PaO2/FiO2 Ratio Research Articles

Higher protein intake may benefit in patients with prolonged mechanical ventilation

BackgroundPatients with prolonged mechanical ventilation (PMV) is usually associated with muscle wasting and diaphragm weakness, resulting in high medical costs and mortality. Adequate energy and protein intake were beneficial in sarcopenia patients. We aimed to investigate the impact of protein intake in weaning parameters in patients with PMV.Materials and methodsWe enrolled patients with PMV (mechanical ventilation ≥6 h/day for ≥21 days) from a respiratory care center (RCC) of a tertiary medical center from December 2020 to October 2022, and classified them into weaning success and weaning failure groups. The patients’ characteristics, nutrition records, weaning parameters and outcomes were analyzed.ResultsA total of 289 patients were included (mean age 73.5 years). Of the 289 patients, 149 were weaned successfully and 140 were not. The average protein intake was higher in the weaning success group than in the weaning failure group (1.22 ± 0.320 versus 0.99 ± 0.332 g/kg/day, p < 0.001). No significant differences were noted in the average calorie intake and whey protein intake between the two groups. RSBI <90 breaths/min/L (OR = 2.38, p = 0.045), serum albumin at 4th week ≥3 g/dL (OR = 2.89, p = 0.027), daily protein intake ≥1.01 g/kg/day (OR = 8.10, p < 0.001), PaO2/FiO2 (PF) ratio ≥ 300 (OR = 2.56, p = 0.027) were independent predictors for weaning from ventilator. Weak positive correlations were found between average protein intake with PF ratio (r = 0.1576, p = 0.0227) and PaO2 (r = 0.13359, p = 0.0497).ConclusionDaily protein intake had positively correlated with PF ratio and had independently benefit for weaning in patients with PMV.

Comparison of Pulmonary Outcome in Minimally Invasive (TCRAT) and Full Sternotomy CABG.

Pulmonary complications are among the main causes of increased mortality, and morbidity, as well as prolonged intensive care unit (ICU) and hospital stay after cardiac surgery. Recently, a sternum-sparing concept of minimally invasive total coronary revascularization via anterior minithoracotomy (TCRAT) was introduced. A higher risk of pulmonary injury could be anticipated due to the thoracic incision and the longer duration of surgery. Pulmonary complications in TCRAT were compared to standard coronary artery bypass grafting (CABG) via full median sternotomy (FS). Records of 151 consecutive TCRAT (from September 2021 to November 2022) and 229 consecutive FS patients (from January 2017 to December 2018) patients, who underwent elective or urgent CABG, were analyzed. Preoperative baseline characteristics (age, sex, body mass index, diabetes, hypertension, chronic obstructive pulmonary disease, smoking status, left ventricular ejection fraction, pulmonary hypertonus, and EuroScore II) were comparable between groups. Differences between examined groups examined were found for the pulmonary parameters: Horowitz index 6 hours after operation (TCRAT 270 ± 72 vs. FS 293 ± 73, p < 0.05), pneumothorax (TCRAT 0% vs. FS 2.6%, p < 0.05), bronchoscopies (TCRAT 5.9% vs. FS 1.7%, p < 0.05), and pleural effusion (TCRAT 8.6% vs. FS 3.5%, p < 0.05). Moreover, there were differences between groups with regard to mean ICU stay (TCRAT 2.4 ± 3.0 days vs. FS 1.8 ± 1.8 days, p < 0.05), stroke (TCRAT 0% vs. FS 1.3%, p < 0.05), and hospital stay (TCRAT 10.9 ± 8.5 days vs. FS 13.2 ± 9.3 days, p < 0.05). There were no differences regarding atelectasis, reintubations, tracheostomies, ventilation time, and mortality. Pulmonary complications in terms of pleural effusions were more common with TCRAT, however, without substantial impact on clinical outcome.

Bronchoalveolar Lavage and Oleic Acid Two-hit Model for Inducing Acute Respiratory Distress Syndrome in Swine Models.

Acute respiratory distress syndrome (ARDS) is a widespread and often fatal clinical syndrome marked by the acute onset of pulmonary edema and inflammatory-mediated disruptions in alveolar-capillary permeability resulting in impaired gas exchange and tissue oxygenation with subsequent acute respiratory failure that accounts for 10.4% of all intensive care unit admissions worldwide and boasts a mortality rate of 38.5%. The current treatment for ARDS remains largely supportive. This is largely because of the many challenges of achieving a stable and sustainable animal model that recreates the pathophysiology of ARDS experimentally in a controlled setting to allow research to elucidate potential treatments of ARDS moving forward. The bronchoalveolar lavage and oleic acid models are currently the 2 most frequently used experimental models in inducing ARDS in animal models. This study demonstrated that combining them into a "two-hit model" can produce sustained ARDS in swine models per the Horowitz index (PaO2/FiO2 ratio of ≤300 mmHg). Additionally, expected changes in pH, pCO2, lung compliance, cytokines, and tissue histopathology were observed and add to our confidence and reliability that the "two-hit model" produces symptomatic ARDS in a manner very similar to that observed in humans. In conclusion, we demonstrated a viable animal model of human ARDS that is maintained for a prolonged period, suitable for continuous monitoring of the progression, and evaluation of potential future treatments and procedures to reduce patient morbidity and mortality. To carry out this two-hit model, lung injury was induced through a combination of bronchoalveolar lavage and oleic acid administration and the disease process of ARDS is subsequently tracked through clinically relevant parameters such as respiratory mechanics, cytokine response, aretrial blood gas (ABG) changes, and observation of postmortem histopathologic changes. This promising new model has the capacity to successfully replicate human ARDS which is a well-known and notoriously multifactorial pathogenic process to reproduce experimentally for an extended period of time. The "two-hit model" is a viable and appropriate model for the research of novel treatments for ARDS.

The impact and validity of the Berlin criteria on burn-induced ARDS: Examining mortality rates, and inhalation injury influences. A single center observational cohort study

BackgroundAs several recent studies have shown low mortality rates in burn injury induced ARDS early (≤7 days) after the burn, the Berlin criteria for the ARDS diagnosis in this setting may be disputed. Related to this issue, the present study investigated the incidence, trajectory and risk factors of early Acute Respiratory Distress Syndrome (ARDS) and outcome in burn patients, as per the Berlin criteria, along with the concurrent prevalence and influence of inhalation injury, and ventilator-acquired pneumonia (VAP). MethodsOver a 2.5-year period, burn patients with Total Burn Surface Area (TBSA) exceeding 10% admitted to a national burn center were included. The subgroup of interest comprised patients with more than 48 h of ventilatory support. This group was assessed for ARDS, inhalation injury, and VAP. ResultsOut of 292 admissions, 62 sustained burns > 10% TBSA. Of these, 28 (45%) underwent ventilatory support for over 48 h, almost all, 24 out of 28, meeting the criteria for ARDS early, within 7 days post-injury and with a PaO2/FiO2 (PF) ratio nadir at day 5. The mortality rate for this early ARDS group was under 10%, regardless of PF ratios (mean TBSA% 34,8%). Patients with concurrent inhalation injury and early ARDS showed significantly lower PF ratios (p < 0.001), and higher SOFA scores (p = 0.004) but without impact on mortality. Organ failure, indicated by SOFA scores, peaked early (day 3) and declined in the first week, mirroring PF ratio trends (p < 0.001). ConclusionsThe low mortality associated with early ARDS in burn patients in this study challenges the Berlin criteria’s for the early ARDS diagnosis, which for its validity relies on that higher mortality is linked to worsening PF ratios. The finding suggests alternative mechanisms, leading to the early ARDS diagnosis, such as the significant impact of inhalation injury on early PF ratios and organ failure, as seen in this study. The concurrence of early organ failure with declining PF ratios, supports, as expected, the hypothesis of trauma-induced inflammation/multi-organ failure mechanisms contributing to early ARDS. The study highlights the complexity in differentiating between the contributions of inhalation injury to early ARDS and the related organ dysfunction early in the burn care trajectory. The Berlin criteria for the ARDS diagnosis may not be fully applicable in the burn care setting, where the low mortality significantly deviates from that described in the original Berlin ARDS criteria publication but is as expected when considering the actual not very extensive burn injury sizes/Baux scores as in the present study.

Analysis of viral pneumonia and risk factors associated with severity of influenza virus infection in hospitalized patients from 2012 to 2016

BackgroundInfluenza viruses cause pneumonia in approximately one-third of cases, and pneumonia is an important cause of death. The aim was to identify risk factors associated with severity and those that could predict the development of pneumonia.MethodsThis retrospective, observational study included all adult patients with confirmed influenza virus infection admitted to Son Espases University Hospital during four influenza seasons in Spain (October to May) from to 2012–2016.ResultsOverall, 666 patients with laboratory-confirmed influenza were included, 93 (14%) of which were severe; 73 (10.9%) were admitted to Intensive Care Unit (ICU), 39 (5.8%) died, and 185 (27.7%) developed pneumonia. Compared to less severe cases, patients with severe disease: were less vaccinated (40% vs. 28%, p = 0.021); presented with more confusion (26.9% vs. 6.8%), were more hypoxemic (Horowitz index (PaO2/FiO2) 261 vs. 280), had higher C-reactive protein (CRP) (12.3 vs. 4.0), had more coinfections (26.8% vs. 6.3%) and had more pleural effusion (14% vs. 2.6%) (last six all p < 0.001). Risk factors significantly associated with severity were pneumonia [OR (95% CI) = 4.14 (2.4–7.16)], history of heart disease (1.84, 1.03–3.28), and confusion at admission (4.99, 2.55–9.74). Influenza vaccination was protective (0.53, 0.28–0.98). Compared to those without pneumonia, the pneumonia group had higher CRP (11.3 vs. 4.0, p < 0.001), lower oxygen saturation (92% vs. 94%, p < 0.001), were more hypoxic (PaO2/FiO2 266 vs. 281, p < 0.001), and incurred more mechanical ventilation, septic shock, admission to the ICU, and deaths (all four p < 0.001). Higher CRP and lower oxygen saturation were independent variables for predicting the development of pneumonia.ConclusionsPneumonia, history of heart disease, confusion and no influenza vaccination were independent variables to present complications in patients admitted with influenza infection.

Optimizing the safety and efficacy of the awake venovenous extracorporeal membrane oxygenation in patients with COVID-19-related ARDS.

Maintaining the patient awake and not intubated during the venovenous extracorporeal membrane oxygenation (VV ECMO) reduces the risk of ventilation-induced lung injury in patients with ARDS. Currently, there is a lack of data on outcomes and complications associated with the awake ECMO approach. To evaluate outcomes and the occurrence of complications of awake ECMO approach guided by local safety protocol comprising ultrasound-guided cannulation, argatroban-based anticoagulation, respiratory support, and routine sedation targeted to reduce respiratory effort and keeping nurse-to-patient ratio of 1:1. A single-center retrospective case series analysis. Consecutive patients with COVID-19-related acute respiratory distress syndrome (ARDS) (CARDS) treated by full awake VV ECMO approach from April 2019 to December 2023 were eligible. Our center treated 10 patients (mean age 54.7 ± 11.6 years) with CARDS with an awake ECMO approach. The reasons for awake ECMO included the presence of barotrauma in six patients, a team consensus to prefer awake ECMO instead of mechanical ventilation in three patients, and the patient's refusal to be intubated in one case. Before ECMO, patients were severely hypoxemic, with a mean value of Horowitz index of 48.9 ± 9.1 mmHg and a mean respiratory rate of 28.8 ± 7.3 breaths per minute on high-flow nasal cannula or noninvasive ventilation support. The mean duration of awake VV ECMO was 558.0 ± 173.6 h. Seven patients (70%) were successfully disconnected from ECMO and fully recovered. Intubation from respiratory causes was needed in three patients (30%), all of whom died eventually. In total, three episodes of delirium, two episodes of significant bleeding, one pneumothorax requiring chest tube insertion, and one oxygenator acute exchange occurred throughout the 5580 h of awake ECMO. No complications related to cannula displacement or malposition occurred. The awake ECMO strategy guided by safety protocol appears to be a safe approach in conscious, severely hypoxemic, non-intubated patients with COVID-19-related ARDS.

Comparison of Different Vascular Biomarkers for Predicting In-Hospital Mortality in Severe SARS-CoV-2 Infection.

Severe SARS-CoV-2 elicits a hyper-inflammatory response that results in intravascular inflammation with endothelial injury, which contributes to increased mortality in COVID-19. To predict the outcome of severe SARS-CoV-2 infection, we analyzed the baseline level of different biomarkers of vascular disorders in COVID-19 subjects upon intensive care unit (ICU) admission and prior to any vaccination. A total of 70 severe COVID-19 patients (37 survivors and 33 non-survivors) were included with 16 age- and sex-matched controls. Vascular dysfunction was monitored via soluble VCAM-1, E-selectin, ACE2 and Lp-PLA2, while abnormal platelet activation was evaluated by soluble P-selectin and CD40L in parallel. These results were correlated with routine laboratory parameters and disease outcomes. Among these parameters, VCAM-1 and ACE2 showed significantly higher serum levels in COVID-19 patients with early death vs. convalescent subjects. VCAM-1 was significantly correlated with the Horowitz index (r = 0.3115) and IL-6 (r = 0.4599), while ACE2 was related to E-selectin (r = 0.4143) and CD40L (r = 0.2948). Lp-PLA2 was altered in none of these COVID-19 subcohorts and showed no relationship with the other parameters. Finally, the pre-treatment level of VCAM-1 (≥1420 ng/mL) and ACE2 activity (≥45.2 μU/mL) predicted a larger risk for mortality (Log-Rank p = 0.0031 and p = 0.0117, respectively). Vascular dysfunction with endothelial cell activation is linked to lethal COVID-19, and highly elevated soluble VCAM-1 and ACE2 at admission to ICU may predict unfavorable outcomes.

Risk factors for postoperative adverse airway events in patients with primary oral cancer undergoing reconstruction without prophylactic tracheostomy

ObjectiveTo identify risk factors associated with adverse airway events (AAEs) in primary oral cancer patients undergoing tumor ablation followed by free tissue transfer without prophylactic tracheostomy. MethodsWe retrospectively collected primary oral cancer patients who underwent tumor ablation surgery following free-tissue transfer without prophylactic tracheostomy during February 2017 to June 2019 in Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan. 379 patients were included. Data were analysed from 2020 to 2021. Demographics, comorbidities, intraoperative variables and postoperative respiration profile were obtained from the medical record. Main outcome was postoperative AAEs, including requirement of endotracheal intubation after extubation and tracheostomy after prolonged intubation. ResultsOf the 379 patients, postoperative AAEs happened in 29 patients (7.6 %). In reintubation group, patients were older with more diabetes mellitus, hypertension and cerebrovascular disease. These patients had lower preoperative hemoglobin, creatinine, and albumin level with more intraoperative blood transfusion. In postoperative respiration profile, rapid shallow breathing index (RSBI) and PaO2/FiO2 (PF) ratio were poorer. On multivariate analysis, patient's age, tumor location, and cross-midline segmental mandibulectomy and a lower PF ratio were independent risk factors for postoperative AAEs. ConclusionsIn head and neck cancer patients that underwent tumor ablation followed by free tissue transfer without prophylactic tracheostomy, patient's age, tumor location, cross-midline segmental mandibulectomy and P/F ratio are associated with postoperative AAEs.

Evidence-Based Care of Staircase Recruitment Maneuver in a Patient with Severe Acute Respiratory Distress Syndrome

&lt;p&gt;急性呼吸窘迫症是致死率很高的急症，嚴重呼吸困難會造成病人有瀕死的危象。筆者於2020 年11月照顧一位67歲男性因急性呼吸衰竭插管治療，對於肺保護通氣策略之效果不佳，甚至使用體外膜氧合維生系統仍嚴重低血氧，引發筆者想解決此醫療困境之動機。運用實證步驟探討階梯式肺再擴張術增加氧合能力之成效，以PICO詮釋臨床問題，P為急性呼吸窘迫症（Acute respiratory distress syndrome, ARDS）、I為階梯式肺再擴張術（Staircase recruitment maneuver, SRM）、C為常規照護（Usual care）、O為氧合能力（PaO2/FiO2 ratio, PFR），檢索Cochrane Library、PubMed、CINAHL和華藝線上圖書館等資料庫，最終納入五篇符合篩選標準之隨機對照試驗研究，經系統性回顧後再進行統合分析，共有1,229 位病人之資料進行統合分析，發現SRM可改善PFR增加氧合，其綜合效量為55.63（95%CI [44.92, 66.33]）。依據研究結果應用於個案，住院第二天在壓力控制模式下執行一次SRM，當驅動壓力15 cmH2O，呼氣末正壓從10 cmH2O開始調升，每40秒增加5 cmH2O，並追蹤個案之動脈血氧，其PFR由174上升至318 mmHg，最終成功脫離呼吸器。因此，建議使用呼吸器之ARDS病人，若肺保護通氣策略下仍有嚴重低血氧時，可以考慮執行SRM來增加病人的氧合，進而讓病人能盡早脫離呼吸器。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Acute Respiratory Distress Syndrome is a highly fatal emergency. Severe dyspnea could lead to a re-spiratory crisis. The author provided care for a 67-year-old man who was intubated due to acute respi-ratory failure in November 2020. The ventilation strategies for lung protection strategies (LPS) were not as effective as expected. Even when using the extracorporeal membrane oxygenation (ECMO) life support system, hypoxemia still presented and deteriorated rapidly. This incident gave the author the motivation to solve this medical dilemma. An evidence-based approach was adopted to assess the ef-fectiveness of the staircase recruitment maneuver for oxygenation. The clinical treatment using PICO interpretations are as follows P: Acute respiratory distress syndrome (ARDS), I: Staircase recruitment maneuver (SRM), C: Usual care, O: PaO2/FiO2 ratio (PFR). Databases such as Cochrane Library, PubMed, CINAHL, and Airiti Library were searched. Five randomized controlled trial studies that met the screening criteria were included, and a meta-analysis was conducted after a systematic review. A total of 1,229 patients were analyzed in the meta-analysis, which showed that SRM can improve PFR and increase oxygenation. The effect size was 55.63 (95% CI [44.92, 66.33]). According to the re-search results applied to this case, SRM was performed in pressure control mode on the second day of hospitalization. When the driving pressure was set at 15cmH2O, the positive end-expiratory pressure (PEEP) was titrated from 10cmH2O, increasing by 5cmH2O every 40 seconds. Tracing the patient&amp;rsquo;s arterial blood oxygenation, the PFR increased from 174 to 318 mmHg, and the patient was successful-ly weaned from the ventilator. Therefore, ventilators are recommended for ARDS patients with severe hypoxemia under LPS. SRM maybe considered to improve the patient&amp;rsquo;s oxygenation, allowing for ear-ly weaning from the ventilator.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

The use of non-invasive respiratory assistance to facilitate bronchofiberoscopy performance in patients with hypoxemic (type one) respiratory failure - Study protocol

PurposeBronchofiberoscopy (FOB) is a procedure routinely performed for: lung cancer, obstruction, interstitial diseases, foreign bodies’ removal, airway clearance, and hemoptysis. It causes acute airway narrowing leading to respiratory and cardiovascular stress. Due to increasing number of ill patients with respiratory failure (RF), conventional oxygen therapy (COT) is frequently insufficient to assure accurate oxygenation and prevent RF in patients requiring FOB. In this clinical scenario, patients may be intubated and supported with invasive mechanical ventilation (IMV) with the specific aim of allowing a safe FOB. However, this invasive strategy is associated with an increased risk of IMV-associated complications. Materials and methodsOur study is a planned prospective multicenter three-arm randomized controlled trial (RCT). The target number of 300 patients was calculated based on the intubation risk in RF patients, which is 0.2–2%. The patients will be assigned to each arm based on Horowitz index. In each arm, the patients will be randomly assigned to one out of two dedicated respiratory support methods in each group i.e. COT/high flow nasal cannula (HFNC), HFNC/non-invasive ventilation (NIV) and NIV/IMV. In the manuscript the current state of art in the area of respiratory support is discussed. We have underlined knowledge gaps in medical evidence which we are planning to reveal with our results. ResultsThe results of our study are clinically crucial, because they address current gaps concerning COT/HFNC/NIV/IMV. ConclusionThe expected findings of this study would allow for careful selection of respiratory support method to safely perform FOB in patients with hypoxemic RF.

Alteration of circulating redox balance in coronavirus disease-19-induced acute respiratory distress syndrome

BackgroundMechanisms underpinning ARDS induced by COVID-19 are mostly immune-mediated, but need to be completely clarified. This study aimed to investigate redox balance in COVID-19 patients with ARDS, trying to recognize possible differences from typical ARDS related to the pathophysiology of severe disease.MethodsPatients affected by ARDS and positive for the SARS-CoV-2 virus (N = 40, COVID-19) were compared to ARDS patients negative to the molecular test (N = 42, No COVID-19). Circulating markers of redox balance were measured in serum and erythrocytes, and related to markers of inflammation and coagulability.ResultsNo differences in serum markers of oxidative damage were found between both groups, but a reduction in total antioxidant status and serum ceruloplasmin level was observed in COVID-19 rather than No COVID-19 patients. Redox balance alterations were described in erythrocytes from COVID-19 with respect to No COVID-19 group, characterized by increased lipofuscin and malondialdehyde concentration, and reduced glutathione S-transferase and glutathione reductase activity. These markers were associated with circulating indexes of respiratory disease severity (Horowitz index and alveolar-to-arterial oxygen gradient), inflammation (interleukin-6 and interleukin-10), and hypercoagulability (D-dimer) in COVID-19 patients with ARDS.ConclusionsARDS caused by COVID-19 is sustained by impairment of redox balance, particularly in erythrocytes. This alteration is associated with the pro-inflammatory and pro-coagulant status which characterizes severe COVID-19.

The Relationship Between Decreased CD-8 T-Cells and Mortality in Patients with COVID-19 Pneumonia in the Intensive Care Unit, A Retrospective Study.

CD-8 T-cells are responsible for the clearance of virally infected cells. In patients with Coronavirus disease-2019 (COVID-19) pneumonia, there are quantitative reductions and functional impairments in T-cells. Low CD-8 T-cell levels cause worse clinical situations. In this study, the relationship between decreased CD-8 T-cells and mortality in patients with COVID-19 pneumonia in the intensive care unit (ICU) was investigated. In this multicenter retrospective study, 277 patients were analyzed. Demographic data, ICU admission scores, blood gas levels, laboratory samples, and outcomes were recorded. Statistical Package for the Social Sciences version 28 was used for statistical analysis. Two hundred forty of 277 patients were included in the study. The mortality rate was 43.3%. In non-survivors, median values of age, Charlson comorbidity index, Acute Physiology and Chronic Health Evaluation II (APACHE-II), procalcitonin, leukocyte count, neutrophil count, neutrophil-lymphocyte count ratio, and duration of invasive mechanical ventilation were significantly higher, whereas median values of PaO2-FiO2 ratio, lymphocyte count, CD-4, and CD-8 T-cells were significantly lower than those in survivors. In the multivariate Cox regression model, the risk of mortality increased 1.04-fold (1.02-1.06) and 1.05-fold (1.01-10.8) by every one unit increase in age and APACHE-II, respectively, whereas it decreased 0.71-fold (0.58-0.87) by every hundred increase in CD-8 T-cells P < 0.001, P=0.007 and P=0.001 respectively. According to our findings, age, APACHE-II, and CD-8 T-cell levels seem to be independent risk factors for mortality in patients with COVID-19 pneumonia in the ICU.

REcovery and SURvival of patients with moderate to severe acute REspiratory distress syndrome (ARDS) due to COVID-19: a multicenter, single-arm, Phase IV itolizumab Trial: RESURRECT

ABSTRACT Background Itolizumab, an anti-CD6 monoclonal antibody, down-regulates COVID-19-mediated inflammation and the acute effects of cytokine release syndrome. This study aimed to evaluate the safety and efficacy of itolizumab in hospitalized COVID-19 patients with PaO2/FiO2 ratio (PFR) ≤200 requiring oxygen therapy. Research design and methods This multicenter, single-arm, Phase 4 study enrolled 300 hospitalized adults with SARS-CoV-2 infection, PFR ≤200, oxygen saturation ≤94%, and ≥1 elevated inflammatory markers from 17 COVID-19 specific tertiary Indian hospitals. Patients received 1.6 mg/kg of itolizumab infusion, were assessed for 1 month, and followed-up to Day 90. Primary outcome measures included incidence of severe acute infusion-related reactions (IRRs) (≥Grade-3) and mortality rate at 1 month. Results Incidence of severe acute IRRs was 1.3% and mortality rate at 1 month was 6.7% (n = 20/300). Mortality rate at Day 90 was 8.0% (n = 24/300). By Day 7, most patients had stable/improved SpO2 without increasing FiO2 and by Day 30, 91.7% patients were off oxygen therapy. Overall, 63 and 10 patients, respectively, reported 123 and 11 treatment-emergent adverse events up to Days 30 and 90. No deaths were attributable to itolizumab. Patient-reported outcomes showed gradual and significant improvement for all five dimensions on EQ-5D-5L. Conclusion Itolizumab demonstrated acceptable safety with a favorable prognosis in hospitalized COVID-19 patients. Clinical trial registration CTRI/2020/09/027941 (Clinical Trials Registry of India).

Effect of targeted coagulopathy management and 5% albumin as volume replacement therapy during lung transplantation on allograft function: a secondary analysis of a randomized clinical trial

BackgroundPrimary graft dysfunction (PGD) after lung transplantation (LuTx) contributes substantially to early postoperative morbidity. Both intraoperative transfusion of a large amount of blood products during the surgery and ischemia–reperfusion injury after allograft implantation play an important role in subsequent PGD development.MethodsWe have previously reported a randomized clinical trial of 67 patients where point of care (POC) targeted coagulopathy management and intraoperative administration of 5% albumin led to significant reduction of blood loss and blood product consumption during the lung transplantation surgery. A secondary analysis of the randomized clinical trial evaluating the effect of targeted coagulopathy management and intraoperative administration of 5% albumin on early lung allograft function after LuTx and 1-year survival was performed.ResultsCompared to the patients in the control (non-POC) group, those in study (POC) group showed significantly superior graft function, represented by the Horowitz index (at 72 h after transplantation 402.87 vs 308.03 with p < 0.001, difference between means: 94.84, 95% CI: 60.18–129.51). Furthermore, the maximum doses of norepinephrine administered during first 24 h were significantly lower in the POC group (0.193 vs 0.379 with p < 0.001, difference between the means: 0.186, 95% CI: 0.105–0.267). After dichotomization of PGD (0–1 vs 2–3), significant difference between the non-POC and POC group occurred only at time point 72, when PGD grade 2–3 developed in 25% (n = 9) and 3.2% (n = 1), respectively (p = 0.003). The difference in 1-year survival was not statistically significant (10 patients died in non-POC group vs. 4 patients died in POC group; p = 0.17).ConclusionsUtilization of a POC targeted coagulopathy management combined with Albumin 5% as primary resuscitative fluid may improve early lung allograft function, provide better circulatory stability during the early post-operative period, and have potential to decrease the incidence of PGD without negative effect on 1-year survival.Trial registrationThis clinical trial was registered at ClinicalTrials.gov (NCT03598907).

Comparison of Efficacy of Spontaneous Breathing with Pressure Support and Volume-Controlled Mandatory Ventilation during General Combined Anesthesia without Muscle Relaxants

To compare efficacy of spontaneous breathing with pressure support and volum e-c ontrolled mandatory ventilation during combined general anesthesia using desflurane and without muscle relaxants. Subjects and Methods. 100 patients were included in the study. All underwent lo w-t raumatic operations on the lower limbs under general combined anesthesia using supraglottic air devices without muscle relaxants. Immediately prior to the induction of anesthesia, patients were randomly divided into two groups: Group 1 ( VCV ) where a mandatory volume control mode was used ( n = 50) and Group 2 ( PSV ) where a pressure support mode was used ( n = 50). The following parameters were assessed: hemodynamics, gas exchange, depth of anesthesia before induction, during and after the end of general anesthesia; arterial blood gas composition one hour after induction of anesthesia; indicators of pressure in the respiratory tract during mechanical ventilation, as well as time parameters of awakening. Results. In patients of Group 2 ( PSV ), according to the analysis of arterial blood gases, a higher level of PaO 2 ( p = 0.006), Horowitz index ( p = 0.005), and carbon dioxide level ( p &lt; 0.0001) were noted. In Group 1 ( VCV ), higher mean and peak airway pressures were found one hour after induction and 10 minutes before the end of surgery ( p &lt; 0.05). Also in the groups, there were statistically significant differences in the time parameters of awakening (233 ± 58 sec and 352 ± 83 sec in the PSV and VCV groups, respectively), supraglottic airway device removal time (268 ± 62 sec and 398 ± 84 sec in the PSV and VCV groups, respectively) and transfer to the ward (395 ± 60 sec and 571 ± 66 sec in the PSV and VCV groups, respectively) ( p &lt; 0.0001). There were no significant differences in the main parameters of hemodynamics and depth of anesthesia, the consumption of anesthetics used during induction and maintenance of general anesthesia. Conclusion: The use of spontaneous breathing with pressure support during general combined anesthesia without muscle relaxants has a number of advantages versus mandatory ventilation mode. These include better oxygenation rates, lower airway pressure, faster awakening, supraglottic airway device removal time, and transfer of the patient to the ward. At the same time, acceptable ventilation, stable hemodynamic parameters and depth of anesthesia are maintained.

798: COMPARING OUTCOMES IN RESPONDERS VERSUS NONRESPONDERS TO INHALED EPOPROSTENOL IN COVID-19 ARDS

Introduction: Novel coronavirus SARS-COV-2 is primarily spread via droplets with respiratory involvement being the most common presentation. Approximately 14% of patients with COVID-19 pneumonia will progress to develop ARDS which is associated with high mortality. Pulmonary vasodilators have been shown to improve oxygenation in severe ARDS. Inhaled epoprostenol (iEPO) promote pulmonary vasodilation by decreasing intracellular calcium and possess anti-inflammatory and antiplatelet effects which may be beneficial in C-ARDS. Methods: This was a retrospective cohort study that was IRB approved and included patients diagnosed with COVID-19 ARDS who received inhaled epoprostenol during period of 3/1/2020 and 12/31/2021. Patients that met study inclusion criteria were classified as responders or non-responders based on percent change of 10% or more in PaO2/FiO2 (PF) ratio post iEPO. The primary outcome was to compare the incidence of in-hospital mortality between both groups. Secondary outcomes included mechanical ventilation duration, ICU and hospital length of stay (LOS) and adverse events. Results: 148 patients were included in the analysis and based on post iEPO arterial blood gas (ABG) were classified as responders (n=87) and non-responders (n=61). Baseline characteristics were similar between both groups except for a lower weight and more prone positioning utilized in the responder group. Post iEPO PF ratio was significantly higher in the responder group compared to non-responder (158.69 vs. 107.67, p< 0.001) with similar duration of therapy in both groups (5.44 vs. 6.04 days, p=0.51). There was no difference in in-hospital mortality between responders and non-responders (69% vs. 72.1% p=0.68). There was no difference noted in ICU LOS, hospital LOS and duration of mechanical ventilation between both groups. A multivariable regression analysis was performed and noted no association between variables evaluated and response to inhaled epoprostenol therapy. Conclusions: Despite over 50% of patients in cohort responding to iEPO as demonstrated by significant improvement in oxygenation there was no difference in patient outcomes noted in responders as compared to non-responders.

Quantification of changes in lung aeration associated with physiotherapy using lung ultrasound in mechanically ventilated patients: a prospective cohort study

BackgroundLung ultrasound (LUS) is a novel and emerging tool for physiotherapists in ICU and may provide a way of monitoring lung aeration change in response to respiratory physiotherapy treatment during a patient’s ICU stay. ObjectiveTo measure change in the LUS score associated with a respiratory physiotherapy treatment; to determine whether change in LUS score correlates with other physiological measures. Design and settingA single-centre prospective cohort study was undertaken in a tertiary teaching hospital in Sydney, Australia. PatientsAdult mechanically ventilated patients in ICU with suspicion of atelectasis. MeasurementsPrimary outcome: pre-post difference in LUS score. Secondary outcomes: PaO2/FiO2 (PF) ratio, tidal volume (VT), lung auscultation score, driving pressure (DP) and the modified radiological atelectasis score (mRAS) on CXR. Results43 patients were included. There was a mean improvement in total LUS score after physiotherapy treatment of − 2.9 (95%CI −4.4, −1.4), and a mean improvement in LUS of the right and left lungs of − 1.6 (−2.5, −0.7) and − 1.3 (−2.5, −0.1) respectively. There was a mean improvement in PF ratio, VT and auscultation score of 10.4 (−11.89, 32.7), 19 (−7.4, 44.5) and − 1.8 (−2.6, −1.0) respectively. There was no improvement in mRAS or DP. There was a weak correlation between change in LUS score compared with change in mRAS score. LimitationsLimitations included the prospective cohort single site design and the small sample size. ConclusionsThe LUS score can be used to detect changes in lung aeration associated with respiratory physiotherapy treatment for acute lobar atelectasis in mechanically ventilated patients.Australian and New Zealand Clinical Trials Registry Number: ACTRN12619000783123. Contribution of the Paper•Assessment and measurement tools currently used by physiotherapists lack diagnostic accuracy. Lung ultrasound has high diagnostic accuracy in detecting pathologies pertinent to physiotherapists and may be helpful in monitoring treatment response.•The lung ultrasound score detects changes in lung aeration associated with respiratory physiotherapy treatment.•This study highlights lung ultrasound as a potential new tool for lung monitoring for physiotherapists in ICU.

The short-term efficacy of high flow nasal oxygen therapy on cardiovascular surgical patients: a randomized crossover trial

BackgroundOxygen therapy after extubation in the intensive care unit (ICU) is essential in order to maintain adequate oxygenation, especially in patients who have undertaken cardiovascular surgery. A Venturi mask (VM) has been routinely used as an oxygen therapy in the ICU. Recently, however, the high flow nasal cannula (HFNC) has become available, and this device can deliver up to 60 L/min of humidified oxygen. The aim of this study is to evaluate the short-term efficacy between HFNC and VM in cardiovascular surgical patients.MethodsForty patients who underwent cardiovascular surgery were randomized to either protocol A (HFNC followed by VM) or protocol B (VM followed by HFNC). After 60-minutes of use with either device, arterial blood gas analysis was performed, and the PaO2/FiO2 ratio (PFR) was calculated. Simultaneously, physiological data (respiratory rate, heart rate, mean arterial pressure, continuous cardiac index, and mixed venous oxygen saturation) were recorded. During this procedure, FiO2 and gas flow were maintained at a fixed rate. These variables were compared by using the paired t-test, and a p value < 0.05 was considered significant. All data were expressed as mean (standard deviation).ResultsThirty-five patients (17 from protocol A and 18 from protocol B) were enrolled, and 5 patients were excluded from analysis in accordance with the exit criteria. PaO2 was significantly higher in the HFNC group than in the VM group [101.7 (25.9) vs. 91.8 (23.0), mean difference 9.87 (18.5), 95% confidence interval 3.5 to 16.2, p = 0.003]. Moreover, PFR was significantly higher in the HFNC group than in the VM group [265.9 (81.4) vs. 238.7 (68.5), p = 0.002]. Moreover, PaCO2 was significantly lower in the HFNC group than in the VM group [33.8 (3.5) vs. 34.7 (2.9), p = 0.033]. The respiratory rate was significantly lower in the HFNC group than in the VM group [18 (4) vs. 21 (4), p = 0.006], and no significant differences were seen in any of the other parameters.ConclusionsCompared to VM, HFNC ameliorated oxygenation function and decreased patients’ effort in breathing. The hemodynamic state did not differ between HFNC and VM. Therefore, HFNC can be used safely in cardiovascular surgical patients.Trial registrationThis trial was registered with the UMIN Clinical Trials Registry (ID UMIN000016572).

Puerperium could have better intensive care outcomes with acute respiratory distress syndrome caused by COVID-19.

Acute respiratory distress syndrome (ARDS) with (COVID-19 often result in mortality. Treatment outcomes among puerperant, when compared with non-pregnant women (NPW) with the same syndrome. Physiological changes underwent within the gestation period have a considerable impact on the immune system, respiratory system, cardiovascular function, and coagulation. Through this research, it was aimed to compare intensive care unit (ICU) follow-up and treatment results of postpartum-period patients with those of non-pregnant ones. During the first week of ICU, 23 puerperant COVID-19 patients with ARDS and 34 non-pregnant COVID-19 patients took part in the study. Age, height, and predictive body weight (PBW) at admission to the ICU were compared with the clinical parameters of disease severity, such as FiO2 (fraction of inspired oxygen), PaO2 (arterial oxygen partial pressure), Horowitz index (PaO2/FiO2), procalcitonin (PCT), and C-reactive protein (CRP). Respiration parameters were recorded a meta-vision back server. Demographic data, FiO2, PaO2, Horowitz index, PCT, CRP and respiration parameters values were similar in both groups. The duration of non-mechanical ventilation and number of patients were seen to be significantly greater among the puerperant group than control group (P; .04 and .002, respectively). The duration of mechanical ventilation was similar in both groups (P; .07), while the mortality rate was lower in the puerperant group (P; .004). The postpartum women with COVID-19 induced ARDS were observed to have better ICU follow-up results and lower mortality. However, it is considered that the present results need to be supported greater number of participants.

The MARPELLA risk score for prediction of mortality in all-cause refractory cardiogenic shock treated with microaxial transvalvular pump: the MARPELLA study

Abstract Background Although Impella may serve as an alternative strategy in order to stabilize the heart function without the detrimental effects of catecholamines or to bridge the patients in definite therapies in the setting of cardiogenic shock (CS), leading to a widespread use of this device, data concerning reliable prediction or predefining which patients would benefit from the implantation of such a device are completely lacking. Purpose To evaluate and to compare the prognostic accuracy of the Acute-Physiology-And-Chronic-Health II (APACHE II), the Simplified-Acute-Physiology-Score II (SAPS II), the Sepsis-related-organ-failure-assessment (SOFA), the intra-aortic-balloon-pump (IABP), the CardShock Score in refractory CS treated with Impella 2.5/CP. Moreover, we aimed to assess the prediction-of-Cardiogenic-shock-Outcome-foR-AMI-patients-salvaGed by VA-ECMO (ENCOURAGE) and the Survival-after -Veno-Arterial-extracorporeal-membranoxygenation (VA-ECMO) (SAVE) score, though initially for VA-ECMO patients created, in patients with CS as well as to develop a new prognostic score in this setting. Methods Single center study of consecutive Impella patients with CS admitted to Cardiology department of our university, from February 2013 until December 2020. Results A total of 401 patients were included in the analysis. 31% of the patients were supported with Impella CP, whereas 153 (38,1%) patients were resuscitated prior admission. Causes of CS was acute myocardial infarction in 311 (77,5%) patients, followed by dilatative cardiomyopathy/myocarditis (11,1%) and aortic stenosis (6%). The expected mortality according to scores was: SOFA 50%, SAPS II 70%, IABP Shock 55%, CardShock 60%, APACHE II 65%, ENCOURAGE 75% and SAVE score 70%. We observed a survival of 48,9% on hospital discharge and 45,6% after 12 months follow-up. Among the traditional scores estimated, the ENCOURAGE score was the most effective predictive model of mortality outcome presenting a moderate area under curve (AUC) of 0.72, followed by the CardShock, which derived an AUC of 0,7. The SAPS II, SOFA, IABP and the SAVE scores failed to predict outcome in this setting. According to the main predictors of outcome in our population derived from univariate analysis (vasoactive score &amp;gt;31, lactate&amp;gt;4,7 mmol/l, pH&amp;lt;7,31, Creatinine&amp;gt;1,33 mg/dl, Horowitz Index&amp;lt;238, age&amp;gt;71 years and prior resuscitation) as well as the odds ratio derived from binary regression analysis on mortality, a new score, the MARPELLA score, was created. This score reached an AUC of 0.83 (Figure 1). A mortality of 37%, 62% and 83,2% was observed in the low-, intermediate and high-risk group of the MARPELLA score, respectively (Figure 2). Conclusion MARPELLA Score is a new more potent score in the setting of all-cause CS that may guide clinicians to optimize the therapy in this group of patients, outweighing the traditional CS and intensive care unit scores. Funding Acknowledgement Type of funding sources: None.