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The article discusses the relationship between acute kidney injury (AKI) and acute respiratory distress syndrome (ARDS) in critically ill patients. The study analyzed data from 10 randomized controlled trials conducted in the United States between 1996 and 2018. The authors found that AKI occurred in approximately 43.7% of patients with ARDS, with a higher incidence of AKI stage 3 and acute kidney disease (AKD) in patients with more severe AKI. The study also found that AKI was associated with higher mortality rates at 28 and 90 days. However, the study has some limitations, including the lack of consideration for certain variables and the heterogeneity of ARDS and AKI subphenotypes. Further research is needed to better understand the relationship between AKI and ARDS and to identify strategies for improving outcomes. [Extracted from the article]

Purpose: Severe acute respiratory distress syndrome (ARDS) with PaO2/FiO2 < 80 mmHg is a life-threatening condition. The optimal management strategy is unclear. The aim of this meta-analysis was to compare the effects of low tidal volumes (Vt), moderate Vt, prone ventilation, and venovenous extracorporeal membrane oxygenation (VV-ECMO) on mortality in severe ARDS. Methods: We performed a frequentist network meta-analysis of randomised controlled trials (RCTs) with participants who had severe ARDS and met eligibility criteria for VV-ECMO or had PaO2/FiO2 < 80 mmHg. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to discern the relative effect of interventions on mortality and the certainty of the evidence. Results: Ten RCTs including 812 participants with severe ARDS were eligible. VV-ECMO reduces mortality compared to low Vt (risk ratio [RR] 0.77, 95% confidence interval [CI] 0.59–0.99, moderate certainty) and compared to moderate Vt (RR 0.75, 95% CI 0.57–0.98, low certainty). Prone ventilation reduces mortality compared to moderate Vt (RR 0.78, 95% CI 0.66–0.93, high certainty) and compared to low Vt (RR 0.81, 95% CI 0.63–1.02, moderate certainty). We found no difference in the network comparison of VV-ECMO compared to prone ventilation (RR 0.95, 95% CI 0.72–1.26), but inferences were based solely on indirect comparisons with very low certainty due to very wide confidence intervals. Conclusions: In adults with ARDS and severe hypoxia, both VV-ECMO (low to moderate certainty evidence) and prone ventilation (moderate to high certainty evidence) improve mortality relative to low and moderate Vt strategies. The impact of VV-ECMO versus prone ventilation remains uncertain. [ABSTRACT FROM AUTHOR]

This document, titled "Setting the ventilator in acute brain injury," discusses the use of a lung-protective strategy in patients with acute brain injury (ABI) who require invasive mechanical ventilation (IMV). Historically, ABI patients have received higher tidal volume and lower positive end expiratory pressure (PEEP) due to concerns about increased intra-cranial pressure (ICP) and impaired cerebral perfusion pressure. However, recent findings support the safety and efficacy of a protective ventilation strategy in most ABI patients. The document outlines a concise strategy for IMV settings, arterial blood gas targets, and management of concurrent ABI and acute respiratory distress syndrome (ARDS). It also emphasizes the importance of continuous monitoring and individualized approaches in specific clinical scenarios. [Extracted from the article]

Purpose: Venovenous extracorporeal membrane oxygenation (VV-ECMO) can be used to support patients with refractory acute respiratory failure, though guidance on patient selection is lacking. While age is commonly utilized as a factor in establishing the potential VV-ECMO candidacy of these patients, little is known regarding its association with outcome. We studied the association between increasing patient age and outcomes among patients with acute respiratory failure receiving VV-ECMO. Methods: In this registry-based cohort study, we used individual patient data from 144 centres. We included adult patients (≥ 18 years of age) receiving VV-ECMO from 2017 to 2022. The primary outcome was hospital mortality. Secondary outcomes included a composite of complications following initiation of VV-ECMO. We conducted Bayesian analyses to estimate the association between chronological age and outcomes. Results: We included 27,811 patients receiving VV-ECMO. Of these, 11,533 (41.5%) died in hospital. For the analysis conducted using weakly informed priors, and as compared to the reference category of age 18–29, the age brackets of 30–39 (odds ratio [OR] 1.17, 95% credible interval [CrI] 1.06–1.31), 40–49 (OR 1.65, 95% CrI 1.49–1.82), 50–59 (OR 2.39, 95% CrI 2.16–2.61), 60–69 (OR 3.29, 95% CrI 2.97–3.67), 70–79 (OR 4.57, 95% CrI 3.90–5.37), and ≥ 80 (OR 8.08, 95% CrI 4.85–13.74) were independently associated with increasing hospital mortality. Similar results were found between increasing age and post-ECMO complications. Conclusions: Among patients receiving VV-ECMO for acute respiratory failure, increasing age is significantly associated with poorer outcomes, and this association emerges as early as 30 years of age. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with severe acute respiratory distress syndrome (ARDS). The impact of ECMO on long-term outcomes of patients with severe ARDS is unclear. Methods: We searched electronic databases from inception to January 17th 2023. We selected clinical trials and observational studies reporting on long-term outcomes of patients supported with ECMO for ARDS. Health-related quality of life (HRQoL) was the primary outcome. Secondary outcomes included cognitive function, mental health, functional status, respiratory symptoms, and return to work. Results: Of the 7126 screened citations, 1 randomized clinical trial and 31 observational studies were included, of which 7 compared conventional mechanical ventilation (CMV) and ECMO. Overall quality of studies of the included studies was limited, with the majority being either low (45%) or fair (32%) quality. There was no significant difference in HRQoL measured with the SF-36 score between ECMO and CMV patients (physical component score [PCS]: mean difference 3.91 (− 6.22 to 14.05), mental component score [MCS] mean difference 1.33 (− 3.93 to 6.60)). There was no difference between cognitive function, mental health, functional status, and respiratory symptoms between ECMO and CMV, but data available for comparison were limited. There were high rates of disability for ECMO survivors with 49% of patients returning to work and 23% needing assistance at home on follow-up. Conclusion: Survivors of ECMO for ARDS experience significant disability in multiple domains. Further studies are needed to examine the effect of ECMO on long-term outcomes of patients compared to CMV. [ABSTRACT FROM AUTHOR]

The article discusses the use of prone positioning (PP) during extracorporeal membrane oxygenation (ECMO) for patients with severe acute respiratory distress syndrome (ARDS). The authors explain that PP has been shown to improve oxygenation and respiratory mechanics in ARDS patients, and it may also help mitigate the risk of ventilator-induced lung injury. However, the evidence regarding the routine application of PP during ECMO is conflicting, and more research is needed. The authors conclude that while waiting for more conclusive data, PP remains a promising treatment option for ARDS patients in specialized ECMO centers. [Extracted from the article]

Two sets of guidelines on the respiratory management of acute respiratory distress syndrome (ARDS) have been released by international experts. The guidelines, from the European Society of Intensive Care Medicine (ESICM) and the American Thoracic Society (ATS), aim to synthesize evidence from randomized trials and provide practical recommendations. While there are some differences between the two sets of guidelines, they both emphasize the importance of individualizing patient care and highlight areas of uncertainty that could be addressed through further research. The guidelines cover topics such as venovenous extracorporeal membrane oxygenation, positive end-expiratory pressure, and neuromuscular blockade. [Extracted from the article]

The article discusses the use of prone positioning during extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS). Randomized controlled trials (RCTs) are considered the gold standard for evaluating the efficacy and safety of medical interventions, but their results often contradict observational studies. The PRONECMO trial, which involved 170 COVID-19 patients on VV-ECMO, found that prone positioning during ECMO did not provide significant benefits compared to maintaining a supine position. These results contradict previous observational studies suggesting that prone positioning during ECMO can lead to accelerated weaning and lower mortality. The article emphasizes the need for further research to address critical questions regarding mechanical ventilation on ECMO. [Extracted from the article]

A recent study published in the journal Intensive Care Medicine examined the use of prone positioning during extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS). Previous observational studies have suggested that prone positioning can improve outcomes in ARDS patients, but the results of this randomized controlled trial (RCT) were negative. The trial focused on COVID-19-related ARDS and found no difference in rates of successful weaning from ECMO, mortality, or respiratory system compliance between the prone and supine groups. The authors suggest that further investigation is needed to determine if prone positioning may be beneficial for non-COVID-19-related ARDS. [Extracted from the article]

The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research. [ABSTRACT FROM AUTHOR]

This document is a reply to a comment made on an article about extracorporeal membrane oxygenation (ECMO) and positioning in the treatment of acute respiratory distress syndrome (ARDS). The authors acknowledge the concerns raised about study quality and missing data, but state that these issues were addressed in the discussion section of their paper. They also explain that a randomized trial comparing ECMO to prone positioning in severe ARDS is unlikely due to ethical considerations and practical challenges. The authors assert that their study provides the best estimates of the relative efficacy of ECMO, prone positioning, and low tidal volume for severe ARDS. [Extracted from the article]

This comment discusses a network meta-analysis comparing different treatments for severe hypoxemic acute respiratory distress syndrome (ARDS). The authors raise concerns about the inclusion of heterogeneous studies, the reliance on indirect comparisons, and the variability in definitions and durations of prone positioning. They also highlight the high rate of crossover in one study and the unclear methodology for handling missing data. The authors conclude that while the analysis provides important findings, the methodological limitations caution against overinterpretation and emphasize the need for more high-quality studies. [Extracted from the article]

Mechanical ventilation is provided to up to 20 million patients annually in intensive care units (ICUs) worldwide. 1, recent advances in invasive mechanical ventilation are characterized by the growing awareness that ARDS is a highly heterogeneous syndrome, and interventions to improve clinical outcomes need to be tailored to specific patient subgroups that share distinct clinical and possibly molecular phenotypes. Acute respiratory distress syndrome Most evidence surrounding ventilation strategies is based on studies in ARDS patients. Despite lung-protective mechanical ventilation strategies, the mortality of mechanically ventilated patients remains high, especially in patients with acute respiratory distress syndrome (ARDS). [Extracted from the article]

Purpose: The question of whether cancer patients with severe respiratory failure benefit from veno-venous extracorporeal membrane oxygenation (vv-ECMO) remains unanswered. We, therefore, analyzed clinical characteristics and outcomes of a large cohort of cancer patients treated with vv-ECMO with the aim to identify prognostic factors. Methods: 297 cancer patients from 19 German and Austrian hospitals who underwent vv-ECMO between 2009 and 2019 were retrospectively analyzed. A multivariable cox proportional hazards analysis for overall survival was performed. In addition, a propensity score-matched analysis and a latent class analysis were conducted. Results: Patients had a median age of 56 (IQR 44–65) years and 214 (72%) were males. 159 (54%) had a solid tumor and 138 (47%) a hematologic malignancy. The 60-day overall survival rate was 26.8% (95% CI 22.1–32.4%). Low platelet count (HR 0.997, 95% CI 0.996–0.999; p = 0.0001 per 1000 platelets/µl), elevated lactate levels (HR 1.048, 95% CI 1.012–1.084; p = 0.0077), and disease status (progressive disease [HR 1.871, 95% CI 1.081–3.238; p = 0.0253], newly diagnosed [HR 1.571, 95% CI 1.044–2.364; p = 0.0304]) were independent adverse prognostic factors for overall survival. A propensity score-matched analysis with patients who did not receive ECMO treatment showed no significant survival advantage for treatment with ECMO. Conclusion: The overall survival of cancer patients who require vv-ECMO is poor. This study shows that the value of vv-ECMO in cancer patients with respiratory failure is still unclear and further research is needed. The risk factors identified in the present analysis may help to better select patients who may benefit from vv-ECMO. [ABSTRACT FROM AUTHOR]

Purpose: Previous studies support the potential efficacy of venovenous extracorporeal membrane oxygenation (vvECMO) for improving survival in severe acute respiratory distress syndrome (ARDS) cases. Prone positioning (PP) has been shown to improve the outcomes of moderate-to-severe ARDS patients. Few studies and no randomized controlled trials have evaluated the effect of PP performed in ECMO patients. Methods: We performed a systematic review and meta-analysis examining the effect of prone positioning for ARDS patients receiving vvECMO on survival. All authors were contacted to obtain complementary information not mentioned in the original articles. The main objective was to compare 28-day survival in vvECMO patients with PP to vvECMO patients without PP (controls). Results: Thirteen studies with a combined population of 1836 patients satisfied the inclusion criteria. PP was associated with a significant improvement in 28-day survival (503 survivors among 681 patients in the PP group [74%; 95% CI 71–77] vs. 450 survivors among 770 patients in the control group [58%, 95% CI 55–62]; RR 1.31 [95% CI 1.21–1.41]; I2 22% [95% CI 0–62%]; P < 0.0001). Survival was also improved in terms of other endpoints (60-day survival, 90-day survival, ICU survival, and hospital survival). In contrast, the duration of mechanical ventilation was increased in vvECMO patients with PP (mean difference 11.4 days [95% CI 9.2–13.5]; 0.64 [95% CI 0.50–0.78]; I2 8%; P < 0.0001). Conclusion: According to this meta-analysis, survival was improved when prone positioning was used in ARDS patients receiving vvECMO. The impact of this combination on survival should be investigated in prospective randomized controlled trials. [ABSTRACT FROM AUTHOR]

Dear Editor, Venovenous (VV) extracorporeal membrane oxygenation (ECMO) has proven to be useful in the management of patients with severe acute respiratory distress syndrome (ARDS) associated with coronavirus disease 2019 (COVID-19) [[1]]. We designed a single-center, retrospective cohort study of adult patients treated with VV ECMO for COVID-19 ARDS at Toronto General Hospital between May and October 2020. [Extracted from the article]