Efficacy of prone positioning ventilation in acute respiratory distress syndrome after acute Stanford type A aortic dissection surgery / 中国胸心血管外科临床杂志

@#Objective     To explore the efficacy of prone positioning ventilation in patients with acute respiratory distress syndrome (ARDS) after acute Stanford type A aortic dissection (STAAD) surgery. Methods     From November 2019 to September 2021, patients with ARDS who was placed prone position after STAAD surgery in the Xiamen Cardiovascular Hospital of Xiamen University were collected. Data such as the changes of blood gas, respiratory mechanics and hemodynamic indexes before and after prone positioning, complications and prognosis were collected for statistical analysis. Results    A total of 264 STAAD patients had surgical treatment, of whom 40 patients with postoperative ARDS were placed prone position. There were 37 males and 3 females with an average age of 49.88±11.46 years. The oxygen partial pressure, oxygenation index and peripheral blood oxygen saturation 4 hours and 12 hours after the prone positioning, and 2 hours and 6 hours after the end of the prone positioning were significantly improved compared with those before prone positioning ventilation (P<0.05). The oxygenation index 2 hours after the end of prone positioning which was less than 131.42 mm Hg, indicated that the patient might need ventilation two or more times of prone position. Conclusion     Prone position ventilation for patients with moderate to severe ARDS after STAAD surgery is a safe and effective way to improve the oxygenation.

Effects of atelectatic areas on the surrounding lung tissue during mechanical ventilation in an experimental model of acute lung injury induced by lipopolysaccharide / Efeitos das áreas atelectásicas no tecido pulmonar circundante durante a ventilação mecânica em um modelo experimental de lesão pulmonar aguda induzida por lipopolissacarídeo

ABSTRACT Objective: To assess the effect of atelectasis during mechanical ventilation on the periatelectatic and normal lung regions in a model of atelectasis in rats with acute lung injury induced by lipopolysaccharide. Methods: Twenty-four rats were randomized into the following four groups, each with 6 animals: the Saline-Control Group, Lipopolysaccharide Control Group, Saline-Atelectasis Group, and Lipopolysaccharide Atelectasis Group. Acute lung injury was induced by intraperitoneal injection of lipopolysaccharide. After 24 hours, atelectasis was induced by bronchial blocking. The animals underwent mechanical ventilation for two hours with protective parameters, and respiratory mechanics were monitored during this period. Thereafter, histologic analyses of two regions of interest, periatelectatic areas and the normally-aerated lung contralateral to the atelectatic areas, were performed. Results: The lung injury score was significantly higher in the Lipopolysaccharide Control Group (0.41 ± 0.13) than in the Saline Control Group (0.15 ± 0.51), p < 0.05. Periatelectatic regions showed higher lung injury scores than normally-aerated regions in both the Saline-Atelectasis (0.44 ± 0.06 x 0.27 ± 0.74 p < 0.05) and Lipopolysaccharide Atelectasis (0.56 ± 0.09 x 0.35 ± 0.04 p < 0.05) Groups. The lung injury score in the periatelectatic regions was higher in the Lipopolysaccharide Atelectasis Group (0.56 ± 0.09) than in the periatelectatic region of the Saline-Atelectasis Group (0.44 ± 0.06), p < 0.05. Conclusion: Atelectasis may cause injury to the surrounding tissue after a period of mechanical ventilation with protective parameters. Its effect was more significant in previously injured lungs.

RESUMO Objetivo: Avaliar o efeito da atelectasia durante a ventilação mecânica nas regiões periatelectáticas e pulmonares normais em um modelo de atelectasia em ratos com lesão pulmonar aguda induzida por lipopolissacarídeo. Métodos: Foram distribuídos aleatoriamente 24 ratos em quatro grupos, cada um com 6 animais: Grupo Salina-Controle, Grupo Lipopolissacarídeo-Controle, Grupo Salina-Atelectasia e Grupo Lipopolissacarídeo-Atelectasia. A lesão pulmonar aguda foi induzida por injeção intraperitoneal de lipopolissacarídeo. Após 24 horas, a atelectasia foi induzida por bloqueio brônquico. Os animais foram submetidos à ventilação mecânica por 2 horas com parâmetros ventilatórios protetores, e a mecânica respiratória foi monitorada durante esse período. Em seguida, foram realizadas análises histológicas de duas regiões de interesse: as áreas periatelectásicas e o pulmão normalmente aerado contralateral às áreas atelectásicas. Resultados: O escore de lesão pulmonar foi significativamente maior no Grupo Controle-Lipopolissacarídeo (0,41 ± 0,13) do que no Grupo Controle-Solução Salina (0,15 ± 0,51), com p < 0,05. As regiões periatelectásicas apresentaram escores maiores de lesão pulmonar do que as regiões normalmente aeradas nos Grupos Atelectasia-Solução Salina (0,44 ± 0,06 versus 0,27 ± 0,74, p < 0,05) e Atelectasia-Lipopolissacarídeo (0,56 ± 0,09 versus 0,35 ± 0,04, p < 0,05). O escore de lesão pulmonar nas regiões periatelectásicas foi maior no Grupo Atelectasia-Lipopolissacarídeo (0,56 ± 0,09) do que na região periatelectásica do Grupo Atelectasia-Solução Salina (0,44 ± 0,06), p < 0,05. Conclusão: A atelectasia pode causar lesão no tecido circundante após um período de ventilação mecânica com parâmetros ventilatórios protetores. Seu efeito foi mais significativo em pulmões previamente lesionados.

Puntaje APP como predictor de mortalidad en pacientes con síndrome de dificultad respiratoria agudo grave por COVID-19 en un hospital referencial del norte del Perú

Introducción: La mortalidad por pacientes por COVID-19 grave que desarrollaban neumonía grave y síndrome de dificultad respiratoria agudo (SDRA) grave ha sido significativa a pesar del tratamiento oportuno. Es importante determinar predictores tempranos de enfermedad que nos ayuden a estratificar aquellos pacientes con mayor riesgo de fallecer. Se pretende estudiar el comportamiento del puntaje APP (APPS) como predictor de ello, basados en algunos reportes de uso y utilidad en el SDRA. no COVID-19. Objetivo: Determinar si el APPS es útil como predictor de mortalidad en SDRA. por COVID-19 grave. Pacientes y Método: Se realizó un estudio tipo cohorte retrospectivo, incluyendo pacientes de la Unidad de Cuidados Intensivos (UCI), con SDRA. por COVID-19 grave, que ingresaron a la UCI del Hospital Regional Docente de Trujillo (HRDT) en el período abril 2020- abril 2021. Se evalúo la utilidad del APPS como predictor de mortalidad em dicha población. Resultados: El APPS demostró ser un factor asociado a mortalidad en pacientes con SDRA. y COVID-19 grave (RPa 1,34; IC 95% 1,16 a 1,56; p < 0,001). Además, encontramos que, al realizar un modelo de predicción ajustado por edad, sexo, SOFA, APPS, shock, Indice de Charlson (ICh), se comportan como factores asociados a mortalidad el APPS, el sexo masculino (RPa: 1,48; IC 95% 1,09 a 2,049; p < 0,05) y el ICh (RPa: 1,11; IC 95% 1,02 a 1,21; p < 0,05). Conclusión: El APPS, el sexo masculino y el ICh son predictores de mortalidad en SDRA. por COVID-19 grave.

Background: Mortality in patients with severe COVID-19 who developed severe pneumonia and severe Acute Respiratory Distress Syndrome (ARDS) has been significant despite timely treatment. It is important to determine early predictors of disease that help us to stratify those patients with a higher risk of death. It is intended to study the behavior of the APPS score as a predictor of this, based on some reports of use and usefulness in non-COVID-19 ARDS. Aim: To determine if the APP score is useful as a predictor of mortality in ARDS due to severe COVID-19. Method: A retrospective cohort study was carried out, including patients from the Intensive Care Unit (ICU) with ARDS due to severe COVID-19 who were admitted to the ICU of the Trujillo Regional Teaching Hospital (HRDT) in the period March 2020 to March 2021. The usefulness of the APP score as a predictor of mortality in mentioned population was evaluated. Results: The APP score proved to be a factor associated with mortality in patients with ARDS and severe COVID-19 (APR 1.34; 95% CI 1.16 to 1.56; p < 0.001). We also found that when performing a prediction model adjusted for age, sex, SOFA, APP score, shock and Charlson Index (ICh) we found that the APP score, male sex (APR: 1.48; 95% CI 1.09 to 2.049; p < 0.05) and the ICh behave as factors associated with mortality (RPa: 1.11; 95% CI 1.02 to 1.21; p < 0.05). Conclusion: The APP score, male sex, and ICh are predictors of mortality in ARDS due to severe COVID-19.

Características de pacientes con SARS-CoV-2 en estado crítico en un centro COVID-19 de referencia en Uruguay

Introducción: la pandemia de COVID-19 produjo una alta mortalidad en el mundo. Sin embargo, las presentaciones más críticas de la enfermedad han sido poco caracterizadas en nuestra región. Objetivo: estudiar la presentación clínica, evolución y mortalidad en pacientes ingresados en la unidad de medicina intensiva de un centro COVID-19 de referencia. Pacientes y método: estudio clínico, prospectivo, observacional de SARS-CoV-2 durante las primeras etapas de la pandemia en Uruguay. Se definió mortalidad en unidad de cuidados intensivos (UCI) como desenlace primario. Resultados: en 274 pacientes, la edad mediana fue de 65 años (IQR 54-73), el sexo masculino representó el 57% y el índice de Charlson tuvo una mediana de 3 (IQR 2-5). La mortalidad en UCI fue 59,9%. Las principales causas de muerte fueron: hipoxemia refractaria, disfunción orgánica múltiple y shock refractario. La edad (Odds Ratio (OR) = 1,06; IC de 95% 1,03 - 1,09), ocupación de camas (OR = 1,04, IC 95%: 1,02 - 1,07), sexo masculino (OR = 2,14, IC 95%: 0,93 - 5,06), ventilación mecánica invasiva (OR = 51,7, IC 95%: 16,5 - 208,6), coinfección al ingreso (OR = 2,34, IC 95%: 0,88 - 6,77) y enfermedad renal crónica previa (OR = 13,1, IC 95%: 2,29 - 129,2) fueron predictores independientes de mortalidad. La primera ola de la pandemia se produjo por la circulación de las variantes P.6 y P.1 del coronavirus, en una población con muy bajo porcentaje de vacunación (8%). Conclusiones: estos resultados en pacientes críticos aportan una descripción detallada del impacto de la pandemia por SARS-CoV-2 en un centro de referencia y constituyen una base para enfrentar futuros eventos epidémicos.

Introduction: COVID-19 has caused high mortality worldwide. However, the most critical presentations of the disease have been poorly characterized in our region. Objective: to study the clinical presentation, progression, and mortality in patients admitted to the Intensive Care Unit (ICU) of a COVID-19 Reference Center. Patients and methods: clinical, prospective, observational study of SARS-CoV-2 during the early stages of the pandemic in Uruguay. ICU mortality was defined as the primary outcome. Results: in 274 patients, the median age was 65 years (IQR 54-73), male gender accounted for 57%, and the Charlson Index was 3 (IQR 2-5). ICU mortality was 59.9%. The main causes of death were refractory hypoxemia, multiple organ dysfunction, and refractory shock. Age (Odds Ratio (OR) = 1.06; 95% CI 1.03 - 1.09), bed occupancy (OR= 1.04, 95% CI: 1.02 -1.07), male gender (OR= 2.14, 95% CI 0.93 - 5.06), invasive mechanical ventilation (OR= 51.7, 95% CI 16.5 - 208.6), coinfection at admission (OR= 2.34, 95% CI 0.88 - 6.77), and pre-existing chronic kidney disease (OR= 13.1, 95% CI 2.29 - 129.2) were independent predictors of mortality. The first wave of the pandemic was driven by the circulation of the P.6 and P.1 variants of the coronavirus in a population with a very low vaccination percentage (8%). Conclusions: these results in critical patients provide a detailed description of the impact of the SARS-CoV-2 pandemic in a reference center and serve as a foundation for addressing future epidemic events.

Introdução: a COVID-19 causou alta morbimortalidade em todo o mundo, embora as formas graves da doença tenham sido pouco caracterizadas nos países da América Latina. Objetivos: analisar o quadro clínico, a evolução e a mortalidade em pacientes com COVID-19 atendidos em uma unidade de terapia intensiva (UTI) em um Centro de Referência. Métodos: Estudo clínico, prospectivo e observacional de pacientes com SARS-CoV-2 durante a primeira onda da pandemia no Uruguai. A mortalidade na UTI foi o resultado primário. Resultados: oram estudados 274 pacientes, com uma mediada de idade de 65 anos (IQR 54-73), sendo a maioria do sexo masculino (57%). O índice de Charlson foi de 3 (IQR 2-5). A mortalidade geral na UTI foi de 59,9%. As principais causas de morte foram hipoxemia refratária, disfunção orgânica múltipla e choque refratário. A idade (Odds Ratio (OR) = 1,06; IC 95% 1,03-1,09), ocupação de leitos (OR = 1,04; IC 95%: 1,02-1,07), sexo masculino (OR = 2,14; IC 95%: 0,93-5,06), ventilação mecânica invasiva (OR = 51,7; IC 95%: 16,5-208,6), coinfecção na admissão (OR = 2,34; IC 95%: 0,88-6,77) e doença renal crônica pré-existente (OR = 13,1; IC 95%: 2,29-129,2) foram preditores independentes de mortalidade. A primeira onda da pandemia foi impulsionada pela circulação das variantes P.6 e P.1 do SARS-CoV-2 em uma população com uma taxa de vacinação muito baixa (8%). Conclusões: esses resultados em pacientes críticos fornecem uma descrição detalhada do impacto da pandemia SARS-CoV-2 em um Centro de Referência e constituem uma base para o enfrentamento de futuros eventos epidêmicos.

Uso de cánula nasal de alto flujo artesanal como oxigenoterapia en insuficiencia respiratoria por COVID-19 / Use of artisanal high flow nasal cannula as oxygen therapy in respiratory failure due to COVID-19

Los riesgos asociados a la neumonía por (SARS-CoV-2) es la generación de insuficiencia respiratoria secundaria que en algunos casos desencadenara al tan temido síndrome de distres respiratorio (SDRA); Informes sobre atención clínica, indican que tiene una incidencia (SDRA) de 3-10 % con necesidad de Asistencia Respiratoria Mecánica (ARM) en pacientes hospitalizados; por lo que dispositivos de oxigenación no invasivos siguen siendo una opción atractiva, de forma inicial. Caso clínico: mujer de 47 años con insuficiencia respiratoria secundario a neumonía por COVID-19, por la gravedad se indica su ingreso a terapia intensiva, pero por razones de falta de unidad es manejada en unidad respiratoria, con el uso de dispositivos de oxigenación de armado ARTESAL, de manera exitosa, con la utilización de CNAF-artesanal, se pretende mejorar el trabajo respiratorio, índices de oxigenación, mientras se da tratamiento a la infección por el COVID-19; el objetivo del presente caso es reportar el presente caso con evolución favorable a la literatura disponible. Discusión: El uso de terapia de oxigenación con dispositivo de Cánula Nasal de Alto Flujo, aún no ha sido normatizado en pacientes con COVID-19, pero existe evidencia clínica sobre los efectos beneficiosos en la insuficiencia respiratoria en neonatos mas no en adultos. Conclusión: El uso temprano de la CNAF-artesanal en la insuficiencia respiratoria resulta muy atractivo, más aún con dispositivo de confección artesanal, da una opción más al paciente fuera de UTI, pudiendo apoyar en evitar la intubación y su ingreso a ventilación mecánica.

The risks associated with pneumonia (SARS-CoV-2) is the generation of secondary respiratory failure that in some cases will trigger the much feared respiratory distress syndrome (ARDS); Reports on clinical care indicate that it has an incidence (ARDS) of 3-10% with the need for Mechanical Respiratory Assistance (ARM) in hospitalized patients; so non-invasive oxygenation devices remain an attractive option, initially. Clinical case: a 47-year-old woman with respiratory failure secondary to covid-19 pneumonia. Due to the severity, her admission to intensive care is indicated, but for reasons of lack of unity, she is managed in a common room, with the use of high-pressure oxygenation devices. ARTISAL assembly, successfully, with the use of CNAF-artisanal, is intended to improve the work of breathing, and oxygenation indices, while treating the infection by COVID-19; The objective of this case is to report the present case with a favorable evolution based on the available literature. Discussion: The use of oxygenation therapy with a High Flow Nasal Cannula device has not yet been standardized in patients with COVID-19, but there is clinical evidence on the beneficial effects in respiratory failure in neonates but not in adults. Conclusion: The early use of the artisan HFNC in respiratory failure is very attractive, even more so with an artisanal device, it gives the patient another option outside the ICU, being able to help avoid intubation and admission to mechanical ventilation.

ARDS with septic shock managed successfully using a multidisciplinary approach: A case report

Acute respiratory distress syndrome (ARDS) is an inflammatory process in the lungs that results in hypoxemia and decreased lung compliance. Invasive mechanical ventilation and prone positioning have proven benefits in the management of patients with severe ARDS. Post-extubation rehabilitation programs are equally important for the recovery of these patients. We are reporting the case of a 30-year-old male with severe ARDS where lung protective ventilation, timely intubation, early prone positioning, multidisciplinary communication, and post-discharge follow-up with teleconsultation were used under expert supervision in the successful management of the case

Pronação de pacientes com Síndrome do Desconforto Respiratório Agudo: criação e validação de cenário simulado / Pronation of patients with Acute Respiratory Distress Syndrome: creation and validation of a simulated scenario

Resumo: Trata-se de um estudo metodológico para construção e validação de um cenário simulado com abordagem interprofissional, que permitirá a utilização no ensino e na educação permanente de profissionais da saúde por meio da metodologia ativa de simulação clínica. Este estudo foi realizado em uma universidade pública da região Sul do Brasil, objetivando construir e validar um cenário simulado para a pronação de pacientes críticos com Síndrome do Desconforto Respiratório Agudo (SDRA). Para isto, o estudo ocorreu em duas etapas: revisão de conteúdo, construção do cenário e de validação de conteúdo e de aparência por juízes. A revisão da literatura permitiu conhecer melhor sobre o manejo do paciente com SDRA, bem como subsidiar o desenvolvimento do caso clínico para o cenário. Um protocolo de pronação segura de um hospital universitário foi adotado. A partir desta revisão, a construção do cenário foi realizada considerando um roteiro validado. Como parte desta construção, surgiram como resultados: a descrição do cenário; a relação de materiais e equipamentos necessários para o desenvolvimento do cenário; o roteiro para o ator simulado; o guia de apoio ao facilitador; o guia de apoio ao participante; o quadro de apoio para tomada de decisão e o checklist de observação do desenvolvimento de competências e habilidades para cada profissão envolvida no cenário. Onze juízes participaram do estudo. Em relação ao perfil sociodemográfico dos juízes, a amostra foi predominantemente de enfermeiros (63,6%), seguido por fisioterapeutas (18,1%), médico (9%) e docente de enfermagem (9%). Para medir o percentual de concordância entre os juízes, adotou-se o Índice de Validade de Conteúdo (IVC) para os itens, que foram agrupados de acordo com unidades de significância. Após a leitura do cenário, os juízes responderam a um questionário do tipo Likert com 37 itens, que abordaram sobre a "Experiência Prévia do Participante/Briefing", "Conteúdo/Objetivos"; "Recursos Humanos"; "Preparo do Cenário", "Desenvolvimento do Cenário" e "Avaliação". Todos os itens obtiveram IVC superior ao desejável (0,80) e, portanto, foram considerados válidos. Além disso, os juízes realizaram sugestões de melhorias no cenário, aos quais foram acatadas ou rejeitas e discutidas com a literatura disponível. Este estudo permitiu criar e validar um cenário que reflete a prática real, ao mesmo tempo que oportuniza um ambiente seguro para os participantes e responde aos objetivos da aprendizagem.

Abstract: This is a methodological study for the construction and validation of a simulated scenario with an interprofessional approach, which will allow the use in the teaching and continuing education of health professionals through the active methodology of clinical simulation. This study was carried out in a public university in the South region of Brazil, aiming to build and validate a simulated scenario for the pronation of critically ill patients with Acute Respiratory Distress Syndrome (ARDS). To this end, the study occurred in two stages: content review, scenario construction, and content and appearance validation by judges. The literature review provided a better understanding of the management of the ARDS patient, as well as a basis for developing the clinical case for the scenario. A safe pronation protocol from a university hospital was adopted. Based on this review, the scenario was built using a validated script. As part of this process, the following results emerged: the description of the scenario; the list of materials and equipment needed for the development of the scenario; the script for the simulated actor; the facilitator support guide; the participant support guide; the decision support framework; and the checklist for observing the development of competencies and skills for each profession involved in the scenario. Eleven judges participated in the study. Regarding the sociodemographic profile of the judges, the sample was predominantly nurses (63.6%), followed by physical therapists (18.1%), physicians (9%), and nursing professors (9%). To measure the percentage of agreement between the judges, the Content Validity Index (CVI) was adopted for the items, which were grouped according to significance units. After reading the scenario, the judges answered a Likert-type questionnaire with 37 items, which addressed "Prior Participant Experience/Briefing", "Content/Objectives"; "Human Resources"; "Scenario Preparation", "Scenario Development", and "Evaluation". All items scored higher than desirable CVI (0.80) and were therefore considered valid. In addition, the judges made suggestions for improvements in the scenario, which were accepted or rejected and discussed with the available literature. This study made it possible to create and validate a scenario that reflects actual practice, while providing a safe environment for participants and meeting the learning objectives.

Stroke � Next Wave of Complications from COVID-19

Since the declaration of COVID-19 infection as Pandemic in March, 2020, There has been rise in Multisystem Complications apart from regular Acute Respiratory Syndrome which is hallmark of COVID-19 infection. As the second wave surge of COVID-19 has occurred, most of the patients already suffered from dyspnoea but also rare complications like CVA (Infarct and Haemorrhage) , Seizure and altered sensorium related to Hypoxic Brain Injury. COVID-19 frequently presents with a state of altered coagulability which increases the risk of pulmonary embolism and other Thrombotic events such as Cerebrovascular events. This case report is limited to Neurological complications seen in COVID-19 Infected patients

Clinical significance of alveolar-arterial oxygen gradients for late preterm and full-term infants with acute respiratory distress syndrome / 中国新生儿科杂志

Objective:To study the clinical significance of alveolar-arterial oxygen gradients (P A-aO 2) for late preterm and full-term infants with acute respiratory distress syndrome (ARDS). Methods:From January 2020 to June 2022, infants (gestational age ≥34 weeks) diagnosed with ARDS were admitted to the Neonatology Department of our hospital. The infants were assigned into the invasive group and the non-invasive group according to the ventilation mode. The infants with the same gestational age and diagnosed with neonatal wet lung were assigned into the control group. P A-aO 2 levels within 1 h after birth were compared among the three groups. The correlation of P A-aO 2 with ARDS, ventilation mode and duration were studied. Receiver operating characteristic (ROC) curve was used to determine the predictive value of P A-aO 2 within 1 h after birth for ARDS and the need of invasive ventilation. Results:A total of 36 cases were enrolled in the invasive group, 19 cases in the non-invasive group and 50 cases in the control group. Within 1 h after birth, P A-aO 2 in the invasive group was significantly higher than the non-invasive group and the control group ( P<0.05), and the non-invasive group higher than the control group ( P<0.05). Correlation analysis showed that P A-aO 2 within 1 h after birth in the invasive group was positively correlated with the duration of invasive ventilation and total mechanical ventilation ( r=0.601, P<0.001; r=0.504, P=0.002); P A-aO 2 before successful withdrawal of invasive ventilation was not correlated with subsequent non-invasive ventilation duration; and no correlation existed between P A-aO 2 within 1 h after birth and the duration of non-invasive ventilation in the non-invasive group. The area under the ROC curve for P A-aO 2 within 1 h after birth to predict ARDS was 0.875, with a sensitivity of 87.3% and a specificity of 72.0% at a cutoff value of 50.0 mmHg. The area under the ROC curve for predicting the need for invasive ventilation in infants with ARDS was 0.851, with a sensitivity of 80.0% at a cutoff value of 73.3 mmHg and a specificity of 75.0%. Conclusions:Late preterm and full-term infants have a higher risk of ARDS at P A-aO 2>50.0 mmHg within 1 h after birth. Infants with ARDS are more likely to require invasive ventilation if P A-aO 2>73.3 mmHg. The higher the level of P A-aO 2, the longer the duration of invasive ventilation and total duration of mechanical ventilation.

Comparison of clinical characteristics and outcomes of infants with moderate and severe acute respiratory distress syndrome diagnosed according to baseline oxygenation index / 中国小儿急救医学

Objective:To analyze the difference of clinical characteristics and outcomes of infants with moderate and severe pediatric acute respiratory distress syndrome(PARDS)diagnosed according to baseline oxygenation index(OI) in pediatric intensive care unit(PICU).Methods:Second analysis of the data collected from the "Efficacy of pulmonary surfactant (PS) in the treatment of children with moderate and severe ARDS" program.Retrospectively compare of the differences in clinical data such as general condition, underlying diseases, OI, mechanical ventilation, PS administration and outcomes among infants with moderate and severe PARDS divided by baseline OI who admitted to PICUs at 14 participating tertiary hospitals from 2016 to December 2021.Results:Among the 101 cases, 55 cases (54.5%) were moderate and 46 cases (45.5%) were severe PARDS.The proportion of male in the severe group (50.0% vs.72.7%, P=0.019) and the pediatric critical illness score(PCIS)[72 (68, 78) vs.76 (70, 80), P=0.019] were significantly lower than those in the moderate group, while there was no significant difference regarding age, body weight, etiology of PARDS and underlying diseases.The utilization rate of high-frequency ventilator in the severe group was significantly higher than that in the moderate group (34.8% vs.10.9%, P=0.004), but there was no significant difference in PS use, fluid load and pulmonary complications.The 24 h OI improvement (0.26±0.33 vs.0.04±0.34, P=0.001) and the 72 h OI improvement[0.34 (-0.04, 0.62) vs.0.15 (-0.14, 0.42), P=0.029)]in the severe group were significantly better than those in the moderate group, but there was no significant difference regarding mortality, length of hospital stay and intubation duration after diagnosis of PARDS between the two groups. Conclusion:In moderate and severe(divided by baseline OI) PARDS infants with invasive mechanical ventilation, children in severe group have better oxygenation improvement in the early stage after PARDS identified and are more likely to receive high frequency ventilation compared to those in moderate group.Baseline OI can not sensitively distinguish the outcomes and is not an ideal index for PARDS grading of this kind of patient.

Dynamic changes and clinical value of serum angiopoietin-2 and surfactant protein D in pediatric acute respiratory distress syndrome / 中国小儿急救医学

Objective:To study the relationship between the dynamic changes of angiopoietin-2 (Ang-2) and surfactant protein D (SP-D) in pediatric acute respiratory distress syndrome (pARDS) and the severity and prognosis of the disease.Methods:Using nested case-control study method, 80 children with pneumonia complicated with pARDS admitted to PICU at Fujian Maternal and Child Health Hospital from June 2018 to May 2021 were selected as pARDS group, and 19 healthy children with corresponding age were selected as control group.According to the oxygenation, the children in pARDS group were divided into three subgroups: mild group (23 cases), moderate group (32 cases) and severe group (25 cases). According to the prognosis at discharge, the children in pARDS group were divided into survival group (67 cases) and death group (13 cases). Ang-2 and SP-D were detected by enzyme-linked immunosorbent assay.The levels of Ang-2 and SP-D in children with pARDS of different severity on the first day were compared; The changes of Ang-2 and SP-D levels on the 1st, 3rd and 8th day of children in survival group and death group were compared, and the receiver operating characteristic (ROC) curve was plotted to compare the predictive value of Ang-2 and SP-D for pARDS prognosis.Results:(1) The levels of Ang-2 and SP-D on the first day in pARDS group were significantly higher than those in control group( P<0.001). (2) The levels of Ang-2 and SP-D on the first day in children with pARDS of different severity levels were significantly different ( P<0.001), and the levels of Ang-2 and SP-D increased gradually with the increase of disease severity.(3) The levels of Ang-2 and SP-D in death group were significantly higher than those in survival group on the 1st, 3rd and 8th day ( P<0.05). (4) Prognostic efficacy of Ang-2 and SP-D levels in pARDS group at different time points: when the areas under the ROC curve predicted by Ang-2 on the 1st, 3rd and 8th day for inpatient mortality in children with pARDS were 0.808, 0.981 and 0.989, respectively; the optimal cut-off values were 6 000 pg/mL, 6 971 pg/mL and 4 171 pg/mL, respectively; the sensitivity was 84.6%, 92.3% and 92.3%, respectively; and the specificity was 76.1%, 97.0% and 98.5%, respectively.The areas under the ROC curve predicted by SP-D on the 1st, 3rd and 8th day for inpatient mortality in children with pARDS were 0.689, 0.993 and 0.983, respectively; the optimal cut-off values were 13544 pg/mL, 16003 pg/mL and 12294 pg/mL, respectively; the sensitivity was 84.6%, 100.0% and 100.0%, respectively; and the specificity was 46.3%, 98.5% and 97.0%, respectively. Conclusion:Serum Ang-2 and SP-D levels in children with pARDS increase with the aggravation of the disease.The dynamic changes of Ang-2 and SP-D in children with pARDS with different prognosis are different during the course of disease, and monitoring serum Ang-2 and SP-D during the course of disease has a certain predictive value for clinical outcome.

Who is the core of lung-kidney interaction in critical illness: anoxia, fluid, inflammatory factors? / 中国小儿急救医学

Acute kidney injury and acute lung injury/acute respiratory distress syndrome are common in the pediatric intensive care unit.Lung-kidney interaction in critically ill patients is closely related to anoxia, fluid management, and inflammatory response in acute kidney injury and acute lung injury/acute respiratory distress syndrome patients.Strengthening the understanding of lung-kidney interaction can help clinicians to systematically manage critically ill patients.

Significance of sputum heparin binding protein in prognostic evaluation of children with sepsis complicated with acute respiratory distress syndrome / 中国小儿急救医学

Objective:To investigate the predictive value of sputum heparin binding protein(HBP) in sepsis related acute respiratory distress syndrome(ARDS).Methods:This study was a prospective case-control study.A total of 134 children with sepsis who were admitted in PICU at Hunan Children′s Hospital from January 2020 to November 2021 were included, including 63 children who had completed fiberoptic bronchoscopy.The 63 children were divided into sepsis without ARDS group, sepsis with mild ARDS group, and sepsis with moderate to severe ARDS group according to the presence and severity of ARDS.Sputum was collected and HBP was detected in all children with sepsis when they were admitted to the hospital.The alveolar lavage fluid within 72 hours of admission was reserved for HBP.The levels of interleukin (IL)-6 and tumor necrosis factor (TNF)- α were detected, and the blood biochemistry, pulmonary imaging, pediatric critical case score and other data within 72 hours were collected.Results:(1) Among 63 children with fiberoptic bronchoscopy, 29 were in sepsis without ARDS group, 18 were in the sepsis with mild ARDS group, and 16 were in the sepsis with moderate to severe ARDS group.There was no significant difference in the pediatric critical case score and the location of primary infection focus among the three groups at admission.The primary infection focus was respiratory system in 36 cases, whose sputum HBP level was (42.1±9.8) ng/mL, and 27 children with other systems infection, whose sputum HBP level was (37.8±10.8) ng/mL, there was no significant difference between two groups ( t=1.65, P=0.104). (2) There were significant differences in sputum HBP, alveolar lavage fluid HBP, IL-6 and TNF-α levels among sepsis with mild ARDS group, sepsis with moderate and severe ARDS group and sepsis without ARDS group ( P<0.05). The sputum HBP of 34 children with sepsis combined with ARDS was positively correlated with alveolar lavage fluid HBP, IL-6, TNF-α levels and lung injury score, and negatively correlated with SpO 2/FiO 2 ( P<0.05). (3)Among the 34 children with sepsis combined with ARDS, the sputum HBP concentration of children with invasive ventilation was significantly higher than that of children with non-invasive ventilation ( P<0.05). The sputum HBP concentration in children with three or more organ damage was significantly higher than that of children with two or less organ damage ( P<0.05). The sputum HBP concentration of dead children was higher than that of surviving children ( P<0.05). (4) The area under curve of sputum HBP for predicting ARDS was 0.772 (95% CI: 0.655~0.889). When the cut-off point value of sputum HBP was 27.9 mU/L, whose sensitivity and specificity were 70.6% and 79.3%, respectively.The area under curve of sputum HBP for predicting moderate and severe ARDS was 0.793 (95% CI: 0.661~0.926). When the cut-off point value of sputum HBP was 51.55 mU/L, whose sensitivity and specificity were 81.3% and 76.6%, respectively. Conclusion:Sputum HBP is elevated in children with sepsis and ARDS, which is related with the severity of the disease.Sputum HBP has a good predictive value for the diagnosis and severity of children with sepsis and ARDS, and can be used as a clinically effective and convenient evaluation index for children with sepsis related ARDS.

The preliminary study of extracorporeal carbon dioxide removal in acute respiratory distress syndrome for a pediatric patient / 中国小儿急救医学

Objective:Extracorporeal carbon dioxide removal(ECCO 2R) is a technique that aims to decarboxylate the blood and thus to correct hypercapnia and respiratory acidosis in acute respiratory failure, but is rarely used in children.We successfully completed the ECCO 2R treatment for a pediatric case with adenovirus pneumonia, severe acute respiratory distress syndrome(ARDS) and hypercapnia in PICU, which provided clinical references for the use of ECCO 2R in acute respiratory failure for children. Methods:A patient with adenovirus pneumonia and severe ARDS was successfully treated with ECCO 2R-continuous renal replacement therapy(CRRT)combined system after weaning from extracorporeal membrane oxygenation(ECMO). We reported the treatment process, ECCO 2R treatment effect and side effects, so as to provide clinical reference for ECCO 2R treatment of children with ARDS. Results:One-year and four-month-old boy was treated with mechanical ventilation and venous-arterial ECMO due to adenovirus pneumonia and severe ARDS.After ECMO treatment for 25 days, he developed severe hypercapnia after weaning from ECMO.ECCO 2R was initiated.The pH value increased by 11.2%(from 7.222 to 7.303) 1 hour after ECCO 2R treatment, partial pressure of blood carbon dioxide(PCO 2)decreased by 29.1%(from 72.6 mmHg to 51.5 mmHg, 1 mmHg=0.133 kPa) and the average airway pressure of high-frequency ventilation decreased by 5 cmH 2O(from 20 cmH 2O to 15 cmH 2O, 1 cmH 2O=0.098 kPa) after 6 hours of ECCO 2R.The CO 2 removal rate of ECCO 2R system was 29.1 mL/min.It was stopped because of ECCO 2R-membrane clotting after 72 h. There was no increase of PCO 2.Extubation was successfully after undergoing invasive mechanical ventilation for 39 days and with noninvasive ventilation for 5 days.The boy was hospitalized in PICU for 54 days, improved and discharged from the hospital.Followed up for 2 years after discharge, the growth and development were good, but the strenuous exercise endurance was still poor. Conclusion:ECCO 2R is effective in improving gas exchange, reducing PCO 2 and lowering ventilator pressure in children with ARDS and hypercapnia, which allow more protective ventilation.ECCO 2R provide transitional treatment for ECMO weaning and provide meaningful clinical reference for the use of ECCO 2R as part of respiratory support in children with respiratory failure.

Predictive value of lactate clearance rate combined with syndecan-1 in patients with septic shock and ARDS / 中华急诊医学杂志

Objective:To observe the changes of lactate clearance rate (LCR) and serum polyligandosan-1 (SDC-1) in patients with septic shock complicated with acute respiratory distress syndrome (ARDS) and to evaluate its prognostic value.Methods:Patients with septic shock and ARDS who were admitted to the Respiratory Intensive Care Unit (RICU) of Zhengzhou Central Hospital Affiliated to Zhengzhou University from February 2021 to April 2022 were selected as subjects. The patients were divided into the survival group and death group according to their 28-day survival status. General clinical data and related indicators of patients in the two groups were collected and compared. The related factors influencing the 28-day death of patients with septic shock and ARDS were screened, and receiver operating characteristic (ROC) curve was drawn to evaluate the individual and combined forecast value of LCR and SDC-1 for the prognosis of patients with septic shock and ARDS.Results:Compared with the survival group, sequential organ failure score (SOFA) and acute physiology and chronic health status score Ⅱ(APACHE Ⅱ) at admission to RICU, the levels of 24 h Lac, 6 h SDC-1, 24 h SDC-1 and 72 h SDC-1 in the death group increased significantly (all P< 0.05), and the levels of 6 h LCR, 24 h LCR, 6 h OI, 24 h OI and 72 h OI significantly decreased (all P<0.05). Spearman correlation analysis showed that SDC-1 at 6 h, 24 h and 72 h was significantly negatively correlated with OI at corresponding time points (all P<0.05), and LCR at 6 h and 24 h was significantly positively correlated with OI at corresponding time points (all P<0.05). Multivariate Logistic regression analysis showed that SOFA score, 24 h LCR, 24 h SDC-1 and 72 h SDC-1 were the risk factors of 28-d death in patients with septic shock and ARDS (all P<0.05). The areas under ROC curve of each related factor were SOFA score, 24 h LCR, 24 h SDC-1 and 72 h SDC-1, which could predict the prognosis (all P<0.05). 24 h LCR combined with 24 h SDC-1 had the maximum area under the curve (AUC=0.805, 95% CI: 0.691-0.920, with a sensitivity of 75.0% and a specificity of 74.4%). Conclusions:24 h LCR, 24 h SDC-1 and 72 h SDC-1 are the risk factors of the 28-day death of patients with septic shock and ARDS. 24 h LCR combined with 24 h SDC-1 can improve the test efficiency compared with the single indicator.

The assessment value of endothelial glycocalyx degradation products in pulmonary edema patients with acute respiratory distress syndrome / 中华急诊医学杂志

Objective:To investigate the application of endothelial glycocalyx degradation products in assessing the severity of pulmonary edema in patients with acute respiratory distress syndrome (ARDS).Methods:A prospective study was conducted to select patients diagnosed with ARDS at Wuxi People's Hospital from July 1, 2018 to December 31, 2019. The extravascular lung water index (EVLWI) was recorded within 2 h after admission by continuous cardiac output with pulse indicator. The indexes of glycocalyx degradation products syndecan-1 (SDC-1), heparan sulfate (HS), hyaluronic acid (HA) and the concentrations of inflammatory factors [blood tumor necrosis factor α (TNF-α), interleukin (IL)-6 and IL-10] were measured by enzyme-linked immunosorbent assay. Pearson correlation method was adopted to analyze the correlation of glycocalyx degradation products with EVLWI and inflammatory factors in ARDS patients. The patients were divided into the mild pulmonary edema group and severe pulmonary edema group according to EVLWI at the cut-off value of 10 mL/kg, and the differences of glycocalyx degradation products and inflammatory factors between the two groups were compared. Receiver operating characteristic (ROC) curve of the subjects were plotted to analyze the value of glycocalyx degradation products in determining the severity of pulmonary edema.Results:A total of 85 ARDS patients were enrolled. Pearson correlation analysis showed that SDC-1, HS, and HA were all positively correlated with IL-6, TNF-α, EVLWI (all P<0.05), but did not correlate with IL-10 (all P>0.05). Comparison of indicators between the mild pulmonary edema group (39 cases) and the severe pulmonary edema group (46 cases) showed that: IL-6[(33.63±3.43) ng/L vs. (39.99±4.64) ng/L], TNF-α[(43.38±6.05) ng/L vs. (50.79±7.35) ng/L], SDC-1[(494.13±47.23) ng/L vs. (563.50±56.36) ng/L], HS[(114.02±18.39) ng/mL vs. (138.93±17.02) ng/mL], and HA[(441.44±62.52) ng/mL vs. (546.23±85.24) ng/mL] were statistically different between the two groups(all P<0.05). Whereas, IL-10 [(24.37±10.11) ng/L vs. (28.75±11.98) ng/L] was not statistically different between the two groups ( P>0.05). ROC curve analysis showed that the combined prediction of SDC-1, HA and HS indicators was superior to the single indicator. The area under the ROC curve combining the three indicators was 0.928 (95% CI: 0.872-1.000), with a sensitivity and specificity of 87.5% and 86.7%, respectively. Conclusions:There is a positive correlation between glycocalyx degradation products SDC-1, HS, HA and EVLWI in ARDS patients. The application of these three glycocalyx degradation products can be used as a reliable indicators for judging the severity of pulmonary edema in ARDS patients.

Research progress of mechanical power in ventilator-induced lung injury / 国际生物医学工程杂志

ICU acute respiratory distress syndrome has a high morbidity and mortality rate, and these patients usually need mechanical ventilation to maintain their respiratory function during treatment. However, improper setting of mechanical ventilation parameters may lead to ventilator-induced lung injury (VILI). In order to effectively prevent the occurrence of VILI, ARDSnet recommends the use of a protective ventilation strategy with low tidal volume and limited airway plateau pressure. However, from the perspective of ventilator energy transfer, VILI is actually the result of a combination of respiratory parameters such as tidal volume, airway pressure, and respiratory rate. The mechanical power well reflects the combined effect of the above parameters and is increasingly becoming a hot topic in clinical research. In this review paper, the definitions of mechanical energy and mechanical power were introduced, and the calculation methods of mechanical power under different respiratory modes are summarized. Moreover, the clinical studies related to mechanical power and VILI and further exploration of the safety threshold of mechanical power are reviewed. It is expected to provide new ideas for the future clinical development of personalized mechanical ventilation strategies and the effective prevention of VILI.

Advances in the fluid management strategies of pediatric acute respiratory distress syndrome / 国际儿科学杂志

Pediatric acute respiratory distress syndrome(PARDS)is a pulmonary inflammation syndrome caused by a variety of proinflammatory factors induced by many causes, which is mainly characterized by noncardiogenic pulmonary edema.The main pathophysiological feature is the destruction of the integrity of the alveolar capillary membrane, and the loss of the alveolar epithelial-endothelial barrier function.In the PARDS′s clinical practice, the mainstay of the treatment is supportive.Although there is still no clear definition and general consensus or guidelines, appropriate liquid therapy is an important part of non-ventilatory treatment measures.Proper fluid management strategy is helpful to improve pulmonary edema, maintain normal circulatory perfusion, prevent functional failure of important organs and improve the prognosis of patients.According to volume status, implementing the goal-oriented and phased differentiated fluid management strategy is significant for the therapy of PARDS patients.However, the effects of fluid strategy management according to PARDS phenotypes remain to be evaluated.

Progress of unfolded protein response in acute respiratory distress syndrome / 国际儿科学杂志

Acute respiratory distress syndrome(ARDS)is a severe respiratory disease in children and the pathogenesis is not fully defined.It is mainly related to various mechanisms of lung injury such as inflammation and autophagy.In recent years, studies have found that, endoplasmic reticulum stress(ERS)can aggravate lung injury in ARDS, in which protein homeostasis imbalance can induce activation of the unfolded protein response(UPR).The UPR reconstructs homeostasis by mediating transmembrane protein-related signaling pathways, while continuous excessive ERS will promote apoptosis and autophagy.This review summarizes the progress of the signaling pathway of UPR related to lung injury and its inflammatory effect in ARDS.

Progress on the mechanisms of low molecular weight heparin in treating acute respiratory distress syndrome caused by viral pneumonia / 国际儿科学杂志

Acute respiratory distress syndrome(ARDS) is an important pathological process in patients with severe viral pneumonia.The coagulation disorder is one of the important characteristics of patients with viral pneumonia.In recent years, more and more studies have been exploring the related mechanisms of ARDS caused by viral pneumonia.Although the application of low molecular weight heparin(LMWH) to prevent and treat thrombotic complications in patients with viral pneumonia has become an industry consensus, in addition to anticoagulation, LMWH also has multiple effects such as anti-inflammatory and antioxidant.Therefore, the therapeutic effect of LMWH on ARDS remains to be fully explored.This article focuses on the pathological and clinical characteristics of viral pneumonia, to explore the evidence and clinical mechanisms of LMWH in the treatment of ARDS.