General Critical Care

70-year-old male presents with one month of hemoptysis and shortness of breath. Acute renal failure, anemia, bilateral infiltrates on chest X-ray.

CT scan of the chest:

Kidney profile:

Bronchoscopy

Analgesia and Sedation Use During Noninvasive Ventilation for Acute Respiratory Failure

Critical Care Medicine (lww.com)

This study examines the use of analgesia and sedation during noninvasive ventilation (NIV) for acute respiratory failure (ARF) across 1,017 U.S. hospitals. Among 433,357 patients, 26.7% received analgesia or sedation, with opioids (11.7%) and benzodiazepines (9.4%) being most common. Medication use was linked to higher odds of intubation (7.4%) or death (5.6%). Patients receiving any study medication had a 38% increased odds of intubation or mortality (aOR 1.38, 95% CI 1.35–1.40). The study highlights potential risks, especially with combinations like opioids and benzodiazepines, and calls for further research.

The liver and kidney in pulmonary hypertension and right heart failure. A, Acute ischemic hepatitis and congestive hepatopathy. Right inset, Centrilobular necrosis in ischemic hepatitis. Left inset, Chronic hepatic congestion with sinusoidal dilatation and portal fibrosis. B, Congestive nephropathy. Right inset, Low perfusion kidney injury caused by hypoperfusion and ischemia, demonstrating fibrosis (*), necrotic cells (arrowhead), and intraluminal debris. Left inset, Congestive nephropathy, characterized by interstitial edema, swollen tubule cells, and tubular compression. ALAT indicates alanine transaminase; AP, arterial pressure; ASAT, aspartate aminotransferase; CVP, central venous pressure; LDH, lactic acid dehydrogenase; and yGT, gamma-glutamyl transpeptidase.

Systemic Consequences of Pulmonary Hypertension and Right-Sided Heart Failure | Circulation (ahajournals.org)

RV dilation and TR associated with PE

Chest X-ray with right lower/middle lobe infiltrate

Turned out to be effusion in the minor fissure on the CT scan.

Conservative versus Liberal Oxygenation Targets in Intensive Care Unit Patients (ICONIC)

In this study, the effectiveness of different oxygenation strategies in intensive care unit (ICU) patients was investigated. The aim was to determine if a low-oxygenation strategy, targeting lower levels of oxygen in the blood, would lead to lower 28-day mortality compared to a high-oxygenation strategy, where higher oxygen levels were maintained.

The study involved a randomized multicenter trial with mechanically ventilated ICU patients who were expected to require ventilation for at least 24 hours. Patients were divided into two groups: the low-oxygenation group (targeting a PaO2 of 55-80 mmHg or SpO2 of 91-94%) and the high-oxygenation group (targeting a PaO2 of 110-150 mmHg or SpO2 of 96-100%). The primary outcome assessed was 28-day mortality.

Between November 2018 and November 2021, a total of 664 patients were included in the trial. The achieved PaO2 levels were 75 mmHg in the…

Extracorporeal Membrane Oxygenation for Refractory Asthma Exacerbations With Respiratory Failure

The research paper examined the use of ECMO as a salvage therapy for refractory AERF and its impact on mortality. The study analyzed 13,714 AERF patients, with 127 receiving ECMO and 13,587 without it. ECMO was associated with reduced mortality in different models (OR ranging from 0.33 to 0.61) compared to standard care. However, ECMO was linked to higher hospital costs without significant effects on ICU or hospital length of stay or time on invasive ventilation. Confirmatory clinical trials are needed to validate ECMO's role as an important salvage therapy for refractory AERF.

Perspective:

ECMO shows promise in reducing mortality for refractory AERF, but further research and clinical trials are crucial to confirm its benefits and assess cost-effectiveness. As physicians, we should consider these findings when managing critically ill AERF patients, weighing the potential mortality benefits against the associated hospital…

Should Patients with COPD Exacerbation Undergo Imaging for VTE?

A prospective study conducted in 11 hospitals in China aimed to investigate the prevalence and risk factors for venous thromboembolism (VTE) in patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease (COPD). The study included nearly 1600 patients who underwent laboratory and imaging screening for VTE, including bilateral lower-extremity ultrasound, computed tomography pulmonary angiography (CTPA), and echocardiogram, and were followed for 1 year. The results showed a VTE prevalence of 25%, with two-thirds of identified VTEs being pulmonary embolisms (PEs), mostly in large vessels. Patients with VTE had significantly higher 1-year mortality compared to those without VTE. The study also identified risk factors associated with VTE, such as cor pulmonale, elevated B-type natriuretic peptide level, or history of VTE, while purulent sputum was associated with a lower risk. Notably, D-dimer elevation was not strongly predictive of VTE. These findings prompt…

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A systematic review and meta-analysis of prone positioning (PP) for non-intubated COVID-19 patients was published in critical care medicine. The study aimed to systematically synthesize the outcomes associated with PP for non-intubated COVID-19 patients. The primary outcome was the reported cumulative intubation risk, while secondary outcomes included mortality, need for escalating respiratory support, hospital length of stay, ICU admission, and adverse events.

The study found that PP significantly reduced the intubation risk compared to supine position. Subgroup analysis showed a significant reduction in intubation risk among patients supported by high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV) but not in patients with conventional oxygen therapy. No significant reduction was seen in mortality, need for escalating respiratory support, hospital length of stay, ICU admission and adverse events.

In conclusion, in non-intubated COVID-19 patients, PP reduced the need for intubation particularly among those requiring respiratory support with HFNC or NIV but did…

A study investigated the use of inhaled prostacyclin as a therapy for Acute Respiratory Distress Syndrome (ARDS including COVID-19 patients) was published in "Respiratory Research". The study was a prospective randomized controlled single-blind multicenter trial conducted across Germany from March 2019 with final follow-up on 12th of August 2021. Patients with moderate to severe ARDS were included and randomized to receive either inhaled prostacyclin or sodium chloride (Placebo). The primary outcome was the oxygenation index on Day 5 of therapy. Secondary outcomes included mortality, secondary organ failure, disease severity and adverse events.

The primary analysis showed that prostacyclin improved oxygenation by 20 mmHg more than Placebo but this result was not statistically significant (p = 0.17). However, secondary analysis showed that oxygenation was significantly improved in patients with ARDS who were COVID-19-positive (34 mmHg, p = 0.04). Mortality did not differ between groups and secondary organ failure and adverse events were similar in both…

A study by Thille and colleagues compared the two protocols for spontaneous-breathing trials - PSV (with a pressure-support level of 8 cm of water, an Fio2 of ≤40%, and no PEEP) or a T-piece (with supplemental oxygen administered at a rate of ≤6 liters per minute) in high risk patients for reintubation.

The primary end point was the total time alive and without exposure to mechanical ventilation (reported as the number of ventilator-free days) at day 28 after the initial spontaneous-breathing trial.

The study found that there was no difference in the number of ventilator free days between groups, 27 days in PSV group vs 27 days in T piece group.

https://www.icureach.com/criticalcaretrials/spontaneous-breathing-trials

The FIRST-ABC trial shows that That HFNC did not meet noninferiority criteria when compared to CPAP in children requiring respiratory support after extubation and may potentially lead to higher 180-day mortality. The trial supports that clinicians may favor the use of CPAP until more evidence becomes available. I suggest to read this editorial in JAMA as it shed more light on the preferred approaches in the management of respiratory failure in PICU.