Pulmonary Acute Respiratory Distress Syndrome Research Articles

PERBANDINGAN ANALISIS SURVIVAL MENGGUNAKAN REGRESI COX PROPORTIONAL HAZARD DAN REGRESI WEIBULL PADA PASIEN COVID-19 DI RSUD TAMAN HUSADA BONTANG

COVID-19 is brought on by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and transmitted to humans through animal. SARS-CoV-2 infection affects patient's metabolism and causes hyperinflammatory. This condition affects individuals with risk factors such as age, gender, diabetes, heart disease, hypertension, Chronic Obstructive Pulmonary Disease (COPD), obesity, and Acute Respiratory Distress Syndrome (ARDS). One approach to figuring out the association between the time of an occurrence and the independent factors is the Cox Proportional Hazard Regression. The Cox PH regression is a semiparametric model because it doesn’t require a specific distribution test. There is a parametric model used in modeling and analyzing failure time data, namely Weibull regression. The case study is patients with COVID-19 at Taman Husada Bontang Regional Public Hospital who underwent hospitalization from August 2021 to September 2021 data. Based on the Cox PH Regression and Weibull Regression models, variables that affect the survival time of COVID-19 patients are heart disease and ARDS. The AIC value obtained using the Cox Proportional Hazard regression is 635.6149, this value is smaller than the Weibull regression which is 745.5509 so the use of survival analysis with the Cox Proportional Hazard regression is better than the Weibull regression in this case.

The potential use of N-acetylcysteine in respiratory conditions

Currently, despite the accumulated experience with the use of N-acetylcysteine (NAC) in scientific and real clinical practice, there are a number of questions about its potential and the future prospects for its use.The aim of this work was to summarize new data on the use of NAC in patients with various conditions, based on publications in domestic and foreign medical journals.Results. The article presents an overview of publications in domestic and foreign medical journals devoted to the use of N-acetylcysteine (NAC) in pulmonology practice. The experience with the use of NAC in chronic bronchitis (CB), chronic obstructive pulmonary disease (COPD), bronchial asthma, community-acquired pneumonia, idiopathic pulmonary fibrosis, postinfectious bronchiectasis, and acute respiratory distress syndrome associated with COVID-19 (COronaVIrus Disease 2019) is summarized. The aspects of dose-dependent clinical effects and long-term administration of NAC in CB and COPD are analyzed. In addition, there are controversial and contradictory data on the possibility of prescribing NAC for idiopathic pulmonary fibrosis.Conclusion. NAC is a drug with a broad spectrum of action. Due to its antioxidant and anti-inflammatory properties, minor side effects compared to other anti-inflammatory drugs even at high doses, and low price, NAC can be prescribed for many respiratory diseases. Although it has been used for more than half a century, interest in both its practical application and clinical research has not waned to this day.

COVID-19 Related Acute Respiratory Distress Syndrome versus Classical Acute Respiratory Distress Syndrome Patients: Inflammatory Biomarkers as Predictors of Mortality in Pulmonary Septic Shock.

Coronavirus disease-2019 (COVID-19)-related severe acute respiratory distress syndrome (ARDS) differs pathophysiological from other pulmonary septic shock-related ARDS. Thus, we assessed whether all-cause in-hospital mortality differs for severe COVID-19-related and classical severe ARDS and which inflammatory biomarkers can predict mortality among these patients. This single-center, retrospective, observational cohort study included pulmonary septic shock patients (n = 114) with COVID-19-related and classical severe ARDS admitted in the Intensive Care Unit. Patients with a mean age of 73 (IQR 62-82), predominantly male (63%), were divided into two groups based on outcomes: survivors (n = 50) and non-survivors (n = 64). COVID-19-related severe ARDS (n = 48) accounts for 75% of deaths. Present comorbidities like heart disease (p = 0.043), neurologic disorders (p = 0.018), and liver disease (p = 0.038) were associated with in-hospital mortality, as well. Regarding inflammatory biomarkers, the AUC/c-statistic was 0.656 (95% CI: 0.53-0.759) for leukocytes, 0.613 (95% CI: 0.509-0.717) C-reactive protein (CRP) and 0.651 (95% CI: 0.548-0.753) for procalcitonin in predicting all-cause in-hospital mortality among patients with pulmonary septic shock and severe ARDS. Patients with pulmonary septic shock and with COVID-19-related severe ARDS had a higher incidence of in-hospital mortality than those with classical severe ARDS. The high value of leukocytes, C-reactive protein, and procalcitonin were predictive for all-cause in-hospital mortality in patients with pulmonary septic shock and ARDS. Infection with COVID-19 was an independent predictor of in-hospital mortality in the presence of ARDS.

Diagnosis and treatment of right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale): a clinical consensus statement of the Association for Acute CardioVascular Care of the European Society of Cardiology.

Acute right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale) is a life-threatening condition that may arise in different clinical settings. Patients at risk of developing or with manifest acute cor pulmonale usually present with an acute pulmonary disease (e.g. pulmonary embolism, pneumonia, and acute respiratory distress syndrome) and are managed initially in emergency departments and later in intensive care units. According to the clinical setting, other specialties are involved (cardiology, pneumology, internal medicine). As such, coordinated delivery of care is particularly challenging but, as shown during the COVID-19 pandemic, has a major impact on prognosis. A common framework for the management of acute cor pulmonale with inclusion of the perspectives of all involved disciplines is urgently needed.

Lactobacillus rhamnosus (LR) ameliorates pulmonary and extrapulmonary acute respiratory distress syndrome (ARDS) via targeting neutrophils

Pulmonary and extrapulmonary acute respiratory distress syndrome (ARDS) is a life-threatening respiratory failure associated with high mortality. Despite progress in our understanding of the pathological mechanism causing the crippling illness, there are currently no targeted pharmaceutical treatments available for it. Recent discoveries have emphasized the existence of a potential nexus between gut and lung health fueling novel approaches including probiotics for the treatment of ARDS. We thus investigated the prophylactic-potential of Lactobacillus rhamnosus-(LR) in lipopolysaccharide (LPS)-induced pulmonary and cecal ligation puncture (CLP) induced extrapulmonary ARDS mice. Our in-vivo findings revealed that pretreatment with LR significantly ameliorated vascular-permeability (edema) of the lungs via modulating the neutrophils along with significantly reducing the expression of inflammatory-cytokines in the BALF, lungs and serum in both pulmonary and extrapulmonary mice-models. Interestingly, our ex-vivo immunofluorescence and flow cytometric data suggested that mechanistically LR via short chain fatty acids (butyrate being the most potent and efficient in ameliorating the pathophysiology of both pulmonary and extra-pulmonary ARDS) targets the phagocytic and neutrophils extracellular traps (NETs) releasing potential of neutrophils. Moreover, our in-vivo data further corroborated our ex-vivo findings and suggested that butyrate exhibits enhanced potential in ameliorating the pathophysiology of ARDS via reducing the infiltration of neutrophils into the lungs. Altogether, our study establishes the prophylactic role of LR and its associated metabolites in the prevention and management of both pulmonary and extrapulmonary ARDS via targeting neutrophils.

Association of Late Radiographic Assessment of Lung Edema Score with Clinical Outcome in Patients with Influenza-Associated Acute Respiratory Distress Syndrome

Background: Influenza virus infection leads to acute pulmonary injury and acute respiratory distress syndrome (ARDS). The Radiographic Assessment of Lung Edema (RALE) score has been proposed as a reliable tool for the evaluation of the opacity of chest X-rays (CXRs). This study aimed to examine the RALE scores and outcomes in patients with influenza-associated ARDS. Methods: Patients who were newly diagnosed with influenza-associated ARDS from December 2015 to March 2016 were enrolled. Two independent reviewers scored the CXRs obtained on the day of ICU admission and on days 2 and 7 after intensive care unit (ICU) admission. Results: During the study, 47 patients had influenza-associated ARDS. Five died within 7 days of ICU admission. Of the remaining 42, non-survivors (N = 12) had higher Sequential Organ Failure Assessment scores (SOFA) at ICU admission and higher day 7 RALE scores than survivors (N = 30). The day 7 RALE score independently related to late in-hospital mortality (aOR = 1.121, 95% CI: 1.014–1.240, p = 0.025). Conclusions: The RALE score for the evaluation of opacity on CXRs is a highly reproducible tool. Moreover, RALE score on day 7 was an independent predictor of late in-hospital mortality in patients with influenza-associated ARDS.

Design and Operation of High Flow Oxygen Therapy: A novel approach to producing high concentration humidified oxygen for covid-19 patients

High-flow oxygen therapy provides adequate oxygen to those patients who suffer from pulmonary disorders due to the COVID-19 virus. The purpose of this research is to develop an oxygen therapy device that produces high-flow oxygen and provides a humidified supply of oxygen to patients suffering from Chronic Obstructive Pulmonary Disease (COPD) and Acute Respiratory Distress Syndrome (ARDS) caused by COVID-19. The development of a High-Flow Oxygen Therapy (HFOT) device using cannulation is a much-needed solution to fill the gap in the availability of ventilators in resource-limited settings like Pakistan. The HFOT has a system that offers high-flow oxygen with the help of a blender that is capable of producing a balanced mix of air and oxygen while keeping the fraction of inspired oxygen (FiO2) at the desired level. A Proportional, Integral, and Derivative (PID) valve is used to control the flow of the mixed gas as per the requirement. The mixed air is then passed through a humidifier that warms, humidifies, and purifies respiratory gas. The flow rate of the device is designed to produce up to 60 Liters Per Minute (LPM) with ± 0.5 variations with proper humidity. The designed prototype is tested for the gas flow rate, oxygen concentration, and desired pressure using professional calibrators and artificial lungs. The test results show significant achievements in delivering humid gases with high flow rates. ness together with appropriate humidification, gas warming, and concentration of oxygen.

SnRNA-Seq analysis reveals ten hub genes associated with alveolar epithelial cell injury during pulmonary acute respiratory distress syndrome

BackgroundAlveolar epithelial cell injury is a key factor in the occurrence and development of pulmonary acute respiratory distress syndrome (ARDSp). Yet the gene expression profile of alveolar epithelial cells of patients with ARDSp remains unclear. MethodsWe analyzed single nuclear RNA sequencing (snRNA-Seq) data from autopsy lung tissues of both ARDSp patients and healthy donors. Sequence data for type 2 alveolar epithelizal cells (AT2) were extracted by the Seurat package. Differentially expressed genes (DEGs) in AT2 were identified by the criteria |log2FC| ≥ 0.25 and P < 0.05 with DESeq2. A protein interaction network was constructed using Search Tool for the Retrieval of Interacting Genes (STRING) and Cytoscape software to identify hub genes. We then constructed an ARDSp rat model through induction by lipopolysaccharide (LPS) airway instillation. Left lung RNA was extracted and sequenced via Illumina Hiseq platforms. Analysis of the rat RNA sequencing data was then used to verify hub genes. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were performed on the identified hub genes. ResultsIn AT2, a total of 289 genes were identified as differentially expressed between those from ARDSp patients and healthy donors, and these included 190 upregulated and 99 downregulated genes. Ten hub genes were further identified (RPS27A, ACTG1, CAV1, HSP90AA1, HSPA5, CCND1, ITGA3, B2M, NEDD4L, and SEMA5A). There was a similar expression trend of HSPA5 between rat RNA and snRNA sequencing data. DiscussionARDSp altered the gene expression profile of AT2. The identified hub genes were enriched in biological processes mainly involved in cell growth and transformation. Relatedly, ferroptosis and autophagy are possibly involved in AT2 injury during ARDSp. These novel insights into ARDSp may aid the discovery of potential targets for the diagnosis and treatment of ARDSp.

Evaluation of Patients with Acute Respiratory Distress Syndrome Followed on Mechanical Ventilator in a Tertiary Pediatric Intensive Care and the Factors That May Be Associated with Death in These Patients.

We aimed to evaluate the clinical, demographic, and laboratory characteristics of the patients followed up with pediatric acute respiratory distress syndrome in our pediatric intensive care unit and to determine the factors that have an effect on the outcomes. The medical records of 40 patients with acute respiratory distress syndrome who were followed up on mechanical ventilators in the pediatric intensive care unit of Adıyaman University were retrospectively scanned. From the medical records, the demographic data, clinical features, and laboratory characteristics were recorded. Eighteen of the patients were female and 22 were male. The mean age was 45.25 ± 56.63 months. A total of 27 (67.5%) of the patients were classified as pulmonary and 13 (32.5%) as extrapulmonary acute respiratory distress syndrome. Sixteen (40%) patients were followed in pressure-controlled mode only, 2 (5%) patients in volume-controlled mode only, and 22 (55%) patients in alternate modes. A total of 17 (42.5%) patients died. The median pediatric index of mortality, pediatric index of mortality-II, pediatric risk of mortality, and pediatric logistic organ dysfunction score values of the surviving patients were significantly lower than the dead patients. Median aspartate aminotransferase (P = .003) and lactate dehydrogenase (P = .008) values were found to be significantly higher in patients who died, while median pH values (P = .049) were found to be lower. The median length of stay in pediatric intensive care unit and duration of mechanical ventilators were significantly shorter in patients who died. Also, the median pediatric index of mortality, pediatric index of mortality-II, pediatric risk of mortality, and pediatric logistic organ dysfunction values of pulmonary acute respiratory distress syndrome patients were significantly lower than those of extrapulmonary acute respiratory distress syndrome patients. Despite advances in follow-up and management, mortality due to acute respiratory distress syndrome is still high. Mechanical ventilator duration, length of stay in pediatric intensive care unit, some mechanical ventilator parameters, mortality scores, and laboratory tests were associated with mortality. Alternatively, mechanical ventilator applications may reduce mortality rates.

Modeling the noninvasive bi-level positive airway pressure ventilation therapy system and simulated application

Without artificial airway though oral, nasal or airway incision, the bi-level positive airway pressure (Bi-PAP) has been widely employed for respiratory patients. In an effort to investigate the therapeutic effects and measures for the respiratory patients under the noninvasive Bi-PAP ventilation, a therapy system model was designed for virtual ventilation experiments. In this system model, it includes a sub-model of noninvasive Bi-PAP respirator, a sub-model of respiratory patient, and a sub-model of the breath circuit and mask. And based on the Matlab Simulink, a simulation platform for the noninvasive Bi-PAP therapy system was developed to conduct the virtual experiments in simulated respiratory patient with no spontaneous breathing (NSB), chronic obstructive pulmonary disease (COPD) and acute respiratory distress syndrome (ARDS). The simulated outputs such as the respiratory flows, pressures, volumes, etc, were collected and compared to the outputs which were obtained in the physical experiments with the active servo lung. By statistically analyzed with SPSS, the results demonstrated that there was no significant difference ( P > 0.1) and was in high similarity ( R > 0.7) between the data collected in simulations and physical experiments. The therapy system model of noninvasive Bi-PAP is probably applied for simulating the practical clinical experiment, and maybe conveniently applied to study the technology of noninvasive Bi-PAP for clinicians.

Same but Different-ECMO in COVID-19 and ARDS of Other Etiologies. Comparison of Survival Outcomes and Management in Different ARDS Groups.

Background: COVID-19 has led to increased numbers of patients in need of venovenous extracorporeal membrane oxygenation (ECMO) support, but knowledge on management in comparison to acute respiratory distress syndrome (ARDS) of other etiologies is still lacking. We analyzed venovenous ECMO management and survival outcomes in patients with COVID-19 in comparison to influenza ARDS and pulmonary ARDS of other origin. Results: Retrospective analysis of prospective venovenous ECMO registry-based data collection was performed. One hundred consecutive venovenous ECMO patients with severe ARDS were included (41 COVID-19, 24 influenza A, 35 ARDS of other etiologies). Patients with COVID-19 had higher BMI (body mass index), lower SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology and Chronic Health Evaluation II) scores, lower C-reactive protein and procalcitonin levels and less vasoactive support at ECMO initiation. Significantly more patients were mechanically ventilated for more than 7 days prior to ECMO initiation in the COVID-19 group, however they were ventilated with lower tidal volumes and more often received additional rescue therapies prior to and on ECMO. COVID-19 patients had significantly more barotrauma and thrombotic events on ECMO. There were no differences in weaning of ECMO, however duration of ECMO runs and ICU length of stay was significantly longer in the COVID-19 group. The leading cause of death in the COVID-19 group was irreversible respiratory failure, while uncontrolled sepsis and multiorgan failure were leading causes in the other 2 groups. All patients who survived ICU treatment were discharged out of hospital, and there were no differences in survival among groups at 180 days. Conclusions: Survival outcomes of venovenous ECMO patients do not differ between COVID-19 and ARDS of other pulmonary etiologies. ARDS guidelines were in greater proportion adhered to in COVID-19 patients, with, however, longer time to ECMO initiation. COVID-19 ARDS seems specific as a more single-organ disease with longer ECMO duration and irreversible respiratory failure as a main cause of ICU mortality.

Non-invasive Ventilation Failure - Predict and Protect.

Pratyusha K, Jindal A. Non-invasive Ventilation Failure - Predict and Protect. Indian J Crit Care Med 2023;27(2):149.

Effect of Soft Tissue Manual Technique and Breathing Exercises on Pulmonary Function, Chest Expansion and Functional Status in Post COVID-19 Survivors: A Quasi-experimental Study

Introduction: It is known that around one third of Coronavirus Disease-2019 (COVID-19) patients develop severe pulmonary complications and acute respiratory distress syndrome, leading to long-term impairments in Pulmonary Function Test (PFT) and physical performance. Due to deteriorating health status of the COVID-19 survivors after their recovery, rehabilitation is must. Aim: To evaluate the effect of soft tissue manual technique and breathing exercises on PFT, chest expansion and functional status in Post COVID-19 Survivors. Materials and Methods: This quasi-experimental study was carried out in the Department of Cardiorespiratory Physiotherapy, MGM hospital, Aurangabad, Maharashtra, India, from November 2021 to July 2022. Total 54 subjects diagnosed with COVID-19 who required oxygen therapy and had persistent respiratory symptoms for three weeks to six months after the infection, were included. All the subjects received one week of soft tissue manual techniques which included proprioceptive neuromuscular function, muscle energy technique for recruitment of diaphragm, muscles of respiration and the ribcage. Breathing exercises were inculcated at the end of the session to ensure relaxation of the subjects. Subjects were assessed for PFT, chest expansion and post COVID-19 Functional Status Scale (PCFS) pre and post-treatment. Data were analysed through Wilcoxon signed-rank Test. Results: Amongst total 54 subjects included, 10 (18.6%) males and 44 (81.4%) females with mean age of 29.92±11.94. After one week of intervention p-value was 0.0001 for Forced Expiratory Volume (FEV1), FEV1/Forced Vital Capacity (FVC), Peak Expiratory Flow (PEF) with mean values for FEV1 at baseline was 1.91±0.51 and post-treatment was 2.45±0.34, FVC was 2.25±0.50 before the treatment whereas it was 2.73±0.36 post-treatment with p-value of 0.002, FEV1/FVC and PEF was 83.99±12.03 and 4.36±1.78 at baseline whereas, post-treatment it was 87.76±7.29 and 5.88±0.95 respectively. The p-value of 0.0001 was also similar for chest expansion. No statistically significant difference was found in post COVID-19 functional status (p-value=0.013). Conclusion: Positive changes in the ribcage’s activation and integration with its muscles were seen in all of the study variables. Therefore, it is concluded that soft tissue manipulation techniques and breathing exercise improves functional status, thoracic expansion, in post COVID-19 survivors.

Effect of tracheostomy timing in pediatric patients with traumatic brain injury.

Traumatic brain injury (TBI) is a prevalent cause of disability and death in the pediatric population, often requiring prolonged mechanical ventilation. Patients with significant TBI or intracranial hemorrhage require advanced airway management to protect against aspiration, hypoxia, and hypercarbia, eventually necessitating tracheostomy. While tracheostomy is much less common in children compared to adults, its prevalence among pediatric populations has been steadily increasing. Although early tracheostomy has demonstrated improved outcomes in adult patients, optimal tracheostomy timing in the pediatric population with TBI remains to be definitively established. This retrospective cohort analysis aims to evaluate pediatric TBI patients who undergo tracheostomy and to investigate the impact of tracheostomy timing on outcomes. The Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID), collected between in 2016 and 2019, was queried using International Classification of Disease 10th edition (ICD10) codes for patients with traumatic brain injury who had received a tracheostomy. Baseline demographics, insurance status, and procedural day data were analyzed with univariate and multivariate regression analyses. Propensity score matching was performed to estimate the incidence of medical complications and mortality related to early versus late tracheostomy timing (as defined by median=9 days). Of the 68,793 patients (mean age=14, IQR 4-18) who suffered a TBI, 1,956 (2.8%) received a tracheostomy during their hospital stay. TBI patients who were tracheostomized were older (mean age=16.5 vs 11.4 years), more likely to have injuries classified as severe TBIs and more likely to have accumulated more than one indicator of parenchymal injury as measured by the Composite Stroke Severity Scale (CSSS >1) than non-tracheostomized TBI patients. TBI patients with a tracheostomy were more likely to encounter serious complications such as sepsis, acute kidney injury (AKI), meningitis, or acute respiratory distress syndrome (ARDS). They were also more likely to necessitate an external ventricular drain (EVD) or decompressive hemicraniectomy (DHC) than TBI patients without a tracheostomy. Tracheostomy was also negatively associated with routine discharge. Procedural timing was assessed in 1,867 patients; older children (age >15 years) were more likely to undergo earlier placements (p<0.001). Propensity score matching (PSM) comparing early versus late placement was completed by controlling for age, gender, and TBI severity. Those who were subjected to late tracheostomy (>9 days) were more likely to face complications such as AKI or deep vein thrombosis (DVT) as well as a host of respiratory conditions such as pulmonary embolism, aspiration pneumonitis, pneumonia, or ARDS. While the timing did not significantly impact mortality across the PSM cohorts, late tracheostomy was associated with increased length of stay (LOS) and ventilator dependence. Tracheostomy, while necessary for some patients who have sustained a TBI, is itself associated with several risks that should be assessed in context of each individual patient's overall condition. Additionally, the timing of the intervention may significantly impact the trajectory of the patient's recovery. Early intervention may reduce the incidence of serious complications as well as length of stay and dependence on a ventilator and facilitate a timelier recovery.

Highway to heal: Influence of altered extracellular matrix on infiltrating immune cells during acute and chronic lung diseases.

Environmental insults including respiratory infections, in combination with genetic predisposition, may lead to lung diseases such as chronic obstructive pulmonary disease, lung fibrosis, asthma, and acute respiratory distress syndrome. Common characteristics of these diseases are infiltration and activation of inflammatory cells and abnormal extracellular matrix (ECM) turnover, leading to tissue damage and impairments in lung function. The ECM provides three-dimensional (3D) architectural support to the lung and crucial biochemical and biophysical cues to the cells, directing cellular processes. As immune cells travel to reach any site of injury, they encounter the composition and various mechanical features of the ECM. Emerging evidence demonstrates the crucial role played by the local environment in recruiting immune cells and their function in lung diseases. Moreover, recent developments in the field have elucidated considerable differences in responses of immune cells in two-dimensional versus 3D modeling systems. Examining the effect of individual parameters of the ECM to study their effect independently and collectively in a 3D microenvironment will help in better understanding disease pathobiology. In this article, we discuss the importance of investigating cellular migration and recent advances in this field. Moreover, we summarize changes in the ECM in lung diseases and the potential impacts on infiltrating immune cell migration in these diseases. There has been compelling progress in this field that encourages further developments, such as advanced in vitro 3D modeling using native ECM-based models, patient-derived materials, and bioprinting. We conclude with an overview of these state-of-the-art methodologies, followed by a discussion on developing novel and innovative models and the practical challenges envisaged in implementing and utilizing these systems.

Bedside lung ultrasonography: comparison with chest radiography (BLUR), a diagnostic study in a developing country

BackgroundThis study determines the diagnostic utility of lung ultrasonography (LUS) in a medical ward in a developing country. In a low resource country like India, we hope that use of...

Whole pulmonary assessment 1 year after paediatric acute respiratory distress syndrome: prospective multicentre study

BackgroundLong-term pulmonary sequelae, including 1-year thoracic computed tomography (CT) sequelae of paediatric acute respiratory distress syndrome (ARDS) remain unknown. The purpose of the study was to determine pulmonary abnormalities in child survivors of pulmonary (p-ARDS) and extra-pulmonary ARDS (ep-ARDS) 1 year after paediatric intensive care unit discharge (PICUD).MethodsProspective multicentre study in four paediatric academic centres between 2005 and 2014. Patients with ARDS were assessed 1 year after PICUD with respiratory symptom questionnaire, thoracic CT and pulmonary function tests (PFT).Results39 patients (31 p-ARDS) aged 1.1–16.2 years were assessed. Respiratory symptoms at rest or exercise and/or respiratory maintenance treatment were reported in 23 (74%) of children with p-ARDS but in 1 (13%) of those with ep-ARDS. Thoracic CT abnormalities were observed in 18 (60%) of children with p-ARDS and 4 (50%) of those with ep-ARDS. Diffuse and more important CT abnormalities, such as ground glass opacities or mosaic perfusion patterns, were observed in 5 (13%) of children, all with p-ARDS. PFT abnormalities were observed in 30 (86%) of patients: lung hyperinflation and/or obstructive pattern in 12 (34%) children, restrictive abnormalities in 6 (50%), mild decrease in diffusing capacity in 2 (38%) and 6-min walking distance decrease in 11 (73%). Important PFT abnormalities were observed in 7 (20%) children, all with p-ARDS. Increasing driving pressure (max plateau pressure—max positive end-expiratory pressure) was correlated with increasing CT-scan abnormalities and increasing functional residual capacity (more hyperinflation) (p < 0.005).ConclusionsChildren surviving ARDS requiring mechanical ventilation present frequent respiratory symptoms, significant CT-scan and PFT abnormalities 1 year after PICUD. This highlights the need for a systematic pulmonary assessment of these children.Trial registration The study was registered on Clinical Trials.gov PRS (ID NCT01435889)

Point of care ultrasound as initial diagnostic tool in acute dyspnea patients in the emergency department of a tertiary care center: diagnostic accuracy study

BackgroundDyspnea is one of the common symptoms patients present to the emergency department (ED). The broad spectrum of differentials often requires laboratory and radiological testing in addition to clinical evaluation, causing unnecessary delay. Point of care ultrasound (PoCUS) has shown promising results in accurately diagnosing patients with dyspnea, thus, becoming a popular tool in ED while saving time and maintaining safety standards. Our study aimed to determine the utilization of point of care ultrasound in patients with acute dyspnea as an initial diagnostic tool in our settings.MethodologyThe study was conducted at the emergency department of a tertiary healthcare center in Northern India. Adult patients presenting with acute dyspnea were prospectively enrolled. They were clinically evaluated and necessarily investigated, and a provisional diagnosis was made. Another EP, trained in PoCUS, performed the scan, blinded to the laboratory investigations (not the clinical parameters), and made a PoCUS diagnosis. Our gold standard was the final composite diagnosis made by two Emergency Medicine consultants (who had access to all investigations). Accuracy and concordance of the ultrasound diagnosis to the final composite diagnosis were calculated. The time to formulate a PoCUS diagnosis and final composite diagnosis was compared.ResultsTwo hundred thirty-seven patients were enrolled. The PoCUS and final composite diagnosis showed good concordance (κ = 0.668). PoCUS showed a high sensitivity for acute pulmonary edema, pleural effusion, pneumothorax, pneumonia, pericardial effusion, and low sensitivity for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and acute respiratory distress syndrome (ARDS)/acute lung injury (ALI). High overall specificity was seen. A high positive predictive value for all except left ventricular dysfunction, pericardial effusion, non-cardiopulmonary causes of dyspnea, and a low negative predictive value was seen for pneumonia. The median time to make a PoCUS diagnosis was 16 (5–264) min compared to the 170 (8–1346) min taken for the final composite diagnosis. Thus, time was significantly lower for PoCUS diagnosis (p value <0.001).ConclusionBy combining the overall accuracy of PoCUS, the concordance with the final composite diagnosis, and the statistically significant reduction in time taken to formulate the diagnosis, PoCUS shows immense promise as an initial diagnostic tool that may expedite the decision-making in ED for patients’ prompt management and disposition with reliable accuracy.

The Association Between Oxygenation Status at 24 h After Diagnosis of Pulmonary Acute Respiratory Distress Syndrome and the 30-Day Mortality among Pediatric Oncological Patients.

BackgroundPediatric oncology patients with acute respiratory distress syndrome (ARDS) secondary to pneumonia are at high risk of mortality. Our aim was to describe the epidemiology of ARDS in this clinical population and to identify the association between the oxygenation status at 24 h after diagnosis and the 30-day mortality rates, stratified by the severity of ARDS.MethodsThis was a retrospective cohort study of 82 pediatric oncology patients, with a median age of 4 years, admitted to our pediatric intensive care unit with a diagnosis of ARDS between 2013 and 2021. Demographic and clinical factors were compared between the survivor (n = 52) and non-survivor (n = 30) groups. Univariate and multivariate Cox proportional hazards regression models were used to determine the association between the oxygenation status at 24 h after diagnosis and the 30-day mortality rates.ResultsThe mean airway pressure at ARDS diagnosis, PaO2/FiO2 (P/F) ratio, oxygenation index (OI) value, peak inspiratory pressure, and lactate level at 24 h after ARDS diagnosis, as well as complications (i.e., septicemia and more than two extrapulmonary organ failures) and adjunctive continuous renal replacement therapy, were significant mortality risk factors. After adjusting for other covariates, the oxygenation status P/F ratio (Hazard ratio [HR] = 0.98, 95% confidence interval [CI] = 0.96–1.00, P = 0.043) and OI value (HR = 1.12, 95% CI = 1.02–1.23, P = 0.016) at 24 h remained independent mortality risk factors. According to the Kaplan–Meier survival curve, a low P/F ratio (≤ 150) and high OI (>10) were associated with a higher risk of 30-day mortality (50.9 and 52.9%, respectively; both P < 0.05)ConclusionThe P/F ratio and OI value measured at 24 h after ARDS diagnosis can provide a better stratification of patients according to ARDS disease severity to predict the 30-day mortality risk.

Ways Forward in Preventing Severe Maternal Morbidity and Maternal Health Inequities: Conceptual Frameworks, Definitions, and Data, from a Population Health Perspective.

Ways Forward in Preventing Severe Maternal Morbidity and Maternal Health Inequities: Conceptual Frameworks, Definitions, and Data, from a Population Health Perspective.