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Background: There is a limited data examining the practice of using the airway pressure release ventilation mode for patients with acute respiratory distress syndrome among respiratory therapists. Objectives: To evaluate the current practice and barriers when using airway pressure release ventilation mode in the management of patients with acute respiratory distress syndrome. Methods: A cross-sectional online survey was disseminated between November 2022 and April 2023 to respiratory therapists in Saudi Arabia. Descriptive statistics were used to analyze the respondents’ characteristics. Results: Overall, 802 respiratory therapists (male: 59.60%) completed the survey. Five hundred nineteen (64.71%) did not receive training on airway pressure release ventilation mode. Moreover, 325 (40.52%) and 391 (48.75%) did not know if airway pressure release ventilation was used at their hospitals and if the mode was managed via protocol with acute respiratory distress syndrome patients. Of the participants, 276 (34.41%) reported that plateau pressure should be used as a target when setting P-high initially, while 427 (53.24%) believed that the initial P-low should be equal to 0 cmH 2 O. Moreover, 468 (58.36%) believed that the initial T-high should be between 4 and 6 s, while 548 (68.33%) believed the initial T-low should be a set time (between 0.4 and 0.8) seconds. The most appropriate intervention to improve ventilation and oxygenation was to increase the P-high, which was reported by 370 (46.14%) and 326 (40.65%) respiratory therapists, respectively. Inadequate training was the most common barrier (678, 84.54%) to airway pressure release ventilation implementation. Conclusion: Airway pressure release ventilation management varies between respiratory therapists which may be due to inadequate training and the absence of protocols.

Background: Mechanical thrombectomy is the treatment of choice for ischemic strokes of the anterior circulation with proximal occlusion. Mechanical thrombectomy can be performed under sedation, which can lead to episodes of periprocedural agitation. The aim of this study is to describe the prevalence of agitation and determine the consequences during and after mechanical thrombectomy., Methods: This is an ancillary study to the AMETIS study (Anesthesia Management in Endovascular Therapy for Ischemic Stroke). We evaluated the patients from the sedation group of this randomized trial; some patients presented at least 1 episode of agitation during the procedure (determined by a Richmond Agitation-Sedation Scale score >1) prospectively collected. We explored the association between agitation and a composite outcome (Thrombolysis in Cerebral Infarction score <2b and/or arterial perforation) through univariate and multivariate analyses, accounting for confounders (agitation, age, National Institutes of Health Stroke Scale score, local thrombus) identified a priori by the acyclic diagram method., Results: Among the 138 participants (average age, 71±14 years; 72 [52%] male; average National Institutes of Health Stroke Scale score, 15±6), 53 (38%) experienced at least 1 agitation episode. Agitation was neither a risk factor of Thrombolysis in Cerebral Infarction score <2b and/or arterial perforation in univariate and multivariate analyses (adjusted odds ratio, 1.29 [0.57-2.92]; P =0.5), nor a risk of unfavorable outcome (adjusted OR, 0.7 [0.18-2.56]; P =0.56). Although, agitated patients had a higher incidence of conversion with intubation (21% versus 5%; OR, 5.3 [1.7-20]; P <0.01) and significantly worse radiological image quality (62% versus 17%; OR, 8.37 [3.9-19.1]; P <0.01)., Conclusions: Our study found a high frequency of agitation during mechanical thrombectomy under sedation. Despite the absence of any significant link with prognosis, Thrombolysis in Cerebral Infarction score, and perforations, there is more conversion to general anesthesia with intubation and poorer quality images., Competing Interests: Dr Molliex reports compensation from Viatris for other services; compensation from Merck Sharp & Dohme for other services; and compensation from GE Global Research, an unincorporated business of GE Company, for other services. Dr Cognard reports compensation from Medtronic for consultant services; compensation from Stryker Corporation for consultant services; compensation from Johnson & Johnson Health Care Systems, Inc, for consultant services; compensation from MicroVention, Inc, for consultant services; and compensation from anaconda for consultant services. The other authors report no conflicts.

Background: Long-term controlled mechanical ventilation (CMV) in intensive care unit (ICU) induces ventilatory-induced-diaphragm-dysfunction (VIDD). The transition from CMV to assisted mechanical ventilation is a challenge that requires clinicians to balance over-assistance and under-assistance. While the effects of over-assistance on the diaphragm are well known, we aimed to assess the impact of under-assistance on diaphragm function and structure in piglet model with pre-existing VIDD (after long-term CMV) or without VIDD (short-term CMV)., Methods: Twenty-two Large-White female piglets were anesthetized, ventilated, and separated into two groups: a VIDD group (n=10) with long-term 72-hour CMV, and a no-VIDD group (n=12) with short-term 2-hour CMV. After sedation reduction at the end of CMV period, each piglet was switched to under-assisted ventilation for 2 hours. Diaphragm function (supramaximal diaphragm pressure-generating capacity assessed by negative tracheal pressure after transvenous phrenic nerve stimulation) and diaphragm structure (mini-invasive in vivo biopsies) were assessed before and after under-assisted ventilation., Results: In VIDD group, supramaximal diaphragm pressure-generating capacity decreased by 22% from 69.9±12.7 to 54.9±19.7 cmH2O (p=0.04) after 72 hours of CMV evidencing VIDD, then dropped by a further 29% from 54.9±19.7 to 38.9±15.5 cmH2O (p<0.01) after 2 hours of under-assisted ventilation. Diaphragm pressure-generating capacity remains stable from 55.3±22.7 to 58.2±24 cmH2O (p=0.24) in no-VIDD group. Diaphragm structure showed sarcomeric injuries increase from 13±10% to 24±19% (p<0.01) and lipid droplets decrease from 14±8% to 11±6% (p=0.03) of the total micrograph area after 2 hours of under-assisted ventilation in the VIDD group. Sarcomeric injuries and lipid droplets accounted respectively for 17±16% and 2±3% of the total micrograph area after under-assisted ventilation in the no-VIDD group., Conclusions: In this porcine model, a short two-hour exposure of under-assisted ventilation induces impairment of diaphragm function with damage to the diaphragm structure in ICU condition with pre-existing VIDD., Competing Interests: Conflict of interest: SJ reports receiving consulting fees from Drager, Mindray, Medtronic, Baxter, Fresenius-Xenios and Fisher & Paykel. ADJ reports receiving consulting fees from Viatris, Medtronic, and Sanofi. LB’s lab has received research grants from Medtronic, Drager and Stimit and equipment from Sentec, Fisher & Paykel and Philips and lecture fees from Fisher & Paykel. No potential conflict of interest relevant to this article was reported for other authors., (Copyright © 2025 American Society of Anesthesiologists. All Rights Reserved.)

Introduction: The COVID-19 pandemic has impacted healthcare workers (HCWs) worldwide, necessitating an understanding of its effects on their health and functional capacity. This study utilized the 6-Minute Walk Test (6MWT) and pulmonary function test (PFT) to evaluate post-infection recovery of HCWs, and analyzed the results in relation to comorbidities, symptoms, and healthcare admission., Methods: HCWs who previously tested positive for SARS-CoV-2 were recruited, and the 6MWT and PFT were conducted. Clinical data, including comorbidities, symptoms, hospitalization history, intensive care unit (ICU) admission, and mechanical ventilation, were collected. Binary logistic regression analysis and Fisher's exact test were employed to examine the associations between these factors and diffusing capacity of the lungs for carbon monoxide (DLCO) and the 6MWT., Results: The study comprised 80 HCWs, with various comorbidities and various presenting symptoms. On average, 167.24 days (± 63.83 days) post-SARS-CoV-2 infection, 34 (42.5 %) had a DLCO% < 80 % of the predicted value, while 46 (57.5 %) had a DLCO% of ≥ 80 %. The mean six-minute-walk distance (6MWD) was 400.6 ± 54.1 m. No significant associations were found between DLCO% and most of the factors examined, except for Forced Expiratory Flow 25-75 % (FEF25-75 %), although this was not statistically significant (P=0.069)., Conclusion: The study provides significant data regarding the functional recovery of HCWs who have recovered from COVID-19 using the 6MWT. Importantly, the findings demonstrated that SARS-CoV-2 infection did not substantially impair the pulmonary functional capacity of HCWs., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: To our knowledge, no large observational study has compared the incidence and risk factors for extubation failure within 48 h and during ICU stay in the same cohort of unselected critically ill patients with and without obesity., Research Question: What are the incidence and risk factors of extubation failure in patients with and without obesity?, Study Design and Methods: In the prospective multicenter observational Practices and Risk Factors for Weaning and Extubation Airway Failure in Adult Intensive Care Unit: A Multicenter Trial (FREEREA) study in 26 ICUs, the primary objective was to compare the incidence of extubation failure within 48 h in patients with and without obesity. Secondary objectives were to describe and to identify the independent specific risk factors for extubation failure using first a logistic regression model and second a decision tree analysis., Results: Of 1,370 extubation procedures analyzed, 288 (21%) were performed in patients with obesity and 1,082 (79%) in patients without obesity. The incidence of extubation failure within 48 h among patients with or without obesity was 23 of 288 (8.0%) vs 118 of 1,082 (11%), respectively (unadjusted OR, 0.71; 95% CI, 0.45-1.13; P = .15); alongside patients with obesity receiving significantly more noninvasive ventilation [87 of 288 (30%) vs 233 of 1,082 (22%); P = .002] and physiotherapy [165 of 288 (57%) vs 527 of 1,082 (49%); P = .02] than patients without obesity. Risk factors for extubation failure also differed according to obesity status: female sex (adjusted OR, 4.88; 95% CI, 1.61-13.9; P = .002) and agitation before extubation (adjusted OR, 6.39; 95% CI, 1.91-19.8; P = .001) in patients with obesity, and absence of strong cough before extubation (adjusted OR, 2.38; 95% CI, 1.53-3.84; P = .0002) and duration of invasive mechanical ventilation before extubation (adjusted OR, 1.03/d; 95% CI, 1.01-1.06; P = .01) in patients without obesity. The decision tree analysis found similar risk factors., Interpretation: Our findings indicate that anticipation and application of preventive measures for patients with obesity before and after extubation led to similar rates of extubation failure among patients with and without obesity., Clinical Trial Registration: ClinicalTrials.gov; No.: NCT02450669; URL: www., Clinicaltrials: gov., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: S. J. reports receiving consulting fees from Drager, Medtronic, Mindray, Fresenius, Baxter, and Fisher & Paykel. A. D. J. reports receiving remuneration for presentations from Medtronic, Drager, and Fisher & Paykel. E. A. has received fees from Gilead Sciences, Alexion, Astellas, MSD, and Drager. J. Pottecher has received fees from Medtronic, Baxter, and Getinge. None declared (M. Capdevila, Y. A., M. Cros, J. Pensier, I. L., C. M., H. Q., R. C., K. A., J.-M. A., C. G., C. P.-B., P. A., A. M.-D., K. L., S. L., G. P., B. C., P. C., C. I., N. M., G. C., L. P.)., (Copyright © 2024 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Utility, a major principle for allocation in the context of transplantation, is questioned in patients with acute-on-chronic liver failure grade 3 (ACLF-3) who undergo liver transplantation (LT). We aimed to explore long-term outcomes of patients included in a three-centre retrospective French study published in 2017., Method: All patients with ACLF-3 (n = 73), as well as their transplanted matched controls with ACLF-2 (n = 145), 1 (n = 119) and no ACLF (n = 292), who participated in the Princeps study published in 2017 were included. We explored 5- and 10-year patient and graft survival rates, causes of death and their predictive factors., Results: Median follow-up of patients with ACLF-3 was 7.5 years. At LT, median MELD was 40. In patients with ACLF-3, 2, 1 and no ACLF, 5-year patient survival rates were 72.6% vs. 69.7% vs. 76.4% vs. 77.0%, respectively (p = 0.31). Ten-year patient survival for ACLF-3 was 56.8% and was not different to other groups (p = 0.37). Leading causes of death in patients with ACLF-3 were infections (33.3%) and cardiovascular events (23.3%). After exclusion of early death, UCLA futility risk score, age-adjusted Charlson comorbidity index and CLIF-C ACLF score were independently associated with 10-year patient survival. Long-term graft survival rates were not different across the groups. Clinical frailty scale and WHO performance status improved over time in patients alive after 5 years., Conclusion: 5- and 10-year patient and graft survival rates were not different in patients with ACLF-3 compared to matched controls. 5-year patient survival is higher than the 50%-70% threshold defining the utility of a liver graft. Efforts should focus on candidate selection based on comorbidities, as well as the prevention of infection and cardiovascular events., Impact and Implications: While short-term outcomes following liver transplantation in the most severely ill patients with cirrhosis (acute-on-chronic liver failure grade 3 [ACLF-3]) are known, long-term data are limited, raising questions about the utility of graft allocation in the context of scarce medical resources. This study provides a favourable long-term update, confirming no differences in 5- and 10-year patient and graft survival following liver transplantation in patients with ACLF-3 compared to matched patients with ACLF-2, ACLF-1, and no-ACLF. The study highlights the risk of dying from infection and cardiovascular causes in the long-term and identifies scores including comorbidity evaluation, such as the age-adjusted Charlson comorbidity index, as independently associated with long-term survival. Therefore, physicians should consider the cumulative burden of comorbidities when deciding whether to transplant these patients. Additionally, after transplantation, the study encourages mitigating infectious risk with tailored immunosuppressive regimens and tightly managing cardiovascular risk over time., (Copyright © 2024 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Objective: To compare the effect of balanced multielectrolyte solutions (BMESs) versus normal saline (NS) for intravenous fluid on chloride levels and clinical outcomes in patients with predicted severe acute pancreatitis (pSAP)., Background: Isotonic crystalloids are recommended for initial fluid therapy in acute pancreatitis, but whether the use of BMES in preference to NS confers clinical benefits is unknown., Methods: In this multicenter, stepped-wedge, cluster-randomized trial, we enrolled patients with pSAP (acute physiology and chronic health evaluation II score ≥8 and C-reactive protein >150 mg/L) admitted within 72 hours of the advent of symptoms. The study sites were randomly assigned to staggered start dates for a one-way crossover from the NS phase (NS for intravenous fluid) to the BMES phase (sterofudin for intravenous fluid). The primary endpoint was the serum chloride concentration on trial day 3. Secondary endpoints included a composite of clinical and laboratory measures., Results: Overall, 259 patients were enrolled from 11 sites to receive NS (n = 147) or BMES (n = 112). On trial day 3, the mean chloride level was significantly lower in patients who received BMES [101.8 mmol/L (SD: 4.8) vs 105.8 mmol/L (SD: 5.9), difference -4.3 mmol/L (95% CI: -5.6 to -3.0 mmol/L) ; P < 0.001]. For secondary endpoints, patients who received BMES had less systemic inflammatory response syndrome (19/112, 17.0% vs 43/147, 29.3%, P = 0.024) and increased organ failure-free days [3.9 days (SD: 2.7) vs 3.5 days (SD: 2.7), P < 0.001] by trial day 7. They also spent more time alive and out of the intensive care unit [26.4 days (SD: 5.2) vs 25.0 days (SD: 6.4), P = 0.009] and hospital [19.8 days (SD: 6.1) vs 16.3 days (SD: 7.2), P < 0.001] by trial day 30., Conclusions: Among patients with pSAP, using BMES in preference to NS resulted in a significantly more physiological serum chloride level, which was associated with multiple clinical benefits (Trial registration number: ChiCTR2100044432)., Competing Interests: W.L. reports consultancy fees and grants from Jiangsu Nhwa Pharmaceuticals. L.K. reports speaker fees from Nhwa Pharmaceuticals. S.J. reports receiving consulting fees from Drager, Medtronic, Mindray, Fresenius, Baxter, and Fisher & Paykel. J.W. reports consulting fees and grants from Fisher and Paykel Healthcare and Viatris Ltd. R.B. received grants and consultancy fees from Baxter Health Care. The remaining authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)