Mortality In Acute Respiratory Distress Syndrome Patients Research Articles

Association of coagulation function with the risk of in-hospital mortality in patients with severe acute respiratory distress syndrome

BackgroundTo evaluate the association of coagulation disorder score with the risk of in-hospital mortality in acute respiratory distress syndrome (ARDS) patients. MethodsIn this cohort study, 7,001 adult patients with ARDS were identified from the Medical Information Mart for Intensive Care Database-IV (MIMIC-IV). Univariate and multivariate Logistic stepwise regression models were used to explore the associations of coagulation-associated biomarkers with the risk of in-hospital mortality in patients with ADRS. Restricted cubic spline (RCS) was plotted to explore the association between coagulation disorder score and in-hospital mortality of ARDS patients. ResultsThe follow-up time for in-hospital death was 7.15 (4.62, 13.88) days. There were 1,187 patients died and 5,814 people survived in hospital. After adjusting for confounding factors, increased risk of in-hospital mortality in ARDS patients was observed in those with median coagulation disorder score [odds ratio (OR) = 1.22, 95% confidence interval (CI): 1.01–1.47) and high coagulation disorder score (OR = 1.38, 95% CI: 1.06–1.80). The results of RCS indicated that when the coagulation disorder score >2, the trend of in-hospital mortality rose gradually, and OR was >1. ConclusionsPoor coagulation function was associated with increased risk of in-hospital mortality in ARDS patients. The findings implied that clinicians should regularly detect the levels of coagulation-associated biomarkers for the management of ARDS patients.

Prognostic value of the systemic immune-inflammation index in patients with acute respiratory distress syndrome: A retrospective study

BackgroundInflammation is critical in the etiology and progression of acute respiratory distress syndrome (ARDS). This study aims to rigorously assess the predictive capacity of systemic immune-inflammation index (SII) in determining the outcomes of patients with ARDS. MethodsPatient data were extracted from version 2.2 of the Medical Information Mart for Intensive Care IV (MIMIC-IV). The Receiver Operating Characteristic (ROC) curve was deployed to determine the optimal cutoff value for the SII, facilitating the stratification of participants into distinct cohorts based on SII levels. The relationship between SII and survival outcomes was rigorously evaluated using Cox proportional hazards models. The association between SII and patient survival was rigorously examined using Cox proportional-hazard models. The impact of varying SII levels on mortality was quantitatively assessed through these models, with the results articulated as hazard ratios (HRs) and 95% confidence intervals (CIs). Three distinct models were formulated for this analysis: Model 1 employed univariate Cox regression to relate SII with mortality; Model 2 introduced adjustments for age and sex; and Model 3 extended these adjustments to include age, sex, race, SAPS II, APSIII, Hemoglobin, Albumin, Pneumonia, SpO2, and SBP. ResultsPost-application of the inclusion criteria, a cohort of 976 eligible patients was delineated for detailed examination. Univariate analysis focusing on 30-day mortality within the SII ≥1694, the hazard ratio (HR) was 1.42 (95% confidence interval (CI): 1.11, 1.81). However, after adjusting for confounding factors such as age, sex, race, Simplified Acute Physiology Score II (SAPS II), Acute Physiology Score (APS) III, Hemoglobin, Albumin, Pneumonia, SpO2, and Systolic Blood Pressure (SBP), an SII value of ≥1694 was identified as an independent and significant risk factor for mortality in patients with ARDS, with an HR of 1.38 (95% CI: 1.08–1.77, P = 0.0016). This trend was consistent for 90-day and one-year mortality rates. ConclusionsSII surfaced as an autonomous determinant of mortality in ARDS patients, affirming its status as an accessible and dependable prognostic indicator for individuals newly diagnosed with this critical condition. Additional research is imperative to further elucidate the prognostic implications of SII in the therapeutic management of patients with ARDS.

Prognostic value of time-varying dead space estimates in mechanically ventilated patients with acute respiratory distress syndrome

BackgroundThe dead space fraction (VD/VT) has proven to be a powerful predictor of higher mortality in acute respiratory distress syndrome (ARDS). However, its measurement relies on expired carbon dioxide, limiting its widespread application in clinical practice. Several estimates employing routine variables have been found to be reliable substitutes for direct measurement of VD/VT. In this study, we evaluated the prognostic value of these dead space estimates obtained in the first 7 days following the initiation of ventilation. MethodsThis retrospective observational study was conducted using data from the Chinese database in intensive care (CDIC). Eligible participants were adult ARDS patients receiving invasive mechanical ventilation while in the intensive care unit between 1st January 2014 and 31st March 2021. We collected data during the first 7 days of ventilation to calculate various dead space estimates, including ventilatory ratio (VR), corrected minute ventilation (V˙Ecorr), VD/VT (Harris–Benedict), VD/VT (Siddiki estimate), and VD/VT (Penn State estimate) longitudinally. A time-dependent Cox model was used to handle these time-varying estimates. ResultsA total of 392 patients (median age 66 [interquartile range: 55–77] years, median SOFA score 9 [interquartile range: 7–12]) were finally included in our analysis, among whom 132 (33.7%) patients died within 28 days of admission. VR (hazard ratio [HR]=1.04 per 0.1 increase, 95% confidence interval [CI]: 1.01 to 1.06; P=0.013), V˙Ecorr (HR=1.08 per 1 increase, 95% CI: 1.04 to 1.12; P < 0.001), VD/VT (Harris–Benedict) (HR=1.25 per 0.1 increase, 95% CI: 1.06 to 1.47; P=0.006), and VD/VT (Penn State estimate) (HR=1.22 per 0.1 increase, 95% CI: 1.04 to 1.44; P=0.017) remained significant after adjustment, while VD/VT (Siddiki estimate) (HR=1.10 per 0.1 increase, 95% CI: 1.00 to 1.20; P=0.058) did not. Given a large number of negative values, VD/VT (Siddiki estimate) and VD/VT (Penn State estimate) were not recommended as reliable substitutes. Long-term exposure to VR >1.3, V˙Ecorr >7.53, and VD/VT (Harris–Benedict) >0.59 was independently associated with an increased risk of mortality in ARDS patients. These findings were validated in the fluid and catheter treatment trial (FACTT) database. ConclusionsIn cases where VD/VT cannot be measured directly, early time-varying estimates of VD/VT such as VR, V˙Ecorr, and VD/VT (Harris–Benedict) can be considered for predicting mortality in ARDS patients, offering a rapid bedside application.

Effect of total cholesterol and statin therapy on mortality in ARDS patients: a secondary analysis of the SAILS and HARP-2 trials

BackgroundTwo acute respiratory distress syndrome (ARDS) trials showed no benefit for statin therapy, though secondary analyses suggest inflammatory subphenotypes may have a differential response to simvastatin. Statin medications decrease cholesterol levels, and low cholesterol has been associated with increased mortality in critical illness. We hypothesized that patients with ARDS and sepsis with low cholesterol could be harmed by statins.MethodsSecondary analysis of patients with ARDS and sepsis from two multicenter trials. We measured total cholesterol from frozen plasma samples obtained at enrollment in Statins for Acutely Injured Lungs from Sepsis (SAILS) and Simvastatin in the Acute Respiratory Distress Syndrome (HARP-2) trials, which randomized subjects with ARDS to rosuvastatin versus placebo and simvastatin versus placebo, respectively, for up to 28 days. We compared the lowest cholesterol quartile (< 69 mg/dL in SAILS, < 44 mg/dL in HARP-2) versus all other quartiles for association with 60-day mortality and medication effect. Fisher’s exact test, logistic regression, and Cox Proportional Hazards were used to assess mortality.ResultsThere were 678 subjects with cholesterol measured in SAILS and 509 subjects in HARP-2, of whom 384 had sepsis. Median cholesterol at enrollment was 97 mg/dL in both SAILS and HARP-2. Low cholesterol was associated with higher APACHE III and shock prevalence in SAILS, and higher Sequential Organ Failure Assessment score and vasopressor use in HARP-2. Importantly, the effect of statins differed in these trials. In SAILS, patients with low cholesterol who received rosuvastatin were more likely to die (odds ratio (OR) 2.23, 95% confidence interval (95% CI) 1.06–4.77, p = 0.02; interaction p = 0.02). In contrast, in HARP-2, low cholesterol patients had lower mortality if randomized to simvastatin, though this did not reach statistical significance in the smaller cohort (OR 0.44, 95% CI 0.17–1.07, p = 0.06; interaction p = 0.22).ConclusionsCholesterol levels are low in two cohorts with sepsis-related ARDS, and those in the lowest cholesterol quartile are sicker. Despite the very low levels of cholesterol, simvastatin therapy seems safe and may reduce mortality in this group, though rosuvastatin was associated with harm.Graphical abstract

Plasma bioactive adrenomedullin on intensive care unit admission is associated with acute respiratory distress syndrome: an observational study

BackgroundBioactive adrenomedullin (bio-ADM) is a vasoactive peptide with a key role in reducing vascular hyperpermeability and improving endothelial stability during infection, but it also has vasodilatory properties. Bioactive ADM has not been studied in conjunction with acute respiratory distress syndrome (ARDS), but it has recently been shown to correlate with outcomes after severe COVID-19. Therefore, this study investigated the association between circulating bio-ADM on intensive care unit (ICU) admission and ARDS. The secondary aim was the association between bio-ADM and ARDS mortality.MethodsWe analysed bio-ADM levels and assessed the presence of ARDS in adult patients admitted to two general intensive care units in southern Sweden. Medical records were manually screened for the ARDS Berlin criteria. The association between bio-ADM levels and ARDS and mortality in ARDS patients was analysed using logistic regression and receiver-operating characteristics analysis. The primary outcome was an ARDS diagnosis within 72 h of ICU admission, and the secondary outcome was 30-day mortality.ResultsOut of 1224 admissions, 11% (n = 132) developed ARDS within 72 h. We found that elevated admission bio-ADM level was associated with ARDS independently of sepsis status and of organ dysfunction as measured by the Sequential organ failure assessment (SOFA) score. Both lower levels (< 38 pg/L) and high (> 90 pg/L) levels of bio-ADM were independently (of the Simplified acute physiology score, SAPS-3) predictive of mortality. Patients with indirect mechanisms of lung injury had higher bio-ADM levels than those with a direct mechanism of injury, and bio-ADM increased with increasing ARDS severity.ConclusionsHigh levels of bio-ADM on admission are associated with ARDS, and bio-ADM levels significantly differ depending on the injury mechanism. In contrast, both high and low levels of bio-ADM are associated with mortality, possibly due to the dual action of bio-ADM in stabilising the endothelial barrier and causing vasodilation. These findings could lead to improved diagnostic accuracy of ARDS and potentially lead to new therapeutic strategies.

Added value of chest CT images to a personalized prognostic model in acute respiratory distress syndrome: a retrospective study.

Acute respiratory distress syndrome (ARDS) is a critical disease in the intensive care unit (ICU) with high morbidity and mortality. The accuracy for predicting ARDS patients' outcome with mechanical ventilation is limited, and most based on clinical information. The patients diagnosed with ARDS between January2014 and June 2019 were retrospectively recruited. Radiomics features were extracted from the upper, middle, and lower levels of the lung, and were further analyzed with the primary outcome (28-day mortality after ARDS onset). The univariate and multivariate logistic regression analyses were applied to figure out risk factors. Various predictive models were constructed and compared. Of 366 ARDS patients recruited in this study, 276 (median age, 64years [interquartile range, 54-75years]; 208 male) survive on the Day 28. Among all factors, the APACHE II Score (OR 2.607, 95% CI 1.896-3.584, P < 0.001), the Radiomics_Score of the middle lung (OR 2.230, 95% CI 1.387-3.583, P = 0.01), the Radiomics_Score of the lower lung (OR 1.633, 95% CI 1.143-2.333, P = 0.01) were associated with the 28-day mortality. The clinical_radiomics predictive model (AUC 0.813, 95% CI 0.767-0.850) show the best performance compared with the clinical model (AUC 0.758, 95% CI 0.710-0.802), the radiomics model (AUC 0.692, 95% CI 0.641-0.739) and the various ventilator parameter-based models (highest AUC 0.773, 95% CI 0.726-0.815). The radiomics features of chest CT images have incremental values in predicting the 28-day mortality in ARDS patients with mechanical ventilation. The online version contains supplementary material available at 10.1007/s42058-023-00116-x.

Analysis of clinical characteristics and prognostic factors of ARDS caused by community-acquired pneumonia in people with different immune status

ABSTRACT Background The purpose of this study is to describe the clinical characteristics and prognostic risk factors of acute respiratory distress syndrome (ARDS) caused by community-acquired pneumonia under different immune states. Methods The patients were divided into immunocompetent and immunocompromised groups according to their immune status. The basic clinical data of the two groups were collected and statistically analyzed, and the clinical characteristics and prognostic factors of ARDS caused by community-acquired pneumonia under different immune states were summarized. Results 128 patients with ARDS caused by community-acquired pneumonia were enrolled. The chest High-Resolution Computed Tomography (HRCT) scores of patients with immunosuppression were higher (236.0 ± 55.0 vs. 207.5 ± 49.6, p < 0.05) and the score of APACHE II was higher (17.3 ± 4.8 vs. 15.1 ± 5.4, p < 0.05). The 28-day intensive care unit (ICU) mortality was higher in the immunocompromised group (54.5% vs. 34.7%, p = 0.045). The 28-day in-hospital mortality in the immunocompetent group was mainly related to NLR and the oxygenation index. The 28-day in-hospital mortality in the immunocompromised group was mainly related to LDH and APACHE II. Conclusion There are differences in clinical characteristics and mortality of ARDS patients caused by community-acquired pneumonia under different immune states.

Initial oxygenation as early predictor of mortality in acute respiratory distress syndrome: a retrospective study

Introduction: Acute respiratory distress syndrome (ARDS) is a major contributor to mortality and morbidity of adult patients admitted to intensive care units (ICU). Numerous scoring systems have been developed for critically ill patients with the goal of more accurately predicting clinical outcomes. However, the variability in these scores among individual patients, and consequently, their individual predictive ability is quite limited. Aim: To evaluate the role of initial oxygenation as an early predictor of mortality in ARDS patients. Methodology: One hundred and six mechanically ventilated adult patients with ARDS were enrolled retrospectively. Baseline parameters from the day of ICU admission were recorded. The details of ventilation, inspired oxygen fraction required, positive end-expiratory pressure and number of days on ventilation along with duration of hospital stay were recorded. Similarly, the status of oxygenation was assessed using PaO2/FiO2 (P/F) ratio. Survival of the patients was correlated with the baseline status of oxygenation. Results: Of the 106 patients, 65 were males and 41 female. The mean (± SD) age was 44 years (16.08). The difference in the P/F ratio between survivors and nonsurvivors was statistically significant. The ROC curve showed a cutoff value for P/F ratio of 108. Among survivors, the ICU stay was shorter in patients in pulmonary group compared to extrapulmonary group. Conclusion: Mortality is high if the baseline P/F ratio at admission is below 108. There is no difference in mortality due to lung injury caused by pulmonary or extrapulmonary aetiologies. ICU stay is longer among survivors if cause of ARDS is extrapulmonary.

Total bilirubin is associated with all-cause mortality in patients with acute respiratory distress syndrome: a retrospective study.

Acute respiratory distress syndrome (ARDS) is a life-threatening disease for which biomarkers to predict mortality are needed. Total bilirubin (TBIL), an end-product of hemoglobin catabolism in mammals reflecting liver dysfunction, has been demonstrated as an independent risk indicator for critically ill patients. This study aimed to examine whether TBIL on intensive care unit (ICU) admission is associated with ARDS mortality. We analyzed the data of patients diagnosed with ARDS according to the Berlin definition from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The primary endpoint was 30-day ICU mortality after admission to the ICU, and the second endpoint was in-hospital mortality. Multivariable logistic analysis adjusted for potential confounders was used to determine the association between TBIL and short-term mortality. Of 1,539 ARDS patients enrolled, 261 patients died within 30 days of admission to the ICU. In the multivariable logistic analysis, each 1 g/dL increase in TBIL levels led to a 4% increase in the odds of 30-day ICU mortality [adjusted odds ratio (OR) =0.04; 95% confidence interval (CI): 0.01to0.08] and a 4% increase in the odds of in-hospital mortality (adjusted OR =0.04; 95% CI: 0.01to0.07). Furthermore, TBIL levels ≥2 mg/dL were significantly associated with 30-day ICU mortality (adjusted OR =1.51, 95% CI: 1.02 to 1.07) and in-hospital mortality (OR =1.41; 95% CI: 1.01to1.87). Similarly, associations between serum TBIL levels and 30-day ICU mortality were found in all subgroups stratified by comorbidities, the severity of ARDS, and other variables. A higher serum TBIL on ICU admission was independently associated with mortality in ARDS patients. Intensive care and observation should be provided to ARDS patients with increased TBIL.

Covid-19 Hastalarında Gelişen Solunum Yetmezliğinde Veno-venöz Ekstrakorporeal Membran Oksijenasyonu; Güney Marmara Bölgesi Tek Merkez Deneyimi

Giriş ve Amaç: Covid-19 hastalığında gelişen Akut Respiratuar Distres Sendromu (ARDS) sonucunda mekanik ventilasyon ihtiyacı ve mortalite oranları artmaktadır. Covid-19 pandemisinde, Ekstrakorporeal Membran Oksijenasyon (ECMO) destek tedavisinin rolü hala tam olarak bilinmemektedir. Bu retroprespektif çalışmada, Covid-19 nedeniyle ARDS gelişen hastalarda uyguladığımız ECMO destek tedavisinin etkinliğini değerlendirmeyi amaçladık.&#x0D; Gereç ve Yöntemler: Bursa Şehir Hastanesi Anestezi ve Reanimasyon Yoğun Bakım ünitesinde Mart 2021-Eylül 2021 tarihleri arasında ECMO desteği alan hastalar geriye dönük olarak değerlendirildi. Çalışma süresinde 12 hastada ARDS nedeniyle ECMO destek tedavisi uygulandı.&#x0D; Bulgular: 12 hastaya veno-venöz ECMO (vv-ECMO) uygulandı. Hastaların dokuzu (%75) erkek, üçü (%25) kadın ve ortalama yaş 49.4 (35-70) olarak bulundu. Hastaların hastaneye yatışından entübasyon için geçen süre ortalama 8.08 (1-23) gündü. Entübasyon gününden ECMO desteğinin başlangıcına kadar geçen süre ortalama 3.08 (1-7) gün ve ECMO desteğinin ortalama süresi 12.3 (1-23) gün olarak bulundu. Sadece 1 hasta (%8,3) dekanüle edildikten sonra taburcu oldu.&#x0D; Sonuç: ECMO destek tedavisi, Covid-19 hastalığına sekonder gelişen ARDS hastalarında yüksek mortalite ile ilişkilidir. Ancak Covid-19 hastalığında ECMO, erken dönemde uygulandığı zaman hayat kurtarıcı bir destek yöntemidir. ECMO'nun Covid-19 nedeniyle ARDS tablosundaki kritik hastalarda kurtarma tedavisi olarak faydası şu ana kadar sınırlıdır ve bu hasta grubunda kullanımını için daha çok çalışmalara ihtiyaç vardır.

Meta-Analysis of the Effect of Glucocorticoids on Adult Acute Respiratory Distress Syndrome.

Objectives The aim of this study is to investigate the effect of glucocorticoids in adult patients with acute respiratory distress syndrome (ARDS) by meta-analysis. Methods PubMed, Cochrane Library, Embase, CNKI, Wanfang Database, and Chinese Biomedical literature database were searched. A randomized controlled trial (RCTS) on glucocorticoid therapy in adult patients with ARDS was conducted from the time of database construction to December 2021. The content is about the randomized controlled trial (RCT) of glucocorticoid treatment for adult patients with ARDS, without limiting the dose and course of glucocorticoid treatment. The quality of the included RCTS was evaluated by using the bias risk assessment tool of the Cochrane Collaboration network, and the basic information, clinical features, and target outcomes of the literature were extracted. The effects of glucocorticoids on mortality and oxygenation index (PaO2/FiO2) in adult ARDS patients were evaluated by meta-analysis. Results A total of 1,441 ARDS patients in 10 RCTs were finally included, including 734 patients in the glucocorticoid treatment group (hormone group) and 707 patients in the conventional treatment group (control group). The 10 studies included have a good overall design and high quality. Compared with controls, glucocorticoid use was significantly associated with a decrease in mortality in adult ARDS patients (relative risk (RR) = 0.73, 95% confidence interval (95% CI) = 0.59–0.90, P = 0.003). Analysis showed that glucocorticoids significantly reduced the mortality in ARDS patients treated with medium and low doses of steroids (RR = 0.73, 95% CI = 0.58–0.92, P = 0.007). In patients with early administration of steroids, intervention with glucocorticoids was significantly associated with the decreased mortality in adult ARDS patients compared with controls (RR = 0.74, 95% CI 0.56–0.99, P = 0.04). Among patients with more than 7 days of hormone therapy, treatment with glucocorticoids was significantly associated with decreased mortality in adult ARDS patients (RR = 0.66, 95% CI = 0.50–0.88, P = 0.005) compared with controls. Glucocorticoids tended to improve PaO2/FiO2 in adult ARDS patients compared with controls, but the difference was not statistically significant (weighted mean difference (WMD) = 11.60, 95% = CI = 15.02–38.22, P = 0.39). Conclusion Glucocorticoid therapy can reduce mortality in adult ARDS patients, and the benefit is more pronounced in patients with medium- and low-dose hormone therapy, early hormone administration, and hormone therapy for more than 7 days. However, no improvement in PaO2/FiO2 by glucocorticoid treatment was found, which needs to be confirmed by further studies.

Abstract 158: Burden And Predictors Of Mortality And Major Adverse Cardiovascular Outcomes In Heart Failure Preserved Ejection Fraction Patients Admitted With Acute Respiratory Distress Syndrome (ARDS)

Background: Relation between Acute Respiratory Distress Syndrome (ARDS) and heart failure with preserved ejection fraction (HFpEF) are understudied and the data on these two concomitantly is lacking in the literature. Therefore, we sought to assess the burden and predictors of major adverse cardiovascular and cerebrovascular events (MACCE) and all-cause mortality in ARDS patients with HFpEF. Methods: The National Inpatient Sample (NIS) database was used to identify patients with HFpEF (after excluding patients with heart failure reduced ejection fraction) who required inpatient hospitalization for ARDS. Administrative ICD10 codes were used to identify the population of interest. Multivariate regression analysis was performed to assess the predictors of all-cause mortality and major adverse cardiovascular outcomes in the selected cohort. Results: Of 28,731,562 hospital admissions, 3,010 (0.14%) patients were admitted with ARDS and had HFpEF. Of those patients, 1,095 (36.4%) had all-cause mortality, and 1,415 (47.0%) had MACCE. In multivariate regression analysis, older age (OR 3.60, CI 1.40-9.28), 26-50 th quartile income (OR 2.10, CI 1.13-3.91), urban hospital admissions (OR 2.19, CI 1.20-4.01) as well as comorbidities such as coagulopathy (OR 1.77, CI 1.09-2.88), fluid and electrolyte imbalance (OR 1.65, CI 1.05-2.60), prior CABG (OR 2.99, CI 1.19-7.47), need for mechanical ventilation (OR 2.18, CI 1.12-4.23) were significant predictors of all-cause mortality. In our analysis, chronic pulmonary disease, valvular heart disease, hypertension, smoking, obesity were not significant predictors. The result of our analysis is reported in Table 1. Conclusion: These results suggest HFpEF remains important comorbidity in ARDS patients. Here, we identified predictors of poor outcomes in this patient population which may help physicians to identify the high-risk patients and decrease mortality.

Clinical impact of ventilator-associated pneumonia in patients with the acute respiratory distress syndrome: a retrospective cohort study

BackgroundThe clinical impact and outcomes of ventilator-associated pneumonia (VAP) have been scarcely investigated in patients with the acute respiratory distress syndrome (ARDS).MethodsPatients admitted over an 18-month period in two intensive care units (ICU) of a university-affiliated hospital and meeting the Berlin criteria for ARDS were retrospectively included. The association between VAP and the probability of death at day 90 (primary endpoint) was appraised through a Cox proportional hazards model handling VAP as a delay entry variable. Secondary endpoints included (i) potential changes in the PaO2/FiO2 ratio and SOFA score values around VAP (linear mixed modelling), and (ii) mechanical ventilation (MV) duration, numbers of ventilator- and vasopressor-free days at day 28, and length of stay (LOS) in patients with and without VAP (median or absolute risk difference calculation). Subgroup analyses were performed in patients with COVID-19-related ARDS and those with ARDS from other causes.ResultsAmong the 336 included patients (101 with COVID-19 and 235 with other ARDS), 176 (52.4%) experienced a first VAP. VAP induced a transient and moderate decline in the PaO2/FiO2 ratio without increase in SOFA score values. VAP was associated with less ventilator-free days (median difference and 95% CI, − 19 [− 20; − 13.5] days) and vasopressor-free days (− 5 [− 9; − 2] days) at day 28, and longer ICU (+ 13 [+ 9; + 15] days) and hospital (+ 11.5 [+ 7.5; + 17.5] days) LOS. These effects were observed in both subgroups. Overall day-90 mortality rates were 35.8% and 30.0% in patients with and without VAP, respectively (P = 0.30). In the whole cohort, VAP (adjusted HR 3.16, 95% CI 2.04–4.89, P < 0.0001), the SAPS-2 value at admission, chronic renal disease and an admission for cardiac arrest predicted death at day 90, while the COVID-19 status had no independent impact. When analysed separately, VAP predicted death in non-COVID-19 patients (aHR 3.43, 95% CI 2.11–5.58, P < 0.0001) but not in those with COVID-19 (aHR 1.19, 95% CI 0.32–4.49, P = 0.80).ConclusionsVAP is an independent predictor of 90-day mortality in ARDS patients. This condition exerts a limited impact on oxygenation but correlates with extended MV duration, vasoactive support, and LOS.

Predictive Value of the Baseline and Early Changes in Blood Eosinophils for Short-Term Mortality in Patients with Acute Respiratory Distress Syndrome.

BackgroundEosinophils play an essential role in the pathogenesis of acute respiratory distress syndrome (ARDS). We aimed to assess the association between the baseline blood eosinophils, eosinophil changes during the first week in the intensive care unit (ICU) and short-term patient outcomes.MethodsAll patients meeting the Berlin definition of ARDS from the Medical Information Mart for Intensive Care IV database were retrospectively analyzed. We used logistic regression, Kaplan–Meier survival and random forest analysis to determine the association between the baseline eosinophils and short-term mortality. Then the trends in eosinophils over time were compared between the survivors and non-survivors using a generalized additive mixed model (GAMM), which is a common approach used for analysis of repeated measurement data. Area under the receiver-operating characteristic curve (AUC) was used to evaluate the predictive value.ResultsA total of 1685 patients were included, and the 30-day mortality was 25.1%. Kaplan–Meier analysis showed that patients with high baseline eosinophils (>0.3%) had lower 30-day mortality (p < 0.001). Random forest model selected the baseline eosinophils as an important factor associated with 30-day mortality. Multivariable logistic regression analysis identified high baseline eosinophils as an independent factor for 30-day mortality (OR 0.743, 95% CI 0.568–0.970). The GAMM result showed that the levels of eosinophils were increased in both survival and non-survival groups, and the between-group differences increased over time, with an average of 0.154 daily after adjusting for confounders. The AUC of changes in eosinophils within the first week was significantly higher than that of baseline eosinophils.ConclusionThere is a negative association between the baseline eosinophils and short-term mortality in ARDS patients, and the differences in eosinophils increased over time between the survivors and non-survivors. Higher increase in eosinophils is associated with decreased short-term mortality, and dynamic monitoring of eosinophils could better predict the survival of ARDS patients.

High-resolution computed tomography for the prediction of mortality in acute respiratory distress syndrome: A retrospective cohort study.

Background and AimsAcute respiratory distress syndrome (ARDS) demonstrates several image patterns on high‐resolution computed tomography (HRCT). The purpose of this study was to investigate the relationship between specific HRCT findings and the prognosis of ARDS.MethodsThis was a retrospective cohort study performed in a single hospital in Japan. We categorized HRCT findings into three distribution patterns: diffuse, subpleural sparing, and dorsal patterns. All patterns were assessed at three levels of each lung. Multivariable logistic regression analysis was used to identify parameters associated with in‐hospital mortality.ResultsA total of 144 patients with ARDS (age: 72 ± 16 years, 112 men) were included in the study. The in‐hospital mortality rate was 42% (survivors, n = 83; nonsurvivors, n = 61). Nonsurvivors were significantly older (70 ± 17 vs 76 ± 13, P = 0.01) and had lower serum albumin levels (P = 0.01), more traction bronchiectasis (P = 0.02), and more diffuse pattern (P < 0.001) than survivors. The presence of diffuse patterns was an independent adverse prognostic factor for predicting mortality (odds ratio, 1.32; 95% confidence interval [CI]: 1.08‐1.61, P = 0.007).ConclusionsHRCT distribution patterns may predict mortality in ARDS patients.

Influence of rosuvastatin treatment on cerebral inflammation and nitro-oxidative stress in experimental lung injury in pigs

BackgroundMany patients with acute respiratory distress syndrome (ARDS) suffer from cognitive impairment after hospital discharge. Different mechanisms have been implicated as potential causes for this impairment, inter alia cerebral inflammation. A class of drugs with antioxidant and anti-inflammatory properties are β-HMG-CoA-reductase inhibitors (“statins”). We hypothesized that treatment with rosuvastatin attenuates cerebral cytokine mRNA expression and nitro-oxidative stress in an animal model of acute lung injury.MethodsAfter approval of the institutional and state animal care committee, we performed this prospective randomized controlled animal study in accordance with the international guidelines for the care and use of laboratory animals. Thirty-two healthy male pigs were randomized to one of four groups: lung injury by central venous injection of oleic acid (n = 8), statin treatment before and directly after lung injury (n = 8), statin treatment after lung injury (n = 8), or ventilation-only controls (n = 8). About 18 h after lung injury and standardized treatment, the animals were euthanised, and the brains and lungs were collected for further examinations. We determined histologic lung injury and cerebral and pulmonal cytokine and 3-nitrotyrosine production.ResultsWe found a significant increase in hippocampal IL-6 mRNA after lung injury (p < 0.05). Treatment with rosuvastatin before and after induction of lung injury led to a significant reduction of hippocampal IL-6 mRNA (p < 0.05). Cerebral 3-nitrotyrosine was significantly higher in lung-injured animals compared with all other groups (p < 0.05 vs. animals treated with rosuvastatin after lung injury induction; p < 0.001 vs. all other groups). 3-Nitrotyrosine was also increased in the lungs of the lung-injured pigs compared to all other groups (p < 0.05 each).ConclusionsOur findings highlight cerebral cytokine production and nitro-oxidative stress within the first day after induction of lung injury. The treatment with rosuvastatin reduced IL-6 mRNA and 3-nitrotyrosine concentration in the brains of the animals. In earlier trials, statin treatment did not reduce mortality in ARDS patients but seemed to improve quality of life in ARDS survivors. Whether this is attributable to better cognitive function because of reduced nitro-oxidative stress and inflammation remains to be elucidated.

Red Cell Distribution Width at Admission Predicts the Frequency of Acute Kidney Injury and 28-Day Mortality in Patients With Acute Respiratory Distress Syndrome.

ABSTRACTObjectives:To determine the association of red cell distribution width (RDW) at admission with frequency of acute kidney injury (AKI) and 28-day mortality in acute respiratory distress syndrome (ARDS) patients.Methods:Two hundred fifty-eight ARDS patients were investigated in retrospective and prospective studies. The primary outcome was frequency of AKI. The secondary outcome was 28-day mortality.Results:The retrospective study included 193 ARDS patients, of which 67 (34.7%) were confirmed AKI and 76 (39.4%) died within 28 days. The RDW level in the AKI group was significantly higher than in the non-AKI group ([15.15 ± 2.59]% vs. [13.95 ± 1.89]%). Increased RDW was a significant predictor of frequency of AKI (odds ratio: 1.247, 95% confidence interval [CI]: 1.044, 1.489). The area under the receiver operating characteristic curve of RDW for predicting AKI was 0.687 (95%CI: 0.610, 0.764) and the cut-off value was 14.45 (sensitivity, 56.7%; specificity, 72.8%). In addition, the proportion of patients with RDW ≥ 14.45% in the non-survival group was notably higher compared with the survival group (48.7% vs. 29.1%). Furthermore, cox regression analysis revealed that RDW ≥ 14.45% was associated with 28-day mortality (hazard ratio: 1.817, 95%CI: 1.046, 3.158), while Kaplan–Meier analysis showed patients with RDW ≥ 14.45% had a significantly lower survival rate than those with RDW < 14.45%. The prospective study, on the other hand, included 65 ARDS patients, with frequency of AKI and 28-day mortality in the RDW ≥ 14.45% group significantly higher than in RDW < 14.45%.Conclusion:RDW was a significant, independent predictor for frequency of AKI and 28-day mortality in ARDS patients.

The Controversy About the Effects of Different Doses of Corticosteroid Treatment on Clinical Outcomes for Acute Respiratory Distress Syndrome Patients: An Observational Study.

Background: Corticosteroid usage in acute respiratory distress syndrome (ARDS) remains controversial. We aim to explore the correlation between the different doses of corticosteroid administration and the prognosis of ARDS.Methods: All patients were diagnosed with ARDS on initial hospital admission and received systemic corticosteroid treatment for ARDS. The main outcomes were the effects of corticosteroid treatment on clinical parameters and the mortality of ARDS patients. Secondary outcomes were factors associated with the mortality of ARDS patients.Results: 105 ARDS patients were included in this study. Corticosteroid treatment markedly decreased serum interleukin-18 (IL-18) level (424.0 ± 32.19 vs. 290.2 ± 17.14; p = 0.0003) and improved arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) (174.10 ± 65.28 vs. 255.42 ± 92.49; p < 0.0001). The acute physiology and chronic health evaluation (APACHE II) score (16.15 ± 4.41 vs. 14.88 ± 4.57, p = 0.042) decreased significantly on the seventh day after systemic corticosteroid treatment. Interestingly, the serum IL-18 decreased significantly (304.52 ± 286.00 vs. 85.85 ± 97.22, p < 0.0001), whereas the improvement of PaO2/FiO2 (24.78 ± 35.03 vs. 97.17 ± 44.82, p < 0.001) was inconspicuous after systemic corticosteroid treatment for non-survival patients, compared with survival patients. Furthermore, the receiver operating characteristic (ROC) model revealed, when equivalent methylprednisolone usage was 146.5 mg/d, it had the best sensitivity and specificity to predict the death of ARDS. Survival analysis by Kaplan–Meier curves presented the higher 45-day mortality in high-dose corticosteroid treatment group (logrank test p < 0.0001). Multivariate Cox regression analyses demonstrated that serum IL-18 level, APACHE II score, D-dimer, and high-dose corticosteroid treatment were associated with the death of ARDS.Conclusion: Appropriate dose of corticosteroids may be beneficial for ARDS patients through improving the oxygenation and moderately inhibiting inflammatory response. The benefits and risks should be carefully weighed when using high-dose corticosteroid for ARDS.Trial registration: This work was registered in ClinicalTrials.gov. Name of the registry: Corticosteroid Treatment for Acute Respiratory Distress Syndrome. Trial registration number: NCT02819453. URL of trial registry record: https://register.clinicaltrials.gov.

The Role of Glucocorticoids in the Treatment of ARDS: A Multicenter Retrospective Study Based on the eICU Collaborative Research Database.

Background: Acute respiratory distress syndrome (ARDS) is a common cause of respiratory failure in patients in intensive care unit (ICU). The therapeutic value of glucocorticoids (GCs) in the prognosis of ARDS remains controversial. The aim of this research is studying the impacts of GCs treatment on ARDS patients in ICU.Methods: We retrospectively studied 2,167 ARDS patients whose data were collected from the public eICU Collaborative Research Database, among which 254 patients who received glucocorticoid (GCs) treatment were 1:1 matched by propensity matching analysis (PSM). The primary outcome was ICU mortality. Every oxygenation index (PaO2/FiO2) measurement before death or ICU discharge was recorded. A joint model (JM) which combined longitudinal sub-model (mixed-effect model) and time-to-event sub-model (Cox regression model) by trajectory functions of PaO2/FiO2 was conducted to determine the effects of GCs treatment on both ICU mortality and PaO2/FiO2 level and further PaO2/FiO2's effect on event status. The marginal structural cox model (MSCM) adjusted the overall PaO2/FiO2 of patients to further validate the results.Results: The result of the survival sub-model showed that GCs treatment was significantly associated with reduced ICU mortality in ARDS patients [HR (95% CI) = 0.642 (0.453, 0.912)], demonstrating that GCs treatment was a protective factor of ICU mortality. In the longitudinal sub-model, GCs treatment was not correlated to the PaO2/FiO2. After adjusted by the JM, the HR of GCs treatment was 0.602 while GCs was still not significantly related to PaO2/FiO2 level. The JM-induced association showed that higher PaO2/FiO2 was a significant protective factor of mortality in ARDS patients and the HR was 0.991 which demonstrated that one level increase of PaO2/FiO2 level decreased 0.9% risk of ICU mortality. MSCM results also show that GCs can improve the prognosis of patients.Conclusion: Rational use of GCs can reduce the ICU mortality of ARDS patients in ICU. In addition to the use of GCs treatment, clinicians should also focus on the shifting trend of PaO2/FiO2 level to provide better conditions for patients' survival.

Neuromuscular Blocking Agent Use in Acute Respiratory Distress Syndrome: Which Variable is Important?

Background: The study of neuromuscular blocking agents (NMBAs) in the management of acute respiratory distress syndrome (ARDS) has provided conflicting results in terms of their effect on mortality. Objectives: The main purpose of this study was to evaluate mortality in ARDS patients who underwent NMBA. Methods: A retrospective secondary analysis of 4200 patients with ARDS was collected from two academic medical centers, Tehran, Iran. This study was performed to assess the impact of NMBAs use in ARDS patients with different subgroups including mild and moderate-to-severe ARDS, age more and less than 65 years, having medical turnover vs. not-having, and high acute nursing care vs. moderate to low nursing care. Results: Intensive care unit (ICU) mortality has occurred in 1169 (27.8%) participants. The mortality rate was 28.6% and 27.5% in patients with mild and moderate-to-severe ARDS, respectively. In the subjects without medical turnover, the moderate dose of NMBAs significantly reduces the mortality of patients (P=0.044). In patients who need high acute nursing care, increasing the NMBAs dose significantly reduces patients’ mortality (P=0.010). In addition, increasing the NMBAs doses significantly reduces ICU length of stay (LOS). Conclusion: This study provides evidence that the administration of different doses of NMBAs had no effect on patients’ mortality with mild or moderate-to-severe ARDS. However, higher doses of NMBAs than low doses increased the risk of mortality in patients over 80 years and can reduce the risk of death in patients less than 55 years.