Effect of early administration of dexamethasone in patients with COVID-19 pneumonia without acute hypoxemic respiratory failure and risk of development of acute respiratory distress syndrome: EARLY-DEX COVID-19 trial.

Introduction and objectives: Corticosteroids are among the drugs demonstrating a mortality benefit for coronavirus disease 2019 (COVID-19). The RECOVERY trial highlighted that dexamethasone reduced 28-day mortality for hospitalized COVID-19 patients requiring either supplemental oxygen or mechanical ventilation. It is noted that approximately 30% of COVID-19 patients, initially presenting with mild symptoms, will advance to acute respiratory distress syndrome (ARDS), especially those with detectable laboratory markers of inflammation indicative of disease progression. Our research aimed to explore the efficacy of dexamethasone in preventing the progression to ARDS in patients hospitalized with COVID-19 pneumonia who do not yet require additional oxygen but are at high risk of developing ARDS, potentially leading to a reduction in morbimortality. Methods: In this multicenter, randomized, controlled trial, we evaluated the impact of dexamethasone on adult patients diagnosed with COVID-19 pneumonia who did not need supplementary oxygen at admission but were identified as having risk factors for ARDS. The risk of ARDS was determined based on specific criteria: elevated lactate dehydrogenase levels over 245 U/L, C-reactive protein levels exceeding 100 mg/L, and a lymphocyte count below 0.80 × 109/L. Participants were randomly allocated to either receive dexamethasone or the standard care. The primary endpoints included the incidence of moderate or severe ARDS and all-cause mortality within 30 days post-enrollment. Results: One hundred twenty-six patients were randomized. Among them, 41 were female (30.8%), with a mean age of 48.8 ± 14.4 years. Ten patients in the dexamethasone group (17.2%) and ten patients in the control group (14.7%) developed moderate ARDS with no significant differences. Mechanical ventilation was required in six patients (4.7%), with four in the treatment group and two in the control group. There were no deaths during hospitalization or during follow-up. An intermediate analysis for futility showed some differences between the control and treatment groups (Z = 0.0284). However, these findings were within the margins close to the region where the null hypothesis would not be rejected. Conclusion: In patients with COVID-19 pneumonia without oxygen needs but at risk of progressing to severe disease, early dexamethasone administration did not lead to a decrease in ARDS development. Clinical trial registration: ClinicalTrials.gov, identifier NCT04836780.

Mapping knowledge structure and emerging trends of extracorporeal membrane oxygenation for acute respiratory distress syndrome: a bibliometric and visualized study.

Introduction: With the discovery of extracorporeal membrane oxygenation (ECMO), it is considered as a valuable tool for supporting the treatment of severe acute respiratory distress syndrome (ARDS). It has gained increasing attention, particularly during the COVID-19 epidemic. However, to date, no relevant bibliometric research on the association between ECMO and ARDS (ECMO-ARDS) has been reported. Our study aimed to summarize the knowledge structure and research focus of ECMO-ARDS through a bibliometric analysis. Method: Publications related to ECMO-ARDS from 2000 to 2022 were obtained from the Web of Science Core Collection (WoSCC). Research data underwent bibliometric and visual analysis by using CiteSpace, VOSviewer, and one online analysis platform. By analyzing the countries, institutions, journals, authors, the geographic distribution of research contributions as well as the leading institutions and researchers in this field were identified. Additionally, prominent journals and highly cited publications were highlighted, indicating their influence and significance in the field. Moreover, the co-citation references and co-occurring keywords provided valuable information on the major research topics, trends, and potential emerging frontiers. Results: A total of 1,565 publications from 60 countries/regions were retrieved. The annual publication number over time revealed exponential growth trends (R2 = 0.9511). The United States was dominant in ECMO-ARDS research, whereas the Univ Toronto was most productive institution. Prof Combes A published the most publications in this area. ASAIO Journal and Intensive Care Medicine were the most active and co-cited journals, respectively. Reference co-citation analysis showed that current research focus has shifted to COVID-related ARDS, multi-center studies, as well as prone positioning. Apart from the keywords "ECMO" and "ARDS", other keywords appearing at high frequency in the research field were "COVID-19", "mechanical ventilation", "extracorporeal life support", "respiratory failure", "veno-venous ECMO", "SARS-CoV-2", "outcome". Among them, keywords like "mortality", "veno-venous ECMO", "epidemiology", "obesity", "coagulopathy", "lung ultrasound", "inhalation injury", "noninvasive ventilation", "diagnosis", "heparin", "cytokine storm" has received growing interest in current research and also has the potential to continue to become research hotspots in the near future. Conclusion: This bibliometric analysis offers a comprehensive understanding of the current state of ECMO-ARDS research and can serve as a valuable resource for researchers, policymakers, and stakeholders in exploring future research directions and fostering collaborations in this critical field.

Evaluation of vitamin D in the diagnosis of infants with respiratory distress, the clinical value: A systematic review and meta-analysis.

INTRODUCTION: Respiratory distress (RD) is the most common cause of admission to the Neonatal Intensive Care Unit (NICU). The role of Vitamin D in the development and fortification of fetal pulmonary architecture and the synthesis of surfactants is well-documented. While different serum levels of 25-hydroxyvitamin D (Vit. D) have been studied for their diagnostic significance in RD, there is limited research on how it specifically affects the development of respiratory problems in infants and their mothers. The purpose of the present study is a systematic review and meta-analysis to evaluate the correlation between serum levels of Vit. D in mothers and newborns with RD, and to determine the impact of treating either population on the clinical outcomes of afflicted infants. METHODS: A comprehensive literature search was conducted across various databases, including PubMed, ScienceDirect, Cochrane Library, ISI, and Google Scholar, using a combination of keywords such as RD, diagnosis, vitamin D, mothers, infants, vitamin D supplementation, Respiratory distress syndrome(RDS), and Transient Tachypnea of Newborn (TTN). The search was carried out until March 2024.The level of vitamin D in both mothers and their infants was systematically extracted and analyzed to determine the diagnostic efficacy of Vit. D levels. The mean difference (MD) was calculated along with a 95% confidence interval to determine the association between the Vit. D levels in newborns and their mothers and the likelihood of RD, RDS and TTN in infants. To assess potential publication bias, a funnel plot was generated and Egger's regression test was applied, utilizing a random-effects model. RESULTS: Initially a total of 298 relevant articles was retrieved. Among them, 17 articles with a total of 1,582 infants (745 cases and 837 healthy controls) met the criteria as eligible studies. Of these six were prospective cohort studies, four retrospective case-control studies, four randomized controlled trials (RCTs), and three descriptive-analytical studies. The meta-results revealed a significant association between Vit. D levels and risk of RD in infants (MD = 6.240, 95 %CI: 4.840-7.840, P < 0.001) and mothers (MD = 8.053, 95 %CI: 4.920-11.186, P < 0.001). Furthermore, a strong association was found for risk of RDS (MD = 5.493, 95 %CI: 3.356-7.631, P < 0.001) in infants and TTN (MD = 6.672, 95 %CI: 4.072-9.272, P < 0.001), (MD = 8.595, 95%CI: 4.604-12.586, P < 0.001) both in infants and mothers. Administering 50,000 units of vitamin D to mothers (MD = 8.595, 95 %CI: 4.604-12.586, P < 0.001) prior to childbirth was observed to reduce the likelihood of RD in newborns by 64 % (RR = 0.36, 95 %CI: 0.23-0.57, P < 0.001). Supplemental vitamin D provided to infants was associated with several clinical benefits. CONCLUSION: Our meta-results indicated a significant correlation between serum levels of Vit. D and the risk of RD, RDS and TTN in infants. Prophylactic maternal administration of vitamin D plays a protective role against neonatal RD. Additionally, providing vitamin D to premature infants has shown a significant impact in reducing the incidence of respiratory complications.

A Case Report of Pulmonary Alveolar Proteinosis Masquerading as Respiratory Distress Syndrome in Preterm Neonates.

A rare and challenging case of a preterm neonate with clinical and radiological signs of respiratory distress syndrome (RDS) since the first hour of life but was refractory to its standard treatment regimes like surfactant therapy and ventilation. Postmortem lung biopsy led us to the diagnosis of congenital pulmonary alveolar proteinosis (PAP). It occurs due to the aggregation of abnormal surfactant proteins and lipids in the alveoli, which hampers gas diffusion across the alveoli. It presents as respiratory distress at birth, and its diagnosis is often missed due to its resemblance with RDS. Although the exact etiology remains elusive, mutations in genes encoding surfactant and granulocyte-macrophage colony-stimulating factor (GM-CSF) pathway components have been implicated in the pathogenesis of PAP. Treatment options are limited and only supportive. Among all these, whole-lung lavage is the most widely used management modality but with limited success in neonates.

Lung ultrasound to predict the duration of respiratory support in newborn infants with respiratory distress.

AIM: Lung ultrasound (LU) and clinical parameters evaluated during the first postnatal hour potentially predict the length of CPAP therapy in newborns with respiratory distress. METHODS: In a single-centre, prospective observational pilot study, 130 newborns ≥36 weeks gestational age were assessed using standardised LU at 30 and 60 min postnatally. Various clinical parameters were evaluated influencing CPAP duration (<1 vs. ≥1 h) using univariate and multivariate analyses. RESULTS: Lung ultrasound score >5, FiO2 > 0.21 and respiratory acidosis 30 min postnatally were associated with CPAP ≥1 h. Our model showed good diagnostic quality (ROC AUC = 0.87) and was confirmed by classification and regression tree (CART) analysis. Additional LU findings like double lung point and pleural line abnormalities were frequently observed, with good interrater reliability for LU interpretation (ICC = 0.76-0.77). CONCLUSION: Newborns with postnatal respiratory distress at risk for prolonged CPAP therapy can be identified based on specific LU and clinical parameters assessed 30 min postnatally. Despite the need for validation in an independent sample, these findings may lay the groundwork for a prediction tool. LU proved feasible and reliable for assessing respiratory status in this population, highlighting potential utility in clinical practice.

The impact of a lung-protective ventilation mode using transpulmonary driving pressure titrated positive end-expiratory pressure on the prognosis of patients with acute respiratory distress syndrome.

OBJECTIVE: This study aimed to assess the impact of a lung-protective ventilation strategy utilizing transpulmonary driving pressure titrated positive end-expiratory pressure (PEEP) on the prognosis [mechanical ventilation duration, hospital stay, 28-day mortality rate and incidence of ventilator-associated pneumonia (VAP), survival outcome] of patients with Acute Respiratory Distress Syndrome (ARDS). METHODS: A total of 105 ARDS patients were randomly assigned to either the control group (n = 51) or the study group (n = 53). The control group received PEEP titration based on tidal volume [A tidal volume of 6 mL/kg, flow rate of 30-60 L/min, frequency of 16-20 breaths/min, constant flow rate, inspiratory-to-expiratory ratio of 1:1 to 1:1.5, and a plateau pressure ≤ 30-35 cmH2O. PEEP was adjusted to maintain oxygen saturation (SaO2) at or above 90%, taking into account blood pressure], while the study group received PEEP titration based on transpulmonary driving pressure (Esophageal pressure was measured as a surrogate for pleural pressure using an esophageal pressure measurement catheter connected to the ventilator. Tidal volume and PEEP were adjusted based on the observed end-inspiratory and end-expiratory transpulmonary pressures, aiming to maintain a transpulmonary driving pressure below 15 cmH2O during mechanical ventilation. Adjustments were made 2-4 times per day). Statistical analysis and comparison were conducted on lung function indicators [oxygenation index (OI), arterial oxygen tension (PaO2), arterial carbon dioxide tension (PaCO2)] as well as other measures such as heart rate, mean arterial pressure, and central venous pressure in two groups of patients after 48 h of mechanical ventilation. The 28-day mortality rate, duration of mechanical ventilation, length of hospital stay, and ventilator-associated pneumonia (VAP) incidence were compared between the two groups. A 60-day follow-up was performed to record the survival status of the patients. RESULTS: In the control group, the mean age was (55.55 ± 10.51) years, with 33 females and 18 males. The pre-ICU hospital stay was (32.56 ± 9.89) hours. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was (19.08 ± 4.67), and the mean Murray Acute Lung Injury score was (4.31 ± 0.94). In the study group, the mean age was (57.33 ± 12.21) years, with 29 females and 25 males. The pre-ICU hospital stay was (33.42 ± 10.75) hours. The mean APACHE II score was (20.23 ± 5.00), and the mean Murray Acute Lung Injury score was (4.45 ± 0.88). They presented a homogeneous profile (all P > 0.05). Following intervention, significant improvements were observed in PaO2 and OI compared to pre-intervention values. The study group exhibited significantly higher PaO2 and OI compared to the control group, with statistically significant differences (all P < 0.05). After intervention, the study group exhibited a significant increase in PaCO2 (43.69 ± 6.71 mmHg) compared to pre-intervention levels (34.19 ± 5.39 mmHg). The study group's PaCO2 was higher than the control group (42.15 ± 7.25 mmHg), but the difference was not statistically significant (P > 0.05). There were no significant differences in hemodynamic indicators between the two groups post-intervention (all P > 0.05). The study group demonstrated significantly shorter mechanical ventilation duration and hospital stay, while 28-day mortality rate and incidence of ventilator-associated pneumonia (VAP) showed no significant differences. Kaplan-Meier survival analysis revealed a significantly better survival outcome in the study group at the 60-day follow-up (HR = 0.565, 95% CI: 0.320-0.999). CONCLUSION: Lung-protective mechanical ventilation using transpulmonary driving pressure titrated PEEP effectively improves lung function, reduces mechanical ventilation duration and hospital stay, and enhances survival outcomes in patients with ARDS. However, further study is needed to facilitate the wider adoption of this approach.

Liberation from extracorporeal membrane oxygenation in a patient with severe COVID-19-associated acute respiratory distress syndrome using traditional Chinese medicine: A case report.

INTRODUCTION: Due to the continued threat to public health posed by SARS-CoV-2 and the ongoing emergence of novel variants, the integration of traditional Chinese medicine (TCM) with Western medicine provides a novel alternative management for critically ill patients. CASE PRESENTATION: This case report describes a 54-year-old male with severe COVID-19-associated acute respiratory distress syndrome (ARDS) who required extracorporeal membrane oxygenation (ECMO) support. Despite standard treatment, ECMO liberation was unsuccessful, and complications such as pneumothorax and hemothorax ensued. However, upon initiating combined TCM therapy on the 19th day of ECMO support, the patient exhibited gradual improvements in oxygenation and ventilation, leading to successful ECMO liberation on the 31st day. CONCLUSION: This case underscores the potential of integrating TCM with conventional therapies for severe COVID-19 cases, offering a valuable treatment option amidst the evolving landscape of SARS-CoV-2 variants.

Effects of pulmonary surfactant combined with noninvasive positive pressure ventilation in neonates with respiratory distress syndrome.

BACKGROUND: Neonatal respiratory distress syndrome (NRDS) is one of the most common diseases in neonatal intensive care units, with an incidence rate of about 7% among infants. Additionally, it is a leading cause of neonatal death in hospitals in China. The main mechanism of the disease is hypoxemia and hypercapnia caused by lack of surfactant. AIM: To explore the effect of pulmonary surfactant (PS) combined with noninvasive positive pressure ventilation on keratin-14 (KRT-14) and endothelin-1 (ET-1) levels in peripheral blood and the effectiveness in treating NRDS. METHODS: Altogether 137 neonates with respiratory distress syndrome treated in our hospital from April 2019 to July 2021 were included. Of these, 64 control cases were treated with noninvasive positive pressure ventilation and 73 observation cases were treated with PS combined with noninvasive positive pressure ventilation. The expression of KRT-14 and ET-1 in the two groups was compared. The deaths, complications, and PaO2, PaCO2, and PaO2/FiO2 blood gas indexes in the two groups were compared. Receiver operating characteristic curve (ROC) analysis was used to determine the diagnostic value of KRT-14 and ET-1 in the treatment of NRDS. RESULTS: The observation group had a significantly higher effectiveness rate than the control group. There was no significant difference between the two groups in terms of neonatal mortality and adverse reactions, such as bronchial dysplasia, cyanosis, and shortness of breath. After treatment, the levels of PaO2 and PaO2/FiO2 in both groups were significantly higher than before treatment, while the level of PaCO2 was significantly lower. After treatment, the observation group had significantly higher levels of PaO2 and PaO2/FiO2 than the control group, while PaCO2 was notably lower in the observation group. After treatment, the KRT-14 and ET-1 levels in both groups were significantly decreased compared with the pre-treatment levels. The observation group had a reduction of KRT-14 and ET-1 levels than the control group. ROC curve analysis showed that the area under the curve (AUC) of KRT-14 was 0.791, and the AUC of ET-1 was 0.816. CONCLUSION: Combining PS with noninvasive positive pressure ventilation significantly improved the effectiveness of NRDS therapy. KRT-14 and ET-1 levels may have potential as therapeutic and diagnostic indicators.

Salivary Gland Anlage Tumor: A Case Report on Abnormal Breathing Found in a Late-Preterm Infant.

There are many etiologies for respiratory distress in newborns, one of the rare causes being nasopharyngeal tumors. Of that category, salivary gland anlage tumor (SGAT) is exceedingly rare. Symptoms of SGAT vary by patient, but the most common presenting symptom is respiratory distress. The rarity of SGAT and infantile nasopharyngeal tumors in general can lead to delayed diagnosis in newborns with respiratory distress. We report an unexpected and incidental finding of this potentially life-threatening condition in the neonatal population. A preterm male infant with respiratory distress, who was undergoing a neurological workup for new hypotonia, was found to have an incidental nasopharyngeal mass after brain MRI. Upon eventual minimally invasive endoscopic surgical excision and pathologic workup for the mass, the patient was diagnosed with SGAT. The patient has since been with outpatient follow-up visits with no evidence of recurrence of the mass. The purpose of this report is to present a rare and often overlooked life-threatening diagnosis of respiratory distress in the neonatal population.

Causes, outcomes and diagnosis of acute breathlessness hospital admissions in Malawi: protocol for a multicentre prospective cohort study.

Background: Hospital admission due to breathlessness carries a significant burden to patients and healthcare systems, particularly impacting people in low-income countries. Prompt appropriate treatment is vital to improve outcomes, but this relies on accurate diagnostic tests which are of limited availability in resource-constrained settings. We will provide an accurate description of acute breathlessness presentations in a multicentre prospective cohort study in Malawi, a low resource setting in Southern Africa, and explore approaches to strengthen diagnostic capacity. Objectives: Primary objective: Delineate between causes of breathlessness among adults admitted to hospital in Malawi and report disease prevalence. Secondary objectives : Determine patient outcomes, including mortality and hospital readmission 90 days after admission; determine the diagnostic accuracy of biomarkers to differentiate between heart failure and respiratory infections (such as pneumonia) including brain natriuretic peptides, procalcitonin and C-reactive protein. Methods: This is a prospective longitudinal cohort study of adults (≥18 years) admitted to hospital with breathlessness across two hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Chiradzulu, Malawi. Patients will be consecutively recruited within 24 hours of emergency presentation and followed-up until 90 days from hospital admission. We will conduct enhanced diagnostic tests with robust quality assurance and quality control to determine estimates of disease pathology. Diagnostic case definitions were selected following a systematic literature search. Discussion: This study will provide detailed epidemiological description of adult hospital admissions due to breathlessness in low-income settings, which is currently poorly understood. We will delineate between causes using established case definitions and conduct nested diagnostic evaluation. The results have the potential to facilitate development of interventions targeted to strengthen diagnostic capacity, enable prompt and appropriate treatment, and ultimately improve both patient care and outcomes.

BACKGROUND: People admitted to hospital with symptoms of breathlessness are often severely ill and need quick, accurate assessment to facilitate timely initiation of appropriate treatments. In low resource settings, such as Malawi, limited access to diagnostic equipment impedes patient assessment. Failure to identify and treat the underlying diagnosis may lead to preventable death. AIMS: This cohort study aims to delineate between common, treatable causes of breathlessness among adult patients admitted to hospital in Malawi and measure survival. We will also evaluate the performance of blood markers to diagnose and differentiate between conditions. The results will help us develop context-appropriate diagnostic and treatment algorithms based on resources available in the health system Methods in brief: We will recruit adult patients who present to hospital with breathlessness in a central national referral hospital (Queen Elizabeth Central Hospital, Blantyre), and a district hospital (Chiradzulu District Hospital, Chiradzulu). We will conduct enhanced diagnostic tests to determine causes of breathlessness against internationally accepted diagnostic guidelines. Patients will be followed up throughout their hospital admission and after discharge, until 90 days. INTERPRETATION: This study aligns with World Health Assembly resolutions on 'Strengthening diagnostics capacity' and on 'Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies'. The results of this study will have the potential to facilitate development of interventions targeted to strengthen diagnostic capacity, enable prompt and appropriate treatment, and ultimately improve care and outcomes for acutely unwell patients.

A Comprehensive Compilation of Data on the Relationship Between Surfactant Protein-B (SFTPB) Polymorphisms and Susceptibility to Neonatal Respiratory Distress Syndrome.

BACKGROUND: This study aims to explore the association between variations in the Surfactant Protein-B (SFTPB) gene and the risk of neonatal respiratory distress syndrome (NRDS). METHODS: A comprehensive literature search was conducted across PubMed, Scopus, EMBASE, and CNKI databases up to February 10, 2024, to identify pertinent studies. RESULTS: A total of seventeen studies examining the +1580 C/T polymorphism (2,058 cases and 2,596 controls) and five studies investigating the -18 A/C polymorphism (680 cases and 739 controls) were included in the analysis. The pooled data indicated that the +1580 C/T polymorphism confers a protective effect against NRDS in various populations and ethnic groups. Conversely, the -18 A/C polymorphism did not demonstrate a significant association either globally or among Asian neonates. CONCLUSIONS: The +1580 C/T variant appears to be protective against NRDS, whereas the -18 A/C polymorphism shows minimal impact on the disease's progression.

Comparative Biophysical Study of Clinical Surfactants using Constrained Drop Surfactometry.

Surfactant replacement therapy is crucial in managing neonatal respiratory distress syndrome (RDS). Currently licensed clinical surfactants in the United States and Europe, including Survanta, Infasurf, Curosurf, and Alveofact, are all derived from bovine or porcine sources. We conducted a comprehensive examination of the biophysical properties of these four clinical surfactant preparations under physiologically relevant conditions, utilizing constrained drop surfactometry (CDS). The assessed biophysical properties included the adsorption rate, quasi-static and dynamic surface activity, resistance to surfactant inhibition by meconium, and the morphology of the adsorbed surfactant films. This comparative study unveiled distinct in vitro biophysical properties of these clinical surfactants and revealed correlations between their chemical composition, lateral film structure, and biophysical functionality. Notably, at 1 mg/mL, Survanta exhibited a significantly lower adsorption rate compared to the other preparations at the same surfactant concentration. At 10 mg/mL, Infasurf, Curosurf, and Survanta all demonstrated excellent dynamic surface activity, while Alveofact exhibited the poorest quasi-static and dynamic surface activity. The suboptimal surface activity of Alveofact is found to be correlated with its unique monolayer-predominant morphology, in contrast to other surfactants forming multilayers. Curosurf, in particular, showcased superior resistance to biophysical inhibition by meconium compared to other preparations. Understanding the diverse biophysical behaviors of clinical surfactants provides crucial insights for precision and personalized design in treating RDS and other respiratory conditions. The findings from this study contribute valuable perspectives for development of more efficacious and fully synthetic surfactant preparations.

Positive end-expiratory pressure management in patients with severe ARDS: implications of prone positioning and extracorporeal membrane oxygenation.

The optimal strategy for positive end-expiratory pressure (PEEP) titration in the management of severe acute respiratory distress syndrome (ARDS) patients remains unclear. Current guidelines emphasize the importance of a careful risk-benefit assessment for PEEP titration in terms of cardiopulmonary function in these patients. Over the last few decades, the primary goal of PEEP usage has shifted from merely improving oxygenation to emphasizing lung protection, with a growing focus on the individual pattern of lung injury, lung and chest wall mechanics, and the hemodynamic consequences of PEEP. In moderate-to-severe ARDS patients, prone positioning (PP) is recommended as part of a lung protective ventilation strategy to reduce mortality. However, the physiologic changes in respiratory mechanics and hemodynamics during PP may require careful re-assessment of the ventilation strategy, including PEEP. For the most severe ARDS patients with refractory gas exchange impairment, where lung protective ventilation is not possible, veno-venous extracorporeal membrane oxygenation (V-V ECMO) facilitates gas exchange and allows for a "lung rest" strategy using "ultraprotective" ventilation. Consequently, the importance of lung recruitment to improve oxygenation and homogenize ventilation with adequate PEEP may differ in severe ARDS patients treated with V-V ECMO compared to those managed conservatively. This review discusses PEEP management in severe ARDS patients and the implications of management with PP or V-V ECMO with respect to respiratory mechanics and hemodynamic function.

Should the sex of the fetus be considered when administering antenatal corticosteroids to preterm fetuses?

AIM: We aimed to determine whether the effect of antenatal corticosteroids (ANS) differs in male and female fetuses without anomalies born before 32 weeks in terms of mortality and short-term morbidity. METHODS: This single-center retrospective study included infants born before 32 weeks' gestation and admitted to the neonatal intensive care unit between January 1, 2018, and December 31, 2020. RESULTS: The study included 210 infants with a median gestational age of 28.6 weeks (24-31.6), a birth weight of 1065 g (445-2165), and an ANS use rate of 80%. Compared to female fetuses exposed to ANS, male fetuses exposed to ANS had a lower mortality rate (23% and 11%, respectively, p = 0.038), but there were no differences in intraventricular hemorrhage, retinopathy of prematurity, necrotizing enterocolitis, respiratory distress syndrome, and APGAR scores of 1st and 5th but an increased rate of bronchopulmonary dysplasia (moderate/severe) (p = 0.008). In addition, the mortality rate was similar in exposed and unexposed female fetuses (p = 0.850). Enzyme activities and steroid levels in the placenta might be different in male and female fetuses, which could explain the results of ANS administration. CONCLUSIONS: In our study, we have shown that ANS has no effect on mortality in female fetuses younger than 32 weeks. Future studies may focus on adjusting the administration of ANS based on fetal sex, altering the dose or taking fetal sex into account when performing ANS.

Subglottic Hemangioma: A Hidden Cause of an Infant's Respiratory Distress.

Subglottic hemangiomas are uncommon forms of infantile vascular tumors often misdiagnosed due to symptom overlap with other conditions like laryngomalacia, bronchiolitis, and asthma. Early and accurate diagnosis is vital for effective management. This case report discusses a unique presentation of subglottic hemangioma in a three-month-old infant, highlighting its diagnostic challenge and management. It adds valuable insights into the differentiation of subglottic hemangioma from other common causes of respiratory distress in infants. The infant presented with severe respiratory distress since birth, worsening over the last four weeks, accompanied by gastroesophageal reflux and poor weight gain. Initially, the case was suspected and treated as croup and laryngomalacia. A CT angiogram revealed a vascular lesion in the subglottic area, confirmed by flexible bronchoscopy as a hemangioma. Treatment with propranolol led to significant improvement. Early diagnosis and treatment of subglottic hemangioma are crucial for a good prognosis. This case emphasizes the importance of considering subglottic hemangioma in infants with unresolved airway distress.

Clinical Characteristics and Risk Factors of Mechanical Ventilation Among COVID-19 Patients on High-Flow Nasal Oxygen (HFNO).

INTRODUCTION: COVID-19 is a viral infection affecting the respiratory system, primarily. It has spread globally ever since it first appeared in China in 2019. The use of high-flow nasal oxygen (HFNO) for the treatment of COVID-19 has not been well established. OBJECTIVES: The primary objectives of this study are to observe the success of HFNO in preventing escalation to mechanical ventilation (MV) and to measure the prevalence of HFNO in King Abdulaziz Medical City (KAMC). The secondary objective is to describe patients who received HFNO clinically. METHODS: This is a retrospective cohort study of all polymerase chain reaction (PCR)-confirmed COVID-19 patients who require oxygen therapy in KAMC, Jeddah between March 1st, 2020, and December 31st, 2020. Any patients requiring MV on admission were excluded. RESULTS: 259 patients fit the inclusion criteria, and 25.5% of those included received HFNO. The number of non-survivors is 47 (18.1%). Mortality for HFNO, MV, and intensive care unit (ICU) are 30 (45.5%), 31 (60.8%), and 24 (32%), respectively. Their demographic was as follows; 160 were males, with a mean age of 60.93±15.01. Regarding the types of oxygen, low-flow nasal oxygen (LFNO) was administered to 243 out of the 259 patients, 66 received HFNO, 42 received MV, and 49 received other modes of ventilation. Additionally, 43.9% received HFNO escalated to MV. Patients who did not receive HFNO or MV were 178 (68.7%) in total. CONCLUSION: The use of HFNO in COVID-19 patients could show better outcomes than MV in addition to preventing the use of MV. Larger studies are required to determine the efficacy of HFNO in COVID-19 patients.

Physiological effects and safety of bed verticalization in patients with acute respiratory distress syndrome.

BACKGROUND: Trunk inclination in patients with Acute Respiratory Distress Syndrome (ARDS) in the supine position has gained scientific interest due to its effects on respiratory physiology, including mechanics, oxygenation, ventilation distribution, and efficiency. Changing from flat supine to semi-recumbent increases driving pressure due to decreased respiratory system compliance. Positional adjustments also deteriorate ventilatory efficiency for CO2 removal, particularly in COVID-19-associated ARDS (C-ARDS), indicating likely lung parenchyma overdistension. Tilting the trunk reduces chest wall compliance and, to a lesser extent, lung compliance and transpulmonary driving pressure, with significant hemodynamic and gas exchange implications. METHODS: A prospective, pilot physiological study was conducted on early ARDS patients in two ICUs at CHU Clermont-Ferrand, France. The protocol involved 30-min step gradual verticalization from a 30° semi-seated position (baseline) to different levels of inclination (0°, 30°, 60°, and 90°), before returning to the baseline position. Measurements included tidal volume, positive end-expiratory pressure (PEEP), esophageal pressures, and pulmonary artery catheter data. The primary endpoint was the variation in transpulmonary driving pressure through the verticalization procedure. RESULTS: From May 2020 through January 2021, 30 patients were included. Transpulmonary driving pressure increased slightly from baseline (median and interquartile range [IQR], 9 [5-11] cmH2O) to the 90° position (10 [7-14] cmH2O; P < 10-2 for the overall effect of position in mixed model). End-expiratory lung volume increased with verticalization, in parallel to decreases in alveolar strain and increased arterial oxygenation. Verticalization was associated with decreased cardiac output and stroke volume, and increased norepinephrine doses and serum lactate levels, prompting interruption of the procedure in two patients. There were no other adverse events such as falls or equipment accidental removals. CONCLUSIONS: Verticalization to 90° is feasible in ARDS patients, improving EELV and oxygenation up to 30°, likely due to alveolar recruitment and blood flow redistribution. However, there is a risk of overdistension and hemodynamic instability beyond 30°, necessitating individualized bed angles based on clinical situations. Trial registration ClinicalTrials.gov registration number NCT04371016 , April 24, 2020.

Comorbid burden at ICU admission in COVID-19 compared to sepsis and acute respiratory distress syndrome.

BACKGROUND: Comorbidities are similarly associated with short-term mortality for COVID-19, acute respiratory distress syndrome (ARDS) and sepsis in intensive care unit (ICU) patients, but their adjusted frequencies at admission are unknown. Thus, we aimed to evaluate the adjusted distribution, reported as odds ratios, of known risk factors (i.e., age, sex and comorbidities) for ICU admission between COVID-19, sepsis and ARDS patients in this nationwide registry-based study. METHODS: In this cohort study, we included adult patients admitted to Swedish ICUs with COVID-19 (n = 7382) during the pandemic and compared them to patients admitted to ICU with sepsis (n = 22,354) or ARDS (n = 2776) during a pre-COVID-19 period. The main outcomes were the adjusted odds for comorbidities, sex, and age in multivariable logistic regression on diagnostic categories in patients admitted to ICU, COVID-19 or sepsis and COVID-19 or ARDS. RESULTS: We found that most comorbidities, as well as age, had a stronger association with sepsis admission than COVID-19 admission with the exception of male sex, type 2 diabetes mellitus, and asthma that were more strongly associated with COVID-19 admission, while no difference was seen for chronic renal failure and obesity. For COVID-19 and ARDS admission most risk factors were more strongly associated with ARDS admission except for male sex, type 2 diabetes mellitus, chronic renal failure, and obesity which were more strongly associated with COVID-19 admission, whereas hypertension, chronic obstructive pulmonary disease and asthma were not different. CONCLUSIONS: Patients admitted to ICU with sepsis or ARDS carry a heavier burden of comorbidity and high age than patients admitted with COVID-19. This is likely caused by a combination of: (1) respiratory failure in COVID-19 being less dependent on comorbidities than in other forms of ARDS, and the cause of critical illness in other infections causing sepsis and (2) COVID-19 patients being deferred admission in situations where patients with the other syndromes were admitted.

Upper limb peripheral nerve injuries in patients with ARDS requiring prone positioning: A systematic review with proportion meta-analysis.

OBJECTIVE: To investigate the prevalence of upper limb peripheral nerve injuries (PNI) in adult patients admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) undergoing prone positioning. METHODS: This systematic review with meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines. Four electronic databases including PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Library, and EMBASE were searched from inception to January 2024. The quality of the included studies was evaluated according to the Joanna Briggs Institute Critical Appraisal Tools. A proportion meta-analysis was conducted to examine the combined prevalence of upper limb PNI among patients requiring prone positioning. RESULTS: A total of 8 studies (511 patients) were pooled in the quantitative analysis. All studies had a low or moderate risk of bias in methodological quality. The overall proportion of patients with upper limb PNI was 13% (95%CI: 5% to 29%), with large between-study heterogeneity (I2 = 84.6%, P<0.001). Both ulnar neuropathy and brachial plexopathy were described in 4 studies. CONCLUSION: During the COVID-19 pandemic, prone positioning has been used extensively. Different approaches among ICU teams and selective reporting by untrained staff may be a factor in interpreting the large variability between studies and the 13% proportion of patients with upper limb PNI found in the present meta-analysis. Therefore, it is paramount to stress the importance of patient assessment both after discharge from the ICU and during subsequent follow-up evaluations. IMPLICATIONS FOR CLINICAL PRACTICE: Specialized training is essential to ensure safe prone positioning, with careful consideration given to arms and head placement to mitigate potential nerve injuries. Therefore, healthcare protocols should incorporate preventive strategies, with patient assessments conducted by expert multidisciplinary teams.