Invasive ventilation saves lives but carries major risks, including ventilation-associated lung damage and long-term functional impairment. Data from recent studies compel reassessment of the evidence for every step of the clinical treatment pathway. This updated clinical practice guideline is based on pertinent publications retrieved by a systematic search in Medline, Embase, and the Cochrane Library up to April 2023, supplemented by further high-quality studies published up to June 2024. The recommendations were developed in evidence-to-decision-frameworks (EtDF) according to GRADE, with the participation of intensive-care nurses and early career clinician-scientists. For patients in acute respiratory failure, it is suggested that noninvasive respiratory support techniques should be used so that intubation can be avoided. It is further suggested that spontaneous breathing should be enabled early on during invasive ventilation. For the first time, the use of various techniques for titrating the positive end-expiratory pressure (PEEP) is suggested for patients with moderate to severe acute respiratory distress syndrome (ARDS). In such patients, techniques aiming at a higher PEEP can lower mortality by 9% in absolute terms (95% confidence interval [1; 16]) compared to lower-PEEP strategies. Strong recommendations are given against the routine use of muscle relaxation or corticosteroid therapy in moderate to severe ARDS. For patients with ARDS with a persistent, severe gas exchange disturbance after conservative options have been exhausted, veno-venous extracorporeal membrane oxygenation should be considered. VvECMO for patients with severe ARDS should be carried out at centers that are experienced in treating patients with severe ARDS and that fulfill specific structural requirements. The goals of ventilator therapy should be to enable spontaneous breathing as soon as possible, keep respiratory parameters in the protective range, and adjust PEEP individually. Muscle relaxation or corticosteroids should not be part of the routine treatment of moderately severe ARDS.

CircUBXN7 as a prognostic risk biomarker for ARDS modulates LPS-stimulated lung epithelial cell injury and the inflammatory response by competitively binding miR-622.

Effects of chest wall loading in supine position on respiratory mechanics in low-compliance ARDS patients.

The gut-lung axis is involved in acute lung injury (ALI) and its fatal sequela, acute respiratory distress syndrome (ARDS), yet the molecular mechanisms governing this crosstalk remain poorly defined. Untargeted metabolomics of plasma revealed significant dysregulation of tryptophan metabolism in ARDS patients compared to healthy controls. Murine dietary interventions demonstrated that high tryptophan intake alleviated ALI severity, whereas deficiency exacerbated injury, with protection being gut microbiota dependent. 16S ribosomal RNA (16S rRNA) gene sequencing revealed marked depletion of a functionally central bacterium Lactobacillus johnsonii (L. johnsonii) during ALI. Supplementation with L. johnsonii or its encapsulated form attenuated ALI, but this required dietary tryptophan sufficiency. Mechanistically, L. johnsonii converts tryptophan into oxindole, which enters pulmonary macrophages, promotes the aryl hydrocarbon receptor-RelA binding, and thereby suppresses RelA-mediated transcriptional activation of C-X-C motif chemokine 13 (CXCL13). Both genetic ablation and pharmacological inhibition of CXCL13 ameliorated ALI symptoms. Importantly, oxindole and CXCL13 levels correlated with ARDS severity in patients, suggesting their clinical relevance. Collectively, these findings define a protective microbiota-dependent gut-lung axis in ALI/ARDS that is mediated by dietary tryptophan-derived oxindole, which acts at least partially through CXCL13 suppression to underscore targetable diet-microbe-metabolite therapeutic paradigms.

To assess the association between the oxygenation index (OI) and survival in mechanically ventilated dogs with primary pulmonary parenchymal disease. Retrospective, multicenter study. Three veterinary medical teaching institutions and one private veterinary referralcenter. Seventy-nineclient-owned dogs. None. OI, calculated as (mean airway pressure×FiO2×100)/PaO2, and the PaO2/FiO2 (PF) ratio were calculated for dogs undergoing mechanical ventilation for primary pulmonary disease. Median OI was lower in survivors (2.6) than nonsurvivors (6.6; p<0.001), while PF was higher in survivors (317.9 vs. 177.9; p<0.001). OI predicted mortality with an area under the receiver operating characteristic curve of 0.73, sensitivity of 65%, and specificity of 80% at an optimal cutoff of 4.3. Median PF had an area under the receiver operating characteristic curve of 0.72, sensitivity of 70%, and specificity of 73% at an optimal cutoff of 237.8. Each 1-unit increase in OI was associated with a 35% higher mortality risk (odds ratio: 1.35; 95% confidence interval: 1.14-1.61). Survivors showed greater improvement in OI during ventilation (p=0.004). Using Pediatric Acute Lung Injury Consensus Conference and pediatric acute respiratory distress syndrome thresholds, survival likelihood declined with increasing severity, with no survivors in the severe category (OI >16). Similar trends were observed using updated Pediatric Acute Lung Injury Consensus Conference-2 criteria and acute respiratory distress syndrome severity classifications. Higher OI values and lower PF ratios were associated with mortality in this group of mechanically ventilated dogs, with both metrics demonstrating similar predictive accuracy. Results suggest species-specific OI and PF thresholds are needed.

ABSTRACT Acute respiratory distress syndrome (ARDS) is a life-threatening condition that often necessitates advanced ventilatory strategies. This case presents a 43-year-old female with severe ARDS who required invasive mechanical ventilation and individualized positive end-expiratory pressure (PEEP) titration guided by transpulmonary pressure (PL) monitoring by esophageal balloon catheter. A 43-year-old morbidly obese female (body mass index – 40) with a history of heavy smoking presented with a 2-day history of worsening shortness of breath, chest pain, and productive cough. She developed severe ARDS and required intubation within 12 h of hospital admission after failure of noninvasive ventilation. Lung-protective ventilation and prone positioning were initiated, PEEP increased up to 16 cmH2O, but oxygenation remained poor with PaO 2 /FiO 2 ratio &lt; 00. The patient was considered for ECMO support as a last resort. But the treating team decided before ECMO to check the PL, esophageal balloon catheter was placed to guide further management. Based on PL monitoring, PEEP was titrated up to 28 cmH 2 O, leading to significant improvement in oxygenation and compliance. The patient was gradually weaned, discharged from the intensive care unit after 27 days, and later discharged home safely. An esophageal balloon catheter provided real-time data that was associated with improved outcomes in severe ARDS. This case underscores the role of esophageal balloon catheter monitoring in optimizing PEEP and improving outcomes in severe ARDS, particularly in patients with complex comorbidities such as morbid obesity.

Identifying reliable biomarkers associated with clinical outcomes in patients with acute respiratory distress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) is essential. Elevated serum Krebs von den Lungen-6 (KL-6) has been linked to increased mortality in ARDS; however, its prognostic utility in ECMO remains unclear. This multicenter retrospective cohort study analyzed adult patients with severe ARDS who received veno-venous ECMO in 24 Japanese hospitals between 2012 and 2022. Serum KL-6 was measured within 3 days before or after ECMO initiation. The primary outcome was 90 day in-hospital mortality, and the secondary outcome was successful ECMO liberation. Among 373 patients, 265 (71.0%) survived, and 108 (29.0%) died. In multivariable Cox proportional hazards models using restricted cubic splines, higher KL-6 levels were significantly associated with increased 90 day mortality (p = 0.004), whereas lower KL-6 levels were significantly associated with successful liberation from ECMO (p < 0.001). These findings suggest that serum KL-6 measured around the time of ECMO initiation is associated with mortality and liberation outcomes in patients with, supporting its potential as a biomarker of disease severity.

Staged management of severe polytrauma with pericardial and diaphragmatic rupture and open pelvic ring injury: a case report with literature review

Few studies have examined the prognostic impact of high fever after decannulation from veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory distress syndrome (ARDS). We aimed to investigate the incidence and prognostic significance of post-decannulation high fever in this population, exploring its association with mortality, stratified by the presence of infectious complications at decannulation. This study was a post hoc analysis of a multicenter retrospective registry that included adult patients with severe ARDS who were successfully weaned off V-V ECMO between 2012 and 2022 across 24 institutions in Japan. High fever was defined as a core body temperature of ≥ 39.0°C within 3days after ECMO decannulation. The primary outcome was 90-day in-hospital mortality. Cox proportional hazards models were used to examine the association between post-decannulation high fever and mortality. As a subgroup analysis, we evaluated this association according to the presence or absence of infectious complications. Among 522 patients, 121 (23.2%) developed high fever within 3days after ECMO decannulation. In the overall cohort, 90-day in-hospital mortality did not differ significantly between the high-fever and no-fever groups (19.0% vs. 13.7%, p = 0.372). Multivariable analysis showed no statistically significant association between high fever and mortality (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.55-1.56, p = 0.770). Subgroup analyses revealed opposite associations depending on infection status. High fever was associated with reduced mortality in patients with infection (HR 0.33, 95% CI 0.12-0.89, p = 0.045) but increased mortality in those without (HR 2.25, 95% CI 1.23-4.11, p = 0.011). Post-decannulation high fever occurs in nearly one-fourth of patients with severe ARDS treated with V-V ECMO. Its association with mortality appears to differ depending on the infection status at decannulation, underscoring the importance of carefully assessing infectious complications.

In acute respiratory distress syndrome (ARDS), spontaneous breathing is often encouraged to preserve lung function, yet excessive patient-generated inspiratory effort can paradoxically worsen injury, a phenomenon termed patient self-inflicted lung injury (P-SILI). In mechanically heterogeneous lungs, uncontrolled effort amplifies regional stress, strain, and mechanical power, driving alveolar overdistension, cyclic recruitment-derecruitment, pendelluft, and inflammation. Cardiovascular consequences include elevated right ventricular afterload, impaired left ventricular filling, and exacerbation of pulmonary edema. While moderate spontaneous breathing may improve aeration in mild injury, evidence shows that vigorous effort in severe ARDS accelerates histological damage and regional lung stress. Early bedside assessment of respiratory drive and inspiratory effort identifies patients at highest risk, enabling targeted interventions. Strategies to preserve protective spontaneous breathing while limiting injurious effort include individualized positive end-expiratory pressure, titrated sedation, prone positioning, and short-term neuromuscular blockade. By integrating continuous physiological monitoring with personalized ventilatory management, clinicians can mitigate P-SILI, protect the diaphragm, and optimize outcomes. Future studies are needed to test physiology-guided interventions and establish evidence-based approaches to safely harness the benefits of spontaneous breathing in ARDS.

Emergency management of severe polytrauma with traumatic diaphragmatic hernia via EMSS: case report and literature review

This case report describes an exceptionally rare occurrence of severe acute respiratory distress syndrome following laparoscopic appendectomy in a previously healthy 57-year-old male. The patient presented with acute appendicitis and underwent an uncomplicated surgical procedure. Approximately 4 h postoperatively, he developed rapid respiratory deterioration with severe hypoxemia, fulfilling the Berlin criteria for severe acute respiratory distress syndrome (partial pressure of arterial oxygen/fraction of inspired oxygen ratio, 99.2). Other causes, including aspiration, pulmonary embolism, and cardiac failure, were excluded. The patient was managed in the intensive care unit with lung-protective ventilation in accordance with the Acute Respiratory Distress Syndrome Network (ARDSNet) protocol along with antibiotics and corticosteroids. He demonstrated rapid clinical improvement, was extubated on postoperative day 7, and discharged on postoperative day 8. This case highlights that severe acute respiratory distress syndrome, although rare, can complicate routine surgical procedures and underscores the importance of early recognition and multidisciplinary management in achieving favorable outcomes.

The optimal level of positive end-expiratory pressure (PEEP) during venovenous extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) remains uncertain. This study aimed to evaluate the association between initial PEEP settings at ECMO initiation and the rate of successful ECMO liberation in patients with severe ARDS. We conducted a post hoc analysis of the multicenter Japan Chest CT for ARDS Requiring Venovenous ECMO (J-CARVE) registry. Adult patients with severe ARDS treated with venovenous ECMO between 2012 and 2022 at 24 institutions were included. Participants were categorized into three groups according to PEEP at ECMO initiation: low (< 8 cm H2O), middle (8-10 cm H2O), and high (> 10 cm H2O). The primary outcome was successful liberation from ECMO within 30 days. Multivariable Cox proportional hazards models were used to evaluate associations. Secondary outcomes included 60-day mortality, duration of ECMO support, and duration of mechanical ventilation. Among 683 patients analyzed, the overall ECMO liberation rate at 30 days was 69.2%. Liberation rates were 57.8% (103/178), 73.5% (259/352), and 72.5% (111/153) in the low, middle, and high PEEP groups, respectively. After adjustment, the low group had a significantly lower likelihood of successful ECMO liberation (hazard ratio [HR], 0.56; 95% CI, 0.39-0.81) compared with the middle group. No significant difference was observed between the high and middle groups (HR, 0.80; 95% CI, 0.58-1.10). The low group had longer ECMO duration; however, 60-day mortality and hospital length of stay did not differ significantly among groups. Lower PEEP levels at ECMO initiation were associated with reduced likelihood of successful ECMO liberation compared with moderate PEEP, whereas estimates for high vs. moderate PEEP were not statistically significant. These findings support avoiding insufficiently low PEEP and underscore the need for prospective studies to refine optimal PEEP strategies in patients with severe ARDS.

Severe acute respiratory distress syndrome as a complication of an acute systemic lupus erythematosus flare

Preferential boosting of SARS-CoV-2 Omicron lineage-specific immune responses by monovalent XBB.1.5 vaccination.

Investigating the effect of inhaled nitric oxide combined with prone position ventilation on ventilation/perfusion matching in patients with moderate-to-severe acute respiratory distress syndrome.

Role of the Perioperative Growth Differentiation Factor-15 Kinetics in Identifying Patients at High Risk for Postoperative Pulmonary Complications Following Thoracic Surgery.

Prone positioning improves survival in patients with acute respiratory distress syndrome (ARDS) by reducing ventilator-induced lung injury and enhancing ventilation-perfusion matching. Whether these physiological benefits translate to patients supported with veno-venous extracorporeal membrane oxygenation (VV-ECMO) remains uncertain. This study compared the effects of prone versus supine positioning on the wet-to-dry lung weight ratio, gas exchange, respiratory mechanics, electrical impedance tomography, histopathology, microbiology, hemodynamics, and extracorporeal circuit function in pigs with severe ARDS undergoing VV-ECMO.Pigs with severe ARDS were placed on VV-ECMO according to EOLIA criteria and then randomized to either prone or supine positioning for 48h, while receiving an ultraprotective ventilation strategy. Futility analyses were performed at half of the planned sample size using conditional power calculations, with early termination criteria set at < 10% probability of achieving statistical significance. Eight pigs with severe ARDS were randomized after VV-ECMO initiation. Prone positioning, compared with the supine position, resulted in a similar wet-to-dry lung weight ratio (6.77 [6.13-8.17] vs. 6.70 [6.22-8.48]; p = 0.89), meeting the futility threshold. Compared with the supine position, prone positioning significantly reduced the proportion of ventilation in non-dependent lung regions (51 [47-61.25]% vs. 86 [68.50-90]%; p = 0.02), thereby indicating a redistribution of ventilation toward dependent areas. Consistent with this shift in ventilation distribution, prone positioning redistributed histopathological lung injury, with relative preservation of non-dependent regions and greater damage in dependent zones, but without a net global decrease. Shunt fraction approached 100% in both groups, with no significant differences. Pulmonary CO₂ elimination was 8.45 (1.45-26.13) mL/min in the prone group and 0 (0-0.70) mL/min in the supine group (p = 0.23). Lung compliance showed no intergroup differences (14.67 [12.75-19.91] vs. 16.68 [15.51-19.47] mL/cmH₂O; p = 0.88), with similarly elevated end-inspiratory transpulmonary pressures. No significant differences were observed in systemic or pulmonary hemodynamics, nor in VV-ECMO circuit function. Prone positioning did not decrease the overall severity of lung injury. Rather, it shifted the distribution of damage, with greater involvement of dependent regions and relative preservation of non-dependent areas.

Bridge to transplant using a flow-adaptive extracorporeal total artificial lung system following bilateral pneumonectomy.

Prospective Evaluation after 3 Years on Survival Quality of Life and Functional Outcomes in COVID-19 Patients with Severe Acute Respiratory Distress Syndrome Managed with Veno-venous ECMO