Adult Respiratory Distress Syndrome Patients Research Articles

Impact of Sedation Practices on Mortality in COVID-19-Associated Adult Respiratory Distress Syndrome Patients: A Multicenter Retrospective Descriptive Study.

Background: Reduction in sedation exposure is an important metric in intensive care unit (ICU) patients. However, challenges arose during the coronavirus disease-2019 (COVID-19) pandemic in adhering to this practice, driven by concerns on transmission and disease severity issues. Accordingly, diverse sedation approaches emerged, although the effect on mortality has not been studied thoroughly. Methods: Retrospective cohort study in the medical ICU of seven hospitals within a major Health System in Northeast Ohio. We included all adult patients admitted with COVID-19 requiring invasive mechanical ventilation (IMV) from March 2020 to December 2021. Results: Study included 2394 COVID-19 patients requiring IMV. Across waves, sample included 55-63% male subjects, with an average age of 61-68 years (P < 0.001), Acute Physiologic and Chronic Health Evaluation (APACHE)-III score 65.8-68.9 (P = 0.37), median IMV duration 8-10 days (P = 0.14), and median ICU duration 9.8-11.6 days (P = 0.084). Propofol remained the primary sedative (84-92%; P = 0.089). Ketamine use increased from the first (9.7%) to fourth (19%) wave (P = 0.002). Midazolam use decreased from the first (27.4%) to third (9.4%) wave (P = 0.001). Dexmedetomidine use declined from 35% to 27-28% (P = 0.002) after the first wave. A multivariable regression analysis indicated clinical variables explained 34% of the variation in hospital mortality (R2). Factors associated with higher mortality included age [aOR = 1.059 (95% CI 1.049-1.069); P < 0.001], COVID-19 wave, especially fourth wave [aOR = 2.147, (95% CI 1.370-3.365); P = 0.001], and higher number of vasopressors [aOR = 31.636, (95% CI 17.603-56.856); P < 0.001]. Addition of sedative medications to a second model led to an increase in the R2 by only 1.6% to 35.6% [aOR = 1 (95% CI 1-1); P > 0.05] for propofol, ketamine, and midazolam. Dexmedetomidine demonstrated a decrease in the odds of mortality [aOR = 0.96 (95% CI 0.94-0.97); P < 0.001]. Conclusion: Mortality in critical COVID-19 patients was mostly driven by illness severity, and the choice of sedation might have minimal impact when other factors are controlled.

Clinical Characteristics and Mortality Predictors of Acute Respiratory Distress Syndrome Patients in ICU- an Observational Study

Introduction: Adult respiratory distress syndrome (ARDS) is an inflammatory lung condition characterized by a sudden onset of severe oxygen deficiency, bilateral chest infiltrates, and high morbidity and mortality rates. The causes and prognostic factors for ARDS may vary in tropical regions.&#x0D; Objective: This study aimed to investigate the causes, clinical characteristics, and outcomes of ARDS patients admitted in ICU.&#x0D; Methodology: We conducted a prospective observational study involving 92 ARDS patients admitted to the medical and surgical intensive care units of a tertiary care hospital in eastern Nepal from 2021 to 2023. We included patients aged 15 years and above who met all the Berlin criteria for ARDS. Patients with burns, end-stage renal disease, hepatic disease, head injuries, congestive cardiac failure, and postoperative patients were excluded. We assessed demographic parameters, initial clinical presentations, causative agents, ventilation parameters, organ failure during the ICU stay, and factors influencing patient mortality.&#x0D; Results: Our cohort had a mean age of 45.71 ± 20.02 years, with a predominance of male patients. The majority of patients presented with fever and shortness of breath. Approximately 26.1% had mild ARDS, while 25% had severe ARDS. The initial Sequential Organ Failure Assessment (SOFA) score was 10.11 ± 6.07, with most patients having a lung injury score of less than 2.5. Higher lung injury scores and low PaO2/FiO2 ratios were associated with increased mortality (P&lt;0.05). The overall mortality rate in our study was 33.6%.&#x0D; Conclusion: Pneumonia emerged as the most common cause of ARDS in our region. Low PaO2/FiO2 ratios and higher lung injury scores significantly influenced ARDS mortality.

Early and Timely Use of Hemofiltration Therapy with Poly Methyl Meth Acrylate (PMMA) Filters in Severe COVID-19 Adult Respiratory Distress Syndrome Patients: A Single Centre Study in India

A high Interleukin-6 (IL-6) level in COVID-19 plays a major role in the pathophysiology and is considered a reliable parameter in predicting the adversity of the disease. In COVID-19. Extracorporeal blood purification has been proposed as an adjuvant therapy and it aims at controlling the dysregulation in the immune system. Essentially, it lowers the upregulated levels of several mediators and therefore controls the cytokine storm, instead of actively targeting individual pathways of inflammation. Positive IL-6 balance post-Polymethyl methacrylate (PMMA) filter used for Cytokine storm in COVID-19 patients with dialysis has shown to be an independent predictor of mortality. A retrospective analysis of seventeen patients wherein hemofiltration was used for cytokine storm with dialysis, sepsis, and septic shock. The inflammatory markers post-hemofiltration sessions were supervised to understand hemofiltration's efficacy. The average age of the patients was 70.2 (18.2) years. They were classified as responders or non-responder groups based on the decrease or no change/ increase respectively between the pre-and post-filtration IL-6 levels. A 3.6-fold increase was noticed in non-responders (N=11) for IL-6 levels post hemofiltration. Responders demonstrated a 21.4% (p&lt;0.05) reduction in IL-6 levels post hemofiltration. Of these, 4 who survived demonstrated a decrease in IL-6 levels of 66.2%. Of 10 non-responders, none survived. However, the survival rate was 71.43 percent among the responders. There was a significant statistical difference in the mortality rate between the two groups (p= 0.003).Cytokine storm, an overwhelming immunological response in COVID-19 patients, can be controlled successfully by the early and timely use of hemofiltration therapy with PMMA filters like Hemofeel. However, patients with higher positive IL-6 balance post-hemofiltration may be associated with limited outcomes.

A Systematic Review of Mortality Rates Among Adult Acute Respiratory Distress Syndrome Patients Undergoing Extracorporeal Membrane Oxygenation Therapy.

Acute respiratory distress syndrome (ARDS) is a severe lung disease associated with a high mortality rate. Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for severe ARDS patients who do not respond to conventional treatments. Nevertheless, the optimal management of ARDS patients undergoing ECMO and their mortality rates remain subjects of controversy. Thus, this systematic review aims to assess mortality rates in ARDS patients on ECMO and identify associated factors. The review adhered to the Preferred Reporting Items for Systemic Review and Meta-Analysis (PRISMA) 2020 guidelines. A comprehensive literature search was conducted on PubMed, PubMed Central (PMC), Medline, and Embase. In accordance with our inclusion and exclusion criteria, filters, and key terms, we proceeded to screen the articles. After assessing the relevance of each article to our topic, further screening was carried out. Quality assessment of the articles was conducted, resulting in the inclusion of a total of 12 articles for the review. The primary outcome focused on mortality rates among ARDS patients undergoing ECMO. Secondary outcomes explored potential contributors to mortality, including patient age, underlying cause of ARDS, and Sequential Organ Failure Assessment (SOFA) scores at the initiation of ECMO. Mortality rates exhibited significant variation, ranging from 22% to 62.6%. Several factors emerged as potential predictors of mortality, encompassing patient age, comorbidities, complications during ECMO therapy, and treatment-related variables. This systematic review offers valuable insights into the intricate factors influencing mortality rates among ARDS patients on ECMO. A comprehension of these factors is essential to steer clinical practice and enhance patient outcomes. While ECMO serves as a restorative avenue for ARDS patients, future research is warranted to further elucidate these complex interactions and refine ECMO therapy protocols.

The Use of Nitric Oxide as a Rescue Modality for Severe Adult Acute Respiratory Distress Syndrome Patients, Including COVID-19, in Critical Care Rotor Transport: A Retrospective Community Outcome Study

ObjectiveSevere acute respiratory distress syndrome (ARDS) mortality increases in smaller outlying facilities, and patients (especially those diagnosed with coronavirus disease 2019 [COVID-19]) are often “stuck” at these facilities. These patients are on maximal ventilator settings and are often in the prone position. Our purpose was to show that with the use of inhaled nitric oxide (iNO), a “community-based” rotor wing critical care transport (CCT) team can safely, consistently, and effectively transport these extremely precarious patients to the tertiary care that is needed. MethodsThis was a retrospective database review of 50 patients (39 patients with COVID-19) transported between 2017 and 2021 in whom iNO was brought to the bedside and initiated by the rotor wing critical care transport team. The review included patient demographics, vital signs, and ventilator settings from the sending hospital, in-flight, and the receiving hospital. We reviewed the transition from transport to venovenous extracorporeal membrane oxygenation (if applicable), hospital disposition, and length of stay from the receiving hospital side. Concerning the actual transport, we reviewed the mode of transport, the sending facility size, and the distances covered. ResultsUpon arrival at the sending facilities, we found severely ill patients with almost half (46%) in the prone position or recently transitioned from a prone position within the last 2 hours. Eighty-six percent were pharmaceutically paralyzed, and 44% were in shock. There was a younger and heavier predominance with an average age of 44 years and an average weight of 103 kg. Thirty-nine patients were diagnosed with COVID-19. The other 11 had a mix of non–COVID-19 ARDS, pulmonary embolism, and pulmonary edema. The patients presented from 27 different community hospitals. Forty-four percent were from small referring hospitals that had less than 200 beds. Twenty-eight patients were transported by a Bell 407 helicopter, 18 with an Airbus H135 helicopter, and 4 by ground ambulance. Forty-one percent of patients were transported within 25 miles, and 4 patients were transferred from > 100 miles away. All 50 patients were safely transported without significant deterioration or significant pulmonary pressure increases. Thirty-seven patients were placed on venovenous extracorporeal membrane oxygenation (34 of those patients cannulated within 2 hours of arrival). The overall mortality rate was 27%, and the COVID-19 mortality rate was 24%. ConclusioniNO retrieval for severe ARDS can be safely and effectively completed within the COVID-19 population and the nonacademic community setting using helicopters prevalent in the global air medical industry (Bell 407 and Airbus H135).

Incidence and effects of deep vein thrombosis on the outcome of patients with coronavirus disease 2019 infection

BackgroundDeep vein thrombosis (DVT) has been reported to occur at different rates in patients with coronavirus disease 2019 (COVID-19). Limited data exist regarding comparisons with non–COVID-19 patients with similar characteristics. Our objective was to compare the rates of DVT in patients with and without COVID-19 and to determine the effect of DVT on the outcomes. MethodsWe performed a retrospective, observational cohort study at a single-institution, level 1 trauma center comparing patients with and without COVID-19. The 573 non–COVID-19 patients (age, 61 ± 17 years; 44.9% male) had been treated from March 20, 2019 to June 30, 2019, and the 213 COVID-19 patients (age, 61 ± 16 years; 61.0% male) had been treated during the same interval in 2020. Standard prophylactic anticoagulation therapy consisted of 5000 U of heparin three times daily for the medical patients without COVID-19 who were not in the intensive care unit (ICU). The ICU, surgical, and trauma patients without COVID-19 had received 40 mg of enoxaparin daily (not adjusted to weight). The patients with COVID-19 had also received enoxaparin 40 mg daily (also not adjusted to weight), regardless of whether treated in the ICU. The two primary outcomes were the rate of deep vein thrombosis (DVT) in the COVID-19 group vs that in the historic control and the effect of DVT on mortality. The subgroup analyses included patients with adult respiratory distress syndrome (ARDS), pulmonary embolism (PE), and intensive care unit patients (ICU). ResultsThe rate of DVT and PE for the non–COVID-19 patients was 12.4% (71 of 573) and 3.3% (19 of 573) compared with 33.8% (72 of 213) and 7.0% (15 of 213) for the COVID-19 patients, respectively. Unprovoked PE had developed in 10 of 15 COVID-19 patients (66.7%) compared with 8 of 497 non–COVID-19 patients (1.6%). The 60 COVID-19 patients with ARDS had had an incidence of DVT of 46.7% (n = 28). In contrast, the incidence of DVT for the 153 non–COVID-19 patients with ARDS was 28.8% (n = 44; P = .01). The COVID-19 patients requiring the ICU had had an increased rate of DVT (39 of 90; 43.3%) compared with the non–COVID-19 patients (33 of 123; 33.3%; P = .01). The risk factors for mortality included age, DVT, multiple organ failure syndrome, and prolonged ventilatory support with the following odd ratios: 1.030 (95% confidence interval [CI], 1.002-1.058), 2.847 (95% CI, 1.356-5.5979), 4.438 (95% CI, 1.973-9.985), and 5.321 (95% CI, 1.973-14.082), respectively. ConclusionsThe incidence of DVT for COVID-19 patients receiving standard-dose prophylactic anticoagulation that was not weight adjusted was high, especially for ICU patients. DVT is one of the factors contributing to increased mortality. These results suggest a reevaluation is necessary of the present standard-dose thromboprophylaxis for patients with COVID-19.

Meta-analysis and trials sequential analysis for the efficacy and safety of low- and medium-dose glucocorticoids in adult acute respiratory distress syndrome patients

To explore the efficacy and safety of low- and medium-dose of glucocorticoids in adult patients with acute respiratory distress syndrome (ARDS) through Meta-analysis and trials sequential analysis (TSA). Databases associated with adult ARDS treatment with low- and medium-dose glucocorticoids both in English and in Chinese were searched from PubMed, Medline, China Biology Medicine (CBM), Cochrane Library, CNKI, Wanfang Data and VIP, of which the search duration was from the establishment of the database to December 2020. Low-dose glucocorticoids were defined as methylprednisolone ≤ 1 mg×kg-1×d-1, and medium dose glucocorticoids were defined as methylprednisolone ≤ 2 mg×kg-1×d-1. According to the Cochrane Collaboration bias risk assessment tool, the quality of the included literature was evaluated, and the data were extracted. Meta-analysis and TSA were used to evaluate the effects of low- and medium-dose glucocorticoids on the hospital mortality, intensive care unit (ICU) mortality, and mechanical ventilation free time in ICU for 28 days, PaO2/FiO2, and the occurrence of nosocomial infections and hyperglycemia. A total of 996 patients in 7 literatures were finally included, including 515 patients in the low- and medium-dose glucocorticoid group (hormone group) and 481 patients in the conventional treatment group (control group). The research quality of 7 literatures was relatively high. The results of Meta-analysis and TSA showed that, compared with the control group, the hospital mortality in the hormone group was significantly decreased [relative risk (RR) = 0.77, 95% confidence interval (95%CI) was 0.66-0.89, P = 0.000 6], and mechanical ventilation free time in ICU for 28 days was significantly prolonged [standardized mean difference (SMD) = 0.50, 95%CI was 0.36-0.65, P < 0.000 1]. Although Meta-analysis showed that the ICU mortality of the hormone group was significantly lower than that of the control group (RR = 0.61, 95%CI was 0.38-0.99, P = 0.04), the TSA results showed that the cumulative Z value crossed the traditional threshold, but did not cross the TSA cut-off value, and the sample size did not reach required information size (RIS, n = 3 252), needed more research to confirm. Although Meta-analysis showed that PaO2/FiO2 in the hormone group was significantly higher than that in the control group (SMD = 0.78, 95%CI was 0.13-1.43, P = 0.02), TSA showed that the cumulative Z value did not pass the traditional and TSA cut-off values. More research was needed for verification. Meta-analysis also showed that there was no significant difference in the incidence of new infection (RR = 0.93, 95%CI was 0.74-1.17, P = 0.54) and the incidence of hyperglycemia (RR = 1.11, 95%CI was 1.00-1.23, P = 0.05) between the hormone group and the control group. Low- and medium-dose of glucocorticoids therapy can reduce the hospital mortality of adult ARDS patients and shorten the mechanical ventilation duration in ICU for 28 days, and low- and medium-dose of glucocorticoids therapy does not increase the risk of infection and hyperglycemia.

Corticosteroids in adult respiratory distress syndrome - an inconvenient truth?

ObjectivesRecent studies have demonstrated mortality benefits from corticosteroid use in COVID-19 patients requiring respiratory support. However, clinical practice may warrant the use of corticosteroids outside the context of a clinical trial. Such data are rarely, if ever, reported. We explored the use of corticosteroids for adult respiratory distress syndrome (ARDS) indications in patients with non-COVID ARDS.MethodsWe retrospectively studied patients with moderate-to-severe ARDS, admitted to our intensive care unit (ICU) between January 2018 and March 2020.Key findingsOf the 91 patients with ARDS identified, 80% were treated with a corticosteroid during their ICU admission. Of these, 73 (82%) had corticosteroids administered for reasons other than ARDS.ConclusionsCorticosteroid use for non-ARDS indications is commonplace in ARDS patients in our ICU. The use of corticosteroids outside a randomisation process in randomised clinical trials may be more common than appreciated and needs to be routinely reported.

The Implementation of Protocol-Based Utilization of Neuromuscular Blocking Agent Using Clinical Variables in Acute Respiratory Distress Syndrome Patients.

The recent conflicting data on the mortality benefit of neuromuscular blocking agents in acute respiratory distress syndrome and the potential adverse effects of continuous neuromuscular blocking agent necessitates that these medications should be used judiciously with dose reduction in mind. The aims of the study were to improve the process of care by provider education of neuromuscular blocking agent titration and monitoring and to determine the impact of clinical endpoint based neuromuscular blocking agent titration protocol. We conducted a proof-of-concept historically controlled study of protocol-based intervention standardizing paralytic monitoring and titration using clinical variables. Education of the protocol was provided to ICU staff via bedside teaching and workshops. The primary outcomes were the time to reach goal paralysis and cumulative neuromuscular blocking agent dose. Secondary outcomes included maintenance of deeper sedation (Richmond Agitation and Sedation Scale -5) prior to neuromuscular blocking agent initiation, total time on mechanical ventilation, length of stay, and mortality. Medical ICU at a quaternary academic hospital between March 2019 and June 2020. Adult severe acute respiratory distress syndrome (Pao2/Fio2 <150) patients requiring neuromuscular blocking agent for greater than or equal to 12 hours. Eighty-two patients fulfilled inclusion criteria, 46 in the control group and 36 in the intervention group. Education and implementation of standardized protocol. Compared with the control group, the time to reach goal paralysis in the intervention group was shorter (8.55 ± 9.4 vs 2.63 ± 5.9 hr; p < 0.0001) on significantly lower dose of cisatracurium (total dose 1,897.96 ± 1,241.0 vs 562.72 ± 546.7 mg; p < 0.0001 and the rate 5.84 ± 2.66 vs 1.99 ± 0.95 µg/kg/min; p < 0.0001). Deeper sedation was achieved at the time of initiation of neuromuscular blocking agent in the intervention arm (mean Richmond Agitation and Sedation Scale -3.3 ± 1.9 vs -4.3 ± 1.7; p = 0.015). There was no significant difference in total time on mechanical ventilation, length of ICU stay, length of hospital stay, and mortality between the two groups. Implementation of comprehensive education, standardization of sedation prior to neuromuscular blocking agent initiation, integration of clinical variables in determining paralysis achievement, and proper use of peripheral nerve stimulation served as optimal strategies for the titration and monitoring of neuromuscular blocking agent in acute respiratory distress syndrome. This reduced drug utilization while continuing to achieve benefit without causing adverse effects.

Prone versus Supine Position Ventilation in Adult Patients with Acute Respiratory Distress Syndrome: A Meta-Analysis of Randomized Controlled Trials.

The purpose of this meta-analysis was to compare the efficacy and safety of prone versus supine position ventilation for adult acute respiratory distress syndrome (ARDS) patients. The electronic databases of PubMed, Embase, and the Cochrane Library were systematically searched from their inception up to September 2020. The relative risks (RRs) and weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were employed to calculate pooled outcomes using the random-effects models. Twelve randomized controlled trials that had recruited a total of 2264 adults with ARDS were selected for the final meta-analysis. The risk of mortality in patients who received prone position ventilation was 13% lower than for those who received supine ventilation, but this effect was not statistically significant (RR: 0.87; 95% CI: 0.75–1.00; P = 0.055). There were no significant differences between prone and supine position ventilation on the duration of mechanical ventilation (WMD: −0.22; P = 0.883) or ICU stays (WMD: –0.39; P = 0.738). The pooled RRs indicate that patients who received prone position ventilation had increased incidence of pressure scores (RR: 1.23; P = 0.003), displacement of a thoracotomy tube (RR: 3.14; P = 0.047), and endotracheal tube obstruction (RR: 2.45; P = 0.001). The results indicated that prone positioning during ventilation might have a beneficial effect on mortality, though incidence of several adverse events was significantly increased for these patients.

Prone Position in Acute Respiratory Distress Syndrome Patients: A Retrospective Analysis of Complications.

Early application of prolonged prone positioning has been shown to improve patient survival in moderate to severe adult respiratory distress syndrome (ARDS) patients. Prone position is a key component of lung protective mechanical ventilation in association with low tidal volume and neuromuscular blocking agents in patients with severe ARDS. Pressure sores are the major prone position complication. The rate of complication is lowering with the increase in center expertise. The aim of this study was to examine the onset of pressure sores and other complications caused by the use of prone position in patients having ARDS. This is a single-center, retrospective, observational study. One hundred seventy patients were enrolled, with a median age of 49 years (interquartile range [IQR], 38-63). Of all participants, 58% (n = 98) survived the intensive care unit recovery. The total prone position maneuvers were 526, with a median of 2 prone position sessions for each patient (IQR, 1-3). The median length of the prone position session was 9 hours (IQR, 7-12). Twenty-three patients developed pressure sores after prone position (14%). The anatomical positions of pressure sores were as follows: face/chin, 5% (n = 8); face/cheekbones, 6% (n = 11); thorax, 2% (n = 3); trochanter, 1% (n = 1); and other sites, 5% (n = 8). Complications were observed in 1% (n = 6) of all pronation maneuvers (vomit, 2%; respiratory device removal, 0.4%). No removal of intravascular catheter was observed. The onset rate of complications given by the use of prone position in ARDS patients is similar to data reported by previous literature. The implementation of a dedicated protocol in specialized centers and the involvement of 5 trained and skilled professionals while moving the patient in the prone position are recommended to prevent the occurrence of similar adverse events.

Why Prone? Why Now? Improving Outcomes for ARDS Patients

The latest evidence I have seen is that proning more than 16 to 18 hours/day showed benefits. Was the 12-hour mark a new change?The current evidence suggests that patients should remain in the prone position for most of the day (&gt;16 h), if tolerated. Derecruitment of the lungs can occur when the patient is turned supine because of an increase in ventral-dorsal pleural pressure on the lungs. The greater than 12-hour mark is the recommendation from the American Thoracic Society/Society of Critical Care Medicine guidelines for patients with moderate to severe adult respiratory distress syndrome (ARDS) who are receiving mechanical ventilation. If no improvement is seen on initial prone positioning, consider a consecutive 48-hour trial, then stop if no improvement. Evidence of improvement includes fraction of inspired oxygen (Fio2) reduced by 0.10 or a 30-point increase in Pao2/Fio2 ratio. Discontinue proning if instability occurs or if the Pao2/Fio2 ratio is greater than 150 mm Hg and the Fio2 is less than 0.60.How do you determine whether prone positioning is best versus extracorporeal membrane oxygenation (ECMO)?Consider ECMO only after routine treatment strategies have failed, including the following:Are standards to place patients in the prone position quickly or within so many hours of diagnosis of ARDS?The time from lung injury to prone positioning should be less than 48 hours. Begin as soon as possible, if conventional ventilation is not meeting goals.How do you deal with hemodynamic instability during the 10 to 15 minutes after proning?For cardiovascular instability, adjust vasopressor dosage temporarily and then titrate back down as appropriate. For oxygen, repeat the hyperoxygenation until patients adjust. The body’s oxygen demand increases during a turn, so providing greater support may be enough to overcome the increase in demand. For life-threatening arrhythmias, return patients to the supine position immediately.

Does lack of thoracic trauma attenuate the severity of pulmonary failure? An 8-year analysis of critically injured patients.

PurposePatients with thoracic trauma are presumed to be at higher risk for pulmonary dysfunction, but adult respiratory distress syndrome (ARDS) may develop in any patient, regardless of associated chest injury. This study evaluated the impact of thoracic trauma and pulmonary failure on outcomes in trauma patients admitted to the intensive-care unit (ICU).MethodsAll trauma patients admitted to the ICU over an 8-year period were identified. Patients that died within 48 h of arrival were excluded. Patients were stratified by baseline characteristics, injury severity, development of ARDS, and infectious complications. Multiple logistic regression was used to determine variables significantly associated with the development of ARDS.Results10,362 patients were identified. After exclusions, 4898 (50%) patients had chest injury and 4975 (50%) did not. 200 (2%) patients developed ARDS (3.6% of patients with chest injury and 0.5% of patients without chest injury). Patients with ARDS were more likely to have chest injury than those without ARDS (87% vs 49%, p < 0.001). However, of the patients without chest injury, the development of ARDS still led to a significant increase in mortality compared to those patients without ARDS (58% vs 5%, p < 0.001). Multiple logistic regression found ventilator-associated pneumonia (VAP) to be the only independent predictor for the development of ARDS in ICU patients without chest injury.ConclusionsARDS development was more common in patients with thoracic trauma. Nevertheless, the development of ARDS in patients without chest injury was associated with a tenfold higher risk of death. The presence of VAP was found to be the only potentially preventable and treatable risk factor for the development of ARDS in ICU patients without chest injury.

Effect of surfactant administration on outcomes of adult patients in acute respiratory distress syndrome: a meta-analysis of randomized controlled trials

IntroductionSurfactant is usually deficiency in adult acute respiratory distress syndrome(ARDS) patients and surfactant administration may be a useful therapy. The aim of this study was to perform a meta-analysis of the effect of surfactant administration on outcomes of adult patients with acute respiratory distress syndrome.MethodsPubMed, EMBASE, Medline, Cochrane database, Elsevier, Web of Science and http://clinicaltrials.gov were searched and investigated until December 2017. Randomized controlled trials(RCTs) comparing surfactant administration with general therapy in adult patients with ARDS were enrolled. The primary outcome was mortality (7–10-day, 28–30-day and 90–180-day). Secondary outcome included oxygenation (PaO2/FiO2 ratio). Demographic variables, surfactant administration, and outcomes were retrieved. Sensitivity analyses were used to evaluate the impact of study quality issues on the overall effect. Funnel plot inspection, Egger’s and Begger’s test were applied to investigate the publication bias. Internal validity was assessed with the risk of bias tool. Random errors were evaluated with trial sequential analysis(TSA). Quality levels were assessed by Grading of Recommendations Assessment, Development, and Evaluation methodology(GRADE).ResultsEleven RCTs with 3038 patients were identified. Surfactant administration could not improve mortality of adult patients [Risk ratio (RR) (95%CI)) = 1.02(0.93–1.12), p = 0.65]. Subgroup analysis revealed no difference of 7–10-day mortality [RR(95%CI)) = 0.89(0.54–1.49), p = 0.66], 28–30-day mortality[RR(95%CI) = 1.00(0.89–1.12), p = 0.98] and 90–180-day mortality [RR(95%CI) = 1.11(0.94–1.32), p = 0.22] between surfactant group and control group. The change of the PaO2/FiO2 ratio in adult ARDS patients had no difference [MD(95%CI) = 0.06(− 0.12–0.24), p = 0.5] after surfactant administration. Finally, TSA and GRADE indicated lack of firm evidence for a beneficial effect.ConclusionsSurfactant administration has not been shown to improve mortality and improve oxygenation for adult ARDS patients. Large rigorous randomized trials are needed to explore the effect of surfactant to adult ARDS patients.

Performance of Multiple Risk Assessment Tools to Predict Mortality for Adult Respiratory Distress Syndrome with Extracorporeal Membrane Oxygenation Therapy: An External Validation Study Based on Chinese Single-center Data.

Background:There has been no external validation of survival prediction models for severe adult respiratory distress syndrome (ARDS) with extracorporeal membrane oxygenation (ECMO) therapy in China. The aim of study was to compare the performance of multiple models recently developed for patients with ARDS undergoing ECMO based on Chinese single-center data.Methods:A retrospective case study was performed, including twenty-three severe ARDS patients who received ECMO from January 2009 to July 2015. The PRESERVE (Predicting death for severe ARDS on VV-ECMO), ECMOnet, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score, a center-specific model developed for inter-hospital transfers receiving ECMO, and the classical risk-prediction scores of Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) were calculated. In-hospital and six-month mortality were regarded as the endpoints and model performance was evaluated by comparing the area under the receiver operating characteristic curve (AUC).Results:The RESP and APACHE II scores showed excellent discriminate performance in predicting survival with AUC of 0.835 (95% confidence interval [CI], 0.659–1.010, P = 0.007) and 0.762 (95% CI, 0.558–0.965, P = 0.035), respectively. The optimal cutoff values were risk class 3.5 for RESP and 35.5 for APACHE II score, and both showed 70.0% sensitivity and 84.6% specificity. The excellent performance of these models was also evident for the pneumonia etiological subgroup, for which the SOFA score was also shown to be predictive, with an AUC of 0.790 (95% CI, 0.571–1.009, P = 0.038). However, the ECMOnet and the score developed for externally retrieved ECMO patients failed to demonstrate significant discriminate power for the overall cohort. The PRESERVE model was unable to be evaluated fully since only one patient died six months postdischarge.Conclusions:The RESP, APCHAE II, and SOFA scorings systems show good predictive value for intra-hospital survival of ARDS patients treated with ECMO in our single-center evaluation. Future validation should include a larger study with either more patients’ data at single-center or by integration of domestic multi-center data. Development of a scoring system with national characteristics might be warranted.

Optimal support techniques when providing mechanical ventilation to patients with acute respiratory distress syndrome.

Adult respiratory distress syndrome (ARDS) is a type of acute diffuse lung injury characterized by severe inflammation, increased pulmonary vascular permeability and a loss of aerated lung tissue. The effects of high fraction of inspired oxygen (FiO2 ) include oxygen toxicity manifested by damage to the lung parenchyma in the acute phase of lung injury. There is still a high mortality rate among this group of patients, so clinically sensitive evidence-based interventions are paramount to maximize survival chances during critical care. The aim of this article is to explore the current opinion concerning optimal mechanical ventilation support techniques for patients with acute respiratory distress syndrome. A literature search of clinical trials and observation studies, reviews, discussion papers, meta-analyses and clinical guidelines written in English up to 2015, derived from the databases of Scopus, CINAHL, Cochrane Library databases and PubMed was conducted. Low tidal volume, pressure limitation and prone positioning in severe ARDS patients appear to be of some benefit. More research is required and further development and use of standardized protocols is an important strategy for reducing practice variations across disciplines, as well as giving clear guidelines to nurses practising in critical care. There is also evidence that this syndrome is under-diagnosed and the utilization of lung protective ventilation is still variable. It is important that nurses have underlying knowledge of both aetiology of ARDS and ventilation management, and that they monitor patients very closely. The adoption of a low tidal ventilation protocol, which is based on quality evidence guidelines, the value of rescue therapies and patient observation practices in the overall patient management, and the need to place emphasis on long-term patient outcomes, all these emerge as key factors for consideration and future research. However, there is also a need for more research that would explore the unique contribution of nurses in the management of this patient group, as it is difficult to discern this in the current literature.

Clinical associations of host genetic variations in the genes of cytokines in critically ill patients.

Host genetic variations may influence a changing profile of biochemical markers and outcome in patients with trauma/injury. The objective of this study was to assess clinical associations of single nucleotide polymorphisms (SNPs) in the genes of cytokines in critically ill patients. A total of 430 patients were genotyped for SNPs in the genes of pro- (IL1B, IL6, IL8) and anti-inflammatory (IL4, IL10, IL13) cytokines. The main end-points were sepsis, mortality and adult respiratory distress syndrome (ARDS). We evaluated the dynamic levels of bilirubin, blood urea nitrogen, creatine kinase, creatinine and lactate dehydrogenase in five points of measurements (between 1 and 14 days after admission) and correlated them with SNPs. High-producing alleles of proinflammatory cytokines protected patients against sepsis (IL1B -511A and IL8 -251A) and mortality (IL1B -511A). High-producing alleles of anti-inflammatory cytokines IL4 -589T and IL13 431A (144Gln) were less frequent in ARDS patients. The carriers of IL6 -174C/C genotypes were prone to the increased levels of biochemical markers and acute kidney and liver insufficiency. Genotype-dependent differences in the levels of biochemical indicators gradually increased to a maximal value on the 14th day after admission. These findings suggest that genetic variability in pro- and anti-inflammatory cytokines may contribute to different clinical phenotypes in patients at high risk of critical illness.

Differences in degree, differences in kind: characterizing lung injury in trauma.

Acute lung injury following trauma remains a significant source of morbidity and mortality. Although multiple trauma studies have used hypoxemia without radiographic adjudication as a surrogate for identifying adult respiratory distress syndrome (ARDS) cases, the differences between patients with hypoxemia alone and those with radiographically confirmed ARDS are not well described in the literature. We hypothesized that nonhypoxemic, hypoxemic, and ARDS patients represent distinct groups with unique characteristics and predictors. Laboratory, demographic, clinical, and outcomes data were prospectively collected from 621 intubated, critically injured patients at an urban Level 1 trauma center from 2005 to 2013. Hypoxemia was defined as PaO2/FIO2 ratio of 300 or lower. ARDS was adjudicated using Berlin criteria, with blinded two-physician consensus review of chest radiographs. Group comparisons were performed by hypoxemia and ARDS status. Logistic regression analyses were performed to separately assess predictors of hypoxemia and ARDS. Of the 621 intubated patients, 64% developed hypoxemia; 46% of these hypoxemic patients developed ARDS by chest radiograph. Across the three groups (no hypoxemia, hypoxemia, ARDS), there were no significant differences in age, sex, or comorbidities. However, there was an increase in severity of shock, injury, and chest injury by group, with corresponding trends in transfusion requirements and volume of early fluid administration. Outcomes followed a similar stepwise pattern, with pneumonia, multiorgan failure, length of intensive care unit stay, number of ventilator days, and overall mortality highest in ARDS patients. In multiple logistic regression, early plasma transfusion, delayed crystalloid administration, body mass index, and head and chest injury were independent predictors of hypoxemia, while head and chest injury, early crystalloid infusion, and delayed platelet transfusion were independent predictors of ARDS. Hypoxemia and ARDS exist on a spectrum of respiratory dysfunction following trauma, with increasing injury severity profiles and resuscitation requirements. However, they also represent distinct clinical states with unique predictors, which require directed research approaches and targeted therapeutic strategies. Prognostic and epidemiologic study, level III.

The role of noninvasive ventilation in mild to moderate acute respiratory distress syndrome.

Sir, We read with great interest the research article, “A study on the role of NIV in mild to moderate acute respiratory distress syndrome,” published in the previous issue.[1] It was alarming to note that only 44% had successful noninvasive ventilation (NIV) use while the rest of the patients had to be intubated. The mortality quoted for NIV failure group was 46.3% (19 out of 23), which is rather high in the present scenario. The mortality of moderate adult respiratory distress syndrome (ARDS) in a study done by Thille et al. was only 32%.[2] The author suggests high APACHE scores and delay in intubations as the reasons of the high mortality. The mortality rate is unacceptable and could have been reduced if they were not subjected to further trial of NIV after 1 h. A retrospective study of NIV role in moderate ARDS in esophagectomy patients concluded that it would be an effective option to consider invasive mechanical ventilation in those with P/F ratio 150.[2] Patients who have P/F ratio of 1.5 have to be taken into consideration to go for invasive ventilation.[4] We manage large number of ARDS patients in our department. ARDS patients (P/F ratio >150) can be treated with NIV while moderate to severe ARDS (P/F ratio <150) should be managed with pressure-controlled mechanical ventilation. Our mortality rates have been 11.4% in the past 3 years.[4] NIV for ARDS has to be chosen cautiously and needs vigilant monitoring as it can lead to high mortality, even when one makes a decision to shift from NIV to invasive ventilation quickly. I entirely agree with editorial remarks that the acute inflammation of lung can spread very quickly making the recruitment process slow and delayed. One has to be extremely careful when you choose NIV for ARDS. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Adult respiratory distress syndrome risk factors for injured patients undergoing damage-control laparotomy: AAST multicenter post hoc analysis.

Severely injured patients undergoing damage-control laparotomy (DCL) have multiple risk factors for adult respiratory distress syndrome (ARDS), making it challenging to differentiate the contributions of individual causative factors. We aimed to determine the relative contributions of ARDS risk factors. Analysis of the prospectively collected American Association for the Surgery of Trauma Multi-institutional Open Abdomen Database was performed. Inclusion criteria were any patient, 18 years or older, undergoing DCL at 1 of 14 participating Level I trauma centers. Univariable and multivariable Cox regression analyses were performed to determine the association of variables with the development of ARDS during hospitalization. A total of 563 patients (78% men; mean [SD] age, 40 [18] years) were identified, of whom 77 developed ARDS (14%). Overall mortality was 23%, with a 39% mortality rate for ARDS patients. Univariable analysis demonstrated that Injury Severity Score (ISS, 1.03; 95% confidence interval [CI], 1.02-1.05), intraoperative (IO) estimated blood loss (hazard ratio [HR], 1.09; 95% CI, 1.04-1.13), IO plasma transfusion (HR, 1.17; 95% CI, 1.10-1.25), 24-hour colloid volume (HR, 1.07; 95% CI, 1.04-1.10), and 24-hour crystalloid volume (HR, 1.01; 95% CI, 1.00-1.01) were associated with the development of ARDS. Cox multivariable analysis demonstrated that ISS, IO plasma transfusions, and total fluid balance through 23 hours all increased the risk of ARDS development. Severity of injury, plasma transfusions, and greater fluid administration by 24 hours were independently associated with ARDS development. Judicious use of plasma and other fluids may reduce rates of ARDS in this critically injured population. Prognostic study, level III; therapeutic study, level IV.