Author Response.

How to cite this article: Todur P, Chaudhuri S. Author Response. Indian J Crit Care Med 2024;28(2):179-180.

Comparison of the Recent ExPreS Score, WEANSNOW Score, and the Parsimonious HACOR Score as the Best Predictor of Weaning: An Externally Validated Prospective Observational Study.

Background: Since weaning failure is multifactorial, comprehensive weaning scores encompassing not only the respiratory component but also nonrespiratory aspects are quintessential for successful weaning prediction. Materials and methods: This was a single-center prospective observational study on 128 intensive care unit (ICU) patients undergoing spontaneous breathing trials (SBT). The extubation prediction score (ExPreS), heart rate, acidosis, consciousness, oxygenation, respiratory rate (HACOR), and weaning parameters, endotracheal tube size, arterial blood gas analysis, nutrition, secretions, neuromuscular affecting agents, obstructive airway problems and wakefulness (WEANSNOW) scores were compared for their diagnostic accuracy for successful weaning prediction. Results: Out of 128 patients, 49 (38.3%) patients had weaning failure, and 79 (61.7%) had weaning success. The patients in the weaning failure group had significantly higher APACHE II scores, WEANSNOW scores, HACOR scores, MV days, and significantly lower ExPreS scores as compared to the successful weaning group. Multivariable regression analysis showed that ExPreS score p = 0.015, adjusted OR 0.960, 95% CI (0.929-0.992) and HACOR score p < 0.001, adjusted OR 1.357, 95% CI (1.176-1.567) were independent predictors of weaning failure. The HACOR score had an AUC of 0.830, cut-off ≥5, p < 0.001, sensitivity 76%, specificity 68%, diagnostic accuracy 70% to predict weaning failure. The ExPreS score had an AUC of 0.735, cut-off ≥69, p < 0.001, sensitivity of 70.9%, specificity of 69.4%, and diagnostic accuracy of 70.3% to predict weaning success. Both the HACOR and ExPreS scores were good models for predicting weaning outcomes (model quality 0.76 and 0.64 respectively). Conclusion: The parsimonious HACOR score is comparable to the ExPreS score for the prediction of weaning outcomes in critically ill patients. How to cite this article: Nayak G, Chaudhuri S, Ravindranath S, Todur P. Comparison of the Recent ExPreS Score, WEANSNOW Score, and the Parsimonious HACOR Score as the Best Predictor of Weaning: An Externally Validated Prospective Observational Study. Indian J Crit Care Med 2024;28(3):273-279.

Changes in Driving Pressure vs Oxygenation as Predictor of Mortality in Moderate to Severe Acute Respiratory Distress Syndrome Patients Receiving Prone Position Ventilation.

Background: Prone position ventilation (PPV) causes improvement in oxygenation, nevertheless, mortality in severe acute respiratory distress syndrome (ARDS) remains high. The changes in the driving pressure (DP) and its role in predicting mortality in moderate to severe ARDS patients receiving PPV is unexplored. Methods: A prospective observational study, conducted between September 2020 and February 2023 on moderate-severe ARDS patients requiring PPV. The values of DP and oxygenation (ratio of partial pressure of arterial oxygen to fraction of inspired oxygen [PaO2/FiO2]) before, during, and after PPV were recorded. The aim was to compare the DP and oxygenation before, during and after PPV sessions among moderate- severe ARDS patients, and determine the best predictor of mortality. Results: Total of 52 patients were included; 28-day mortality was 57%. Among the survivors, DP prior to PPV as compared to post-PPV session reduced significantly, from 16.36 ± 2.57 cmH2O to 13.91 ± 1.74 cmH2O (p-value < 0.001), whereas DP did not reduce in the non-survivors (19.43 ± 3.16 to 19.70 ± 3.15 cmH2O (p-value = 0.318)]. Significant improvement in PaO2/FiO2 before PPV to post-PPV among both the survivors [92.75 [67.5-117.75]) to [205.50 (116.25-244.50)], (p-value < 0.001) and also among the non-survivors [87.90 (67.75-100.75)] to [112 (88.00-146.50)], (p-value < 0.001) was noted. Logistic regression analysis showed DP after PPV session as best predictor of mortality (p-value = 0.044) and its AUROC to predict mortality was 0.939, cut-off ≥16 cmH2O, 90% sensitivity, 82% specificity. The Kaplan-Meier curve of DP after PPV ≥16 cmH2O and <16 cmH2O was significant (Log-rank Mantel-Cox p-value < 0.001). Conclusion: Prone position ventilation-induced decrease in DP is prognostic marker of survival than the increase in PaO2/FiO2. There is a primacy of DP, rather than oxygenation, in predicting mortality in moderate-severe ARDS. Post-PPV session DP ≥16 cmH2O was an independent predictor of mortality. How to cite this article: Todur P, Nileshwar A, Chaudhuri S, Shanbhag V, Cherisma C. Changes in Driving Pressure vs Oxygenation as Predictor of Mortality in Moderate to Severe Acute Respiratory Distress Syndrome Patients Receiving Prone Position Ventilation. Indian J Crit Care Med 2024;28(2):134-140.

Incidence, Outcomes, and Predictors of Subphenotypes of Acute Kidney Injury among Acute Respiratory Distress Syndrome Patients: A Prospective Observational Study.

Background: Acute kidney injury (AKI) is a heterogeneous syndrome with subphenotypes. Acute kidney injury is one of the most common complications in acute respiratory distress syndrome (ARDS) patients, which influences mortality. Material and methods: It was a single-center observational study on 266 ARDS patients on invasive mechanical ventilation (IMV) to determine the subphenotypes of AKI associated with ARDS. Subphenotyping was done based on the serum creatinine (SCr) trajectories from day 1 to day 5 of IMV into resolving (subphenotype 1) or non-resolving (subphenotype 2) AKI. Results: Out of 266 ARDS patients, 222 patients were included for data analysis. 141 patients (63.51%) had AKI. The incidence of subphenotype 2 AKI among the ARDS cohort was 78/222 (35.13%). Subphenotype 2 AKI was significantly more among the non-survivors (87.7% vs 36.2 %, p < 0.001). Subphenotype 2 AKI was an independent predictor of mortality among ARDS patients (p < 0.001, adjusted odds ratio 8.978, 95% CI [2.790-28.89]. AKI subphenotype 1 had higher median day 1 SCr than subphenotype 2 but lower levels by day 3 and day 5 of IMV. The median time of survival was 8 days in AKI subphenotype 2 vs 45 days in AKI with subphenotype 1 [Log-Rank (Mantel-Cox) p < 0.001]. The novel DRONE score (Driving pressure, Oxygenation, and Nutritional Evaluation) ≥ 4 predicted subphenotype 2 AKI. Conclusion: The incidence of subphenotype 2 (non-resolving) AKI among ARDS patients on IMV was about 35% (vs 20% subphenotype 1 AKI), and it was an independent predictor of mortality. The DRONE score ≥4 can predict the AKI subphenotype 2. Highlights: The serum creatinine trajectory-based subphenotype of AKI (resolving vs non-resolving) determines survival in ARDS patients. Non-resolving AKI subphenotype 2 is an independent predictor of mortality in ARDS. The novel DRONE score (driving pressure, oxygenation, and nutritional evaluation) ≥ 4 within 48 hours of IMV predicted the AKI subphenotype 2 among ventilated ARDS patients. How to cite this article: Todur P, Nileshwar A, Chaudhuri S, Srinivas T. Incidence, Outcomes, and Predictors of Subphenotypes of Acute Kidney Injury among Acute Respiratory Distress Syndrome Patients: A Prospective Observational Study. Indian J Crit Care Med 2023;27(10):724-731.

Utility of the One-time HACOR Score as a Predictor of Weaning Failure from Mechanical Ventilation: A Prospective Observational Study.

Aim: To determine the utility of the HACOR score in predicting weaning failure in resource-limited settings. Objectives: The primary objective was to determine a cut-off value of the HACOR score, sensitivity, and specificity to predict failed weaning. The secondary objective was to determine which out of five components of the score was significantly different between the successful weaning and the failed weaning groups. Introduction: Most weaning indices are either inaccurate or are dependent on complex ventilatory parameters, which are difficult to measure in resource-limited settings. This study aimed to determine the utility of the HACOR score consisting of heart rate, acidosis, consciousness level, oxygenation, and respiratory rate as a predictor of weaning in the intensive care unit. Materials and methods: It was a prospective observational study on 120 patients between 18 and 90 years. The HACOR score was evaluated at 30 minutes of spontaneous breathing trial (SBT). The total duration of SBT was 120 minutes. Results: Out of 120 patients, 83 (69.2%) had successful weaning, whereas 37 (30.8%) had weaning failure. The median and interquartile range (IQR) of the HACOR score in the successful weaning group was 2 (0-3) and 6 (5-8) in the failed weaning group (p-value <0.001). There was a significant difference in each of the five components of the HACOR score between the successful and failed weaning groups (p <0.05). HACOR score ≥5 predicted failed weaning, sensitivity 83.8%, specificity 96.4%, area under the curve (AUC) 0.950, and 95% confidence interval (CI) [0.907-0.993], p <0.001. Multivariable logistic regression analysis showed that HACOR score ≥5 is an independent predictor of weaning failure [p <0.001, 95% CI (1.9-4.2), adjusted odds ratio 2.82]. Conclusion: A HACOR score ≥5 is an excellent predictor of weaning failure. This score may be useful as a weaning strategy in the intensive care unit. How to cite this article: Chaudhuri S, Gupta N, Adhikari SD, Todur P, Maddani SS, Rao S. Utility of the One-time HACOR Score as a Predictor of Weaning Failure from Mechanical Ventilation: A Prospective Observational Study. Indian J Crit Care Med 2022;26(8):900-905. Ethical approval: Prior to the commencement of the study, Institutional Ethics Committee permission was obtained (IEC: 197/2021) and Clinical Trial Registry of India (CTRI) registration was done before recruitment (CTRI/2021/07/035139). We obtained written informed consent from the legally authorized representative prior to recruiting patients for the study.

Correlation of Oxygenation and Radiographic Assessment of Lung Edema (RALE) Score to Lung Ultrasound Score (LUS) in Acute Respiratory Distress Syndrome (ARDS) Patients in the Intensive Care Unit.

BACKGROUND: Lung ultrasound score (LUS) as well as radiographic assessment of lung edema (RALE) score as calculated from chest radiography (CXR) have been applied to assess Acute Respiratory Distress Syndrome (ARDS) severity. CXRs, which are frequently performed in ARDS patients, pose a greater risk of radiation exposure to patients and health care staff. AIMS AND OBJECTIVES: The aim of the study was to evaluate if LUS had a better correlation to oxygenation (PaO2/FiO2) compared with the RALE score in ARDS patients. We also aimed to analyse if there was a correlation between RALE score and LUS. We wanted to determine the LUS and RALE score cut-off, which could predict a prolonged length of intensive care unit (ICU) stay (≥10 days) and survival. METHODS: Thirty-seven patients aged above 18 years with ARDS as per Berlin definition and admitted to the ICU were included in the study. It was a retrospective study done over a period of 11 months. On the day of admission to ICU, the global and basal LUS, global and basal RALE score, and PaO2 /FiO2 were recorded. Outcome and days of ICU stay were noted. RESULTS: Global LUS score and PaO2/FiO2 showed the best negative correlation (r = -0.491), which was significant (p = 0.002), followed by global RALE score and PaO2/FiO2 (r = -0.422, p = 0.009). Basal LUS and PaO2/FiO2 also had moderate negative correlation (r = -0.334, p = 0.043) followed by basal RALE score and PaO2/FiO2 (r = -0.34, p = 0.039). Global RALE score and global LUS did not show a significant correlation. Similarly, there was no significant correlation between basal RALE score and basal LUS. Global and basal LUS as well as global and basal RALE score were not beneficial in predicting either a prolonged length of ICU stay or survival as the area under curve was low. CONCLUSION: In ARDS patients, global LUS had the best correlation to oxygenation (PaO2/FiO2), followed by global RALE score. Basal LUS and basal RALE score also had moderate correlation to oxygenation. However, there was no significant correlation between global LUS and global RALE score as well as between basal LUS and basal RALE score. Global and basal LUS as well as global and basal RALE scores were not able to predict a prolonged ICU stay or survival in ARDS patients.

"Post-COVID-19 syndrome:" The New Pandemic Affecting Healthcare Workers and How the Frontline Warriors Are Battling it.

OBJECTIVES: "Post-COVID-19 syndrome," which may be the new pandemic, has affected various domains of quality of life; even among those who have recovered from mild COVID-19 disease. The aim of our study was to explore the health, social and psychological impact on healthcare workers (HCWs) who have recovered from active COVID-19 illness and highlight their needs post-recovery. MATERIALS AND METHODS: It was a web-based survey study. A total of 163 eligible consenting HCWs participated in this survey. The Institutional Ethical Committee approval was obtained before study recruitment and the study was registered with the Clinical Trial Registry of India. Each participant responded to 25 questions. RESULTS: Among those participated, 51% were doctors, 32% were nurses and others were allied health professionals and students. About 82% had mild COVID-19 illness and 40% required hospitalisation for COVID-19 treatment. In the post-recovery period, 66% experienced health issues and fatigue on mild exertion was the most common symptom (42.94%). It was followed by anosmia and ageusia (21.47%), headache and myalgia (15.34%) and breathlessness (8.59%). About 82% HCW felt the need for a post-COVID-19 recovery health care unit. Potential risk of infecting family members was the most common concern (53.46%) followed by the fear of contracting the virus again (46.54%). About 35% of HCW experienced the fear of developing post-COVID-19 complications. About 78% of HCW did not report any psychological concerns, but one-third were stressed due to the financial impact. CONCLUSION: Post-COVID-19 syndrome impacts all domains of quality of life. Fatigue, loss of taste and smell, headache, myalgia and breathlessness continue to persist beyond recovery of active illness. Most of the HCWs emphasised the need to set up post-COVID-19 care units. The fear of contracting the virus again and financial drain due to hospital expenses continued to distress HCWs.

Development and Internal Validation of a Novel Prognostic Score to Predict Mortality in Acute Respiratory Distress Syndrome - Driving Pressure, Oxygenation and Nutritional Evaluation - "DRONE Score".

Introduction: There are few scores for mortality prediction in acute respiratory distress syndrome (ARDS) incorporating comprehensive ventilatory, acute physiological, organ dysfunction, oxygenation, and nutritional parameters. This study aims to determine the risk factors of ARDS mortality from the above-mentioned parameters at 48 h of invasive mechanical ventilation (IMV), which are feasible across most intensive care unit settings. Methods: Prospective, observational, single-center study with 150 patients with ARDS defined by Berlin definition, receiving IMV with lung protective strategy. Results: Our study had a mortality of 41.3% (62/150). We developed a 9-point novel prediction score, the driving pressure oxygenation and nutritional evaluation (DRONE) score comprising of driving pressure (DP), oxygenation accessed by the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) ratio and nutritional evaluation using the modified nutrition risk in the critically ill (mNUTRIC) score. Each component of the DRONE score with the cutoff value to predict mortality was assigned a particular score (the lowest DP within 48 h in a patient being always ≥15 cmH2O a score of 2, the highest achievable PaO2/FiO2 <208 was assigned a score of 4 and the mNUTRIC score ≥4 was assigned a score of (3). We obtained the DRONE score ≥4, area under the curve 0.860 to predict mortality. Cox regression for the DRONE score >4 was highly associated with mortality (P < 0.001, hazard ratio 5.43, 95% confidence interval [2.94-10.047]). Internal validation was done by bootstrap analysis. The clinical utility of the DRONE score ≥4 was assessed by Kaplan-Meier curve which showed significance. Conclusions: The DRONE score ≥4 could be a reliable predictor of mortality at 48 h in ARDS patients receiving IMV.

Utility of Pulse Oximetry Oxygen Saturation (SpO2) with Incorporation of Positive End-Expiratory Pressure (SpO2 ∗10/FiO2 ∗PEEP) for Classification and Prognostication of Patients with Acute Respiratory Distress Syndrome.

Background: Conventionally, PaO2/FiO2 (P/F ratio) has been used to categorize severity of acute respiratory distress syndrome (ARDS) and prognostication of outcome. Recent literature has shown that incorporation of positive end-expiratory pressure (PEEP) into the P/F ratio (PaO2 ∗10/FiO2 ∗PEEP or P/FP∗10) has a much better prognostic ability in ARDS as compared to P/F ratio. The aim of this study was to correlate SpO2 ∗10/FiO2 ∗PEEP (S/FP∗10) to PaO2 ∗10/FiO2 ∗PEEP (P/FP∗10) and evaluate the utility of S/FP∗10 as a reliable noninvasive indicator of oxygenation in ARDS to avoid repeated arterial blood sampling. Aim: To evaluate if pulse oximetry is a reliable indicator of oxygenation in ARDS patients by calculating SpO2 ∗10/FiO2 ∗PEEP (S/FP∗10). The primary objective was to determine the correlation of S/FP∗10 to P/FP∗10 ratio in ARDS patients. The secondary objective was to determine the cut-off value of S/FP∗10 ratio to predict severe ARDS and survival. Methods: Patients aged 18-80 years on invasive mechanical ventilation (MV) diagnosed with ARDS as defined by the Berlin definition were included. The values of PaO2, FiO2, and SpO2 were collected at three different time points. They were at baseline, i.e., after intubation and initiation of MV (within one hour of intubation), day one (1-24 hours of MV), and day three (48-72 hours of MV). The primary outcome was survival at the end of intensive care unit (ICU) stay. Results: A total of 85 patients with ARDS on invasive MV were included. The data points were obtained at baseline, day one, and day three of MV. S/FP∗10 ratio has an excellent correlation to P/FP∗10 ratio at baseline and day three of invasive MV (r = 0.831 and 0.853, respectively; p < 0.001) and has a strong correlation on day one of invasive MV (r = 0.733, p < 0.001). S/FP∗10 ratio ≤116 at baseline has excellent discriminant function to be categorized as severe ARDS as per Berlin definition (AUC: 0.925, p < 0.001, 90% sensitivity, 93% specificity, CI: [0.862-0.988]). The increase in S/FP∗10 ratio by ≥64.40 from baseline to day three of MV is a good predictor of survival (AUC: 0.877, p < 0.001, 73.5% sensitivity, 97% specificity, CI: [0.803-0.952]). Conclusion: S/FP∗10 has a strong correlation to P/FP∗10 in ARDS patients. S/FP∗10 ≤116 has an excellent discriminant function to be categorized as severe ARDS. The S/FP∗10 ratio on day three of MV and the change in S/FP∗10 ratio from baseline and day one to day three of MV are good predictors of survival in ARDS patients. This trial is registered with CTRI/2020/04/024940.

Utility of the Modified Nutritional Risk in the Critically ill Score as an Outcome Predictor in All-Cause Acute Respiratory Distress Syndrome and Acute Febrile Illness-Induced Acute Respiratory Distress Syndrome.

Introduction: Nutritional risk in the Critically Ill (NUTRIC) score is a predictor of adverse outcomes in the critically ill, and its utility in a specific population of critically ill has been recommended. We aimed to study the utility of modified NUTRIC (mNUTRIC) score as a mortality predictor in acute febrile illness (AFI)-induced acute respiratory distress syndrome (ARDS) and all-cause ARDS patients. Methods: We recorded data from two prospective observational ARDS studies conducted at a single-center tertiary care hospital to evaluate the utility of the mNUTRIC score as an independent mortality predictor in all-cause ARDS and AFI-ARDS. A total of 216 all-cause ARDS patients were included, of which 73 were AFI-ARDS and 143 were non-AFI ARDS. Results: Mortality of AFI-ARDS was 16/73 (21.9%) compared to 62/143 (43.35%) in non-AFI ARDS (P = 0.002). There were no significant differences in severity of ARDS in AFI-ARDS and non-AFI ARDS groups (P = 0.504). The mNUTRIC score was found to be an independent predictor of mortality in all-cause ARDS patients (n = 216) and AFI-ARDS patients (n = 73) after Cox regression multivariable analysis. In all-cause ARDS, the mNUTRIC score had an area under the curve (AUC) of 0.778, cutoff ≥4, 82.1% sensitivity, and 65.9% specificity as a predictor of mortality. In AFI-ARDS, the mNUTRIC score had an AUC of 0.769, cutoff ≥4, 81.3% sensitivity, 66.67% specificity, and P = 0.001 as a predictor of mortality. Conclusion: The mNUTRIC score is an independent mortality predictor for all-cause ARDS and AFI-ARDS patients. AFI-ARDS has significantly lesser mortality than non-AFI ARDS.

Correlation of Serum Albumin Level to Lung Ultrasound Score and Its Role as Predictors of Outcome in Acute Respiratory Distress Syndrome Patients: A Prospective Observational Study.

BACKGROUND: There is ambiguity in the literature regarding hypoalbuminemia as a cause of extravascular lung water and acute respiratory distress syndrome (ARDS) outcomes. The aim of the study was to determine if low serum albumin on admission leads to lung deaeration and higher lung ultrasound score (LUSS) in ARDS patients. Patients and Methods. It was a prospective observational study in which 110 ARDS patients aged between 18 and 70 years were recruited. Serum albumin level and lung ultrasound score were assessed on the day of ICU admission. Length of ICU stay and hospital mortality were recorded. RESULTS: The mean and standard deviation of serum albumin level in mild, moderate, and severe ARDS was 2.92 ± 0.65 g/dL, 2.91 ± 0.77 g/dL, and 3.21 ± 0.85 g/dL, respectively. Albumin level was not correlated to the global LUSS (Pearson correlation r -0.006, p=0.949) and basal LUSS (r -0.066, p=0.513). The cut-off value of albumin for predicting a prolonged length of ICU stay (≥10 days) in ARDS patients was <3.25 g/dL with AUC 0.623, p < 0.05, sensitivity of 86.67%, specificity of 45.45%, and 95% confidence interval (CI) [0.513-0.732], and on multivariate analysis it increased the odds of prolonged ICU stay by 8.9 times (Hosmer and Lemeshow p value 0.810, 95% CI [2.760-28.72]). Serum albumin at admission was not a predictor of mortality. LUSS on the day of admission was not useful to predict either a prolonged length of ICU stay or mortality. Basal LUSS contributed about 56% of the global LUSS in mild and moderate ARDS, and 53% in severe ARDS. CONCLUSION: Serum albumin level was unrelated to LUSS on admission in ARDS patients. Albumin level <3.25 g/dL increased the chances of a prolonged length of ICU stay (≥10 days) but was not associated with an increase in mortality. LUSS on the day of admission could not predict either a prolonged length of ICU stay or mortality. This trial is registered with CTRI/2019/11/021857.