Severe Acute Respiratory Failure Research Articles

Prone positioning in severe acute hypoxemic respiratory failure in the emergency ward

This paper reports the authors’ preliminary experience with three patients affected by severe acute hypoxemic respiratory failure due to bilateral pneumonia placed in a prone position in Emergency Medicine Ward during application of high flow oxygen nasal cannula.

An unusual presentation of pulmonary lymphoma: When diffuse ground glass opacities can mean anything.

Primary lung lymphoma (PLL) is a rare type of lymphoma confined to the lung at the time of diagnosis. Pulmonary diffuse large B cells lymphoma (P-DLBCL) is the second most common type of PLL and it usually appears radiologically as solitary or multiple nodules or areas of consolidation. We present the case of a 63-year-old Caucasian male who developed severe acute respiratory failure and diffuse ground glass opacities (GGO) on chest computerized tomography. Diffuse GGO may be the radiological expression of very different diseases, ranging from infectious processes to interstitial lung diseases (ILDs) and neoplastic diseases. In our case, pneumonia and de novo ILD were initially considered given the symptoms and past medical history. However, bronchoscopy with trans-bronchial biopsies demonstrated the presence of P-DLBCL, despite an unusual radiological presentation and negative cytological analyses on bronchoalveolar lavage. In conclusion, P-DLBCL should be considered among the many differential diagnoses of diffuse GGO.

The Randomized Educational Acute Respiratory Distress Syndrome Diagnosis Study: A Trial to Improve the Radiographic Diagnosis of Acute Respiratory Distress Syndrome.

Radiographic criteria for acute respiratory distress syndrome have been criticized for poor reliability. Our objective was to test an educational intervention to improve the radiographic identification of acute respiratory distress syndrome by participants in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure study. Randomized controlled trial. Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure study centers. Study coordinators in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure study. Participants were randomized to either an online training module followed by a test module (intervention) or test module followed by training module (control). The primary outcome was the number of radiographs correctly identified as meeting criteria for acute respiratory distress syndrome on an online test module (out of 11). Prespecified secondary analyses included a comparison of agreement between the groups and subgroup analyses by profession, age, years of experience, and stated familiarity with diagnostic criteria for acute respiratory distress syndrome. Four-hundred sixty-three study participants consented to participate. There was no effect of the intervention on correct answers by participants (proportion correct 58% [intervention] vs 56% [control]; p = 0.15), or in any subgroup analyses. Overall agreement between raters was 0.296 for the intervention and 0.272 for the control (p < 0.001). Participant recognition of radiographic criteria for acute respiratory distress syndrome was low, with poor agreement. This was not impacted by an educational intervention designed to improve accuracy of identification of radiographic criteria for acute respiratory distress syndrome.

Blockade of the C5a–C5aR axis alleviates lung damage in hDPP4-transgenic mice infected with MERS-CoV

The pathogenesis of highly pathogenic Middle East respiratory syndrome coronavirus (MERS-CoV) remains poorly understood. In a previous study, we established an hDPP4-transgenic (hDPP4-Tg) mouse model in which MERS-CoV infection causes severe acute respiratory failure and high mortality accompanied by an elevated secretion of cytokines and chemokines. Since excessive complement activation is an important factor that contributes to acute lung injury after viral infection, in this study, we investigated the role of complement in MERS-CoV-induced lung damage. Our study showed that complement was excessively activated in MERS-CoV-infected hDPP4-Tg mice through observations of increased concentrations of the C5a and C5b-9 complement activation products in sera and lung tissues, respectively. Interestingly, blocking C5a production by targeting its receptor, C5aR, alleviated lung and spleen tissue damage and reduced inflammatory responses. More importantly, anti-C5aR antibody treatment led to decreased viral replication in lung tissues. Furthermore, compared with the sham treatment control, apoptosis of splenic cells was less pronounced in the splenic white pulp of treated mice, and greater number of proliferating splenic cells, particularly in the red pulp, was observed. These data indicate that (1) dysregulated host immune responses contribute to the severe outcome of MERS; (2) excessive complement activation, triggered by MERS-CoV infection, promote such dysregulation; and (3) blockade of the C5a–C5aR axis lead to the decreased tissue damage induced by MERS-CoV infection, as manifested by reduced apoptosis and T cell regeneration in the spleen. Therefore, the results of this study suggest a new strategy for clinical intervention and adjunctive treatment in MERS-CoV cases.

Application of mesenchymal stem cell in the treatment of acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is severe acute respiratory failure caused by severe infections, trauma or others, and with high mortality rate. The pathogenesis of ARDS is complicated, but the uncontrolled excessive inflammatory response is identified as one of the main causes. Mesenchymal stem cells (MSCs) have the ability to regulate immune responses, and many researches showed that MSCs had potential therapeutic effects on autoimmune diseases and graft versus host diseases. Recently, basic researches showed that MSCs could treat ARDS and many scientists paid attention to the therapeutic use of MSC in the treatment of ARDS. This paper summarized the basic and clinical results obtained in application of MSC in treatment of ARDS, and discussed the problems needed to be resolved in the further studies in order to provide new ideas for clinical treatment of ARDS.

The effect of multidisciplinary extracorporeal membrane oxygenation team on clinical outcomes in patients with severe acute respiratory failure

BackgroundThe Extracorporeal Life Support Organization (ELSO) has suggested that extracorporeal membrane oxygenation (ECMO) patients should be managed by a multidisciplinary team. However, there are limited data on the impact of ECMO team on the outcomes of patients with severe acute respiratory failure.MethodsAll consecutive patients with severe acute respiratory failure who underwent ECMO for respiratory support from January 2012 through December 2016 were divided into the pre-ECMO team period (before January 2014, n = 70) and the post-ECMO team period (after January 2014, n = 46). Clinical characteristics and outcomes were compared between the two groups.ResultsThe mortality rates in the intensive care unit (72.9 vs. 50.0%, P = 0.012) and hospital (75.7 vs. 52.2%, P = 0.009) were significantly decreased in the post-ECMO team period compared to the pre-ECMO team period. The median duration of ECMO support was not different between the two periods. However, the proportion of patients successfully weaned off ECMO was higher in the post-ECMO team period (42.9 vs. 65.2%, P = 0.018). During ECMO support, the incidence of cannula problems (32.9 vs. 15.2%, P = 0.034) and cardiovascular events (88.6 vs. 65.2%, P = 0.002) was reduced after implementation of the ECMO team. The 1-year mortality was significantly different between the pre-ECMO team and post-ECMO team periods (37.8 vs. 14.3%, P = 0.005).ConclusionAfter implementing a multidisciplinary ECMO team, survival rate in patients treated with ECMO for severe acute respiratory failure was significantly improved.

Abstract WP385: Altered Adaptive Immune Response Correlates With Brain Injury in Extracorporeal Membrane Oxygenation Treated Pediatric Patients

Extracorporeal Membrane Oxygenation (ECMO) is a life-saving procedure that provides short-term cardiac and respiratory support to people whose heart and lungs are dysfunctional. Growing use of ECMO has expanded the indications beyond acute severe respiratory and cardiac failure to include extracorporeal cardiopulmonary resuscitation and as a bridge for lung transplantation. Usage of ECMO within the pediatric population has seen a number of complications including an acute induction of systemic inflammatory response syndrome (SIRS) and long-term developmental neurological deficits, with an increasing number of children exhibiting neurological morbidities. We hypothesized that ECMO may potentiate the induction of a central nervous system (CNS)-targeting adaptive immune response which may lead to neurological injury. Using a single center prospective observational study, we sampled 20 pediatric ECMO patients and 5 aged-match disease control patients. Peripheral blood mononuclear cells were isolated using the Ficoll-Paque method and relative analysis revealed an increase in helper T-cells that correlated with ECMO treatment alone, while NK-T cells were found to be increased in the presence of CNS injury. Interestingly, we did see a decrease in activated peripheral T-helper cells (CD4+CD161+), and cytotoxic T cells (CD8+CD161+), which were preceded by an increase in activated macrophages (CD14 + CD11b + ) in ECMO treated patients. Only activated peripheral CD8 T-cells were found to associate with CNS injury. Using the CFSE recall response assay, we tested for CNS specificity by culturing cells with myelin basic protein (MBP), proteolipid lipoprotein (PLP), myelin oligodendrocyte glycoprotein (MOG), NMDA receptor GluN2A, and microtubule associated protein (MAP2) for 7 days and determined a response by measuring CFSE dilution and CD25 expression using flow cytometry. We observed an increased in myelin-targeting B-cells, myelin- and neuronal-targeting CD8 T-cells and no difference in autoreactive CD4 T-cells. In summary, ECMO induces a robust peripheral CNS-targeting adaptive immune response that may predispose a patient to long-term neurological injury.

Early prognostic factors in septic shock cancer patients: a prospective study with a proteomic approach.

Organ failures are the main prognostic factors in septic shock. The aim was to assess classical clinico-biological parameters evaluating organ dysfunctions at intensive care unit admission, combined with proteomics, on day-30 mortality in critically ill onco-hematology patients admitted to the intensive care unit for septic shock. This was a prospective monocenter cohort study. Clinico-biological parameters were collected at admission. Plasma proteomics analyses were performed, including protein profiling using isobaric Tag for Relative and Absolute Quantification (iTRAQ) and subsequent validation by ELISA. Sixty consecutive patients were included. Day-30 mortality was 47%. All required vasopressors, 32% mechanical ventilation, 33% non-invasive ventilation and 13% renal-replacement therapy. iTRAQ-based proteomics identified von Willebrand factor as a protein of interest. Multivariate analysis identified four factors independently associated with day-30 mortality: positive fluid balance in the first 24 h (odds ratio = 1.06, 95% CI = 1.01-1.12, P = 0.02), severe acute respiratory failure (odds ratio = 6.14, 95% CI = 1.04-36.15, P = 0.04), von Willebrand factor plasma level > 439 ng/ml (odds ratio = 9.7, 95% CI = 1.52-61.98, P = 0.02), and bacteremia (odds ratio = 6.98, 95% CI = 1.17-41.6, P = 0.03). Endothelial dysfunction, revealed by proteomics, appears as an independent prognostic factor on day-30 mortality, as well as hydric balance, acute respiratory failure and bacteremia, in critically ill cancer patients admitted to the intensive care unit. Endothelial failure is underestimated in clinical practice and represents an innovative therapeutic target.

Oxygen Administration Improves Survival but Worsens Cardiopulmonary Functions in Chlorine-exposed Rats.

Chlorine is a highly reactive gas that can cause significant injury when inhaled. Unfortunately, its use as a chemical weapon has increased in recent years. Massive chlorine inhalation can cause death within 4 hours of exposure. Survivors usually require hospitalization after massive exposure. No countermeasures are available for massive chlorine exposure and supportive-care measures lack controlled trials. In this work, adult rats were exposed to chlorine gas (LD58-67) in a whole-body exposure chamber, and given oxygen (0.8 FiO2) or air (0.21 FiO2) for 6 hours after baseline measurements were obtained. Oxygen saturation, vital signs, respiratory distress and neuromuscular scores, arterial blood gases, and hemodynamic measurements were obtained hourly. Massive chlorine inhalation caused severe acute respiratory failure, hypoxemia, decreased cardiac output, neuromuscular abnormalities (ataxia and hypotonia), and seizures resulting in early death. Oxygen improved survival to 6 hours (87% versus 42%) and prevented observed seizure-related deaths. However, oxygen administration worsened the severity of acute respiratory failure in chlorine-exposed rats compared with controls, with increased respiratory acidosis (pH 6.91 ± 0.04 versus 7.06 ± 0.01 at 2 h) and increased hypercapnia (180.0 ± 19.8 versus 103.2 ± 3.9 mm Hg at 2 h). In addition, oxygen did not improve neuromuscular abnormalities, cardiac output, or respiratory distress associated with chlorine exposure. Massive chlorine inhalation causes severe acute respiratory failure and multiorgan damage. Oxygen administration can improve short-term survival but appears to worsen respiratory failure, with no improvement in cardiac output or neuromuscular dysfunction. Oxygen should be used with caution after massive chlorine inhalation, and the need for early assisted ventilation should be assessed in victims.

Noninvasive Versus Invasive Mechanical Ventilation to Treat Patients with Hypercapnic Acute Respiratory Failure Secondary to COPD

Objective: Noninvasive ventilation (NIV) had been successfully used in patients with severe hypercapnic acute respiratory failure (HARF). Being lack of a large number of randomized control trials to support NIV in chronic obstructive pulmonary disease (COPD) patients with severe HARF, the effect of NIV for patients with life-threatening HARF should be further confirmed. In order to confirm the effect of NIV on selected patients with HARF due to COPD, we conducted a comparative prospective observational study of NIV vs. IMV (invasive mechanical ventilation) + NIV in COPD patients with HARF. Methods: A total of 420 patients with acute respiratory failure secondary to COPD were prospective screened; 52 cases with PaCO2 ≥ 90 mmHg or PaCO2 <90 mmHg but ≥ 80 mmHg with pH value ≤ 7.20 were enrolled. Twentyone cases received sequential IMV to NIV treatment and were designated as the IMV+NIV group; 31 cases received NIV and were designated as the NIV group. The primary outcome was hospital mortality and mortality within 30 days of discharge. The secondary outcomes included risk factors for mortality and re-hospitalization, length of hospital stay, time of mechanical ventilation and re-admission rate within 30 days of discharge. Results: Mortality in-hospital and within 30 days of discharge had no differences between NIV group and IMV +NIV group (p=0.699). Binary logistic regression found no risk factor for mortality and re-hospitalization in two groups. The length of hospital stay (p=0.000) and time of mechanical ventilation (p=0.000) were significantly longer in the IMV+NIV group compared with the NIV group. Conclusion: Compared to IMV+NIV, NIV has similar efficacy for select patients with severe HARF secondary to acute exacerbation of COPD, and NIV can be safely used in these patients.

Hemodynamic profile of pulmonary hypertension (PH) in ARDS.

Acute respiratory distress syndrome (ARDS) is a diffuse lung injury that leads to a severe acute respiratory failure. Traditional diagnostic criteria for pulmonary hypertension (PH), in this situation, may be unreliable due to the effects of positive pressure ventilation and vasoactive agents. The aim of this study is to describe the hemodynamic characteristics of PH secondary to ARDS, in relation with respiratory parameters. We assessed the hemodynamic, respiratory function, and ventilator parameters in a cohort of 38 individuals with ARDS-associated PH defined by mean pulmonary arterial pressure (mPAP) ≥ 25 mmHg. Individual characteristics: PaO2/FiO2 = 110 ± 60 mmHg, alveolar-arterial oxygen gradient (A-aO2) = 549 ± 148.9 mmHg, positive end-expiratory pressure (PEEP) = 8.7 ± 3.5 cmH2O, pulmonary static compliance (Cstat) = 30 ± 12.1 L*cmH2O-1, mPAP = 35.4 ±6.6 mmHg, pulmonary artery wedge pressure (PAWP) = 15.6 ± 5.5 mmHg, cardiac index (CI) = 3.4 ± 1.2 L/min/m2, pulmonary vascular resistance (PVR) = 3.3 ± 1.6 Wood units (WU), right atrial pressure (RAP) = 13.4 ± 5.4 mmHg, diastolic pulmonary gradient (DPG) = 12.6 ± 6.5 mmHg, and trans-pulmonary gradient (TPG) = 19.7 ± 7.7 mmHg. The composite marker—DPG >7 mmHg and PVR > 3 WU—is associated with lower CI (P = 0.016), higher mPAP (P = 0.003), and lower pulmonary static compliance (P = 0.028). We confirmed a poor prognosis of ARDS associated with PH, with a 50% survival rate after 17 days. We observed that the survival rate at 28 days was better in the case of improvement in the PaO2/FiO2 ratio in the first 24 h (log rank P = 0.003). ARDS associated with PH is a severe condition with a very poor survival rate. The composite marker DPG > 7 mmHg and PVR > 3 WU seemed to better describe the hemodynamic and respiratory dysfunction. The improvement in PaO2/FiO2 ratio in the first 24 h defined a better survival in our cohort of patients.

Effectiveness and Safety of High-Flow Nasal Cannula Oxygen Delivery during Bronchoalveolar Lavage in Acute Respiratory Failure Patients.

BackgroundBronchoalveolar lavage (BAL) is a necessary procedure for diagnosis of various lung diseases. High-flow nasal cannula (HFNC) oxygen delivery was recently introduced. This study aimed to investigate the safety and effectiveness of HFNC oxygen supply during BAL procedure in patients with acute respiratory failure (ARF).MethodsPatients who underwent BAL while using HFNC at a partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO2/FiO2; PF) ratio of 300 or below among patients who had been admitted from March 2013 to May 2017 were retrospectively investigated.ResultsThirty-three BAL procedures were confirmed. Their baseline PF ratio was 166.1±46.7. FiO2 values before, during, and after BAL were 0.45±0.12, 0.74±0.19, and 0.57±0.14, respectively. Flow (L/min) values before, during, and after BAL were 26.5±20.3, 49.0±7.2, and 40.8±14.2, respectively. Both FiO2 and flow during and after the procedure were significantly different from those before the procedure (both p<0.001). Oxygen saturation levels before, during, and after BAL measured by pulse oximeter were 94.8±2.9, 94.6±3.5, and 95.2±2.8%, respectively. There were no significant differences in oxygen saturation among the three groups. Complications of BAL procedure included transient hypoxemia, hypotension, and fever. However, there was no endotracheal intubation within 24 hours. Baseline PF ratio in “without HFNC” group was significantly higher than that in “with HFNC” group. There were no differences in complications between the two groups.ConclusionThe use of HFNC during BAL procedure in ARF patients was effective and safe. However, there were no significant differences in oxygen saturation level and complications comparing “without HFNC” group in mild ARF. More studies are needed for moderate to severe ARF patients.

Managing Persistent Hypoxemia: what is new?

Mechanical ventilation is the standard life-support technique for patients with severe acute respiratory failure. However, some patients develop persistent and refractory hypoxemia because their lungs are so severely damaged that they are unable to respond to the application of high inspired oxygen concentration and high levels of positive end-expiratory pressure. In this article, we review current knowledge on managing persistent hypoxemia in patients with injured lungs.

Retrieval of severe acute respiratory failure patients on extracorporeal membrane oxygenation: Any impact on their outcomes?

ObjectiveMobile extracorporeal membrane oxygenation (ECMO) retrieval teams (MERTs) assure ECMO implantation and under-ECMO retrieval of patients with most severe acute respiratory failure (ARF) to experienced ECMO centers. Although described as feasible, mobile ECMO has only been poorly evaluated in comparison with on-site implantation. This study was undertaken to compare the indications, characteristics, and outcomes of MERT-implanted patients with venovenous (VV)-ECMO versus those implanted on site in our intensive care unit (ICU). MethodsRetrospective, single-center study. ResultsAmong 157 VV-ECMO implantations from 2008 to 2012, the MERT hooked up 118 (75%) patients with refractory ARF, as reflected by their median partial pressure of O2 in arterial blood/fraction of inspired oxygen of 58 (interquartile range, 50–73). ARF was accompanied by severe multiorgan failure, with a median Simplified Acute Physiology Score-II of 71 (61-81), median Sequential Organ Failure Assessment score of 14 (10-16), and with 82% of the patients receiving inotropes. All patients were transported by ground ambulance: median distance was 15 (6-25) km, and median transport time was 35 (25-35) minutes, during which no major ECMO system–related event occurred. For the MERT- and on-site–implanted groups, ICU mortality was comparable (46.6% vs 53.8%, respectively, P = .5), as were ECMO-related complication rates (53.4% of MERT vs 53.8% of on-site–implanted groups, P = 1.0). According to multivariable analysis, MERT ECMO implantation was not associated with ICU mortality (odds ratio, 1.1; 95% confidence interval, 0.4-2.7; P = .85). ConclusionsICU mortality and ECMO-related complications of patients with MERT-implanted VV-ECMO who were transferred to our ECMO referral center were comparable with those implanted on site by the same team, thereby supporting this strategy to manage patients with severe ARF.

Respiracijske transfuzijske reakcije

Respiratory transfusion-related reactions are not very frequent, partly also because recognition and reporting transfusion reactions is still underemphasized. Tis article describes the most important respiratory transfusion reactions, their pathophysiology, clinical picture and treatment strategies. Respiratory transfusion related reactions can be primary or secondary. The most important primary transfusion-related reactions are TRALI - transfusion-related acute lung injury, TACO – transfusion-associated circulatory overload, and TAD - transfusion-associated dyspnea. TRALI is immuneassociated injury of alveolar basal membrane, which becomes highly permeable and causes noncardiogenic pulmonary edema. Treatment of TRALI is mainly supportive with oxygen, fluids (in case of hypotension) and in cases of severe acute respiratory failure also mechanic ventilation. TACO is caused by volume overload in predisposed individuals, such as patients with heart failure, the elderly, infants, patients with anemia and patients with positive fluid balance. Clinical picture is that of a typical pulmonary cardiogenic edema, and the therapy is classical: oxygen and diuretics, and in severe cases also non-invasive or invasive mechanical ventilation. TAD is usually a mild reaction of unknown cause and cannot be classified as TACO or TRALI, nor can it be ascribed to patient’s preexisting diseases. Although the transfusion-related reactions are not very common, knowledge about them can prevent serious consequences. On the one hand preventive measures should be sought, and on the other early recognition is beneficial, so that proper treatment can take place.

Sedation and Mobilization During Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Failure: An International Survey.

To characterize sedation, analgesia, delirium, and mobilization practices in patients supported with venovenous extracorporeal membrane oxygenation for severe acute respiratory failure. Cross-sectional electronic survey administered January 2016 to March 2016. Three-hundred ninety-four extracorporeal membrane oxygenation centers registered with the Extracorporeal Life Support Organization. Extracorporeal membrane oxygenation medical directors and program coordinators. None. We analyzed responses from 209 respondents (53%), mostly from academic centers (63%); 41% respondents provide venovenous extracorporeal membrane oxygenation to adults exclusively. Following venovenous extracorporeal membrane oxygenation initiation, 97% respondents administer sedative/analgesic infusions, and the sedation target was "sedated" or "very sedated" for 59%, "calm and cooperative" for 25%, and "unarousable" for 16%. Use of daily sedation interruption and a sedation/analgesia protocol was reported by 51% and 39%, respectively. Midazolam (48%) and propofol (19%) were reported as the most frequently used sedatives; fentanyl (44%) and morphine (20%) the most frequent opioids. Use of a delirium scale was reported by 55% respondents. Physical therapy was reported by 84% respondents, with 41% initiating it within 72 hours after cannulation. Mobilization goals varied from range of motion exercises (81%) to ambulation (22%). The most frequently perceived barriers to mobilization were hemodynamic instability, hypoxemia, and dependency on venovenous extracorporeal membrane oxygenation support. The majority of respondents reported targeting moderate to deep sedation following cannulation, with the use of sedative and opioid infusions. There is considerable variability surrounding early physical therapy and mobilization goals for patients with acute respiratory failure supported by venovenous extracorporeal membrane oxygenation.

High Flow Oxygen in Pregnancy With Severe Acute Hypoxic Respiratory Failure Due to Community-Acquired Steptococcus Pneumoniae

High Flow Oxygen in Pregnancy With Severe Acute Hypoxic Respiratory Failure Due to Community-Acquired Steptococcus Pneumoniae

A Peculiar Case of Phosphine Toxicity

SESSION TITLE: Occupational and Environmental Lung Diseases SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Phosphine gas is a colorless, flammable and highly toxic gas. Despite aggressive measures, phosphine gas toxicity has a very high mortality rate due to cardiopulmonary failure. We present an unusual case of aluminum phosphide toxicity who was the sole survivor in her family. CASE PRESENTATION: A 45-year-old woman with no medical problems presented to emergency room (ER) with acute onset of nausea, vomiting, diarrhea and dyspnea. Four children also presented with similar symptoms. Family was discharged with diagnosis of acute gastroenteritis. Because of worsening respiratory distress, family again presented to ER. Diagnosis of phosphine toxicity (PT) was made based on history. Husband sprayed Aluminum Phosphide (AP) rodenticide underneath the trailer about 2 weeks ago. Then he attempted to wash out the substance with water, which resulted in creation of phosphine gas. All four children passed away in the ER from severe cardiogenic shock and acute hypoxic respiratory failure from pulmonary edema. She was intubated due to worsening multi-organ failure. Bedside ultrasound showed significantly reduced ejection fraction. Patient was started on vasopressors and inotropes. Patient was taken to cath lab for emergent Impella ventricular support device. Arrangements were made to transfer patient to a tertiary care center for extracorporeal membrane oxygenation (ECMO). Patient was supported with ECMO until patient stabilized. She was discharged home in stable condition without any organ injury. She was the sole survivor of the family due to aggressive management of cardiorespiratory failure. DISCUSSION: Metallic phosphides (zinc and aluminum phosphide) are used worldwide as rodenticides and pesticides. They are banned in US so toxicity is rare here. Acute respiratory failure can occur due to pulmonary edema. Mortality often occurs from severe cardiac toxicity which leads to cardiac arrhythmias or refractory shock and cardiac failure. The cornerstone of treatment is supportive measures, which include oxygen and possible intubation for respiratory support; IVF, vasopressors for hypotension and shock. However, aggressive treatment by emergent Impella and ECMO support was necessary. CONCLUSIONS: PT is a fairly rare occurrence but remains to be a public health threat. Its high mortality rate and when the gas dissipates into the air can affect a large population. Supportive measures are the mainstay of treatment. More research needs to be conducted in order to expand knowledge of the treatment. It is strongly recommended to transfer these patients to ECMO supporting centers as they deteriorate rapidly and are unresponsive to ACLS protocol when the cardiovascular system collapses. Reference #1: Gupta S, Ahlawat SK. Aluminum phosphide poisoning--a review. J Toxicol Clin Toxicol 1995; 33:19. DISCLOSURE: The following authors have nothing to disclose: Totini Chatterjee, Omar Salh, Thien Vo, Manish Patel No Product/Research Disclosure Information

Risk factors and outcomes of severe acute respiratory failure requiring invasive mechanical ventilation in cancer patients: A retrospective cohort study

ObjectivesTo determine the risk factors for severe acute respiratory failure requiring invasive mechanical ventilation (SARF-MV) and its effect upon clinical outcomes in critically ill cancer patients. DesignA retrospective cohort study was carried out. SettingA 12-bed oncological intensive care unit (ICU) from January 2014 to December 2015. PatientsA total of 878 consecutive cancer patients were included. Patients with an ICU stay of ≤1 day were excluded. The final sample size was 691 patients. InterventionsNone. VariablesClinical variables at ICU admission were extracted from the medical records. The primary outcome was SARF-MV. We also measured ICU and hospital mortality, as well as length of stay. ResultsThe SARF-MV rate was 15.8%. The multivariate analysis identified brain tumour (OR 14.54; 95%CI 3.86–54.77; p<0.0001), stage IV cancer (OR 3.47; 95%CI 1.26–9.54; p=0.016), sepsis upon admission (OR 2.28; 95%CI 1.14–4.56; p=0.020) and an APACHE II score≥20 points (OR 5.38; 95%CI 1.92–15.05; p=0.001) as being independently associated to SARF-MV. Compared with the patients without SARF-MV, those with SARF-MV had a prolonged length of ICU stay (p<0.0001), a lower ICU survival rate (p<0.0001) and a lower hospital survival rate (p<0.0001). ConclusionsA number of clinical factors are related to SARF-MV. In this regard, SARF-MV is a powerful factor independently correlated to poor outcomes. Future studies should investigate means for preventing SARF-MV in critically ill cancer patients, which may have an impact upon outcomes.

The efficacy of initial ventilation strategy for adult immunocompromised patients with severe acute hypoxemic respiratory failure: study protocol for a multicentre randomized controlled trial (VENIM)

BackgroundAcute respiratory failure (ARF) is still one of the most severe complications in immunocompromised patients. Our previous systematic review showed noninvasive mechanical ventilation (NIV) reduced mortality, length of hospitalization and ICU stay in AIDS/hematological malignancy patients with relatively less severe ARF, compared to invasive mechanical ventilation (IMV). However, this systematic review was based on 13 observational studies and the quality of evidence was low to moderate. The efficacy of NIV in more severe ARF and in patients with other causes of immunodeficiency is still unclear. We aim to determine the efficacy of the initial ventilation strategy in managing ARF in immunocompromised patients stratified by different disease severity and causes of immunodeficiency, and explore predictors for failure of NIV.Methods and analysisThe VENIM is a multicentre randomized controlled trial (RCT) comparing the effects of NIV compared with IMV in adult immunocompromised patients with severe hypoxemic ARF. Patients who meet the indications for both forms of ventilatory support will be included. Primary outcome will be 30-day all-cause mortality. Secondary outcomes will include in-hospital mortality, length of stay in hospital, improvement of oxygenation, nosocomial infections, seven-day organ failure, adverse events of intervention, et al. Subgroups with different disease severity and causes of immunodeficiency will also be analyzed.DiscussionVENIM is the first randomized controlled trial aiming at assessing the efficacy of initial ventilation strategy in treating moderate and severe acute respiratory failure in immunocompromised patients. The result of this RCT may help doctors with their ventilation decisions.Trial registrationClinicalTrials.gov NCT02983851. Registered 2 September 2016.