Forms Of Acute Respiratory Failure Research Articles

Progress in cytokine research for ARDS: A comprehensive review.

Acute respiratory distress syndrome (ARDS) is a critical form of acute respiratory failure characterized by diffuse alveolar damage, refractory hypoxemia, and non-cardiogenic pulmonary edema, resulting in high mortality. Dysregulated inflammation, driven by cytokines, is central to ARDS pathogenesis, progression, and prognosis. This review synthesizes current knowledge on the role of cytokines in ARDS and evaluates their potential as therapeutic targets, offering new insights for clinical management. A comprehensive analysis of recent studies was conducted to explore the roles of pro-inflammatory cytokines (e.g., IL-1β, IL-6, IL-8) and anti-inflammatory cytokines (e.g., IL-10, IL-22) in ARDS pathogenesis and to assess current and emerging therapies targeting these cytokines. Pro-inflammatory cytokines are crucial in initiating inflammatory responses and lung injury in early ARDS, while anti-inflammatory cytokines help regulate and resolve inflammation. Targeted therapies, such as IL-1 and IL-6 inhibitors, show potential in managing ARDS, particularly in COVID-19, but their clinical efficacy is still debated. Combination therapy strategies may enhance outcomes, but further large-scale, multicenter randomized controlled trials are required to establish their safety and efficacy. Understanding cytokine regulation in ARDS could lead to innovative therapeutic approaches. Future research should focus on cytokine roles across ARDS subtypes and stages and develop biomarker-driven, individualized treatments.

A narrative review of chemokine receptors CXCR1 and CXCR2 and their role in acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is a severe form of acute respiratory failure characterised by extensive inflammatory injury to the alveolocapillary barrier leading to alveolar oedema, impaired gas exchange and, ultimately, hypoxaemia necessitating the use of supplemental oxygen combined with some degree of positive airway pressure. Although much heterogeneity exists regarding the aetiology, localisation and endotypic characterisation of ARDS, what remains largely undisputed is the role of the innate immune system, and in particular of neutrophils, in precipitating and propagating lung injury. Activated neutrophils, recruited to the lung through chemokine gradients, promote injury by releasing oxidants, proteases and neutrophil extracellular traps, which ultimately cause platelet aggregation, microvascular thrombosis and cellular death. Among various neutrophilic chemoattractants, interleukin-8/C-X-C motif ligand 8 and related chemokines, collectively called ELR+ chemokines, acting on neutrophils through the G protein-coupled receptors CXCR1 and CXCR2, are pivotal in orchestrating the neutrophil activation status and chemotaxis in the inflamed lung. This allows efficient elimination of infectious agents while at the same time minimising collateral damage to host tissue. Therefore, understanding how CXCR1 and CXCR2 receptors are regulated is important if we hope to effectively target them for therapeutic use in ARDS. In the following narrative review, we provide an overview of the role of ELR+ chemokines in acute lung injury (ALI) and ARDS, we summarise the relevant regulatory pathways of their cognisant receptors CXCR1/2 and highlight current preclinical and clinical evidence on the therapeutic role of CXCR1 and CXCR2 inhibition in animal models of ALI, as well as in ARDS patients.

Effects of High-Flow Nasal Cannula on Right Heart Dysfunction in Patients with Acute-on-Chronic Respiratory Failure and Pulmonary Hypertension.

High-flow nasal cannula (HFNC) has several benefits in patients affected by different forms of acute respiratory failure, based on its own mechanisms. We postulated that HFNC may have some advantages over conventional oxygen therapy (COT) on the heart function in patients with acute-on-chronic respiratory failure with concomitant pulmonary hypertension (PH). We therefore designed this retrospective observational study to assess if HFNC improves the right and left ventricle functions and morphologies, arterial blood gases (ABGs), and patients' dyspnea, compared to COT. We enrolled 17 hospitalized patients receiving HFNC, matched with 17 patients receiving COT. Echocardiographic evaluation was performed at the time of admission (baseline) and 10 days after (T10). HFNC showed significant improvements in right ventricular morphology and function, and a reduction in sPAP. However, there were no significant changes in the left heart measurements with HFNC application. Conversely, COT did not lead to any modifications in echocardiographic measurements. In both groups, oxygenation significantly improved from baseline to T10 (in the HFNC group, from 155 ± 47 to 204 ± 61 mmHg while in the COT group, from 157 ± 27 to 207 ± 27 mmHg; p < 0.0001 for both comparisons). In conclusion, these data suggest an improvement of oxygenation with both treatments; however, only HFNC was able to improve the right ventricular morphology and function after 10 days from the beginning of treatment in a small cohort of patients with acute-on-chronic respiratory failure with PH.

Single cell transcriptomics identifies distinct profiles in pediatric acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS), termed pediatric ARDS (pARDS) in children, is a severe form of acute respiratory failure (ARF). Pathologic immune responses are implicated in pARDS pathogenesis. Here, we present a description of microbial sequencing and single cell gene expression in tracheal aspirates (TAs) obtained longitudinally from infants with ARF. We show reduced interferon stimulated gene (ISG) expression, altered mononuclear phagocyte (MNP) transcriptional programs, and progressive airway neutrophilia associated with unique transcriptional profiles in patients with moderate to severe pARDS compared to those with no or mild pARDS. We additionally show that an innate immune cell product, Folate Receptor 3 (FOLR3), is enriched in moderate or severe pARDS. Our findings demonstrate distinct inflammatory responses in pARDS that are dependent upon etiology and severity and specifically implicate reduced ISG expression, altered macrophage repair-associated transcriptional programs, and accumulation of aged neutrophils in the pathogenesis of moderate to severe pARDS caused by RSV.

Same but Different? Comparing the Epidemiology, Treatments and Outcomes of COVID-19 and Non-COVID-19 ARDS Cases in Germany Using a Sample of Claims Data from 2021 and 2019.

Acute respiratory distress syndrome (ARDS) is a severe lung condition that can be caused by a variety of underlying illnesses. Due to SARS-CoV-2, the number of cases with ARDS has increased worldwide, making it essential to compare this form of acute respiratory failure with classical causes of ARDS. While there have been several studies investigating the differences between COVID-19 and non-COVID-19 ARDS in early stages of the pandemic, little is known about the differences in later phases, especially in Germany. The aim of this study is to characterize and compare the comorbidities, treatments, adverse events, and outcomes of COVID-19-associated ARDS and non-COVID-19 ARDS using a representative sample of German health claims data from the years 2019 and 2021. We compare percentages and median values of the quantities of interest from the COVID-19 and non-COVID-19 ARDS group, with p-values calculated after conducting Pearson's chi-squared test or the Wilcoxon rank sum test. We also run logistic regressions to access the effect of comorbidities on mortality for COVID-19 ARDS and non-COVID-19 ARDS. Despite many similarities, we find that that there are some remarkable differences between COVID-19 and non-COVID-19 ARDS cases in Germany. Most importantly, COVID-19 ARDS cases display fewer comorbidities and adverse events, and are more often treated with non-invasive ventilation and nasal high-flow therapy. This study highlights the importance of comprehending the contrasting epidemiological features and clinical outcomes of COVID-19 and non-COVID-19 ARDS. This understanding can aid in clinical decision making and guide future research initiatives aimed at enhancing the management of patients afflicted with this severe condition.

Helmet Continuous Positive Airway Pressure in the Emergency Department: A Practical Guide

Helmet continuous positive airway pressure is a simple, noninvasive respiratory support strategy to treat several forms of acute respiratory failure, such as cardiogenic pulmonary edema and pneumonia. Recently, it has been largely used worldwide during the COVID-19 pandemic. Given the increased use of helmet continuous positive airway pressure in the emergency department, we aimed to provide an updated practical guide for nurses and clinicians based on the latest available evidence. We focus our attention on how to set the respiratory circuit. Moreover, we discuss the interactions between flow generators, filters, and positive end-expiratory pressure valves and the consequences regarding the delivered gas flow, fraction of inspired oxygen, positive end-expiratory pressure, and noise level.

Clinical and paraclinical features of the course of infection caused by SARS-CoV-2 in primary school-age children depending on gender

The COVID-19 pandemic has been going on for 2.5 years, which is a serious challenge for the health care systems of most countries of the world. The high frequency of mutations of the SARS-CoV-2 changes the epidemiological characteristics, clinical manifestations of the disease, as well as consequences after infection.Aim of the study. To conduct an analysis of the clinical and paraclinical features of the course of COVID-19 in primary school-age children, taking into account gender, to improve the prognosis of the severity and duration of the disease, to optimize the tactics of managing patients.Materials and methods. 55 clinical cases of COVID-19 in primary school-age patients were analyzed. The gender of the patients was considered a group-forming feature. The obtained results were analyzed by methods of descriptive statistics biostatistics, and clinical epidemiology.Results. It was established that half of the male patients and 44.4% of the girls had registered complications of the main disease, mainly in the form of acute respiratory failure. The onset of the disease was characterized by general weakness and fever. Cough was more likely to be noted among boys, while in girls, there was a tendency to increase the frequency of complaints of nasal congestion. In the hospital, during the physical examination, the pathological sounds under the lungs during auscultation were registered significantly more common in male patients (75.0±8.2 versus 48.1±9.6%, Рφ &lt; 0,05). Male gender, residence in the cities, violation in vaccination schedule, dyspnea, the level of blood oxygen saturation below 95% during hospitalization are characterized with a high predictive value of a longer hospitalization period.Conclusion. The course of COVID-19 in primary school-aged children was not dependent on gender and was multisymptomatic, however, the average duration of hospitalization was significantly higher among male patients. Incomplete vaccination status increased the attributive relative risks of more bed days in the hospital with an odds ratio of 6.7:1.

The Association Between Extravascular Lung Water and Critical Care Outcomes Following Bilateral Lung Transplantation.

Background.Primary graft dysfunction (PGD) is a form of acute respiratory failure that complicates 30% of bilateral lung transplants. Higher grades of PGD correlate with higher severity of respiratory failure and unfavorable outcomes. Immediate PGD determination posttransplant‚ however, is not always predictive of PGD over subsequent days or intensive care unit outcomes. We aimed to evaluate whether extravascular lung water index (ELWI) measured immediately post bilateral lung transplant was associated with higher severity of PGD at 72 h and duration of mechanical ventilation.Methods.We conducted a prospective, observational study of bilateral lung transplant patients admitted to the intensive care unit. ELWI measurements were performed at admission, 6, 12, 24, 36, 48, 60, and 72 h following transplant or until extubation. We evaluated the association between admission ELWI and 72-h PGD grade and duration of mechanical ventilation.Results.Across 56 patients enrolled, 268 transpulmonary thermodilution measurements were conducted. At admission, median ELWI increased with PGD grade (grade 1: 9 mL/kg [interquartile range (IQR), 8–11 mL/kg]‚ grade 2 [10 mL/kg (IQR, 8–12 mL/kg)]‚ and grade 3 [17 mL/kg (IQR, 14–19 mL/kg); P < 0.001]). Using multivariable Poisson regression analysis adjusting for confounders, admission ELWI elevation was associated with higher severity of PGD at 72 h (incidence rate ratio [IRR], 1.06; 95% confidence interval, 1.01-1.12) and duration of mechanical ventilation (IRR, 1.62; 95% confidence interval, 1.23-2.14). The combination of an ELWI of ≥13 mL/kg and partial pressure of oxygen/fraction of inspired oxygen ≤ 100 within 6 h of admission had high sensitivity (75%) and specificity (100%) for grade 3 PGD at 72 h (area under the curve, 0.95) and performed better than ELWI or partial pressure of oxygen/fraction of inspired oxygen alone.Conclusions.Our exploratory study demonstrates an association between admission ELWI and high grades of PGD at 72 h and longer duration of ventilation. These results provide the impetus to study whether goal-directed ELWI algorithms can improve transplant outcomes.

What Is Different in Acute Hematologic Malignancy-Associated ARDS? An Overview of the Literature.

Background and Objectives: Acute hematologic malignancies are a group of heterogeneous blood diseases with a high mortality rate, mostly due to acute respiratory failure (ARF). Acute respiratory distress syndrome (ARDS) is one form of ARF which represents a challenging clinical condition. The paper aims to review current knowledge regarding the variable pathogenic mechanisms, as well as therapeutic options for ARDS in acute hematologic malignancy patients. Data collection: We provide an overview of ARDS in patients with acute hematologic malignancy, from an etiologic perspective. We searched databases such as PubMed or Google Scholar, including articles published until June 2022, using the following keywords: ARDS in hematologic malignancy, pneumonia in hematologic malignancy, drug-induced ARDS, leukostasis, pulmonary leukemic infiltration, pulmonary lysis syndrome, engraftment syndrome, diffuse alveolar hemorrhage, TRALI in hematologic malignancy, hematopoietic stem cell transplant ARDS, radiation pneumonitis. We included relevant research articles, case reports, and reviews published in the last 18 years. Results: The main causes of ARDS in acute hematologic malignancy are: pneumonia-associated ARDS, leukostasis, leukemic infiltration of the lung, pulmonary lysis syndrome, drug-induced ARDS, radiotherapy-induced ARDS, diffuse alveolar hemorrhage, peri-engraftment respiratory distress syndrome, hematopoietic stem cell transplantation-related ARDS, transfusion-related acute lung injury. Conclusions: The short-term prognosis of ARDS in acute hematologic malignancy relies on prompt diagnosis and treatment. Due to its etiological heterogeneity, precision-based strategies should be used to improve overall survival. Future studies should focus on identifying the relevance of such etiologic-based diagnostic strategies in ARDS secondary to acute hematologic malignancy.

Therapeutic Benefits of Mesenchymal Stem Cells in Acute Respiratory Distress Syndrome: Potential Mechanisms and Challenges.

Acute respiratory distress syndrome (ARDS) presents as a form of acute respiratory failure resulting from non-cardiogenic pulmonary edema due to excessive alveolocapillary permeability, which may be pulmonary or systemic in origin. In the last 3 years, the coronavirus disease 2019 pandemic has resulted in an increase in ARDS cases and highlighted the challenges associated with this syndrome, as well as the unacceptably high mortality rates and lack of effective treatments. Currently, clinical treatment remains primarily supportive, including mechanical ventilation and drug-based therapy. Mesenchymal stem cell (MSC) therapies are emerging as a promising intervention in patients with ARDS and have promising therapeutic effects and safety. The therapeutic mechanisms include modifying the immune response and assisting with tissue repair. This review provides an overview of the general properties of MSCs and outlines their role in mitigating lung injury and promoting tissue repair in ARDS. Finally, we summarize the current challenges in the study of translational MSC research and identify avenues by which the discipline may progress in the coming years.

Predictive value of D-dimer in the clinical outcome of severe COVID19 patients: Are we giving it too much credit?

BackgroundCOVID-19 is a new form of acute respiratory failure leading to multiorgan failure and ICU admission. Gathered evidence suggests that a 3-fold rise in D-dimer concentrations may be linked to poor prognosis and higher mortality.PurposeTo describe D-dimer admission profile in severe ICU COVID19 patients and its predictive role in outcomes and mortality.MethodsSingle-center retrospective cohort study. All adult patients admitted to ICU with COVID19 were divided into 3 groups: (1) Lower-values group (D-dimer levels < 3-fold normal range value [NRV] [500ng/mL]), Intermediate-values group (D-dimer ≥3-fold and <10-fold NRV) and Higher-value group (≥10-fold NRV).Results118 patients (mean age 63 years, 73% males) were included (N = 73 Lower-values group, N = 31 Intermediate-values group; N = 11 Higher-values group). Mortality was not different between groups (p = 0.51). Kaplan-Meier survival curves revealed no differences (p = 0.52) between groups, nor it was verified even when gender, age, ICU length of stay, and SOFA score were considered as covariables.ConclusionsIn severe COVID19 patients, the D-dimer profile does not retain a predictive value regarding patients’ survivability and should not be used as a surrogate of disease severity.

Diabetes Mellitus-A Risk Factor for Unfavourable Outcome in COVID-19 Patients-The Experience of an Infectious Diseases Regional Hospital.

Early research into the implications concerning the evolution of the infection caused by the new coronavirus in people with glucose metabolism dysfunction, in this case diabetics, shows that severe forms of the disease predominate in this risk category. Moreover, it seems that even in patients with normal glycaemic status, COVID-19 may predispose to the development of hyperglycaemia which modulates immune mechanisms and inflammatory responses, with direct effects on morbidity and mortality. Thus, taking into account these scientific data, as well as the increased frequency of diabetes in the general population, we aimed to assess the risk of an unfavourable outcome of diabetic patients, which is in a strong connection with the presence and severity of pulmonary disease such as interstitial pneumonia/bronchopneumonia, as well as the effectiveness of Tocilizumab administration. The results of our study indicate a three-fold higher risk of death in patients with diabetes and COVID-19 (RR = 3.03; IC95%: 2.37–3.86; p = 0.001),compared to nondiabetic patients, and the risk of developing severe forms of acute respiratory failure was 1.5 times higher in the first studied category. In conclusion, we can say that the diabetic diagnosed with SARS-CoV-2 infection is more predisposed to immunological and organic dysfunctions that may ultimately result in death, and treatment with monoclonal anti-IL-6 antibodies was more effective in diabetic patients than non-diabetics (p < 0.05). The effectiveness of Tocilizumab was significant in both studied groups, but diabetic patients responded better to this therapy compared to non-diabetes-mellitus (DM) ones (76.7% vs. 35% p = 0.001).

Barotrauma during non-invasive ventilation for acute respiratory distress syndrome caused by COVID-19: a balance between risks and benefits.

Ventilatory support is vital for the management of severe forms of COVID-19. Non-invasive ventilation is often used in patients who do not meet criteria for intubation or when invasive ventilation is not available, especially in a pandemic when resources are limited. Despite non-invasive ventilation providing effective respiratory support for some forms of acute respiratory failure, data about its effectiveness in patients with viral-related pneumonia are inconclusive. Acute respiratory distress syndrome caused by severe acute respiratory syndrome-coronavirus 2 infection causes life-threatening respiratory failure, weakening the lung parenchyma and increasing the risk of barotrauma. Pulmonary barotrauma results from positive pressure ventilation leading to elevated transalveolar pressure, and in turn to alveolar rupture and leakage of air into the extra-alveolar tissue. This article reviews the literature regarding the use of non-invasive ventilation in patients with acute respiratory failure associated with COVID-19 and other epidemic or pandemic viral infections and the related risk of barotrauma.

Microvascular injury in the appendix of a pediatric patient with history of COVID-19 infection: A case report

Introduction: A novel coronavirus (SARS-CoV-2) infection has emerged in the world causing a pandemic disease with severe forms of acute respiratory failure along with other organs manifestations. Besides, frequent association with multisystem inflammatory syndrome in children (MIS-C) as complication after the recovery has been recorded. Hereby we report the histological findings in the appendix of a female pediatric patient with history of COVID-19 infection. Case Report: In our case, an 8-year-old female patient presented to the emergency department of our main tertiary hospital in Bahrain with two days history of low grade fever, lower abdominal pain, nausea, and vomiting. She was admitted to the pediatric surgical unit for a suspected acute appendicitis. A diagnostic laparoscopy and laparoscopic appendectomy was performed. The appendix was sent to the histopathology examination which confirmed the diagnosis of acute suppurative appendicitis with focal endarteritis obliterans. Retrospectively history revealed the child was COVID-19 positive three months back. Conclusion: Microvascular injury in the appendix of our case adds to the preliminary available evidences in the literature indicating that endarteritis obliterans of the gastrointestinal (GI) tract organs could be a complication of the COVID-19 virus infection like in MIS-C which is a known post-infectious complication of the virus.

Randomized Controlled Trial of a Novel Communication Device Assessed During Noninvasive Ventilation Therapy

Noninvasive ventilation (NIV), a form of positive airway pressure (PAP) therapy, is the standard of care for various forms of acute respiratory failure (ARF). Communication impairment is a side effect of NIV, impedes patient care, contributes to distress and intolerance, and potentially increases intubation rates. This study aimed to evaluate communication impairment during CPAP therapy and demonstrate communication device improvement with a standardized protocol. How does an oronasal mask affect communication intelligibility? How does use of an NIV communication device change this communication intelligibility? A single-center randomized controlled trial (36 outpatients with OSA on CPAP therapy) assessed exposure to CPAP 10cm H2O and PAP communication devices (SPEAX, Ataia Medical). Communication impairment was evaluated by reading selected words and sentences for partners to record and were tabulated as %words correct. Each outpatient-partner pair performed three assessments: (1) baseline (conversing normally), (2) mask baseline (conversing with PAP), and (3) randomized to functioning device (conversing with PAP and device) or sham device. After each stage, both outpatients and partners completed Likert surveys regarding perceived intelligibility and comfort. While conversing with PAP, word and sentence intelligibility decreased relatively by 52%(87%vs41%) and relatively by 57%(94%vs40%), respectively, compared with normal conversation. Word and sentence intelligibility in the intervention arm increased relatively by 75%(35%vs61%; P< .001) and by 126%(33%vs76%; P< .001) higher than the control arm, respectively. The device improved outpatient-perceived PAP comfort relatively by 233%(15%vs50%, P= .042) and partner-perceived comfort by relatively 245%(20%vs69%, P= .0074). Use of this PAP communication device significantly improves both intelligibility and comfort. This is one of the first studies quantifying communication impairment during PAP delivery. ClinicalTrials.gov; No.: NCT03795753; URL: www.clinicaltrials.gov.

Prognosis of difficult weaning from mechanical ventilation in children with acute respiratory failure

The aim of this study was to determine the signifi­cance of factors such as transthyretin levels, right diaphragm thickening fraction, amplitude of left diaphragm dome movements, stroke volume index (SVI), cardiac in­dex (CI), SpO2/FiO2 ratio and transthyretin/C-reactive protein in unsuccessful weaning from AV in children with various forms of ARF at the stage of weaning from mechanical ventilation (MV).Materials and methods. We complete the prospective single-center cohort study and enrol 67 patients 1 month - 18 years old with hypoxemic and hypercapnic-hypoxemic acute respiratory failure (ARF). 46 of them need invasive mechanical ventilation (MV) for more than 3 days. We divide them into 1st group (n=35, they were successfully weaned) and 2nd group (n=11, they need reintubation and MV within the next 48 hours).We performed ultrasound examination of diaphragm, prolonged non-invasive monitoring of hemodynamic parameters to determine SVI, CI, SpO2 with esCCO technology (estimated continuous cardiac output), NIHON COHDEN; determination of transthyretin (TTR) with G-Biosciences/Geno Technology, (USA) kit. Data were recorded on the first day of MV (d1), on 3rd, 5th, 7th day of treatment (d3, d5, d7). Logistic regression method was used to make a predictive model of the probability of unsuccessful weaning from MV.Results. We have established (formula 1), that the risk of unsuccessful weaning from MV in patients with hypoxemic ARF increases with low values of transthyretin serum level, right hemidiaphragm thickening fraction, SVI and high CI.R= -12,008 + 0,242*(TTR, ng/ml) + 1,720*(right hemidiaphragm thickening fraction, %) + 1,711*(SVI, ml/beat/m2) – 3,120*(СІ, l/min/m2) (1).The risk of unsuccessful weaning from MV in patients with hypercapnic-hypoxemic ARF (formula 2) increases with low values of transthyretin serum level, amplitude of left hemidiaphragm movement, SVI, SpO2/FiO2 and transthyretin/C-reactive protein ratio.R= - 42,233 + 0,389*(TTR, ng/ml) + 22,189*(amplitude of left hemidiaphragm movement, mm) + 1,120*(SpO2/FiO2) + 2,885*( SVI, ml/beat/m2) + 14,944*(TTR/CRP) (2).Conclusions. The level of transthyretin and SVI in addition to the indicators of thickening fraction of right hemidiaphragm and CI in children with hypoxemic ARF and the amplitude of left hemidiaphragm movements, ratios SpO2/FiO2 and transthyretin/C-reactive protein in children with hypercapnic-hypoxemic ARF might affect the process of weaning from MV. Thus, acute malnutrition with diaphragmatic dysfunction and hyperdynamic type of blood circulation reduce the likelihood of successful weaning from MV and worsen clinical outcome in children with different types of ARF

Coronavirus Disease 2019 and Acute Respiratory Distress Syndrome: Why the Intensivist Is More Important Than Ever.

Coronavirus Disease 2019 and Acute Respiratory Distress Syndrome: Why the Intensivist Is More Important Than Ever.

Histopathological findings in a COVID-19 patient affected by ischemic gangrenous cholecystitis

BackgroundSince its first documentation, a novel coronavirus (SARS-CoV-2) infection has emerged worldwide, with the consequent declaration of a pandemic disease (COVID-19). Severe forms of acute respiratory failure can develop. In addition, SARS-CoV-2 may affect organs other than the lung, such as the liver, with frequent onset of late cholestasis. We here report the histological findings of a COVID-19 patient, affected by a tardive complication of acute ischemic and gangrenous cholecystitis with a perforated and relaxed gallbladder needing urgent surgery.Case presentationA 59-year-old Caucasian male, affected by acute respiratory failure secondary to SARS-CoV-2 infection was admitted to our intensive care unit (ICU). Due to the severity of the disease, invasive mechanical ventilation was instituted and SARS-CoV-2 treatment (azithromycin 250 mg once-daily and hydroxychloroquine 200 mg trice-daily) started. Enoxaparin 8000 IU twice-daily was also administered subcutaneously. At day 8 of ICU admission, the clinical condition improved and patient was extubated. At day 32, patient revealed abdominal pain without signs of peritonism at examination, with increased inflammatory and cholestasis indexes at blood tests. At a first abdominal CT scan, perihepatic effusion and a relaxed gallbladder with dense content were detected. The surgeon decided to wait and see the evolution of clinical conditions. The day after, conditions further worsened and a laparotomic cholecystectomy was performed. A relaxed and perforated ischemic gangrenous gallbladder, with a local tissue inflammation and perihepatic fluid, was intraoperatively met. The gallbladder and a sample of omentum, adherent to the gallbladder, were also sent for histological examination.Hematoxylin-eosin-stained slides display inflammatory infiltration and endoluminal obliteration of vessels, with wall breakthrough, hemorrhagic infarction, and nerve hypertrophy of the gallbladder.The mucosa of the gallbladder appears also atrophic. Omentum vessels also appear largely thrombosed. Immunohistochemistry demonstrates an endothelial overexpression of medium-size vessels (anti-CD31), while not in micro-vessels, with a remarkable activity of macrophages (anti-CD68) and T helper lymphocytes (anti-CD4) against gallbladder vessels. All these findings define a histological diagnosis of vasculitis of the gallbladder.ConclusionsIschemic gangrenous cholecystitis can be a tardive complication of COVID-19, and it is characterized by a dysregulated host inflammatory response and thrombosis of medium-size vessels.

Risk of Acute Respiratory Distress Syndrome Among Older Adults Living Near Construction and Manufacturing Sites.

Construction and manufacturing sites produce airborne toxins that may affect nearby residents' respiratory health. Living in heavy industrial sites has been linked to respiratory conditions such as asthma and pneumonia. However, limited information is available for risk of acute respiratory distress syndrome (ARDS), a form of acute respiratory failure with high incidence among older adults. We conducted a nationwide ecologic study to investigate associations between annual ZIP code-level changes in industrial activity and annual changes in ZIP code-level hospital admission rates for older community residents. Using adjusted generalized linear mixed models, we analyzed data from nearly 30 million yearly Medicare beneficiaries for the years 2006 through 2012. We found on average 92,363 hospital admissions for ARDS per year and 646,542 admissions over the course of 7 years. We found that an increase of 10 construction sites per year was associated with a 0.77% (95% confidence interval [CI] = 0.71, 0.84) increase in annual hospital admission rates for ARDS and an increase of 10 manufacturing industries per year was associated with a 1.21% (95% CI = 1.09, 1.33) increase in annual hospital admission rates for ARDS across all ZIP codes. The estimated effect of chemical product manufacturing industry on ARDS was higher than that of total manufacturing industries. Residing in ZIP codes with a high number of construction or manufacturing sites was associated with increased ARDS hospital admissions. This nationwide ecologic study of older adults suggests that residence in areas with more construction and manufacturing sites is associated with increased ARDS risk.

ASSESSING RESPIRATORY THERAPISTS’ KNOWLEDGE REGARDING ARDS MANAGEMENT UPDATES

TYPE: Abstract Publication TOPIC: Respiratory Care PURPOSE: Acute respiratory distress syndrome (ARDS) is a known life-threatening form of acute respiratory failure. ARDS is responsible for 10% of ICU admissions globally,and annually representing over 3 million hospital admissions.In 2014, a study was done in the UK showed substantial evidence that there is a high degree of variance in the management strategies used to treat patients with ARDS across the UK.Moreover, the LUNG SAFE study showed unsettling gap between scientific evidence and medical practice,which supports the need to assess the medical community understanding about the importance of lung-protective ventilation and updated ARDS management overall.Upon our extensive research,we have not come across a study in the KSA that assess the knowledge of healthcare providers in regards to ARDS management updates. METHODS: This study is a cross-sectional survey among respiratory therapist across the Kingdom.The questions were adopted and modified from a survey that developed at the University Hospital Southampton NHS Foundation Trust. RESULTS: Most of the sample(83.5%)stated that they are currently practicing evidence based ARDS management updates at their hospitals. Half of the responders chose the Berlin definition of ARDS as the diagnostic definition of ARDS.The rest of the information is illustrated in the below graph. CONCLUSIONS: This study showed that there is a substantial variation between updated evidence regarding ARDS management and what is currently being practiced at hospitals across the Kingdom. CLINICAL IMPLICATIONS: Standardizing and assuring the respiratory therapist knowledge about the updated ARDS management is very vital to lessen the discrepancy and to provide better disease management by applying evidence based practice. DISCLOSURE: No significant relationships. KEYWORDS: ARDS, Respiratory Therapist, ICU