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BACKGROUND: Coronavirus disease 2019 (COVID-19) can cause acute respiratory distress syndrome (ARDS). OBJECTIVE: This single centre cross-section study aimed to grade the severity of pneumonia by bed-side lung ultrasound (LUS). METHODS: A scoring system discriminates 5 levels of lung opacities: A-lines (0 points),≥3 B-line (1 point), coalescent B-lines (2 points), marked pleural disruptions (3 points), consolidations (4 points). LUS (convex 1–5 MHz probe) was performed at 6 defined regions for each hemithorax either in supine or prone position. A lung aeration score (LAS, maximum 4 points) was allocated for each patient by calculating the arithmetic mean of the examined lung areas. Score levels were correlated with ventilation parameters and laboratory markers. RESULTS: LAS of 20 patients with ARDS reached from 2.58 to 3.83 and was highest in the lateral right lobe (Mean 3.67). Ferritin levels (Mean 1885μg/l; r = 0.467; p = 0.051) showed moderate correlation in spearman roh calculation. PaCO2 level (Mean 46.75 mmHg; r = 0.632; p = 0.005) correlated significantly with LAS, while duration of ventilation, Horovitz index, CRP, LDH and IL-6 did not. CONCUSIONS: The proposed LAS describes severity of lung opacities in COVID-19 patients and correlates with CO2 retention in patients with ARDS. [ABSTRACT FROM AUTHOR]

The Respiratory Intensive Care Assembly of the European Respiratory Society gathered in Berlin to organise the third Respiratory Failure and Mechanical Ventilation Conference in February 2024. The conference covered key points of acute and chronic respiratory failure in adults. During the 3-day conference ventilatory strategies, patient selection, diagnostic approaches, treatment and health-related quality of life topics were addressed by a panel of international experts. In this article, lectures delivered during the event have been summarised by early career members of the Assembly and take-home messages highlighted., Competing Interests: Conflict of interest: C. Bianquis reports grants from ASTEN santé and support for attending meetings from Vitalaire. G. De Leo, G. Morana, M. Duarte-Silva and S. Nolasco have nothing to disclose. R. Vilde reports support for attending meetings from Chiesi and has a leadership role with Latvian Junior doctors’ association as a Board member. A. Tripipitsiriwat and P. Viegas have nothing to disclose. M. Purenkovs reports leadership roles with the Latvian Society of Sleep Medicine (Board member), Latvian Society of Innovative Pneumonology and Respiratory Medicine (board member), and Latvian Society of Tuberculosis and Lung Diseases doctors (board member). M. Duiverman reports grants from Fisher & Paykel (High-TeC trial), Vivisol BV (High-TeC trial and Noctivent trial), RESMED Ltd (RECAPTURE trial), Löwenstein BV (Noctivent trial), and Secure BV (Noctivent trial), payment or honoraria for lectures from Vivisol BV, Chiesi, Breas, and AstraZeneca, and a leadership role with ERS as the chair of the NIV group of Assembly 2. C. Karagiannidis and C. Fisser have nothing to disclose., (Copyright ©ERS 2024.)

Background: Intracranial bleeding (ICB) is a serious complication during veno-venous extracorporeal membrane oxygenation (V-V ECMO), with potentially fatal consequences., Purpose: This study aimed to evaluate the incidence, time of detection of ICB among patients treated with V-V ECMO and potential risk factors for developing ICB during V-V ECMO., Methods: Five hundred fifty six patients were included in this retrospective single center analysis., Results: Median time on V-V ECMO was 9 (IQR 6-15) days. Intracranial bleeding during V-V ECMO was detected in 10.9% of all patients (61 patients with ICB). Only 17 patients with ICB presented obvious clinical symptoms. Intracranial bleeding was detected on cerebral imaging in median after 5 days (IQR 1-14) after starting V-V ECMO. Overall survival to hospital discharge was 63.7% (ICB: 29.5%). Risk factors of ICB before starting V-V ECMO in univariable analysis were platelets <100/nl (OR: 3.82), creatinine >1.5mg/dl (OR: 1.98), norepinephrine >2.5mg/h (OR: 2.5), ASAT >80U/L (OR: 1.86), blood-urea >100mg/dl (OR: 1.81) and LDH >550u/L (OR: 2.07). Factors associated with cannulation were rapid decrease in paCO 2 >35mmHg (OR: 2.56) and rapid decrease in norepinephrine >1mg/h (OR: 2.53). Multivariable analysis revealed low platelets, high paCO 2 before ECMO, and rapid drop in paCO 2 after V-V ECMO initiation as significant risk factors for ICB., Conclusion: The results emphasize that ICB is a frequent complication during V-V ECMO. Many bleedings were incidental findings, therefore screening for ICB is advisable. The univariate risk factors reflect the underlying disease severity, coagulation disorders and peri-cannulation factors, and may help to identify patients at risk., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

A 43-year-old male patient presented to the emergency department with progressive dyspnea. CT scan showed pronounced cystic lesions and ground glass opacitiy in both lungs and diagnosis of HIV infection was established. Bronchoscopy confirmed diagnosis of pneumocystis jirovecii pneumonia (PCP). The radiological presentation with perihilar large cysts is typical for PCP in HIV-infected patients, but rarely encountered today., (© 2024. The Author(s).)

Background: Tezepelumab is a novel biologic blocking thymic stromal lymphopoetin, approved for severe asthma irrespective of biomarker levels or phenotype., Objective: To characterize a real-world tezepelumab patient cohort and the efficacy among various asthma phenotypes., Methods: We performed a retrospective, multicenter study on patients with severe asthma initiating tezepelumab. Clinical response was evaluated at 3 and 6 months., Results: We included 129 patients with an average age of 52.5 ± 13.1 years, 59.7% were female. The majority (86.0%) had increased type 2 (T2) biomarkers, 68.2% an allergic and 31.8% an eosinophilic phenotype. 23.3% of patients were biologic-naive. 22 (18.2%) patients discontinued tezepelumab therapy owing to suspected side effects or insufficient efficacy. At 6 months' follow-up, median reduction in annualized exacerbation rate was-1 [25th percentile; 75% percentile {-2.9; 0.0}], the reduction of oral corticosteroid dose among patients with long-term oral corticosteroid therapy was -5 mg [-10; 0] and the Asthma Control Test (ACT) improved by 2 [0; 5] points. A treatment response according to Biologic Asthma Response Score of 80.8% was demonstrated. There were no significant differences in treatment response between T2-high versus T2-low, early- versus adult-onset and eosinophilic versus non-eosinophilic asthma. Prior treatment with other biologics was associated with inferior treatment response., Conclusions: In this real-life cohort, including a large proportion of patients with history of previous biologic use and encompassing various subgroups, the majority responded to tezepelumab. Our data further suggest a steroid-sparing effect of tezepelumab., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Both obstructive and central sleep apnea (OSA and CSA) may contribute to nocturnal cardiac arrhythmias (NCA). Data on the prevalence of clinically important nocturnal atrial and ventricular arrythmias in patients with heart failure with reduced ejection fraction (HFrEF) and obstructive (OSA) or central sleep apnea (CSA) are scarce., Research Questions: In a cohort of patients with HFrEF, how does the prevalence of NCA compare among those with OSA, CSA and those with no to mild sleep apnea? Is the severity of OSA or CSA associated with atrial and ventricular NCA?, Methods: This cross-sectional analysis is an ancillary study of the ADVENT-HF trial. We compared the prevalence of NCA (excessive supraventricular ectopic activity [ESVEA], defined as premature atrial complexes [PAC] ≥30/h or supraventricular tachycardia ≥20 beats); atrial fibrillation/flutter [AF]; and >10 premature ventricular complexes [PVC/h]) on ECGs from polysomnograms of HFrEF patients between those with OSA (apnea-hypopnea index [AHI≥15]), those with CSA (AHI≥15/h) and those with no to mild sleep apnea (AHI<15, control)., Results: Compared to controls (n=76), the prevalence of ESVEA was higher in patients with OSA (n=430) and CSA (n=150), 0%, 9% and 12%, respectively. The prevalences of AF in the control, OSA and CSA groups were 9%, 17% and 27%, and of >10 PVC/h 45%, 59% and 63%, respectively. In multivariable regression analyses PAC/h was associated with OSA severity (obstructive AHI) [22.4% increase per 10 events/h (95% confidence interval: 5.2; 42.3); p=0.009], but neither obstructive nor central AHI were associated with AF or >10 PVC/h., Interpretation: In patients with HFrEF, the prevalences of nocturnal ESVEA, AF and PVC >10/h were higher in those with, than in those without OSA or CSA, and OSA severity was related to the burden of nocturnal atrial ectopy. Severity of OSA or CSA were not significantly related to AF or >10 PVC/h., (Copyright © 2024. Published by Elsevier Inc.)

Background: In lung cancer, molecular testing and next-generation sequencing (NGS) are needed to identify therapeutic targets and are increasingly being used in earlier stages of the disease. Despite its longstanding use, it remains unclear whether transbronchial needle aspiration (TBNA) of peripheral lung lesions provides as adequate material for genetic testing as transbronchial forceps biopsies (TBFBs). In this study, we aim to analyze the use of TBNA using median viable cell area (MVCA) as a surrogate parameter to analyze sample quality., Methods: This prospective single-center study analyzed biopsy specimens or aspirates of patients who underwent bronchoscopy with transbronchial biopsy. Patients underwent bronchoscopy with TBFB and TBNA for suspected lung cancer in peripheral lung lesions. Patients were randomized 1:1 to receive either TBFB or TBNA as the first biopsy technique and then switched to the other. After routine workup, sample slides were digitally scanned, and MVCA was calculated by a pathologist blinded to the biopsy technique used. The primary endpoint was MVCA of TBNA versus TBFB. Secondary endpoints were complications categorized as bleeding, pneumothorax, and other., Results: Between August 2021 and April 2022, 15 patients were included in the per-protocol analysis. Six patients were included in cohort 1 and nine patients in cohort 2. A malignant diagnosis was confirmed in 11/15 (73.3%) cases, of which nine were primary lung malignancies. Overall, MVCA in samples obtained by TBFB was significantly larger than TBNA samples {TBFB-MVCA 9.80 mm 2 [interquartile range (IQR), 2.70-10.39 mm 2 ] vs . TBNA-MVCA 2.70 mm 2 (IQR, 0.14-8.21 mm 2 ), P=0.008}. Despite this difference, molecular testing was feasible in both TBNA and TBFB samples. No major complications were observed., Conclusions: Despite a significantly smaller MVCA provided by TBNA, samples were still considered feasible for NGS, indicating that TBNA represents an alternative method to obtain sufficient tumor tissue in peripheral nodules as part of the diagnosis of suspected lung cancer., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tcr.amegroups.com/article/view/10.21037/tcr-23-2320/coif). The authors have no conflicts of interest to declare., (2024 Translational Cancer Research. All rights reserved.)

Competing Interests: Katharina Buschulte erhielt Vortragshonorare von Boehringer Ingelheim. Klaas Franzen gibt AOP, Chiesi und Inogen als Interessenkonflikte an. Gabriela Leuschner gibt Reise- und Übernachtungskosten, Vortrags- und Beratertätigkeit von Boehringer Ingelheim an. Nina Sicker erhielt Reise- und Übernachtungskosten von Astra Zeneca, Chiesi und Boehringer Ingelheim. Finn Wilkens gibt Boehringer Ingelheim, CSL Behring, Berlin Chemie und DZL als Interessenkonflikte an. Christoph Fisser gibt Reise- und Übernachtungskosten, Vortrags- und Beratertätigkeit von AstraZeneca, Berlin-Chemie, CSL Behring, Chiesi und Novartis an sowie Forschungsunterstützung der deutschen Stiftung für Herzforschung außerhalb der eingereichten Arbeit. Erik Büscher, Armin Frille, Espen Groth, Julia Hoffmann, Andreas Knaack, Johannes Krönig, Christoph Lederer und Eva Pappe geben keine Interessenkonflikte an.

Early career members of Assembly 2 (Respiratory Intensive Care) attended the 2023 European Respiratory Society International Congress in Milan, Italy. The conference covered acute and chronic respiratory failure. Sessions of interest to our assembly members and to those interested in respiratory critical care are summarised in this article and include the latest updates in respiratory intensive care, in particular acute respiratory distress syndrome and mechanical ventilation., Competing Interests: Conflict of interest: C. Bianquis declares support for attending meetings and travel to the ERS 2023 congress from Vitalaire. Conflict of interest: T. Lacoste-Palasset declares support for attending meetings and travel to the ERS 2023 congress from Oxyvie. Conflict of interest: A.L. Vieira declares support for attending meetings and travel to the ERS 2023 congress from Vivisol. Conflict of interest: S. Leiva Agüero, C. Cantero, A. Golfe Bonmatí, J. González, X. Hu, A. Livesey, R. Guillamat Prats, G. Salai, D.L. Sykes, S. Toland, C. van Zeller, P. Viegas, S. Zaneli, C. Karagiannidis and C. Fisser have no conflict of interest to declare regarding this article., (Copyright ©The authors 2024.)

Objective: In this retrospective case series, survival rates in different indications for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and differential diagnoses of COVID-19 associated refractory circulatory failure are investigated., Methods: Retrospective analysis of 28 consecutive COVID-19 patients requiring VA-ECMO. All VA-ECMO's were cannulated peripherally, using a femoro-femoral cannulation., Results: At VA-ECMO initiation, median age was 57 years (IQR: 51-62), SOFA score 16 (IQR: 13-17) and norepinephrine dosing 0.53μg/kg/min (IQR: 0.35-0.87). Virus-variants were: 61% wild-type, 14% Alpha, 18% Delta and 7% Omicron. Indications for VA-ECMO support were pulmonary embolism (PE) (n = 5, survival 80%), right heart failure due to secondary pulmonary hypertension (n = 5, survival 20%), cardiac arrest (n = 4, survival 25%), acute heart failure (AHF) (n = 10, survival 40%) and refractory vasoplegia (n = 4, survival 0%). Among the patients with AHF, 4 patients suffered from COVID-19 associated heart failure (CovHF) (survival 100%) and 6 patients from sepsis associated heart failure (SHF) (survival 0%). Main Complications were acute kidney injury (AKI) 93%, renal replacement therapy was needed in 79%, intracranial hemorrhage occurred in 18%. Overall survival to hospital discharge was 39%., Conclusion: Survival on VA-ECMO in COVID-19 depends on VA-ECMO indication, which should be considered in further studies and clinical decision making. A subgroup of patients suffers from acute heart failure due to inflammation, which has to be differentiated into septic or COVID-19 associated. Novel biomarkers are required to ensure reliable differentiation between these entities; a candidate might be soluble interleukin 2 receptor., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Wiest et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: Analysis of the prevalence and risk factors for weaning failure from venovenous extracorporeal membrane oxygenation (VV-ECMO) in patients with severe acute respiratory insufficiency., Design: Single-center retrospective observational study., Setting: Sixteen beds medical ICU at the University Hospital Regensburg., Patients: Two hundred twenty-seven patients with severe acute respiratory insufficiency requiring VV-ECMO support between October 2011 and December 2017., Interventions: None., Measurements and Main Results: Patients meeting our ECMO weaning criteria (Sp o2 ≥ 90% with F io2 ≤ 0.4 or Pa o2 /F io2 > 150 mm Hg, pH = 7.35-7.45, positive end-expiratory pressure ≤ 10 cm H 2 O, driving pressure < 15 cm H 2 O, respiratory rate < 30/min, tidal volume > 5 mL/kg, ECMO bloodflow ≈ 1. 5 L/min, sweep gas flow ≈ 1 L/min, heart rate < 120/min, systolic blood pressure 90-160 mm Hg, norepinephrine < 0.2 µg/[kg*min]) underwent an ECMO weaning trial (EWT) with pausing sweep gas flow. Arterial blood gas analysis, respiratory and ventilator parameters were recorded prior, during, and after EWTs. Baseline data, including demographics, vitals, respiratory, ventilator, and laboratory parameters were recorded at the time of cannulation. One hundred seventy-nine of 227 (79%) patients were successfully decannulated. Ten patients (4%) underwent prolonged weaning of at least three failed EWTs before successful decannulation. The respiratory rate (19/min vs 16/min, p = 0.002) and Pa co2 (44 mm Hg vs 40 mm Hg, p = 0.003) were higher before failed than successful EWTs. Both parameters were risk factors for ECMO weaning failure (Pa co2 : odds ratio [OR] 1.05; 95% CI, 1.001-1.10; p = 0.045; respiratory rate: OR 1.10; 95% CI, 1.04-1.15; p < 0.001) in multivariable analysis. The rapid shallow breathing index [42 (1/L*min), vs 35 (1/L*min), p = 0.052) was higher before failed than successful EWTs. The decline of Sa o2 and Pa o2 /F io2 during EWTs was higher in failed than successful trials., Conclusions: Seventy-nine percent of patients were successfully decannulated with only 4% needing prolonged ECMO weaning. Before EWT only parameters of impaired ventilation (insufficient decarboxylation, higher respiratory rate) but not of oxygenation were predictive for weaning failure, whereas during EWT-impaired oxygenation was associated with weaning failure., Competing Interests: Dr. Gerhardinger received funding from Studienstiftung des Deutschen Volkes Scholarship, Spital Frutigen, and Inselspital Bern. Dr. Müller disclosed that they are a member of board of Extracorporeal Life Support Organization. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background and Aims: While endomyocardial biopsy (EMB) is recommended in adult patients with fulminant myocarditis, the clinical impact of its timing is still unclear., Methods: Data were collected from 419 adult patients with clinically suspected fulminant myocarditis admitted to intensive care units across 36 tertiary centres in 15 countries worldwide. The diagnosis of myocarditis was histologically proven in 210 (50%) patients, either by EMB (n = 183, 44%) or by autopsy/explanted heart examination (n = 27, 6%), and clinically suspected cardiac magnetic resonance imaging confirmed in 96 (23%) patients. The primary outcome of survival free of heart transplantation (HTx) or left ventricular assist device (LVAD) at 1 year was specifically compared between patients with early EMB (within 2 days after intensive care unit admission, n = 103) and delayed EMB (n = 80). A propensity score-weighted analysis was done to control for confounders., Results: Median age on admission was 40 (29-52) years, and 322 (77%) patients received temporary mechanical circulatory support. A total of 273 (65%) patients survived without HTx/LVAD. The primary outcome was significantly different between patients with early and delayed EMB (70% vs. 49%, P = .004). After propensity score weighting, the early EMB group still significantly differed from the delayed EMB group in terms of survival free of HTx/LVAD (63% vs. 40%, P = .021). Moreover, early EMB was independently associated with a lower rate of death or HTx/LVAD at 1 year (odds ratio of 0.44; 95% confidence interval: 0.22-0.86; P = .016)., Conclusions: Endomyocardial biopsy should be broadly and promptly used in patients admitted to the intensive care unit for clinically suspected fulminant myocarditis., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)