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Neutrophil gelatinase-associated lipocalin (NGAL) is produced in the bronchial and alveolar cells of inflamed lungs and is regarded as a potential prognostic biomarker in various respiratory diseases. However, there are no studies on patients with acute respiratory distress syndrome (ARDS). NGAL levels in serum and bronchoalveolar lavage (BAL) were measured at baseline and on day 7 in 110 patients with ARDS. Baseline NGAL levels were significantly higher in ARDS patients than in healthy controls (serum 25 [14.5–41] vs. 214 [114.5–250.3] ng/mL; BAL 90 [65–115] vs. 211 [124–244] ng/mL). In ARDS, baseline NGAL levels in serum and BAL were significantly higher in non-survivors than in survivors (p < 0.001 and p = 0.021, respectively). Baseline NGAL levels showed a fair predictive power for intensive care unit (ICU) mortality (serum area under the curve (AUC) 0.747, p < 0.001; BAL AUC 0.768, p < 0.001). In a multivariate Cox regression analysis, the baseline serum NGAL level (> 240 ng/mL) was significantly associated with ICU mortality (hazard ratio [HR] 5.39, 95% confidence interval [CI] 2.67–10.85, p < 0.001). In particular, day 7 NGAL was significantly correlated with day 7 driving pressure (serum r = 0.388, BAL r = 0.702), and 28 ventilator-free days (serum r = − 0.298, BAL r = − 0.297). Baseline NGAL has good prognostic value for ICU mortality in patients with ARDS. NGAL can be a biomarker for ventilator requirement, as it may be indicative of potential alveolar epithelial injury. [ABSTRACT FROM AUTHOR]

Size matching is an important challenge in lung transplantation. Although the survival rate after lung transplantation with an oversized allograft was improved, it is associated with substantial immediate postoperative morbidity and mortality. Prone positioning is a rescue therapy showing improved outcomes in acute respiratory distress syndrome. We present a case of immediate postoperative refractory hypoxemia after oversized lung transplantation treated by prone positioning. A 62-year-old man was transferred to our hospital by our extracorporeal membrane oxygenation (ECMO) transport team because of acute exacerbation of idiopathic pulmonary fibrosis. He underwent bilateral lung transplantation through bilateral anterior thoracotomy. For size matching between donor and recipient, multiple wedge resection and lingular segmentectomy were performed, but an oversized lung was implanted. On the immediate postoperative day, chest radiography revealed haziness in the left lower quadrant and the patient had an increased O 2 requirement; he could not be weaned from venovenous (VV) ECMO. Chest computed tomography revealed left lower lobar atelectasis and primary graft dysfunction. To revert the atelectatic portion, improve ventilation/perfusion mismatch, and avoid high ventilation pressure, we performed the recruitment maneuver. Despite this, his blood gas profile did not improve. Therefore, we applied prone positioning with VV ECMO. After conversion to the prone positioning, the hypoxia corrected and the tidal volume increased. After 20 hours, he was changed to the supine position. Thereafter, arterial blood gas analyses were stable and he could be weaned from ECMO. He was discharged on postoperative day 57 and maintained good respiratory function. This case demonstrated the safety and feasibility of prone positioning during the immediate postoperative period after lung transplant by bilateral anterior thoracotomy. Prone positioning successfully reversed postoperative atelectasis and improved primary graft dysfunction after oversized lung transplant. • Size matching is one of the important challenges in lung transplantation. • Prone positioning is one of the rescue therapies improving outcomes in acute respiratory distress syndrome. • Prone positioning successfully reversed postoperative atelectasis and improved primary graft dysfunction after oversized lung transplant. [ABSTRACT FROM AUTHOR]

Background: As extracorporeal membrane oxygenation (ECMO) has been widely used, the patient quality of life following ECMO termination has become an important issue as same as the patient's survival. To date, the factors affecting complete recovery of adult survivors from ECMO have not been investigated. Methods: Data from adult patients in the Extracorporeal Life Support Organization registry who received veno-venous ECMO between 2012 and 2017 were analyzed. Multivariate logistic regression analyses were conducted. Results: In total, 6536 patients with 242,183 days of veno-venous ECMO were reviewed. The overall survival to discharge rate after weaning from ECMO was 89.7% (n = 5861), and 10.3% (n = 675) of the patients died during hospitalization. The discharge location varied as follows: 33.7% (n = 1976) returned home, 23.4% (n = 1369) were transferred to a referral hospital, 41.8% (n = 2447) required hospital services, and 0.6% (n = 36) were discharged to other places. The patients were divided into two groups according to the discharge location: a complete recovery group (n = 1976) and a partial recovery group (n = 3885). In the multivariate analyses, age (≥ 65 years) (odds ratio (OR) 0.72, 95% confidence interval (CI) 0.59–0.87, p = 0.001), cardiac arrest before ECMO (OR 0.76, 95% CI 0.60–0.96, p = 0.021), vasopressor use (OR 0.73, 95% CI 0.64–0.83, p < 0.001), renal replacement therapy (OR 0.40, 95% CI 0.28–0.57, p < 0.001), ECMO-related complications (OR 0.76, 95% CI 0.67–0.85, p < 0.001), and long-term ECMO support (≥ 2 weeks) (OR 0.42, 95% CI 0.37–0.48, p < 0.001) were significantly associated with complete recovery. Conclusion: Complete recovery after veno-venous ECMO support is associated with the patient's baseline condition, ECMO duration, and ECMO-related complications. Respiratory ECMO should aim to increase both the survival and the quality of life after weaning from ECMO. [ABSTRACT FROM AUTHOR]

B RESULTS: b The patients were divided into two groups according to the skeletal muscle index (SMI): low SMI (n = 47) and high SMI (n = 80). The mean Charlson comorbidity index (CCI) was lower in the high SMI group than in the low SMI group (3.0 vs. 2.2, p=0.024). [Extracted from the article]

B Learning Objectives: b Extracorporeal membrane oxygenation (ECMO) has become one of the promising rescue therapy options for acute respiratory failure. We defined success of ECMO treatment as successful ICU discharge, acceptable failure rate as 40%, and unacceptable failure rate as 60%. B Results: b The overall success rate of ECMO treatment was 59.9% (85/142). [Extracted from the article]