Value, time and outcomes of elevated lactate levels in adult patients on extracorporeal membrane oxygenation.

INTRODUCTION: Lactate levels have been recognized as a reliable tool for monitoring critically ill patients requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) or venovenous extracorporeal membrane oxygenation (VV ECMO) but the reasons behind the overproduction of lactate are different and the influance for survival remains controversial. We analyzed the lactate values and lactate clearance in adult patients in these two forms of extracorporeal support. METHODS: Patient demographics, ECMO duration, 30-day mortality, lactate values and lactate clearance at 24, 48 and 72 h from ECMO initiation of patients supported with VV and VA ECMO at Silesian Centre for Heart Deasese, between January 2011 and April 2020 were retrospectively analyzed. The changes in lactate levels were analyzed using the non-parametric U Mann-Whitney tests and Chi-square test. The ROC curves were draw and the area under the curve was calculated. RESULTS: The study comprised 91 adult patients, Mortality in the first 30 days from initiation of VV and VA ECMO was 39% and 66%, respectively. Lactate levels were significantly higher in non-survivors that received VV and VA ECMO (p < .001), while lactate clearance was similar (p = .256 and p = 1.000, respectively). Survival curves for patients with elevated (>2.0 mmol/L) vs normal (≤2.0 mmol/L) lactate levels at 72 h were significantly different for VV ECMO (p = .007) and VA ECMO (p = .037) but in both groups of ECMO, lactate levels above 2.0 mmol/L at 72 h from ECMO initiation predicted 30 day-mortality. CONCLUSION: This results emphasized the importance of lactate levels below 2.0 mmol/L at 72 h from both VV and VA ECMO initiation.

Are There Differences in Inflammatory and Fibrotic Pathways between IPAF, CTD-ILDs, and IIPs? A Single-Center Pilot Study.

In this pilot study, we aim to determine differences in pathogenetic pathways between interstitial pneumonia with autoimmune features (IPAF), connective-tissue-disease-associated interstitial lung diseases (CTD-ILDs), and idiopathic interstitial pneumonias (IIPs). Forty participants were recruited: 9 with IPAF, 15 with CTD-ILDs, and 16 with IIPs. Concentration of transforming growth factor beta (TGF-ß1), surfactant proteins A and D (SP-A, SP-D), interleukin 8 (IL-8), and chemokine 1 (CXCL1) were assessed with ELISA assay in bronchoalveolar lavage (BAL) fluid. We revealed that IL-8 and TGF-ß1 concentrations were significantly lower in the IPAF group than in the CTD-ILD group (p = 0.008 and p = 0.019, respectively), but similar to the concentrations in the IIP group. There were significant correlations of IL-8 (rs = 0.46; p = 0.003) and CXCL1 (rs = 0.52; p = 0.001) and BAL total cell count (TCC). A multivariate regression model revealed that IL-8 (ß = 0.32; p = 0.037) and CXCL1 (ß = 0.45; p = 0.004) are significant predictors of BAL TCC. We revealed that IL-8 and TGF-ß1 BAL concentrations vary in patients with different ILDs and found that IL-8 is a predictor of BAL TCC in IPAF. However, this needs to be confirmed in a multicenter cooperative study (ClinicalTrials.gov Identifier: NCT03870828).

PULMONARY ALVEOLAR MICROLITHIASIS. DISCREPANCIES BETWEEN RADIOLOGICAL FINDINGS AND CLINICAL PATTERN- CASE STUDY.

Pulmonary alveolar microlithiasis is a rare genetic disorder, inherited autosomally recessively, which is characterized by intra-alveolar deposition of microliths built mostly of calcium salts and phosphorus. This case study describing management of patient with pulmonary alveolar microlithiasis. A 49-year-old woman, diagnosed with pulmonary microlithiasis in 1979 was admitted to Pneumology Department due to increased dyspnea. On admission there were no clinical signs of active infection. The chest computer tomography scan confirmed the presence of advanced microlithiasis. Pulmonary function test revealed mild restriction with moderate diffusion impairment, due to severe hypoxemia present on 6-minute walking test patient was sent for specific assessment to local lung transplant team in Zabrze for consideration for lung transplantation. According to International Society for Heart & Lung Transplantation guidelines the patient was observed in 6 months intervals to reveal whether further disease progression will be observed. Clinical condition of our patient does not correlate with radiological scans, severe respiratory symptoms and cardiological complications. Computer tomography scan should not be the only indication for lung transplant.

The influence of chlorine in indoor swimming pools on the composition of breathing phase of professional swimmers.

OBJECTIVES: Swimming is one of the most popular forms of physical activity. Pool water is cleaned with chlorine, which - in combination with compounds contained in water - could form chloramines and trichloromethane in the swimmer's lungs. The aim of the present study was to examine the effect of swimming training in an indoor pool on the composition of swimmers' respiratory phase metabolomics, and develop a system to provide basic information about its impact on the swimmer's airway mucosa metabolism, which could help to assess the risk of secondary respiratory tract diseases i.e. sport results, condition, and health including lung acute and chronic diseases). DESIGN: A group of competitive swimmers participated in the study and samples of their respiratory phase before training, immediately after training, and 2 h after training were assessed. METHODS: Sixteen male national and international-level competitive swimmers participated in this study. Respiratory phase analysis of the indoor swimming pool swimmers was performed. Gas chromatography combined with mass spectrometry (GCMS) was used in the measurements. All collected data were transferred to numerical analysis for trends of tracking and mapping. The breathing phase was collected on special porous material and analyzed using GCMS headspace. RESULTS: The obtained samples of exhaled air were composed of significantly different metabolomics when compared before, during and after exercise training. This suggests that exposition to indoor chlorine causes changes in the airway mucosa. CONCLUSION: This phenomenon may be explained by occurrence of a chlorine-initiated bio-reaction in the swimmers' lungs. The obtained results indicate that chromatographic exhaled gas analysis is a sensitive method of pulmonary metabolomic changes assessment. Presented analysis of swimmers exhaled air indicates, that indoor swimming may be responsible for airway irritation caused by volatile chlorine compounds and their influence on lung metabolism.

Noninvasive Ventilation-Facilitated Bronchofiberoscopy in Patients with Respiratory Failure.

Respiratory failure is one of the most important risk factors for diagnostic bronchofiberoscopy (BF), whereas therapeutic bronchoscopies are typically performed in intubated patients. Only a few published studies analyzed the outcomes of noninvasive mechanical ventilation (NIV)-facilitated BF. In this case series, we present our experiences with NIV-facilitated diagnostic and therapeutic BF performed in patients with respiratory failure that was associated with acute interstitial pulmonary disease, chronic obstructive pulmonary disease, cystic fibrosis exacerbation, foreign body aspiration, tracheal stenosis, pneumonia, and in a patient with a neuromuscular disease. All of the patients were initially hypoxic and some had PaO2/FiO2 < 200, which corresponded to moderate-to-acute respiratory distress syndrome (ARDS). NIV-facilitated BF were performed for the diagnostic or therapeutic purposes. The former consisted of bronchoalveolar lavage and bacterial sampling in a patient with impaired cough reflex, airway assessment in otherwise unexplained respiratory failure and hemoptysis, and the latter of mucous plugs resolution, foreign body removal, and assistance in weaning from mechanical ventilation. All procedures were carried out using NIV in the spontaneous timed (ST) or average volume assured pressure support (AVAPS) mode with oxygen supplementation. There were no procedure-related complications noticed during NIV-facilitated BF. We conclude that NIV is a useful and safe tool that facilitates the performance of BF in severe pulmonary diseases. Prospective studies are required to set the recommendations for the procedure and to define the optimum ventilatory modes to be used.

Chronic Obstructive Pulmonary Disease and Platelet Count.

Recently, it has been shown in the murine model that platelet maturation takes place, to some extent, in the lungs. The extrapolation of these findings to humans leads to the possibility that chronic lung diseases could affect platelet maturation and, consequently, the platelet count. The aim of this study was to investigate whether there are changes in the platelet count in patients with chronic obstructive disease (COPD). The study included 44 patients, aged 66.5 ± 5.5 years, in stage II-IV COPD. The control group consisted of 48 age- and gender-matched patients without any respiratory diseases. We failed to find a significant difference in the platelet count between the two groups: 231 ± 80 vs. 223 ± 63 x 103/µL, respectively (p = 0.61). However, the number of platelets in the COPD patients was inversely associated with hemoglobin content (r = -0.57; p < 0.001), hematocrit (r = -0.40; p = 0.006), and the red cell count (r = -0.51; p < 0.001); the blood morphology indices that are typically increased in severe COPD. Such associations were absent in the control non-COPD group. We conclude that COPD has no influence on the platelet count in humans.

Influence of noninvasive ventilation on clinical status, dyspnea sensation and subsequent copd diagnosis.

Chronic obstructive lung disease (COPD) is a common life-threatening disease characterized by exposure to tobacco smoke, dyspnea and persistent lower airway obstruction coexistence of COPD and chronic heart failure (HF) may present a considerable challenge during both diagnostic and therapeutic processes. Herein, we report an elderly, obese male, an ex-smoker, suffering from both COPD and HF, and treated according to the applied guidelines for 15 years. On admission to hospital, the patient was diagnosed and treated for severe type 2 respiratory failure. The patient's COPD diagnosis was questioned at first, but then reconsidered after treatment described below. Noninvasive ventilation (NIV) improved the patient's clinical condition and reduced his dyspnea sensation. As a consequence, during check-ups, spirometry maneuvers could have been performed properly, revealing the underlying bronchial obstruction, which had been beforehand concealed by debilitation of respiratory muscles and decreased lung tissue compliance in a patient with chronic HF. Conclusion: NIV application in a patient with type 2 respiratory failure may significantly improve one's clinical condition, reduce dyspnea sensation and help establish an accurate diagnosis.

[Profile of adults suffering from COPD in Poland].

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is one of the most common chronic diseases in adults. It is estimated, that in Poland around two million people suffer from COPD. THE AIM: The aim of this study, was to characterize population of patients with COPD in Poland. MATERIAL AND METHODS: The study, established and coordinated by the Polish Respiratory Society, included a representative sample of 500 GPs where were asked to fill questionnaires on diagnosis and treatment of their COPD patients. The questions dealt with disease history and clinical presentation, COPD severity stage, diagnostic and therapeutic procedures. RESULTS: Altogether 298 physicians (59.6% of invited) provided information about 2756 COPD patients aged 61.6 ± 11.1 years (36.3% were women). According to GOLD recommendations 16.6% of patients had mild, 57.0% moderate, 18.6% severe and 2.1% very severe COPD. Smoking history was declared by 97.8% of respondents. 51.4% of COPD patients had continued smoking. Over the last year Ambulance Service intervened in 19.7% of patients and 29.1% of respondents required hospital treatment of COPD. Among more than 80% of patients, doctor diagnosed limitation in exercise tolerance, and shortness of breath at rest, and in approximately 60% of the respondents were presented productive cough, weakened vesicular murmur and prolonged phase of exhalation. CONCLUSIONS: Despite the diagnosis, more than half of men and women had continued smoking. The number of hospitalizations and emergency intervention positively correlated with the severity of the disease. The survey results emphasize the urgent need for health education in patients with COPD.

[Exacerbations in perimenstrual asthma. Clinical significance of peripheral blood eosinophilia and BMI]. / Zaostrzenia w astmie okolomiesiaczkowej. Znaczenie kliniczne eozynofilii w krwi obwodowej i BMI.

INTRODUCTION: Asthma is a heterogeneous disease characterized by lower airways' obstruction, caused by various factors. There are many asthma phenotypes. Lately, perimenstrual asthma (PMA) with a pattern of exacerbations before and during menstruation as well as obesity associated asthma have been a subject of particular scientific and clinical interest. MATERIAL AND METHODS: 30 women were qualified for this three-arm case-control study(women with a pattern of asthma exacerbations in the perimenstrual period, women with asthma but no perimenstrual exacerbations, healthy control group). All patients performed spirometry and assessed disease control using specific questionnaires. Peripheral blood counts with smear were also performed. RESULTS: PMA patients differ in a statistically significant way in respect of anthropometric measurements such as BMI: in PMA group 25.8±1.8; in non-PMA asthmatics 23.9 ±2.2; healthy control 23.1±1.5; p=0.018) and spirometry results (FEV1 [%]: 85.1 (36.3-113.0); in PMA asthmatics, 93.1 (81,6-109,7), in nonPMA group, p<0.05; 105.4 (108,3-119,0) in healthy control and Tiffeneau index [%]: 70.1 (41.2-98.1); in PMA vs 83.5 (59.6-94.4); in non-PMA asthmatics 93.1(81,8-97,5) in healthy control p<0.05; ). PMA asthmatics also complain of poorer disease control than non-PMA asthmatics. There were no differences in peripheral blood eosinophilia or CRP between studied groups, p>0.05). CONCLUSIONS: Asthma exacerbations are not associated with the effect of peripheral blood eosinophilia. Women with greater BMI are more predisposed to perimenstrual asthma.

Lung-heart clinical crosstalk in the course of COPD exacerbation.

INTRODUCTION: COPD exacerbation is a life-threatening condition with acute dyspnoea caused by respiratory or circulatory distress. The significance and co-presence of lung hyperinflation, bronchial obstruction, and changes in haemodynamics in the course of COPD exacerbation treatment have not been well described yet in course of a single study. Our aim was to evaluate the influence of COPD exacerbation treatment on bronchial obstruction, pulmonary hyperinflation, and possible changes of right and left ventricle haemodynamics in relation to the patient's clinical status. MATERIAL AND METHODS: A total of 40 patients (90% males), 67 ± 8 years old, with COPD were assessed pre- and post-exacerbation treatment by the following: respiratory function tests, transthoracic echocardiography, 6MWT, endothelin-1 (ET-1) and NT-proBNP serum concentrations, and MRC scale. RESULTS: A significant decrease in RV%TLC (%) and mean pulmonary artery pressure (PAPmean) [mm Hg] was observed: pre -RV%TLC: 64.3 ± 9.0; post-RV%TLC 60.6 ± 11.1; p = 0.03; pre-PAPmean: 41.2 ± 11.2; post-PAPmean: 39.1 ± 12.1; p = 0.029, coupled with a significant increase of FEV1 [L]-preFEV1: 1.0 ± 0.4, post-FEV1: 1.2 ± 0.5; p < 0.001. A trend for reduced right ventricle systolic pressure (RVSP) [mm Hg]: pre-treatment: 44.5 ± 12.9; post-treatment: 36.3 ± 14.3; p = 0.068 and ET-1 [fmol/ml]: pre-treatment: 1.7 ± 2.8; post-treatment: 1.3 ± 1.9; p = 0.076, but not for NT-proBNP was noticed. Improvement of both, 6MWT [m]: pre-treatment: 294 ± 132; post-treatment: 415 ± 102; p < 0.001 and MRC [pts.]: pre-treatment: 3.3 ± 0.8; post-treatment: 1.8 ± 0.9; p < 0.001, were noticed. 6MWT correlated with RV%TLC (p < 0.05; r = -0.46; r = -0.53; respectively) and FEV1 (p < 0.05; r = 0.55; r = 0.60, respectively) on admission as well as on discharge. There was no such correlation with RVSP or PAPmean. CONCLUSIONS: Pulmonary hyperinflation and bronchial obstruction may be reduced by effective COPD exacerbation treatment and are accompanied by clinical improvement. The mPAP reduction observed in the course of treatment was not correlated with the results of 6MWT and MRC score.

May smoking be considered as the most important factor that determines premature death after hospitalization due to COPD exacerbation? Preliminary data.

INTRODUCTION: COPD, cardiovascular diseases and cancer are smoking-related diseases that have been accepted as the leading causes of premature mortality worldwide. Nevertheless, smoking is still considered to be a risk rather than a prognostic factor for mortality. The aim of the study was to determine the most important factors in predicting the risk of premature death after effective hospital treatment of COPD exacerbation. MATERIAL AND METHODS: 34 consecutive patients hospitalized with COPD exacerbation were followed up and their post-hospitalization survival time was analyzed. Basic clinical data (BORG, MRC, BMI, pack-years and age) was collected. The following tests that were performed prior to discharge were assessed: 6MWT, spirometry, body plethysmography, diffusion capacity, transthoracic echocardiography (TEE) and whole night polysomnography. Routine laboratory and immunoenzymatic tests (hs-CRP, endothelin 1 (ET-1), NT-proBNP, IL-6, TNF-alfa) were analyzed. RESULTS: The average follow-up period was 15.1 ± 8.2 month. The mortality rate was 3/34 = 8.8%. Univariable analysis revealed significant differences that indicated a greater number of deaths at higher values of: pack-years (p = 0.02), BODE (p = 0.03), heart rate (HR) after 6MWT (p = 0.003), ET-1 (p = 0.04), but at lower values of TLCO/VA (p = 0.03) and 6MWT-distance (p = 0.006). Multivariable analysis revealed that only pack-years (p = 0.005) were predictive for mortality. CONCLUSIONS: Smoking history seems to have the strongest impact on short-term mortality after recovery from COPD exacerbation.

Detection of Pneumothorax in Severe Acute Respiratory Distress Syndrome-Lung Ultrasound Pitfalls.

Lung ultrasound is gaining popularity as a quick, easy, and accurate method for the detection of pneumothorax. The typical sonographic features of pneumothorax are the absence of lung sliding, the presence of a lung point, the absence of a lung pulse, and the absence of B-lines. However, we found that in some cases, each of these elements might be misleading.

The Predictive Role of Lactate in the Emergency Department in Patients with Severe Dyspnea.

Objective: An accurate identification of patients at the need for prioritized diagnostics and care are crucial in the emergency department (ED). Blood gas (BG) analysis is a widely available laboratory test, which allows to measure vital parameters, including markers of ventilation and perfusion. The aim of our analysis was to assess whether blood gas parameters in patients with dyspnea at an increased risk of respiratory failure admitted to the ED can predict short-term outcomes. Methods: The study group eventually consisted of 108 patients, with available BG analysis. The clinical and laboratory parameters were retrospectively evaluated, and three groups were distinguished-arterial blood gas (ABG), venous blood gas (VBG), and mixed blood gas. The primary endpoint was short-term, all-cause mortality during the follow-up of median (quartile 1-quartile 3) 2 (1-4) months. The independent risk factors for mortality that could be obtained from blood gas sampling were evaluated. Results: The short-term mortality was 35.2% (38/108). Patients who died were more frequently initially assigned to the red triage risk group, more burdened with comorbidities, and the median SpO2 on admission was significantly lower than in patients who survived the follow-up period. In the multivariable analysis, lactate was the strongest independent predictor of death, with 1 mmol/L increasing all-cause mortality by 58% in ABG (95% CI: 1.01-2.47), by 80% in VBG (95% CI: 1.13-2.88), and by 68% in the mixed blood gas analysis (95% CI: 1.22-2.31), what remained significant in VBG and mixed group after correction for base excess. In each group, pH, pO2, and pCO2 did not predict short-term mortality. Conclusions: In patients admitted to the ED due to dyspnea, at risk of respiratory failure, lactate levels in arterial, venous, and mixed blood samples are independent predictors of short-term mortality.

[Non-invasive ventilation in treatment of adults with chronic respiratory failure]. / Nieinwazyjna wentylacja mechaniczna (NIV) w leczeniu przewleklej niewydolnosci oddychania u doroslych.

Non-invasive mechanical ventilation (NIV) is a modern method of chronic respiratory failure (CRF) treatment. With the development of medicine and society known as "western", the number of elderly people, in whom there is overlapping of chronic diseases such as COPD, is growing. In adult population NIV is used in the treatment of neuromuscular diseases such as amyotrophic lateral sclerosis (ALS) or spinal muscular atrophy. The other main indications include restrictive diseases such as kyphoscoliosis, pulmonary diseases with COPD which is the primary indication, and various forms of central apnea syndrome with epidemiologically essential role of obesity hypoventilation syndrome (OHS). In each of those indications, and in different patients, the mode and ventilation intensity may significantly differ. The aim of this review is to disseminate knowledge on the potential role of NIV in adults with CRF. This paper attempts to analyze the available knowledge concerning NIV in adults with CRF. Special attention is paid to the potential pathomechanisms which should become the subject of future research.

Window of opportunity for respiratory oscillometry: A review of recent research.

Oscillometry has been around for almost 70 years, but there are still many unknowns. The test is performed during tidal breathing and is therefore free from patient-dependent factors that could influence the results. The Forced Oscillation Technique (FOT), which requires minimal patient cooperation, is gaining ground, particularly with elderly patients and children. In pulmonology, it is a valuable tool for assessing obstructive conditions (with a distinction between central and peripheral obstruction) and restrictive disorders (intrapulmonary and extrapulmonary). Its sensitivity allows the assessment of bronchodilator and bronchoconstrictor responses. Different lung diseases show different patterns of changes in FOT, especially studied in asthma and chronic obstructive pulmonary disease. Because of these differences, many studies have analysed the usefulness of this technique in different areas of medicine. In this paper, the authors would like to present the basics of oscillometry with the areas of its most recent clinical applications.

Characteristics of Interstitial Pneumonia With Autoimmune Features (IPAF): Protocol for a Multicenter Prospective Study.

BACKGROUND: "Interstitial lung disease" (ILD) is a broad term encompassing diseases of different backgrounds. "Interstitial pneumonia with autoimmune features" (IPAF) is a recent term that implies the presence of autoimmunity. OBJECTIVE: This study aims to determine the characteristics of Polish patients with IPAF, compare them with patients with other interstitial pneumonias, and search for the prognostic and diagnostic biomarkers of IPAF in serum and bronchoalveolar lavage fluid (BALF). METHODS: This multicenter prospective study plans to recruit 240 participants divided into 1 study group and 2 control groups. Biological fluid samples will be collected according to Polish Respiratory Society management guidelines and stored at -80°C for further tests. Prospective 5-year observations of 60 newly diagnosed individuals are planned. The study will be divided into subsections. First, we plan to characterize Polish patients with IPAF (study group) against their peers with other ILDs (2 control groups). Control group 1 will comprise patients with idiopathic ILDs, including mainly idiopathic pulmonary fibrosis and nonspecific interstitial pneumonia. Control group 2 will comprise patients with connective tissue disease-associated interstitial lung diseases, such as rheumatoid arthritis, systemic sclerosis, polymyositis, dermatomyositis, Sjögren's syndrome, mixed connective tissue disease, and systemic lupus erythematosus. Radiological and functional parameters will be analyzed. Patients will be compared in terms of high-resolution computed tomography results, the 6-minute walking test performance, and pulmonary function test parameters. The diagnosis of IPAF will be reassessed on a regular basis through multidisciplinary discussion in order to determine its clinical stability. In the laboratory arm, inflammation and fibrosis pathways will be assessed. Cytokine levels (interleukin 8, transforming growth factor beta 1, chemokine C-C motif ligand [CXCL]18, CXCL1, surfactant protein [SP]-A, SP-D, Krebs von den Lungen-6 protein, and chitinase 1) will be measured in serum and BALF. A comparative analysis of serum and BALF cytokine levels will be performed in order to establish potential differences between systemic and local inflammatory pathways. In the quality of life (QoL) arm of the study, dyspnea and cough and their impact on various aspects of the QoL will be assessed. Depression and anxiety will be measured with the Hospital Anxiety and Depression Modified Scale and the 9-item Patient Health Questionnaire, and potential correlations with symptom prevalence will be assessed. RESULTS: This study will start recruiting patients to phase 1 in October 2023. The final results will be available in 2028. We plan to publish preliminary results after 2-3 years from the start of phase 1. CONCLUSIONS: This study will be a step toward a better understanding of IPAF etiopathogenesis and outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/44802.

Autopsy Histopathologic Lung Findings in Patients Treated With Extracorporeal Membrane Oxygenation.

CONTEXT.­: Extracorporeal membrane oxygenation (ECMO) is increasingly used in the treatment of respiratory and cardiac failure, but data describing lung histopathology in ECMO recipients are limited. OBJECTIVE.­: To examine pulmonary histopathologic findings in patients who underwent venovenous (VV) ECMO for pulmonary reasons, or venoarterial (VA) ECMO for cardiac indications shortly before death, and to determine if the pulmonary changes provided insights into therapy that may prevent complications and improve outcome. DESIGN.­: We conducted a retrospective study of lung autopsies, from VV and VA ECMO recipients and patients with acute respiratory distress syndrome (ARDS) and non-ECMO treatment, between 2008 and 2020 in Silesia Center for Heart Diseases in Zabrze, Poland. RESULTS.­: Among 83 ECMO patients (42-64 years; male, 57 [68.7%]), the most common histopathologic findings were bronchopneumonia (44 [53.0%]), interstitial edema (40 [48.2%]), diffuse alveolar damage (DAD; 32 [38.6%]), hemorrhagic infarct (28 [33.7%]), and pulmonary hemorrhage (25 [30.1%]). DAD was associated with longer ECMO treatment and longer hospital stay. The use of VV ECMO was a predictor of DAD in patients with ARDS and undergoing ECMO, but it also occurred in 21 of 65 patients (32.3%) in the VA ECMO group, even though VA ECMO was used for heart failure. CONCLUSIONS.­: Although DAD was significantly more common in lung autopsies of VV ECMO patients, one-third of VA ECMO patients had histopathologic changes characteristic of ARDS. The presence of DAD in lung autopsies of patients treated with VA ECMO indicates that in these patients, protective lung ventilation should be considered.

The use of non-invasive respiratory assistance to facilitate bronchofiberoscopy performance in patients with hypoxemic (type one) respiratory failure - Study protocol.

PURPOSE: Bronchofiberoscopy (FOB) is a procedure routinely performed for: lung cancer, obstruction, interstitial diseases, foreign bodies' removal, airway clearance, and hemoptysis. It causes acute airway narrowing leading to respiratory and cardiovascular stress. Due to increasing number of ill patients with respiratory failure (RF), conventional oxygen therapy (COT) is frequently insufficient to assure accurate oxygenation and prevent RF in patients requiring FOB. In this clinical scenario, patients may be intubated and supported with invasive mechanical ventilation (IMV) with the specific aim of allowing a safe FOB. However, this invasive strategy is associated with an increased risk of IMV-associated complications. MATERIALS AND METHODS: Our study is a planned prospective multicenter three-arm randomized controlled trial (RCT). The target number of 300 patients was calculated based on the intubation risk in RF patients, which is 0.2-2%. The patients will be assigned to each arm based on Horowitz index. In each arm, the patients will be randomly assigned to one out of two dedicated respiratory support methods in each group i.e. COT/high flow nasal cannula (HFNC), HFNC/non-invasive ventilation (NIV) and NIV/IMV. In the manuscript the current state of art in the area of respiratory support is discussed. We have underlined knowledge gaps in medical evidence which we are planning to reveal with our results. RESULTS: The results of our study are clinically crucial, because they address current gaps concerning COT/HFNC/NIV/IMV. CONCLUSION: The expected findings of this study would allow for careful selection of respiratory support method to safely perform FOB in patients with hypoxemic RF.