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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]

Background: COVID-19-associated acute respiratory distress syndrome (ARDS) supported by veno-venous extra-corporal membrane oxygenation (vv-ECMO) results in a high in-hospital mortality rate of more than 35%. However, after cannulation, no prognostic factor has been described to guide the management of these patients. The objective was to assess the association between static respiratory compliance over the first 10 days post-vv-ECMO implantation on 180-day mortality. Results: In this multicentric retrospective study in three ECMO referral centers, all patients with COVID-19-associated ARDS supported by vv-ECMO were included from 03/01/2020 to 12/31/2021. Patients were ventilated with ultra-protective settings targeting a driving pressure lower than 15 cmH2O. 122 patients were included. Median age was 59 IQR (52–64), 83 (68%) were male, with a median body mass index of 33 (28–37) kg/m2. Delay between first symptoms to vv-ECMO implantation was 16 (10–21) days. Six-month death was 48%. Over the first ten days, compliance increased in 180 day survivors [from 18 (12–25) to 20 (15–27) mL/cmH2O] compared to non-survivors [from 12 (9–20) to 10 (8–14) mL/cmH2O, p interaction < 0.0001]. A time varying multivariable Cox model found age, history of chronic lung disease, compliance from day one to day ten and sweep gas flow from day one to day ten as independent factors associated with 180-day mortality. Conclusions: In COVID-19-associated ARDS, static respiratory compliance course over the first ten days post-vv-ECMO implantation is associated with 180-day mortality. This new information may provide crucial information on the patient's prognosis for intensivists. Key points: Question: Does static respiratory compliance predict outcomes in patients with COVID-19 associated acute respiratory distress syndrome requiring vv-ECMO? Findings: In 122 included patients, static respiratory compliance course over the first ten days post vv-ECMO implantation was associated with 180-day mortality in a multicentric retrospective study. Meanings: Monitoring static respiratory compliance during the ten first days in these patients may provide crucial information on their prognosis and help intensivits for their management. [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]

Background: Since March 2020, health care systems were importantly affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak, with some patients presenting severe acute respiratory distress syndrome (ARDS), requiring extra-corporeal membrane oxygenation (ECMO). We designed an ambispective observational cohort study including all consecutive adult patients admitted to 5 different ICUs from a university hospital. The main objective was to identify the risk factors of severe COVID-19 ARDS patients supported by ECMO associated with 90-day survival. Results: Between March 1st and November 30th 2020, 76 patients with severe COVID-19 ARDS were supported by ECMO. Median (interquartile range IQR) duration of mechanical ventilation (MV) prior to ECMO was of 6 (3–10) days. At ECMO initiation, patients had a median PaO2:FiO2 of 71 mmHg (IQR 62–81), median PaCO2 of 58 mmHg (IQR 51–66) and a median arterial pH of 7.33 (IQR 7.25–7.38). Forty-five patients (59%) were weaned from ECMO. Twenty-eight day, 60-day and 90-day survival rates were, respectively, 92, 62 and 51%. In multivariate logistic regression analysis, with 2 models, one with the RESP score and one with the PRESERVE score, we found that higher BMI was associated with higher 90-day survival [odds ratio (OR): 0.775 (0.644–0.934), p = 0.007) and 0.631 (0.462–0.862), respectively]. Younger age was also associated with 90-day survival in both models [OR: 1.1354 (1.004–1.285), p = 0.044 and 1.187 (1.035–1.362), p = 0.014 respectively]. Obese patients were ventilated with higher PEEP than non-obese patients and presented slightly higher respiratory system compliance. Conclusion: In this ambispective observational cohort of COVID-19 severe ARDS supported by ECMO, obesity was an independent factor associated with improved survival at 90-day. [ABSTRACT FROM AUTHOR]

Background: Dexamethasone decreases mortality in patients with severe coronavirus disease 2019 (COVID-19) and has become the standard of care during the second wave of pandemic. Dexamethasone is an immunosuppressive treatment potentially increasing the risk of secondary hospital acquired infections in critically ill patients. We conducted an observational retrospective study in three French intensive care units (ICUs) comparing the first and second waves of pandemic to investigate the role of dexamethasone in the occurrence of ventilator-associated pneumonia (VAP) and blood stream infections (BSI). Patients admitted from March to November 2020 with a documented COVID-19 and requiring mechanical ventilation (MV) for ≥ 48 h were included. The main study outcomes were the incidence of VAP and BSI according to the use of dexamethasone. Secondary outcomes were the ventilator-free days (VFD) at day-28 and day-60, ICU and hospital length of stay and mortality. Results: Among the 151 patients included, 84 received dexamethasone, all but one during the second wave. VAP occurred in 63% of patients treated with dexamethasone (DEXA+) and 57% in those not receiving dexamethasone (DEXA−) (p = 0.43). The cumulative incidence of VAP, considering death, duration of MV and late immunosuppression as competing factors was not different between groups (p = 0.59). A multivariate analysis did not identify dexamethasone as an independent risk factor for VAP occurrence. The occurrence of BSI was not different between groups (29 vs. 30%; p = 0.86). DEXA+ patients had more VFD at day-28 (9 (0–21) vs. 0 (0–11) days; p = 0.009) and a reduced ICU length of stay (20 (11–44) vs. 32 (17–46) days; p = 0.01). Mortality did not differ between groups. Conclusions: In this cohort of COVID-19 patients requiring invasive MV, dexamethasone was not associated with an increased incidence of VAP or BSI. Dexamethasone might not explain the high rates of VAP and BSI observed in critically ill COVID-19 patients. [ABSTRACT FROM AUTHOR]

Purpose: To assess the benefit-to-risk balance of bronchoalveolar lavage (BAL) in intensive care unit (ICU) patients.Methods: In 16 ICUs, we prospectively collected adverse events during or within 24 h after BAL and assessed the BAL input for decision making in consecutive adult patients. The occurrence of a clinical adverse event at least of grade 3, i.e., sufficiently severe to need therapeutic action(s), including modification(s) in respiratory support, defined poor BAL tolerance. The BAL input for decision making was declared satisfactory if it allowed to interrupt or initiate one or several treatments.Results: We included 483 BAL in 483 patients [age 63 years (interquartile range (IQR) 53-72); female gender: 162 (33.5%); simplified acute physiology score II: 48 (IQR 37-61); immunosuppression 244 (50.5%)]. BAL was begun in non-intubated patients in 105 (21.7%) cases. Sixty-seven (13.9%) patients reached the grade 3 of adverse event or higher. Logistic regression showed that a BAL performed by a non-experienced physician (non-pulmonologist, or intensivist with less than 10 years in the specialty or less than 50 BAL performed) was the main predictor of poor BAL tolerance in non-intubated patients [OR: 3.57 (95% confidence interval 1.04-12.35); P = 0.04]. A satisfactory BAL input for decision making was observed in 227 (47.0%) cases and was not predictable using logistic regression.Conclusions: Adverse events related to BAL in ICU patients are not infrequent nor necessarily benign. Our findings call for an extreme caution, when envisaging a BAL in ICU patients and for a mandatory accompaniment of the less experienced physicians. [ABSTRACT FROM AUTHOR]

Background: Herpesviridae reactivation among non-immunocompromised critically ill patients is associated with impaired prognosis, especially during acute respiratory distress syndrome (ARDS). However, little is known about herpes simplex virus (HSV) and Cytomegalovirus (CMV) reactivation occurring in patients with severe ARDS under veno-venous extracorporeal membrane oxygenation (ECMO). We tried to determine the frequency of Herpesviridae reactivation and its impact on patients' prognosis during ECMO for severe ARDS. Results: During a 5-year period, 123 non-immunocompromised patients with a severe ARDS requiring a veno-venous ECMO were included. Sixty-seven patients (54%) experienced HSV and/or CMV reactivation during ECMO course (20 viral co-infection, 40 HSV alone, and 7 CMV alone). HSV reactivation occurred earlier than CMV after the beginning of MV [(6–15) vs. 19 (13–29) days; p < 0.01] and after ECMO implementation [(2–8) vs. 14 (10–20) days; p < 0.01]. In univariate analysis, HSV/CMV reactivation was associated with a longer duration of mechanical ventilation [(22–52.5) vs. 17.5 (9–28) days; p < 0.01], a longer duration of ECMO [15 (10–22.5) vs. 9 (5–14) days; p < 0.01], and a prolonged ICU [29 (19.5–47.5) vs. 16 (9–30) days; p < 0.01] and hospital stay [44 (29–63.5) vs. 24 (11–43) days; p < 0.01] as compared to non-reactivated patients. However, in multivariate analysis, viral reactivation remained associated with prolonged MV only. When considered separately, both HSV and CMV reactivation were associated with a longer duration of MV as compared to non-reactivation patients [29 (19.5–41) and 28 (20.5–37), respectively, vs. 17.5 (9–28) days; p < 0.05]. Co-reactivation patients had a longer duration of MV [58.5 (38–72.3); p < 0.05] and ICU stay [51.5 (32.5–69) vs. 27.5 (17.75–35.5) and 29 (20–30.5), respectively] as compared to patients with HSV or CMV reactivation alone. In multivariate analysis, HSV reactivation remained independently associated with a longer duration of MV and hospital length of stay. Conclusions: Herpesviridae reactivation is frequent among patients with severe ARDS under veno-venous ECMO and is associated with a longer duration of mechanical ventilation. The direct causative link between HSV and CMV reactivation and respiratory function worsening under ECMO remains to be confirmed. [ABSTRACT FROM AUTHOR]

Background: Nosocomial infections occurring during extracorporeal membrane oxygenation (ECMO) support have already been reported, but few studied infections directly related to ECMO devices. This study aims to evaluate the rate of both colonisations and infections related to ECMO devices at the time of ECMO removal. Results: We included all consecutive adult patients treated with venovenous ECMO (VV-ECMO) for at least 48 h during a 34-month study. At the time of ECMO removal, blood cultures, swab cultures on insertion cannula site and intravascular cannula extremity cultures were systematically performed. Each ECMO device was classified according to the infectious status into three groups: (1) uninfected/uncolonised ECMO device, (2) ECMO device colonisation and (3) ECMO device infection. Ninety-nine patients underwent 103 VV-ECMO, representing 1472 ECMO days. The ECMO device infection rate was 9.7% (10 events), including 7 ECMO device-related bloodstream infections (6.8%). The ECMO device colonisation rate was 32% (33 events). No difference was observed between the three groups, regarding days of mechanical ventilation, ICU length of stay, ICU mortality and in-hospital mortality. We observed a longer ECMO duration in the ECMO device colonisation group as compared to the uninfected/uncolonised ECMO device group [12 (9-20 days) vs. 5 days (5-16 days), respectively, p < 0.05]. Conclusions: At the time of ECMO removal, systematic blood culture and intravascular extremity cannula culture may help to diagnose ECMO device-related infection. We reported a quite low infection rate related to ECMO device. Further studies are needed to evaluate the benefits of systematic strategies of cannula culture at the time of ECMO removal. [ABSTRACT FROM AUTHOR]

Background: Neuromuscular blocking agents (NMBAs) have been shown to improve the outcome of the most severely hypoxemic, acute respiratory distress syndrome (ARDS) patients. However, the recommended dosage as well as the necessity of monitoring the neuromuscular block is unknown. We aimed to evaluate the efficiency of a nurse-directed protocol of NMBA administration based on a train-of-four (TOF) assessment to ensure a profound neuromuscular block and decrease cisatracurium consumption compared to an elevated and constant dose regimen. A prospective open labeled study was conducted in two medical intensive care units of two French university hospitals. Consecutive ARDS patients with a PaO/FiO ratio less than 120 with a PEEP ≥5 cm HO were included. Cisatracurium administration was driven by the nurses according to an algorithm based on TOF monitoring. The primary endpoint was cisatracurium consumption. The secondary endpoints included the quality of the neuromuscular block, the occurrence of adverse events, and the evolution of ventilatory and blood gas parameters. Results: Thirty patients were included. NMBAs were used for 54 ± 30 h. According to this new algorithm, the initial dosage of cisatracurium was 11.8 ± 2 mg/h, and the final dosage was 14 ± 4 mg/h, which was significantly lower than in the ACURASYS study protocol (37.5 mg/h with a constant infusion rate ( p < 0.001). The overall cisatracurium dose used was 700 ± 470 mg in comparison with 2040 ± 1119 mg for patients had received the ACURASYS dosage for the same period ( p < 0.001). A profound neuromuscular block (TOF = 0, twitches at the ulnar site) was obtained from the first hour in 70% of patients. Modification of the cisatracurium dosage was not performed from the beginning to the end of the study in 60% of patients. Patient-ventilator asynchronies occurred in 4 patients. Conclusion: A nurse-driven protocol based on TOF monitoring for NMBA administration in ARDS patients was able to decrease cisatracurium consumption without significantly affecting the quality of the neuromuscular block. [ABSTRACT FROM AUTHOR]

Purpose: To investigate whether neuromuscular blocking agents (NMBA) exert beneficial effects in acute respiratory distress syndrome (ARDS) by reason of their action on respiratory mechanics, particularly transpulmonary pressures (P L).Methods: A prospective randomised controlled study in patients with moderate to severe ARDS within 48 h of the onset of ARDS. All patients were monitored by means of an oesophageal catheter and followed up for 48 h. Moderate ARDS patients were randomised into two groups according to whether they were given a 48-h continuous infusion of cisatracurium besylate or not (control group). Severe ARDS patients did not undergo randomisation and all received cisatracurium besylate per protocol. The changes during the 48-h study period in oxygenation and in respiratory mechanics, including inspiratory and expiratory P L and driving pressure, were assessed and compared. Delta P L (∆P L) was defined as inspiratory P L minus expiratory P L.Results: Thirty patients were included, 24 with moderate ARDS and 6 with severe ARDS. NMBA infusion was associated with an improvement in oxygenation in both moderate and severe ARDS, accompanied by a decrease in both plateau pressure and total positive end-expiratory pressure. The mean inspiratory and expiratory P L were higher in the moderate ARDS group receiving NMBA than in the control group. In contrast, there was no change in either driving pressure or ∆P L related to NMBA administration.Conclusions: NMBA could exert beneficial effects in patients with moderate ARDS, at least in part, by limiting expiratory efforts. [ABSTRACT FROM AUTHOR]

Purpose: Prone position (PP) improves oxygenation and outcome of acute respiratory distress syndrome (ARDS) patients with a PaO2/FiO2 ratio <150 mmHg. Regional changes in lung aeration can be assessed by lung ultrasound (LUS). Our aim was to predict the magnitude of oxygenation response after PP using bedside LUS.Methods: We conducted a prospective multicenter study that included adult patients with severe and moderate ARDS. LUS data were collected at four time points: 1 h before (baseline) and 1 h after turning the patient to PP, 1 h before and 1 h after turning the patient back to the supine position. Regional lung aeration changes and ultrasound reaeration scores were assessed at each time. Overdistension was not assessed.Results: Fifty-one patients were included. Oxygenation response after PP was not correlated with a specific LUS pattern. The patients with focal and non-focal ARDS showed no difference in global reaeration score. With regard to the entire PP session, the patients with non-focal ARDS had an improved aeration gain in the anterior areas. Oxygenation response was not associated with aeration changes. No difference in PaCO2 change was found according to oxygenation response or lung morphology.Conclusions: In ARDS patients with a PaO2/FiO2 ratio ≤150 mmHg, bedside LUS cannot predict oxygenation response after the first PP session. At the bedside, LUS enables monitoring of aeration changes during PP. [ABSTRACT FROM AUTHOR]

The authors discuss a retrospective observational study to compare outcomes of severe acute respiratory distress syndrome (ARDS) patients under veno-venous extracorporeal membrane oxygenation (vvECMO) according to the use of prone positioning (PP). Findings showed that patients with severe ARDS who underwent PP ECMO were more likely to be weaned from ECMO. They claim that findings from the study warrant justification for further clinical trials on the value of PP in ECMO.

Background: High-frequency oscillatory ventilation (HFOV) has not been shown to be beneficial in the management of moderate-to-severe acute respiratory distress syndrome (ARDS). There is uncertainty about the actual pressure applied into the lung during HFOV. We therefore performed a study to compare the transpulmonary pressure ( P ) during conventional mechanical ventilation (CMV) and different levels of mean airway pressure (mPaw) during HFOV. Methods: This is a prospective randomized crossover study in a university teaching hospital. An esophageal balloon catheter was used to measure esophageal pressures (Pes) at end inspiration and end expiration and to calculate P . Measurements were taken during ventilation with CMV (CMVpre) after which patients were switched to HFOV with three 1-h different levels of mPaw set at +5, +10 and +15 cm HO above the mean airway pressure measured during CMV. Patients were thereafter switched back to CMV (CMVpost). Results: Ten patients with moderate-to-severe ARDS were included. We demonstrated a linear increase in Pes and P with the increase in mPaw during HFOV. Contrary to CMV, P was always positive during HFOV whatever the level of mPaw applied but not associated with improvement in oxygenation. We found significant correlations between mPaw and Pes. Conclusion: HFOV with high level of mPaw increases transpulmonary pressures without improvement in oxygenation. [ABSTRACT FROM AUTHOR]

Background: The relationship between tiredness and the risk of medical errors is now commonly accepted. The main objective of this study was to assess the impact of an intensive care unit (ICU) night shift on the cognitive performance of a group of intensivists. The influence of professional experience and the amount of sleep on cognitive performance was also investigated.Methods: A total of 51 intensivists from three ICUs (24 seniors and 27 residents) were included. The study participants were evaluated after a night of rest and after a night shift according to a randomized order. Four cognitive skills were tested according to the Wechsler Adult Intelligence Scale and the Wisconsin Card Sorting Test.Results: All cognitive abilities worsened after a night shift: working memory capacity (11.3 ± 0.3 vs. 9.4 ± 0.3; p < 0.001), speed of processing information (13.5 ± 0.4 vs. 10.9 ± 0.3; p < 0.001), perceptual reasoning (10.6 ± 0.3 vs. 9.3 ± 0.3; p < 0.002), and cognitive flexibility (41.2 ± 1.2 vs. 44.2 ± 1.3; p = 0.063). There was no significant difference in terms of level of cognitive impairment between the residents and ICU physicians. Only cognitive flexibility appeared to be restored after 2 h of sleep. The other three cognitive skills were altered, regardless of the amount of sleep during the night shift.Conclusions: The cognitive abilities of intensivists were significantly altered following a night shift in the ICU, regardless of either the amount of professional experience or the duration of sleep during the shift. The consequences for patients' safety and physicians' health should be further evaluated. [ABSTRACT FROM AUTHOR]

Objective: To describe current use and diagnostic and therapeutic impacts of point-of-care ultrasound (POCUS) in the intensive care unit (ICU). Background: POCUS is of growing importance in the ICU. Several guidelines recommend its use for procedural guidance and diagnostic assessment. Nevertheless, its current use and clinical impact remain unknown. Methods: Prospective multicentric study in 142 ICUs in France, Belgium, and Switzerland. All the POCUS procedures performed during a 24-h period were prospectively analyzed. Data regarding patient condition and the POCUS procedures were collected. Factors associated with diagnostic and therapeutic impacts were identified. Results: Among 1954 patients hospitalized during the study period, 1073 (55 %) POCUS/day were performed in 709 (36 %) patients. POCUS served for diagnostic assessment in 932 (87 %) cases and procedural guidance in 141 (13 %) cases. Transthoracic echocardiography, lung ultrasound, and transcranial Doppler accounted for 51, 17, and 16 % of procedures, respectively. Diagnostic and therapeutic impacts of diagnostic POCUS examinations were 84 and 69 %, respectively. Ultrasound guidance was used in 54 and 15 % of cases for central venous line and arterial catheter placement, respectively. Hemodynamic instability, emergency conditions, transthoracic echocardiography, and ultrasounds performed by certified intensivists themselves were independent factors affecting diagnostic or therapeutic impacts. Conclusions: With regard to guidelines, POCUS utilization for procedural guidance remains insufficient. In contrast, POCUS for diagnostic assessment is of extensive use. Its impact on both diagnosis and treatment of ICU patients seems critical. This study identified factors associated with an improved clinical value of POCUS. [ABSTRACT FROM AUTHOR]

Purpose: A specific biomarker of post-ARDS fibroproliferation could be useful in the identification of patients who could benefit from therapies aiming to modulate fibroproliferation such as corticosteroids.The aim of this prospective study was to determine the best threshold of the N-terminal-peptidetype III procollagen (NT-PCP-III) in non-resolving ARDS to validate this threshold according to the outcome. Methods: Concerning the best threshold of NT-PCP-III, all consecutive patients with a non-resolving ARDS were included if all the following criteria were fulfilled: moderate to severe ARDS lasting for at least 5 days, lung biopsy performed, serum and alveolar NT-PCP-III obtained within 1 week prior to biopsy, and no documented infection contra-indicating the corticosteroids. In the validation cohort part of the study, patients were included at day 7 if they presented a persistent moderate to severe ARDS. Results: Nineteen of 32 patients had fibroproliferatio nonbiopsy. Serum and alveolar NT-PCP-III were higher in patients with fibroproliferation. Using a threshold of 9 µg/L, alveolar NT-PCP-III had the highest accuracy for diagnosing fibroproliferation (sensitivity = 89.5 % and specificity = 92.3 %). Regarding the 51 patients included in the validation cohort, the mortality rate at day 60 was increased in patients presenting an alveolar NT-PCP-III level higher than 9 µg/L (69 vs. 17 %, p < 0.001). The mean alveolar level of NT-PCP-III on day 7 was 8.1-fold higher in nonsurvivors ( p = 0.03). Conclusions: The determination of NT-PCP-III on BAL done at day 7 in persistent ARDS is able to identify patients with fibroproliferation who could be included in a trial of corticosteroids or any other treatment that might help resolve lung fibroproliferation. [ABSTRACT FROM AUTHOR]

Purpose: Patients with severe acute respiratory distress syndrome (ARDS) are candidates for extracorporeal membrane oxygenation (ECMO) therapy. The evaluation of organ severity is difficult in patients considered for cannulation in a distant hospital. This study was designed to identify early factors associated with hospital mortality in ARDS patients treated with ECMO and retrieved from referring hospitals. Methods: Data from 85 consecutive ARDS patients equipped with ECMO by our mobile team and consequently admitted to our ICU were prospectively collected and analyzed. Results: The main ARDS etiologies were community-acquired bacterial pneumonia (35 %), influenza pneumonia (23 %) (with 12 patients having been treated during the first half of the study period), and nosocomial pneumonia (14 %). The median (interquartile range) time between contact from the referring hospital and patient cannulation was 3 (1–4) h. ECMO was venovenous in 77 (91 %) patients. No complications occurred during transport by our mobile unit. Forty-eight patients died at the hospital (56 %). Based on a multivariate logistic regression, a score including age, SOFA score, and a diagnosis of influenza pneumonia was constructed. The probability of hospital mortality following ECMO initiation was 40 % in the 0–2 score class ( n = 58) and 93 % in the 3–4 score class ( n = 27). Patients with an influenza pneumonia diagnosis and a SOFA score before ECMO of less than 12 had a mortality rate of 22 %. Conclusions: Age, SOFA score, and a diagnosis of influenza may be used to accurately evaluate the risk of death in ARDS patients considered for retrieval under ECMO from distant hospitals. [ABSTRACT FROM AUTHOR]

ARDS is particularly characterized by pulmonary edema caused by an increase in pulmonary capillary permeability. It is considered that limiting pulmonary edema or accelerating its resorption through the modulation of fluid intake or oncotic pressure could be beneficial. This review discusses the principal clinical studies that have made it possible to progress in the optimization of the fluid state during ARDS. Notably, a randomized, multicenter study has suggested that fluid management with the goal to obtain zero fluid balance in ARDS patients without shock or renal failure significantly increases the number of days without mechanical ventilation. On the other hand, it is accepted that patients with hemodynamic failure must undergo early and adapted vascular filling. Liberal and conservative filling strategies are therefore complementary and should ideally follow each other in time in the same patient whose hemodynamic state progressively stabilizes. At present, although albumin treatment has been suggested to improve oxygenation transiently in ARDS patients, no sufficient evidence justifies its use to mitigate pulmonary edema and reduce respiratory morbidity. Finally, the resorption of alveolar edema occurs through an active mechanism, which can be pharmacologically upregluated. In this sense, the use of beta-2 agonists may be beneficial but further studies are needed to confirm preliminary promising results. [ABSTRACT FROM AUTHOR]

Purpose: To compare characteristics, clinical evolution and outcome in adult patients with influenza A (H1N1) acute respiratory distress syndrome (ARDS) treated with or without extracorporeal membrane oxygenation (ECMO). Methods: A prospective observational study of patients treated in Marseille South Hospital from October 2009 to January 2010 for confirmed influenza A (H1N1)-related ARDS. Clinical features, pulmonary dysfunction and mortality were compared between patients treated with and without ECMO. Results: Of 18 patients admitted, 6 were treated with veno-venous and 3 with veno-arterial ECMO after median (interquartile, IQR) duration of mechanical ventilation of 10 (6-96) h. Six ECMO were initiated in a referral hospital by a mobile team, a median (IQR) of 3 (2-4) h after phone contact. Before ECMO, patients had severe respiratory failure with median (IQR) PaO to FiO ratio of 52 (50-60) mmHg and PaCO of 85 (69-91) mmHg. Patients treated with or without ECMO had the same hospital mortality rate (56%, 5/9). Duration of ECMO therapy was 9 (4-14) days in survivors and 5 (2-25) days in non-survivors. Early improvement of PaO to FiO ratio was greater in ECMO survivors than non-survivors after ECMO initiation [295 (151-439) versus 131 (106-144) mmHg, p < 0.05]. Haemorrhagic complications occurred in four patients under ECMO, but none required surgical treatment. Conclusions: ECMO may be an effective salvage treatment for patients with influenza A (H1N1)-related ARDS presenting rapid refractory respiratory failure, particularly when provided by a mobile team allowing early cannulation prior to transfer to a reference centre. [ABSTRACT FROM AUTHOR]

This study was designed to determine if bronchoalveolar lavage (BAL) quantitative culture results can be used confidently for the diagnosis of bacterial ventilator-associated pneumonia (VAP) without taking dilution into account. Prospective observational cohort study. A 12-bed medical ICU in a teaching hospital. A total of 241 BAL (three 50-mL aliquots) were performed in 127 patients presenting a suspicion of VAP. All consecutive adults who were ventilated more than 48 h were included if VAP was clinically suspected. A dilution factor, k, was developed according to the formula: dilution factor k = concentration of urea in plasma/concentration of urea in lavage fluid recovered. Using this dilution factor, the quantitative bacterial counts were interpreted accordingly with a corrected positive threshold at 105 colony forming unit (CFU) mL−1. Eighty-nine BAL with at least one micro-organism ≥104 CFU mL−1 were identified (37%). In 176 BAL (73%), k ranged from 10 to 100. Median k was 24.4 (9.7–40.2) in VAP group and 24.6 (13.1–57.8) in patients without pneumonia (NS). Among the 25 BAL with micro-organism counts of 104 CFU mL−1, 3 had a dilution factor lower than 10, resulting in corrected counts below the threshold of 105 CFU mL−1. Two out of 15 patients with micro-organism counts of 103 CFU mL−1 had corrected micro-organism counts of 105 CFU mL−1. Finally, only five BAL (2.1%) were misclassified when the dilution correction factor was applied. Using urea as dilution factor, we showed that BAL dilution variations did not alter the interpretation of BAL quantitative bacterial culture when administrating three aliquots of 50 mL of saline. [ABSTRACT FROM AUTHOR]

Background: Data on respiratory mechanics of COVID-19 ARDS patients are scarce. Respiratory mechanics and response to positive expiratory pressure (PEEP) may be different in obese and non-obese patients. Methods: We investigated esophageal pressure allowing determination of transpulmonary pressures (PL) and elastances (EL) during a decremental PEEP trial from 20 to 6 cm H2O in a cohort of COVID-19 ARDS patients. Results: Fifteen patients were investigated, 8 obese and 7 non-obese patients. PEEP ≥ 16 cm H2O for obese patients and PEEP ≥10 cm H2O for non-obese patients were necessary to obtain positive expiratory PL. Change of PEEP did not alter significantly ΔPL or elastances in obese patients. However, in non-obese patients lung EL and ΔPL increased significantly with PEEP increase. Chest wall EL was not affected by PEEP variations in both groups. [ABSTRACT FROM AUTHOR]

The article offers information on a study which deals with application of airway pressure release ventilation (APRV) in patients with acute respiratory distress syndrome (ARDS). It mentions that APRV mode is associated with better oxygenation and respiratory system compliance compared with conventional low-tidal ventilation (LTV). It states that early use of neuromuscular blockade was associated with better outcomes in patients with moderate to-severe ARDS.

Background: Lung fibroproliferation in ARDS patients is associated with mortality. Alveolar procollagen III (NT-PCP-III) is a validated biomarker of lung fibroproliferation. A chest CT scan could be useful for the diagnosis of lung fibroproliferation. The aim of this study was to identify lung fibroproliferative CT scan aspects in ARDS patients with high levels of NT-PCP-III. Results: This retrospective study included ARDS patients who had at least one assessment of alveolar NT-PCP-III and a chest CT scan within 3 days before or after NT-PCP-III determination. An alveolar level of NT-PCP-III > 9 µG/L indicated fibroproliferation. The CT scan was scored on interstitial and alveolar abnormalities. Each lobe was scored from 0 to 5 according to the severity of the abnormalities. The crude score and the corrected score (related to the number of scored lobes in cases of important lobar condensation or lobectomy) were used. One hundred ninety-two patients were included, for a total of 228 alveolar NT-PCP-III level and CT scan 'couples'. Crude and corrected CT scan fibrosis scores were higher in the fibroproliferation group compared with the no fibroproliferation group (crude score: 12 [9–17] vs 14 [11–12], p = 0.002; corrected score: 2.8 [2.2–4.0] vs 3.4 [2.5–4.7], p < 0.001). CT scan fibrosis scores and NT-PCP-III levels were significantly but weakly correlated (crude score: ρ = 0.178, p = 0.007; corrected score: ρ = 0.184, p = 0.005). Conclusions: When the alveolar level of NT-PCP-III was used as a surrogate marker of histological lung fibroproliferation, the CT scan fibrosis score was significantly higher in patients with active lung fibroproliferation. Pulmonary condensation is the main limitation to diagnosing fibroproliferation during ARDS. [ABSTRACT FROM AUTHOR]

The article discusses a comparative study that examined the medical charts of patients according to extracorporeal membrane oxygenation (ECMO) configuration. Topics discussed include the performance of cannulation with femorofemoral (FF) and femorojugular (FJ) configurations, the performance of vvECMO circuit and an acceptable arterial oxygenation is delivered with a sufficient ratio of ECMO flow to cardiac output.