Oxygenation Failure Research Articles

Clinical Value of HACOR Score in Predicting High Flow Nasal Oxygen Therapy Failure in Hypoxemic Patients

Objective: To assess the sensitivity of the HACOR score in successfully predicting high flow nasal oxygen (HFNO) failure in acute hypoxemic patients. Methodology: A Prospective observational study was conducted at Critical care departments of Combined Military Hospital, Lahore, Okara and Rahim Yar Khan from Jan-Dec 2023. A total of 390 patients diagnosed as having acute hypoxemic respiratory failure (PaO2<60 mm Hg and/or pH <7.35) were selected and started on HFNO therapy. Primary variables studied were the sensitivity and specificity of the HACOR score in predicting HFNO failure after the first hour of therapy . Secondary variables studied compared the improvement in HACOR parameters after 1-hour of HFNO therapy in those patients who has success with HFNO. Results: While assessing the power of the HACOR score in predicting failure of HFNO therapy with scores obtained after one hour, the area under the curve showed a value of 0.88 showing a good predictive power of failure for the test. A cut off value >6 was able to predict failure with a sensitivity of 85.9%, specificity of 93.8% with a positive and negative predictive value of 96.6% and 76.4% respectively Conclusion: We conclude the HACOR score as a useful method with a cut-off value of more than 6 predicting a failure rate to HFNO to be > 86% after 1 hour of therapy.

Systemic Coagulation Derangement as an Early Sign of Oxygenator Failure in Veno-Venous Extracorporeal Membrane Oxygenation (VV ECMO) Without Anticoagulation

Background and Clinical Significance: Veno-venous extracorporeal membrane oxygenation (VV ECMO) has become a widely accepted supportive treatment for severe acute respiratory distress syndrome (ARDS) in intensive care units (ICUs). Although it has gained popularity, some of its aspects, including optimal anticoagulation management and the best means of monitoring hemostasis, remain unresolved. Thrombosis and bleeding are still important complications of ECMO. Case Presentation: A 44-year-old male patient, with no underlying conditions, was diagnosed with severe acute respiratory distress syndrome (ARDS) due to AH1N1 influenza. He presented severe hypoxemia despite the use of mechanical ventilation, neuromuscular blocking agent infusion and prone position. VV ECMO was used, and coagulation was stopped on ECLS day 6 due to severe pulmonary hemorrhage. The systemic hemostatic disorders found in this patient were difficult to differentiate from disseminated intravascular coagulation (DIC) or sepsis-induced coagulopathy (SIC), improved transiently after circuit exchange, and resolved only after discontinuation of ECMO. The patient was discharged fully conscious and cooperative, with no apparent neurological deficit. Conclusions: Systemic hemostatic abnormalities may precede oxygenator failure and mimic DIC or SIC. Timely oxygenator exchange may therefore be considered. However, it is a high-risk procedure, especially in fully ECLS-dependent patients.

Abstract 4137942: Comparing Outcomes in Low versus High Activated Partial Thromboplastin Time-guided Anticoagulation Monitoring during Extracorporeal Membrane Oxygenation

Introduction: Systemic anticoagulation in Extracorporeal Membrane Oxygenation (ECMO) aims to reduce the risk of patient and circuit thrombosis, but requires monitoring due to risk of bleeding. Activated partial thromboplastin time (aPTT) is one of many tests utilized for this purpose. However, it lacks validation in ECMO patients and its clinical utility necessitates further analysis. Aim: We aim to elucidate associations between low versus high aPTT-guided anticoagulation monitoring and total time, survival, bleeding, and thrombotic events during ECMO. Methods: A retrospective review was conducted on 93 patients requiring ECMO at our institution between January 2020 and March 2021. Study inclusion required more than 2 days on ECMO and maintenance on anticoagulation with aPTT targets predominantly greater (>) or less than (<) 60 seconds (s). Final cohort was 74 subjects; 30 subjects with majority aPTT targets <60s composed the control “low” aPTT group and 44 subjects with aPTT targets >60s composed the “high” aPTT group. Primary outcomes were survival to decannulation, survival to discharge, average time on ECMO, and incidence of bleeding and thrombotic events during ECMO. Bleeding and thrombotic events were classified into subtypes and incidence of each was recorded. Statistical analyses were performed with Fisher’s exact, Pearson’s chi-square, and Student’s t-tests with an alpha level of .05 on IBM SPSS software. Results: The high group required a longer average time on ECMO (29.5 days versus 14.3 days; p = .002; 95% CI [5.5; 24.7]). Chi-square tests did not show an association between the low versus high groups and survival to decannulation (22/30 and 35/44; p = .533), survival to hospital discharge (17/30 and 30/44; p = .312), or overall incidence of bleeding (18/30 and 20/44; p = .219) and thrombotic events (7/30 and 14/44; p = .427). Regarding subtypes of events, Fisher’s exact test showed an association between aPTT target >60s and severe epistaxis (1/30 in the low and 9/44 in the high group; two-tailed p = .042). Though not significant, a greater incidence of oxygenator failure and circuit thrombosis was recorded in the high group. Conclusions: Our findings did not establish a relationship between aPTT target <60s or >60s and survival, bleeding, or thrombotic events. However, aPTT target >60s was associated with longer average ECMO time and severe epistaxis. Further investigation of aPTT-guided anticoagulation monitoring in ECMO patients is needed.

V-A ECMO weaning with pump-controlled retrograde trial off (PCRTO) approach: an illustration of safety, benefits and feasibility

Abstract Introduction Weaning cardiogenic shock patients off V-A ECMO is a crucial but difficult step in the management of these patients. Conventional weaning strategies reduce the ECMO flow to approximately 1 L/min, yet this still entails significant unloading of the cardiopulmonary circulation. Background The PCRTO technique enables controlled retrograde flow of oxygenated blood from the patient’s arterial side into the right ventricle, resulting in an incremental increase of 0.5 L/min in right ventricular preload. This process challenges and evaluates the entire cardiopulmonary system (Figure). Methods We prospectively examined the use of the Pump-Controlled Retrograde Trial Off (PCRTO) approach (-0.5 L/min) compared to conventional ECMO weaning (+1 L/min) in a cross over study including 14 V-A ECMO patients across three quaternary high-output cardiogenic shock centers. Both the conventional and the PCRTO-technique are performed under continuous cardiac echo and PA-catheter guidance. Results After achieving adequate anticoagulation levels (Xa>0.3), no thrombotic or other complications were observed, confirming 100% safety of this technique. Table 1 provides an overview of our PCRTO-cohort and their evaluation after conventional versus PCRTO weaning. In 43% (6/14) of our cohort, conventional weaning strategies determined feasibility of ECMO-device weaning, while ultimately failing with PCRTO due to e.g. right ventricular failure or oxygenation failure. In contrast, 4/14 patients who failed the conventional weaning showed a positive weaning potential with PCRTO, potentially enabling patients to be liberated from bridging to durable ventricular assist devices or heart transplant. Conclusions In conclusion, PCRTO is a safe weaning strategy that increases the likelihood of successful weaning in critically ill V-A ECMO patients by challenging oxygenation/ventilation and cardiac circulation through increased right ventricular preload and reduced left ventricular afterload. Here, PCRTO ultimately led to a different destination scenario in 78,5% of our patient cohort compared to conventional V-A ECMO weaning alone. PCRTO may provide a standardised, reproducible approach to ECMO assessment and liberation which will be useful for future clinical trials in this population.

Failure to oxygenate during cardiopulmonary bypass; treatment options and intervention algorithm.

Membrane oxygenator failure remains a concern for perfusion teams. Successful outcomes for this low-frequency, high-risk intervention are predicated on having written institutional protocols for both the oxygenator change-out procedure as well as how often the procedure is practiced by staff perfusionists. A recent review of peer-reviewed journal articles, textbooks and online resources revealed a lack of a unified intervention algorithm for failure to oxygenate during cardiopulmonary bypass (CPB). While an oxygenator change-out procedure may still be considered the gold standard for a confirmed device failure, temporizing measures exist that, in select cases, can afford time to the clinical team and even obviate the need for an oxygenator change-out procedure. We now consider the venous piggyback technique sourcing blood from the venous limb of the circuit a first-line intervention to afford enhanced patient safety while the clinical team decides on required interventions when oxygenator failure presents during CPB.

63 Utilization of vasopressin and norepinephrine in neonates with cardiorespiratory compromise: A multicenter retrospective cohort study in Canada

Abstract Background Data regarding neonatal clinical experience with Vasopressin (VA) and Norepinephrine (NE) are limited to small studies. The lack of large-scale studies with safety and efficacy data is preventing the widespread adoption of these agents. Objectives To describe epidemiological data on utilization of NE and VA in neonates including their indications, effectiveness and overall outcomes across 3 tertiary Neonatal Intensive Care Units (NICU) in Canada. Design/Methods This retrospective cohort study involved neonates who received NE or VA between January 1, 2015-December 31, 2020 at 3 tertiary NICUs. Data regarding demographic information, indications of use, dosing details, and clinical outcomes were described using mean, standard deviations (SD), frequencies and percentages. When appropriate, a comparative analysis was performed using Mann-Whitney U tests or the chi-square test as appropriate. Post-initiation changes in physiological variables and laboratory parameters over time were analyzed using repeated measure ANOVA. Results 133 neonates (VA:70, NE:63) were included in this study. Baseline demographic features, clinical characteristics at initiation, indication of use, dosing details and clinical response in neonates exposed to both agents are summarized in Table 1. VA was commonly used for oxygenation failure due to persistent pulmonary hypertension of the newborn (PPHN), while NE was commonly used for hypotension due to septic shock. NE was frequently used as a 1st line inotropic agent, whereas VA was used more as an additive agent [30 (47.6%) vs 12 (18.6%); p=<0.001]. During treatment, lower sodium levels were recorded in the VA group vs the NE group [126.5 (8.6) vs 132 (7); p=.035], but other safety parameters were similar. The time to reach predefined stability parameters were similar in both groups. Significant improvement in physiological parameters were seen over time with both agents (Figure 1). Mortality within 7 days of use was high in the cohort, but comparable between VA and NE groups [18 (25.7%) vs 22 (34.9%), p=0.206]. Other neonatal morbidities were comparable between groups (Table 1). Conclusion This multicenter study provides pragmatic insights into the current use of NE and VA in neonates. Our study reports the effective use of each agent in distinct patient subgroups. This cohort represented neonates with high illness severity; however, exposure to either agent did not independently increase the risk of mortality or adverse outcomes. Further prospective studies exploring its optimal use and cardiopulmonary effects would be interesting.

Utility of intraoperative scoring system in rhino-orbital mucormycosis as a prognostic tool.

To assess the utility of an intraoperative scoring system for mucormycosis and to predict prognosis by comparing the score with postoperative outcomes. This study was conducted among 80 patients with mucormycosis who underwent surgical management with mandatory pterygopalatine fossa and infratemporal fossa exploration. All cases were scored using our intraoperative scoring assessment tool. Postoperative outcomes in terms of favourable prognosis and mortality were evaluated and compared with demographics, clinical history and intraoperative findings. An intraoperative score of more than 25 was statistically significant in predicting mortality (p < 0.0001). In all, 86.7% of patients with a score above 25 succumbed to the disease. Statistical significance of mortality (p < 0.05) was observed in those with involvement of pterygopalatine fossa (78.9%), orbit (73.7%), infratemporal fossa (57.9%), cribriform plate (36.8%) and those with history of intake of antiviral drugs (47.4%), use of supplemental oxygen (31.6%) and renal failure (26.3%). This study enabled better prediction of postoperative prognosis in mucormycosis and reiterated the importance of exploration of pterygopalatine fossa and infratemporal fossa in management and prognostication of invasive fungal sinusitis.

Comparative analysis of oxygenator dysfunction in polymethylpentene oxygenators: A pilot study.

Polymethylpentene (PMP) oxygenators serve as the primary oxygenator type utilized for ECMO. With the number of PMP oxygenators available, it has become increasingly important to determine differences among each oxygenator type that can lead to varying metrics of oxygenator dysfunction. This study was a retrospective, single-center analysis of adult patients supported on ECMO between December 2020 to December 2021 with varying PMP oxygenators including the Medtronic Nautilus Smart (Minneapolis, MA), the Eurosets AMG PMP (Medolla, Italy) and Getinge Quadrox-iD and the Getinge Cardiohelp HLS Module Advanced System (Gothenberg, Sweden). A total of 19 patients were included in our study. 10 patients (52.6%) were supported with a Medtronic Nautilus Smart oxygenator, 5 patients (26.3%) were supported with an Eurosets AMG PMP Oxygenator, and 4 patients (21.1%) were supported with either a Getinge Quadrox-iD oxygenator or Getinge Cardiohelp HLS system. Patients supported with Eurosets AMG PMP oxygenators experienced higher resistance and lower post-oxygenator PaO2 in comparison to other cohorts (p < .02 and < .002 respectively). There was no difference in measured oxygen transfer between cohorts (p = .667). Two patients, both supported by Eurosets AMG PMP, experienced oxygenator failure (p = .094). Radial flow oxygenators are prone to higher resistance and lower post-oxygenator PaO2when compared to transverse flow oxygenators. Future larger multicenter studies are required to fully discern the differences between flow-varying polymethylpentene oxygenators and their appropriate cutoffs for oxygenator dysfunction.

Effect of noninvasive ventilation on mortality and clinical outcomes among patients with severe hypoxemic COVID-19 pneumonia after high-flow nasal oxygen failure: a multicenter retrospective French cohort with propensity score analysis

BackgroundWe assessed the effect of noninvasive ventilation (NIV) on mortality and length of stay after high flow nasal oxygenation (HFNO) failure among patients with severe hypoxemic COVID-19 pneumonia.MethodsIn this multicenter, retrospective study, we enrolled COVID-19 patients admitted in intensive care unit (ICU) for severe COVID-19 pneumonia with a HFNO failure from December 2020 to January 2022. The primary outcome was to compare the 90-day mortality between patients who required a straight intubation after HFNO failure and patients who received NIV after HFNO failure. Secondary outcomes included ICU and hospital length of stay. A propensity score analysis was performed to control for confounding factors between groups. Exploratory outcomes included a subgroup analysis for 90-day mortality.ResultsWe included 461 patients with HFNO failure in the analysis, 233 patients in the straight intubation group and 228 in the NIV group. The 90-day mortality did not significantly differ between groups, 58/228 (25.4%) int the NIV group compared with 59/233 (25.3%) in the straight intubation group, with an adjusted hazard ratio (HR) after propensity score weighting of 0.82 [95%CI, 0.50–1.35] (p = 0.434). ICU length of stay was significantly shorter in the NIV group compared to the straight intubation group, 10.0 days [IQR, 7.0-19.8] versus 18.0 days [IQR,11.0–31.0] with a propensity score weighted HR of 1.77 [95%CI, 1.29–2.43] (p < 0.001). A subgroup analysis showed a significant increase in mortality rate for intubated patients in the NIV group with 56/122 (45.9%), compared to 59/233 (25.3%) for patients in the straight intubation group (p < 0.001).ConclusionsIn severely hypoxemic COVID-19 patients, no significant differences were observed on 90-day mortality between patients receiving straight intubation and those receiving NIV after HFNO failure. NIV strategy was associated with a significant reduction in ICU length of stay, despite an increase in mortality in the subgroup of patients finally intubated.

Predictors of membrane oxygenator failure in pediatric extracorporeal membrane oxygenation.

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is increasingly utilized in pediatric patients. Failure to recognize membrane oxygenator failure can lead to critical complications due to rapid deterioration of membrane oxygenator function. Therefore, identifying the predictors for membrane oxygenator exchange is crucial. However, risk factors for membrane oxygenator exchange in pediatric V-A ECMO remain unclear; therefore, this study aimed to evaluate these risk factors. This retrospective cohort study enrolled all pediatric patients aged <18 years who received V-A ECMO between August 2018 and July 2023 at a tertiary-care pediatric hospital in Japan. The Cox proportional hazards model was used to evaluate the predictors of membrane oxygenator failure within 72 h after initiation. During the study period, membrane oxygenator failure occurred in 18/55 (32.7%) children within 72 h; membrane oxygenator failure within 72 h occurred in 4/29 (13.8%) and 14/26 (53.8%) in the groups with ratio of blood flow divided by the blood flow limit of the membrane oxygenator (B/L) of <0.5 and ≥0.5, respectively (adjusted hazards ratio, 4.97 [95% confidence interval, 1.33-18.5]; p = 0.017). After adjusting for delta pressure of the oxygenator, an increase in body weight and aspartate aminotransferase levels were associated with an increase in early membrane oxygenator failure. This retrospective study demonstrated that a B/L ratio >0.5, an increase in body weight, and elevated aspartate aminotransferase were independent risk factors for early membrane oxygenator failure in pediatric V-A ECMO. However, a prospective multicenter study with an appropriate sample size is warranted to mitigate potential bias, and enhance generalizability for further investigation of the association between a B/L ratio and early membrane oxygenator failure.

Cardiorespiratory Instability after Percutaneous Patent Ductus Arteriosus Closure: A Multicenter Cohort Study

ObjectiveTo evaluate post-procedural clinical characteristics of preterm infants undergoing transcatheter patent ductus arteriosus (PDA) closure, including oxygenation/ventilation failure and cardiovascular compromise Study designMulticenter retrospective cohort study of preterm infants who were ≤2 kg at the time of percutaneous PDA closure between August 2018 and July 2021. Indices of cardiorespiratory stability were collected pre-closure, immediately post-closure, and subsequently averaged every 4 hours for the first 24 hours post-procedure. The primary outcome was incidence of post-transcatheter cardiorespiratory syndrome: composite of: (i) hemodynamic instability (defined by systemic hypotension, systemic hypertension, or use of new inotropes/vasopressors in the first 24 hours after catheterization and at least one of the following: (i)ventilation failure or (ii) oxygenation failure. ResultsA total of 197 patients were included with a median [IQR] age and weight at catheterization of 34 [25, 43] days and 1090 [900, 1367] grams, respectively. The primary composite outcome was reported in 46 (23.3%) patients and subcomponents of oxygenation and/or ventilation failure, systolic hypotension or systolic hypertension were noted in 81 (41.1%), 3 (1.5%) and 86 (43.6%) respectively. Logistic regression models showed weight at catheterization and respiratory severity score pre-closure to be significantly associated with post-transcatheter cardiorespiratory syndrome. ConclusionPost-transcatheter cardiorespiratory syndrome is characterized primarily by systemic hypertension and oxygenation failure, with a very low incidence of hypotension and need for inotropes.

Phenotypes and Lung Microbiota Signatures of Immunocompromised Patients with Pneumonia-Related Acute Respiratory Distress Syndrome.

We aim to identify the clinical phenotypes of immunocompromised patients with pneumonia-related ARDS, to investigate the lung microbiota signatures and the outcomes of different phenotypes, and finally, to develop a machine learning classifier for a specified phenotype. This prospective study included immunocompromised patients with pneumonia-related ARDS. We identified phenotypes using hierarchical clustering to analyze clinical variables and serum cytokine levels. We then compared outcomes and lung microbiota signatures between phenotypes. Based on lung microbiota markers, we developed a random forest classifier for a specified phenotype with worse outcomes. This study included 92 patients, who were divided into three phenotypes, namely "type α" (N = 33), "type β" (N = 12), and "type γ" (N = 47). Compared to type α or type β, patients with type γ had no obvious inflammatory presentation and had significantly lower IL-6 levels and more severe oxygenation failure. Type γ was also related to higher 30-day mortality and lower ventilator free days. The microbiota signatures of type γ were characterized by lower alpha diversity and distinct compositions than those of other patients. We developed a lung microbiota-derived random forest model to differentiate patients with type γ from other phenotypes. Immunocompromised patients with pneumonia-related ARDS can be clustered into three clinical phenotypes, namely type α, type β, and type γ. Phenotypes were distinguished from each other with different outcomes and lung microbiota signatures. Type γ, which was characterized by insufficient inflammation response and worse outcomes, can be detected with a random forest model based on lung microbiota markers.

Evaluating Airway Management in Patients With Trisomy 21 in the PICU and Cardiac ICU: A Retrospective Cohort Study.

Children with trisomy 21 often have anatomic and physiologic features that may complicate tracheal intubation (TI). TI in critically ill children with trisomy 21 is not well described. We hypothesize that in children with trisomy 21, TI is associated with greater odds of adverse airway outcomes (AAOs), including TI-associated events (TIAEs), and peri-intubation hypoxemia (defined as > 20% decrease in pulse oximetry saturation [Sp o2 ]). Retrospective database study using the National Emergency Airway Registry for Children (NEAR4KIDS). Registry data from 16 North American PICUs and cardiac ICUs (CICUs), from January 2014 to December 2020. A cohort of children under 18 years old who underwent TI in the PICU or CICU from in a NEAR4KIDS center. We identified patients with trisomy 21 and selected matched cohorts within the registry. None. We included 8401 TIs in the registry dataset. Children with trisomy 21 accounted for 274 (3.3%) TIs. Among those with trisomy 21, 84% had congenital heart disease and 4% had atlantoaxial instability. Cervical spine protection was used in 6%. The diagnosis of trisomy 21 (vs. without) was associated with lower median weight 7.8 (interquartile range [IQR] 4.5-14.7) kg versus 10.6 (IQR 5.2-25) kg ( p < 0.001), and more higher percentage undergoing TI for oxygenation (46% vs. 32%, p < 0.001) and ventilation failure (41% vs. 35%, p = 0.04). Trisomy 21 patients had more difficult airway features (35% vs. 25%, p = 0.001), including upper airway obstruction (14% vs. 8%, p = 0.001). In addition, a greater percentage of trisomy 21 patients received atropine (34% vs. 26%, p = 0.004); and, lower percentage were intubated with video laryngoscopy (30% vs. 37%, p = 0.023). After 1:10 (trisomy 21:controls) propensity-score matching, we failed to identify an association difference in AAO rates (absolute risk difference -0.6% [95% CI -6.1 to 4.9], p = 0.822). Despite differences in airway risks and TI approaches, we have not identified an association between the diagnosis of trisomy 21 and higher AAOs.

Autopsy analysis reveals increased macrophage infiltration and cell apoptosis in COVID-19 patients with severe pulmonary fibrosis

Clinical data indicates that SARS-CoV-2 infection-induced respiratory failure is a fatal condition for severe COVID-19 patients. However, the pathological alterations of different types of respiratory failure remained unknown for severe COVID-19 patients. This study aims to evaluate whether there are differences in the performance of various types of respiratory failure in severe COVID-19 patients and investigate the pathological basis for these differences. The lung tissue sections of severe COVID-19 patients were assessed for the degree of injury and immune responses. Transcriptome data were used to analyze the molecular basis in severe COVID-19 patients. Severe COVID-19 patients with combined oxygenation and ventilatory failure presented more severe pulmonary fibrosis, airway obstruction, and prolonged disease course. The number of M2 macrophages increased with the degree of fibrosis in patients, suggesting that it may be closely related to the development of pulmonary fibrosis. The co-existence of pro-inflammatory and anti-inflammatory cytokines in the pulmonary environment could also participate in the progression of pulmonary fibrosis. Furthermore, the increased apoptosis in the lungs of COVID-19 patients with severe pulmonary fibrosis may represent a critical factor linking sustained inflammatory responses to fibrosis. Our findings indicate that during the extended phase of COVID-19, antifibrotic and antiapoptotic treatments should be considered in conjunction with the progression of the disease.

Adverse Tracheal Intubation Events in Critically Ill Underweight and Obese Children: Retrospective Study of the National Emergency Airway for Children Registry (2013-2020).

Extremes of patient body mass index are associated with difficult intubation and increased morbidity in adults. We aimed to determine the association between being underweight or obese with adverse airway outcomes, including adverse tracheal intubation (TI)-associated events (TIAEs) and/or severe peri-intubation hypoxemia (pulse oximetry oxygen saturation < 80%) in critically ill children. Retrospective cohort using the National Emergency Airway for Children registry dataset of 2013-2020. Critically ill children, 0 to 17 years old, undergoing TI in PICUs. None. Registry data from 24,342 patients who underwent TI between 2013 and 2020 were analyzed. Patients were categorized using the Centers for Disease Control and Prevention weight-for-age chart: normal weight (5th-84th percentile) 57.1%, underweight (< 5th percentile) 27.5%, overweight (85th to < 95th percentile) 7.2%, and obese (≥ 95th percentile) 8.2%. Underweight was most common in infants (34%); obesity was most common in children older than 8 years old (15.1%). Underweight patients more often had oxygenation and ventilation failure (34.0%, 36.2%, respectively) as the indication for TI and a history of difficult airway (16.7%). Apneic oxygenation was used more often in overweight and obese patients (19.1%, 19.6%) than in underweight or normal weight patients (14.1%, 17.1%; p < 0.001). TIAEs and/or hypoxemia occurred more often in underweight (27.1%) and obese (24.3%) patients ( p < 0.001). TI in underweight children was associated with greater odds of adverse airway outcome compared with normal weight children after adjusting for potential confounders (underweight: adjusted odds ratio [aOR], 1.09; 95% CI, 1.01-1.18; p = 0.016). Both underweight and obesity were associated with hypoxemia after adjusting for covariates and site clustering (underweight: aOR, 1.11; 95% CI, 1.02-1.21; p = 0.01 and obesity: aOR, 1.22; 95% CI, 1.07-1.39; p = 0.002). In underweight and obese children compared with normal weight children, procedures around the timing of TI are associated with greater odds of adverse airway events.

Weaning Failure in Mechanical Ventilation

Mechanical ventilation is a method of ventilation support through positive pressure breath application. It is used in cases of ventilation and/ or oxygenation failure. Due to its related complications mechanical ventilation should be withdrawn from the patient as soon as possible, called a weaning process. The result of the weaning of mechanical ventilation determines the patient’s prognosis. Patient will go through several assessments before a weaning decision is made. Subsequently, patient will be placed on an unconstrained breathing test (SBT) to check whether the patient's respiratory muscle is equipped for accepting its work of relaxing. Weaning disappointment is characterized as disappointment on SBT or reintubation at 48 hours following extubation. Several factors related to weaning failure are increasing airflow resistance, decreasing compliance, respiratory muscle fatigue, and the patient’s underlying conditions. Techniques to conquer these variables are expected to lessen the pace of disappointment of the weaning system. Keyword: Mechanical Ventilation, Respiratory Failure, Weaning Failure.

Predicting ICU Mortality in Acute Respiratory Distress Syndrome Patients Using Machine Learning: The Predicting Outcome and STratifiCation of severity in ARDS (POSTCARDS) Study.

To assess the value of machine learning approaches in the development of a multivariable model for early prediction of ICU death in patients with acute respiratory distress syndrome (ARDS). A development, testing, and external validation study using clinical data from four prospective, multicenter, observational cohorts. A network of multidisciplinary ICUs. A total of 1,303 patients with moderate-to-severe ARDS managed with lung-protective ventilation. None. We developed and tested prediction models in 1,000 ARDS patients. We performed logistic regression analysis following variable selection by a genetic algorithm, random forest and extreme gradient boosting machine learning techniques. Potential predictors included demographics, comorbidities, ventilatory and oxygenation descriptors, and extrapulmonary organ failures. Risk modeling identified some major prognostic factors for ICU mortality, including age, cancer, immunosuppression, Pa o2 /F io2 , inspiratory plateau pressure, and number of extrapulmonary organ failures. Together, these characteristics contained most of the prognostic information in the first 24 hours to predict ICU mortality. Performance with machine learning methods was similar to logistic regression (area under the receiver operating characteristic curve [AUC], 0.87; 95% CI, 0.82-0.91). External validation in an independent cohort of 303 ARDS patients confirmed that the performance of the model was similar to a logistic regression model (AUC, 0.91; 95% CI, 0.87-0.94). Both machine learning and traditional methods lead to promising models to predict ICU death in moderate/severe ARDS patients. More research is needed to identify markers for severity beyond clinical determinants, such as demographics, comorbidities, lung mechanics, oxygenation, and extrapulmonary organ failure to guide patient management.

Role of Therapeutic Bronchoscopy in Comparison to Standards of Care in Critically Ill Patients with Acute Respiratory Failure

Abstract Background Acute respiratory failure (ARF) is a sudden failure of oxygenation, carbon dioxide clearance or both, Hypoxic ARF is most commonly caused by pneumonia, cardiogenic or noncardiogenic pulmonary edema, or pulmonary haemorrhage, while the underlying causes of hypercapnic ARF include drug overdose, neuromuscular disease, chest wall abnormalities and severe obstructive airway disorders. Treatment for respiratory failure includes clearing the airways by suction, use of bronchodilators, tracheostomy and endotracheal tube with ventilator support. Additionally, the treatment regimen includes antibiotics for infections, anticoagulants for pulmonary thromboembolism, and electrolyte replacement for fluid imbalance. Objective To evaluate difference between use of therapeutic bronchoscope to standards of care, including open and closed suctioning (no bronchoscopy) regarding patient outcome. Patients and Methods Study included 80 patients who were divided by alternation into two groups: Group A: 40 patients were subjected to traditional standards of care including chest percussion, closed and open suctioning. Group B: 40 patients were subjected to therapeutic bronchoscope (fibreoptic bronchoscopy) with endobronchial washing and suctioning in addition to traditional standards of care. Results Regarding ABG significant improvements were observed, (in terms of PaCO2, PaO2 and PaO2/FiO2 ratio) in group B (fibreoptic bronchoscopy) in comparison with group A (traditional standards of care) at all follow up periods (P &amp;lt; 0.05). Regarding the radiological improvement, in this study we observed significant improvement after 3 days, after 8 days and total improvement were observed in group B (fibreoptic bronchoscopy) compared to group A (traditional standards of care) (P &amp;lt; 0.05). Regarding the patient’s ICU length of stay, both groups demonstrated insignificant differences (8.24±3.06 in group A versus 6.78±4.09 in group B) (P &amp;gt; 0.05). Conclusion The current study revealed that fibreoptic bronchoscopy was associated with significant improvement compared to traditional standards of care, in ARF cases in terms of ABG parameters as well as radiological findings. However, ICU length of stay and duration of mechanical ventilation seemed to be comparable.

Outcomes With Single-Site Dual-Lumen Versus Multisite Cannulation for Adults With COVID-19 Respiratory Failure Receiving Venovenous Extracorporeal Membrane Oxygenation.

To determine whether multisite versus single-site dual-lumen (SSDL) cannulation is associated with outcomes for COVID-19 patients requiring venovenous extracorporeal membrane oxygenation (VV-ECMO). Retrospective analysis of the Extracorporeal Life Support Organization Registry. Propensity score matching (2:1 multisite vs SSDL) was used to control for confounders. The matched cohort included 2,628 patients (1,752 multisite, 876 SSDL) from 170 centers. The mean ( sd ) age in the entire cohort was 48 (11) years, and 3,909 (71%) were male. Patients were supported with mechanical ventilation for a median (interquartile range) of 79 (113) hours before VV-ECMO support. None. The primary outcome was 90-day survival. Secondary outcomes included survival to hospital discharge, duration of ECMO support, days free of ECMO support at 90 days, and complication rates. There was no difference in 90-day survival (49.4 vs 48.9%, p = 0.66), survival to hospital discharge (49.8 vs 48.2%, p = 0.44), duration of ECMO support (17.9 vs 17.1 d, p = 0.82), or hospital length of stay after cannulation (28 vs 27.4 d, p = 0.37) between multisite and SSDL groups. More SSDL patients were extubated within 24 hours (4% vs 1.9%, p = 0.001). Multisite patients had higher ECMO flows at 24 hours (4.5 vs 4.1 L/min, p < 0.001) and more ECMO-free days at 90 days (3.1 vs 2.0 d, p = 0.02). SSDL patients had higher rates of pneumothorax (13.9% vs 11%, p = 0.03). Cannula site bleeding (6.4% vs 4.7%, p = 0.03), oxygenator failure (16.7 vs 13.4%, p = 0.03), and circuit clots (5.5% vs 3.4%, p = 0.02) were more frequent in multisite patients. In this retrospective study of COVID-19 patients requiring VV-ECMO, 90-day survival did not differ between patients treated with a multisite versus SSDL cannulation strategy and there were only modest differences in major complication rates. These findings do not support the superiority of either cannulation strategy in this setting.

The USnational registry for childhood interstitial and diffuse lung disease: Report of study design and initial enrollment cohort.

Childhood interstitial and diffuse lung disease (chILD) encompasses a broad spectrum of rare disorders. The Children's Interstitial and Diffuse Lung Disease Research Network (chILDRN) established a prospective registry to advance knowledge regarding etiology, phenotype, natural history, and management of these disorders. This longitudinal, observational, multicenter registry utilizes single-IRB reliance agreements, with participation from 25 chILDRN centers across the U.S. Clinical data are collected and managed using the Research Electronic Data Capture (REDCap) electronic data platform. We report the study design and selected elements of the initial Registry enrollment cohort, which includes 683 subjects with a broad range of chILD diagnoses. The most common diagnosis reported was neuroendocrine cell hyperplasia of infancy, with 155 (23%) subjects. Components of underlying disease biology were identified by enrolling sites, with cohorts of interstitial fibrosis, immune dysregulation, and airway disease being most commonly reported. Prominent morbidities affecting enrolled children included home supplemental oxygen use (63%) and failure to thrive (46%). This Registry is the largest longitudinal chILD cohort in the United States to date, providing a powerful framework for collaborating centers committed to improving the understanding and treatment of these rare disorders.