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As emerging countries, China, Russia, and South Africa are establishing and/or improving their trauma systems. China has recently established a trauma system named “the Chinese Regional Trauma Care System” and covered over 200 million populations. It includes paramedic-staffed pre-hospital care, in-hospital care in certified trauma centers, trauma registry, quality assurance, continuous improvement and ongoing coverage of the entire Chinese territory. The Russian trauma system was formed in the first decade of the twenty-first century. Pre-hospital care is region-based, with a regional coordination center that determines which team will go to the scene and the nearest hospital where the victim should be transported. Physician-staffed ambulances are organized according to three levels of trauma severity corresponding to three levels of trauma centers where in-hospital care is managed by a trauma team. No national trauma registry exists in Russia. Improvements to the Russian trauma system have been scheduled. There is no unified trauma system in South Africa, and trauma care is organized by public and private emergency medical service in each province. During the pre-hospital care, paramedics provide basic or advanced life support services and transport the patients to the nearest hospital because of the limited number of trauma centers. In-hospital care is inclusive with a limited number of accredited trauma centers. In-hospital care is managed by emergency medicine with multidisciplinary care by the various specialties. There is no national trauma registry in South Africa. The South African trauma system is facing multiple challenges. An increase in financial support, training for primary emergency trauma care, and coordination of private sector, need to be planned. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03681-8.

OBJECTIVE: The goal of this study was to assess lung morphology in patients with acute lung injury according to the presence or the absence of a lower inflection point on the lung pressure-volume curve and to compare the effects of positive endexpiratory pressure (PEEP).MATERIALS AND METHODS: Eight patients with and six without a lower inflection point (LIP) underwent a computed tomography performed at zero end-expiratory pressure (ZEEP) and at two levels of PEEP: PEEP1 = LIP + 2 cmH2O e PEEP2 = LIP + 7 cmH2O, or PEEP1 = 10 cmH2O and PEEP2 = 15 cmH2O in the absence of LIP and, based on the analysis of the lung density histograms, the gas-tissue ratio and the lung areas volumes were calculated (nonaerated, poorly aerated, normally aerated and overdistended volumes).RESULTS: In the ZEEP condition, patients with and without LIP presented similar total lung volume, volume of gas, and volume of tissue, although the percentage ofnormally aerated lung was lower and the percentage of poorly aerated lung was greater in patients with LIP than in patients without it. Lung density histograms ofpatients with LIP showed an unimodal distribution with a peak at 7 Housenfield units (HU), while histograms of patients without LIP had a bimodal distribution, with a first peak at -727 HU, and a second at 27 HU. Lung compliances were lower in patients with LIP whereas all other cardiorespiratory parameters were similar in the two groups. In both groups, PEEP induced an alveolar recruitment that was associated with lung overdistension only in patients without LIP.CONCLUSIONS: The evaluation of the pressure-volume curve in patients with acute lung injury allows us to divide them into two groups according to the presence or absence of LIP. This division is associated with the differences in lung morphology and in the responses to PEEP application in terms of alveolar recruitment andoverdistention, the latter being defined as the occurrence of pulmonary parenchyma under -900 HU. In patients with LIP, gas and tissue are more homogeneously distributed within the lungs and increasing levels of PEEP result in additional alveolarrecruitment without lung overdistention. In patients without LIP, normally aerated areas coexist with nonareted lung areas and increasing levels of PEEP result in lung overdistention rather than in additional alveolar recruitment. OBJETIVO: O objetivo deste estudo foi avaliar, através de tomografia computadorizada, a morfologia pulmonar em pacientes com lesão pulmonar aguda de acordo com a presença ou ausência de ponto de inflexão inferior (Pinf) nas curvas pressão-volume e comparar os efeitos da pressão expiratória final positiva (PEEP).MATERIAIS E MÉTODOS: Oito pacientes com e seis sem Pinf foram submetidos a tomografias computadorizadas realizadas em zero de pressão expiratória final positiva(ZEEP) e em dois níveis de PEEP: PEEP1 = Pinf+2 cmH2O e PEEP2 = Pinf+7 cmH2O, ou PEEP1 = 10 cmH2O e PEEP2 = 15 cmH2O na ausência de Pinf e, a partir da análise dos histogramas de densidade pulmonares, foram calculados a razão gás-tecido e os volumes pulmonares regionais (volumes não-aerado, pobremente aerado, normalmente aerado e hiperdistendido).RESULTADOS: Os pacientes com e sem Pinf apresentaram, em ZEEP, valores similares de volume pulmonar total e volume de gás e tecido, mas a porcentagem de pulmão normalmente ventilado foi menor e a de pulmão pobremente ventilado maior em pacientes com Pinf do que em pacientes sem Pinf. Os histogramas de densidade pulmonares de pacientes com Pinf mostraram uma distribuição unimodal com um pico em 7 unidades Hounsfield (UH), enquanto os pacientes sem Pinf tinham uma distribuição bimodal com um primeiro pico em -727 UH e um segundo em 27 UH. A complacência do sistema respiratório era menor em pacientes com Pinf, enquanto todos os outros parâmetros cardiorrespiratórios eram similares nosdois grupos. Em ambos os grupos, PEEP induziu recrutamento alveolar, o qual foi associado à hiperdistensão pulmonar apenas nos pacientes sem Pinf.CONCLUSÕES: A avaliação das curvas pressão-volume em portadores de lesão pulmonar aguda permite dividi-los em dois grupos, de acordo com a presença ouausência de ponto de inflexão inferior. Esta divisão associa-se com diferenças na morfologia pulmonar e nas respostas à aplicação de PEEP em termos de recrutamento alveolar e hiperdistensão, definindo-se esta última como a ocorrência de parênquima pulmonar abaixo de -900 UH. Em pacientes com Pinf, gás e tecido estão mais homogeneamente distribuídos no interior dos pulmões, e níveis crescentes de PEEP resultam em recrutamento alveolar adicional sem hiperdistensão. Em pacientes sem Pinf, regiões pulmonares normalmente ventiladas coexistem com regiões não-ventiladas, e a aplicação de PEEP, embora cause recrutamento, acarretatambém hiperdistensão, que aumenta com níveis crescentes de PEEP.

OBJECTIVE: Measurement of respiratory compliance based on pressure-volume curves are advocated for assessing the severity of acute respiratory failure. Theaim of the present study was to compare different methods of obtaining pressure volume curves and to evaluate their reproducibility and reliability.MATERIALS AND METHODS: Thoracopulmonary, pulmonary and thoracic pressurevolume curves were obtained in 14 patients and compared using three different methods: supersyringe method, inspiratory occlusions method and constant-flow method, using two different flows: 3 and 9 l.min-1. The slope of the curves, the values of static compliance and upper and lower inflection points, when present, were evaluated.RESULTS: The analysis of the pressure-volume curves through the three different methods showed that the curves obtained using a constant 3 l.min-1 flow weresuperimposable to the ones obtained using the supersyringe and inspiratory occlusions. Curves obtained using the 9 l.min-1 flow method were associated with aslight rightward shift. However, the values of static respiratory compliance and lower inflection points were similar for all patients regardless of the method, allowing the identification of patients with and without lower inflection points.CONCLUSIONS: The evaluation of pressure-volume curves, by any of the tested methods, in patients with acute respiratory failure, allows the evaluation of the values of static respiratory compliance and points of lower inflection, as well as their division into two groups, according to the presence or absence of points, OBJETIVO: As medidas da complacência respiratória, a partir das curvas pressãovolume, são indicadas para avaliar a gravidade da insuficiência respiratória aguda.O objetivo do presente estudo foi comparar diferentes métodos de obtenção das curvas pressão-volume e avaliar sua reprodutibilidade e fidedignidade.MATERIAIS E MÉTODOS: As curvas pressão-volume toracopulmonares, pulmonares e torácicas foram comparadas em 14 pacientes com IRA por três métodos diferentes: a técnica da superseringa, a das oclusões inspiratórias e um novo método automatizado, utilizando fluxos contínuos de 3 e de 9 l.min-1. Foram avaliadas a forma das curvas, bem como os valores de complacência estática e dos pontos de inflexão inferior e superior, quando presentes.RESULTADOS: A análise das curvas pressão-volume pelos diferentes métodos revelou que as curvas obtidas com o método constante de 3 l.min-1 foram superponíveis às obtidas pelos métodos da superseringa e das oclusões inspiratórias, enquanto que com o método de 9 l.min-1 houve um discreto desvio para a direita. Apesar disso, as medidas de complacência estática e os valores dos pontos de inflexão inferior foram semelhantes em todos os métodos, permitindo, todos eles, a identificação de pacientes com e sem pontos de inflexão inferior.CONCLUSÕES: A avaliação das curvas pressão volume em portadores de insuficiência respiratória aguda, por qualquer um dos métodos testados, permite avaliar os valores de complacência estática e de pontos de inflexão inferior, e dividi-los em dois grupos, de acordo com a presença ou ausência de pontos.

OBJECTIVE: The aim of the present study was to establish the tomographic limit of lung overdistention in normal individuals as well as to assess positive end-expiratorypressure-induced overdistention and alveolar recruitment in patients with acute lung injury.MATERIALS AND METHODS: Lung distention was first determined in six healthy volunteers in whom computed tomographic sections were obtained at functionalresidual capacity and total lung capacity with a positive airway pressure of 30 cmH2O. Tomographic scans at zero end-expiratory pressure and positive end-expiratorypressure were performed in six patients with acute lung injury. Computed tomographies were performed from the apex to the diaphragm and lung volumes were quantified by the analysis of the density histograms.RESULTS: Analysis of the density histograms in healthy volunteers was monophasic with a peak at -791 ± 12 Housenfield units. In total lung capacity, lung volumeincreased by 79 ± 35% and the peak of lung density decreased to -886 ±26 Housenfield units. More than 70% of the increase in lung volume was located below-900 Housenfield units, suggesting that this value can be considered as the threshold separating normal aeration from overdistention. In patients with acute lung injury, atzero end-expiratory pressure the distribution of density histograms was either monophasic (n=3) or biphasic (n=3), with mean density of -319 ± 34 Housenfieldunits. With positive end-expiratory pressure application, lung volume increased by 47 ± 19%, while lung density decreased to -538 ± Housenfield units. Positive endexpiratory pressure induced a mean alveolar recruitment of 238 ±320 ml.CONCLUSIONS: The limit of overdistention in healthy individuals was -900 Housenfield units. This threshold can be used in patients with acute lung injury fordifferentiating alveolar recruitment from lung overdistention. OBJETIVO: O objetivo do presente estudo foi determinar o limite tomográfico da hiperdistensão pulmonar em indivíduos normais, bem como avaliar o recrutamentoe a hiperdistensão pulmonares induzidos pela pressão expiratória final positiva em pacientes com lesão pulmonar aguda.MATERIAIS E MÉTODOS: Inicialmente, o limite da hiperdistensão pulmonar foi determinado em seis voluntários sadios, nos quais tomografias computadorizadas espiraladas de tórax foram obtidas em capacidade residual funcional e em capacidadepulmonar total mais pressão positiva de 30 cm H2O. Posteriormente, foram avaliados seis pacientes com lesão pulmonar aguda nos quais as tomografias foram obtidas em zero de pressão expiratória final positiva e em pressão expiratória final positiva. As tomografias computadorizadas foram realizadas do ápex ao diafragma, e os volumes pulmonares quantificados por análise dos histogramas de densidade.RESULTADOS: A análise dos histogramas de densidade em voluntários sadios em capacidade residual funcional mostrou histogramas monofásicos, com um pico em-791 + 12 UH. Em capacidade pulmonar total, o volume pulmonar aumentou em 79 + 35% e o pico das densidades pulmonares caiu para -886 + 26 UH. Mais de 70% do aumento no volume pulmonar foi localizado abaixo de -900 UH, sugerindo que este valor possa ser definido como o limite da hiperdistensão. Os pacientes com lesão pulmonar aguda mostraram em zero de pressão expiratória final positiva uma distribuição monofásica (n=3) ou bifásica (n=3), com densidades pulmonares médias situadas em 319 + 34 UH. Com a aplicação de pressão expiratória final positiva, ovolume pulmonar aumentou em 47 + 19%, enquanto que as densidades pulmonares caíram para -538 + 171 UH. Pressão expiratória final positiva induziu um recrutamento alveolar de 320 + 160 ml e uma hiperdistensão de 238 + 320 ml.CONCLUSÕES: O limite de hiperdistensão em voluntários sadios foi de -900 UH. Este limite pode ser usado em pacientes com lesão pulmonar aguda para diferenciarrecrutamento alveolar de hiperdistensão pressão expiratória final positiva induzidos.

OBJECTIVE: The aim of the present study was to establish the tomographic limit of lung overdistention in normal individuals as well as to assess positive end-expiratorypressure-induced overdistention and alveolar recruitment in patients with acute lung injury.MATERIALS AND METHODS: Lung distention was first determined in six healthy volunteers in whom computed tomographic sections were obtained at functionalresidual capacity and total lung capacity with a positive airway pressure of 30 cmH2O. Tomographic scans at zero end-expiratory pressure and positive end-expiratorypressure were performed in six patients with acute lung injury. Computed tomographies were performed from the apex to the diaphragm and lung volumes were quantified by the analysis of the density histograms.RESULTS: Analysis of the density histograms in healthy volunteers was monophasic with a peak at -791 ± 12 Housenfield units. In total lung capacity, lung volumeincreased by 79 ± 35% and the peak of lung density decreased to -886 ±26 Housenfield units. More than 70% of the increase in lung volume was located below-900 Housenfield units, suggesting that this value can be considered as the threshold separating normal aeration from overdistention. In patients with acute lung injury, atzero end-expiratory pressure the distribution of density histograms was either monophasic (n=3) or biphasic (n=3), with mean density of -319 ± 34 Housenfieldunits. With positive end-expiratory pressure application, lung volume increased by 47 ± 19%, while lung density decreased to -538 ± Housenfield units. Positive endexpiratory pressure induced a mean alveolar recruitment of 238 ±320 ml.CONCLUSIONS: The limit of overdistention in healthy individuals was -900 Housenfield units. This threshold can be used in patients with acute lung injury fordifferentiating alveolar recruitment from lung overdistention., OBJETIVO: O objetivo do presente estudo foi determinar o limite tomográfico da hiperdistensão pulmonar em indivíduos normais, bem como avaliar o recrutamentoe a hiperdistensão pulmonares induzidos pela pressão expiratória final positiva em pacientes com lesão pulmonar aguda.MATERIAIS E MÉTODOS: Inicialmente, o limite da hiperdistensão pulmonar foi determinado em seis voluntários sadios, nos quais tomografias computadorizadas espiraladas de tórax foram obtidas em capacidade residual funcional e em capacidadepulmonar total mais pressão positiva de 30 cm H2O. Posteriormente, foram avaliados seis pacientes com lesão pulmonar aguda nos quais as tomografias foram obtidas em zero de pressão expiratória final positiva e em pressão expiratória final positiva. As tomografias computadorizadas foram realizadas do ápex ao diafragma, e os volumes pulmonares quantificados por análise dos histogramas de densidade.RESULTADOS: A análise dos histogramas de densidade em voluntários sadios em capacidade residual funcional mostrou histogramas monofásicos, com um pico em-791 + 12 UH. Em capacidade pulmonar total, o volume pulmonar aumentou em 79 + 35% e o pico das densidades pulmonares caiu para -886 + 26 UH. Mais de 70% do aumento no volume pulmonar foi localizado abaixo de -900 UH, sugerindo que este valor possa ser definido como o limite da hiperdistensão. Os pacientes com lesão pulmonar aguda mostraram em zero de pressão expiratória final positiva uma distribuição monofásica (n=3) ou bifásica (n=3), com densidades pulmonares médias situadas em 319 + 34 UH. Com a aplicação de pressão expiratória final positiva, ovolume pulmonar aumentou em 47 + 19%, enquanto que as densidades pulmonares caíram para -538 + 171 UH. Pressão expiratória final positiva induziu um recrutamento alveolar de 320 + 160 ml e uma hiperdistensão de 238 + 320 ml.CONCLUSÕES: O limite de hiperdistensão em voluntários sadios foi de -900 UH. Este limite pode ser usado em pacientes com lesão pulmonar aguda para diferenciarrecrutamento alveolar de hiperdistensão pressão expiratória final positiva induzidos.

Additional file 4: Table S1. Bundle of care to prevent pneumonia in VA ECMO patients. Table S2. Lung ultrasound realization: each of the following ultrasound signs was looked for according to this standardized sequence. Table S3. sCPIS score as described by Luna et al [17]. Table S4. LUS-sCPIS score as described by Dureau et al [10]. The criterion based on the interpretation of the chest radiograph is the original sCPIS score is replaced by the presence or absence of a shunt on color Doppler. Table S5. comparison of the two groups, with and without pneumonia, according to the individualized criteria of the sCPIS score. Categorical variables are expressed as headcount (%).

Colistin; Phramacokinetic; Technique of nebulization Colistina; Farmacocinètica; Tècnica de nebulització Colistina; Farmacocinético; Técnica de nebulización Clinical evidence suggests that nebulized colistimethate sodium (CMS) has benefits for treating lower respiratory tract infections caused by multidrug-resistant Gram-negative bacteria (GNB). Colistin is positively charged, while CMS is negatively charged, and both have a high molecular mass and are hydrophilic. These physico-chemical characteristics impair crossing of the alveolo-capillary membrane but enable the disruption of the bacterial wall of GNB and the aggregation of the circulating lipopolysaccharide. Intravenous CMS is rapidly cleared by glomerular filtration and tubular excretion, and 20–25% is spontaneously hydrolyzed to colistin. Urine colistin is substantially reabsorbed by tubular cells and eliminated by biliary excretion. Colistin is a concentration-dependent antibiotic with post-antibiotic and inoculum effects. As CMS conversion to colistin is slower than its renal clearance, intravenous administration can lead to low plasma and lung colistin concentrations that risk treatment failure. Following nebulization of high doses, colistin (200,000 international units/24h) lung tissue concentrations are > five times minimum inhibitory concentration (MIC) of GNB in regions with multiple foci of bronchopneumonia and in the range of MIC breakpoints in regions with confluent pneumonia. Future research should include: (1) experimental studies using lung microdialysis to assess the PK/PD in the interstitial fluid of the lung following nebulization of high doses of colistin; (2) superiority multicenter randomized controlled trials comparing nebulized and intravenous CMS in patients with pandrug-resistant GNB ventilator-associated pneumonia and ventilator-associated tracheobronchitis; (3) non-inferiority multicenter randomized controlled trials comparing nebulized CMS to intravenous new cephalosporines/ß-lactamase inhibitors in patients with extensive drug-resistant GNB ventilator-associated pneumonia and ventilator-associated tracheobronchitis. This research received no external funding.

Additional file 1. The Chinese trauma system: historical background.

Additional file 2. The Russian trauma system: historical background.

Additional file 3. The South African trauma system: historical background.

International audience; Purpose of review: Although experimental evidence supports the use of nebulized antibiotics in ventilator-associated pneumonia (VAP), two recent multicenter randomized controlled trials (RCTs) have failed to demonstrate any benefit in VAP caused by Gram-negative bacteria (GNB). This review examines the methodological requirements concerning future RCTs.Recent findings: High doses of nebulized antibiotics are required to reach the infected lung parenchyma. Breath-synchronized nebulizers do not allow delivery of high doses. Mesh nebulizers perform better than jet nebulizers. Epithelial lining fluid concentrations do not reflect interstitial lung concentrations in patients receiving nebulized antibiotics. Specific ventilator settings for optimizing lung deposition require sedation to avoid patient's asynchrony with the ventilator.Summary: Future RCTs should compare a 3-5 day nebulization of amikacin or colistimethate sodium (CMS) to a 7-day intravenous administration of a new cephalosporine/ß-lactamase inhibitor. Inclusion criteria should be a VAP or ventilator-associated tracheobronchitis caused by documented extensive-drug or pandrug resistant GNB. If the GNB remains susceptible to aminoglycosides, nebulized amikacin should be administered at a dose of 40 mg/kg/day. If resistant to aminoglycosides, nebulized CMS should be administered at a dose of 15 millions international units (IU)/day. In VAP caused by pandrug-resistant GNB, 15 millions IU/day nebulized CMS (substitution therapy) should be compared with a 9 millions IU/day intravenous CMS.