment in the ICU, intubation rate, and mortality did not differ significantly with the use of HFNC or NIV for respiratory support.

Feasibility, safety and efficacy of COVID-19 severe acute respiratory distress syndrome management without invasive mechanical ventilation.

COVID-19 acute respiratory distress syndrome (ARDS) is often managed with mechanical ventilation (MV), requiring sedation and paralysis, with associated risk of complications. There is limited evidence on the use of high flow nasal cannula (HFNC). We hypothesized that management of COVID-19 ARDS without MV is feasible. Included were all adult patients diagnosed with COVID-19 ARDS, with PaO<inf>2</inf>/FiO<inf>2</inf> ratio <100 at admission, and whose management was initially performed without MV. We evaluated need for intubation during ICU stay, mortality and hospital/ICU length of stay (LOS). Out of 118 patients, 41 were managed only with HFNC from hospital admission (and at least during first 24 hours in ICU) and had a PaO<inf>2</inf>/FiO<inf>2</inf> ratio <100 (72.9±13.0). 29/41 patients never required MV: 24 of them survived and were discharged home. Their median ICU LOS was 11 (7-17) days, and their hospital LOS was 29 (18-45) days. We identified PaO<inf>2</inf>/FiO<inf>2</inf> ratio at ICU admission as the only significant predictor for need for MV during ICU stay. We also identified age, length of non-invasive respiratory support before ICU admission, mean value of PaO<inf>2</inf>/FiO<inf>2</inf> ratio during first half and whole ICU stay as predictors of mortality. It is safe to monitor in ICU and use HFNC in patients affected by COVID-19 ARDS who initially present data suggesting an early need for intubation. The 41 patients admitted with a PaO<inf>2</inf>/FiO<inf>2</inf> ratio <100 and initially treated only with HFNC show a 22% mortality that is in the lower range of what is reported in recent literature.

Long short-term memory model identifies ARDS and in-hospital mortality in both non-COVID-19 and COVID-19 cohort

ObjectiveTo identify the risk of acute respiratory distress syndrome (ARDS) and in-hospital mortality using long short-term memory (LSTM) framework in a mechanically ventilated (MV) non-COVID-19 cohort and a COVID-19 cohort.MethodsWe...

Clinical efficacy and safety of multipotent adult progenitor cells (invimestrocel) for acute respiratory distress syndrome (ARDS) caused by pneumonia: a randomized, open-label, standard therapy–controlled, phase 2 multicenter study (ONE-BRIDGE)

BackgroundAcute respiratory distress syndrome (ARDS) is a life-threatening inflammatory lung injury with high mortality; no approved medication exists. Efficacy and safety of bone marrow–derived, allogeneic, multipotent adult progenitor cells (invimestrocel) plus standard treatment in patients with ARDS caused by pneumonia was evaluated.MethodsA randomized, open-label, standard therapy–controlled, phase 2 study (January 2019–September 2021) conducted in 29 centers in Japan. Patients with ARDS caused by pneumonia, with extensive early fibroproliferation on high-resolution computed tomography and low risk of systemic organ failure identified by an Acute Physiology and Chronic Health Evaluation (APACHE II) score were included. Patients were randomized 2:1 to receive a single intravenous infusion of 9.0 × 108 cells of invimestrocel (administered at a rate of up to 10 mL/min over 30–60 min by free flow) plus standard treatment (N = 20) or standard treatment (N = 10) consistent with the clinical practice guidelines of the Japanese Respiratory Society for the management of ARDS. Primary endpoint was ventilator-free days (VFDs) through day 28 after study treatment. Analysis of covariance was performed with treatment group, age, partial pressure arterial oxygen/fraction of inspired oxygen ratio, and APACHE II score as covariates.ResultsMedian (interquartile range) number of VFDs was numerically higher in the invimestrocel group versus standard group (20.0 [0.0–24.0] vs 11.0 [0.0–14.0]) but was not statistically significantly different (least square [LS] means [95% confidence interval (CI)]: invimestrocel group, 11.6 [6.9–16.3]; standard group, 6.2 [− 0.4 to 12.8]; LS mean difference [95% CI], 5.4 [− 1.9 to 12.8]; p = 0.1397). Ventilator weaning rate at day 28 was 65% (13/20) versus 30% (3/10), and mortality rate was 21% (4/19) versus 29% (2/7) at day 28 and 26% (5/19 patients) versus 43% (3/7 patients) at day 180, for the invimestrocel and standard groups, respectively. No allergic or serious adverse reactions were associated with invimestrocel.ConclusionsIn Japanese patients with ARDS caused by pneumonia, invimestrocel plus standard treatment resulted in no significant difference in the number of VFDs but may result in improved survival compared with standard treatment. Invimestrocel was well tolerated.Trial registration: ClinicalTrials.gov, Identifier: NCT03807804; January 8, 2019; https://clinicaltrials.gov/ct2/show/NCT03807804.

Atracurium Versus Cisatracurium in the Treatment of Acute Respiratory Distress Syndrome.

Background: Neuromuscular blocking agents are one of the few medication classes that have demonstrated a clinical benefit in patients with severe acute respiratory distress syndrome (ARDS). However, most literature utilized cisatracurium, and utilization of atracurium is limited to 1 small study. Objective: The purpose of this study was to provide further evidence comparing the safety and efficacy of atracurium versus cisatracurium for the treatment of ARDS. Methods: This multicenter, retrospective, observational cohort noninferiority study was conducted at 3 hospitals within a tertiary health care system. We included subjects diagnosed with ARDS who received either atracurium or cisatracurium for at least 12 hours. The primary outcome measured the change in PaO2/FiO2 (P/F) ratio from baseline to 48 hours after initiation. Results: Baseline characteristics were similar between groups except for a higher median age and a higher proportion of subjects who were COVID-positive in the atracurium group. There were also some noted differences in the baseline P/F ratios. In a multivariable model adjusting for baseline characteristics, the change in the P/F ratio for atracurium was noninferior to cisatracurium at 24, 48, and 72 hours. A significant cost reduction, measured as cost per patient per day, was seen with the use of atracurium ($14.81-$25.16 vs $33.86-$41.91). Conclusion: Atracurium appears to be a safe and cheaper alternative agent in the management of ARDS.