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BACKGROUND: Driving pressure (ΔP) has been described as a risk factor for mortality in patients with ARDS. However, the role of ΔP in the outcome of patients without ARDS and on mechanical ventilation has received less attention. Our objective was to evaluate the association between ΔP on the first day of mechanical ventilation with the development of ARDS. METHODS: This was a post hoc analysis of a multicenter, prospective, observational, international study that included subjects who were on mechanical ventilation for > 12 h. Our objective was to evaluate the association between ΔP on the first day of mechanical ventilation with the development of ARDS. To assess the effect of ΔP, a logistic regression analysis was performed when adjusting for other potential risk factors. Validation of the results obtained was performed by using a bootstrap method and by repeating the same analyses at day 2. RESULTS: A total of 1,575 subjects were included, of whom 65 (4.1%) developed ARDS. The ΔP was independently associated with ARDS (odds ratio [OR] 1.12, 95% CI 1.07–1.18 for each cm H(2)O of ΔP increase, P < .001). The same results were observed at day 2 (OR 1.14, 95% CI 1.07–1.21; P < .001) and after bootstrap validation (OR 1.13, 95% CI 1.04–1.22; P < .001). When taking the prevalence of ARDS in the lowest quartile of ΔP (≤9 cm H(2)O) as a reference, the subjects with ΔP > 12–15 cm H(2)O and those with ΔP > 15 cm H(2)O presented a higher probability of ARDS (OR 3.65, 95% CI 1.32–10.04 [P = .01] and OR 7.31, 95% CI, 2.89–18.50 [P < .001], respectively). CONCLUSIONS: In the subjects without ARDS, a higher level of ΔP on the first day of mechanical ventilation was associated with later development of ARDS. (ClinicalTrials.gov registration NCT02731898.)

The effectiveness of humidified high flow nasal cannula (HFNC) in lung transplant (LTx) recipients readmitted to intensive care unit (ICU) because of acute respiratory failure (ARF) has not been determined to date.Retrospective analysis of a prospectively assessed cohort of LTx patients who were readmitted to ICU because of ARF over a 5-year period. Patients received conventional oxygen therapy (COT) or HFNC (Optiflow, FisherPaykel, New Zealand) supportive therapy according to the attending physician's criteria. Treatment failure was defined as the need for subsequent mechanical ventilation (MV).Thirty-seven LTx recipients required ICU readmission, with a total of 40 episodes (18 COT vs. 22 HFNC). At ICU admission, no differences in comorbidities, pulmonary function, or median sequential organ failure assessment (COT, 4 [interquartile range, 4-6] vs. HFNC, 4 [interquartile range, 4-7]; P = 0.51) were observed. Relative risk of MV in patients with COT was 1.50 (95% confidence interval [95% CI], 1.02-2.21). The absolute risk reduction for MV with HFNC was 29.8%, and the number of patients needed to treat to prevent one intubation with HFNC was 3. Multivariate analysis showed that HFNC therapy was the only variable at ICU admission associated with a decreased risk of MV (odds ratio, 0.11 [95% CI, 0.02-0.69]; P = 0.02). Moreover, nonventilated patients had an increased survival rate (20.7% vs. 100%; relative rate 4.83 [95% CI, 2.37-9.86]; P0.001). No adverse events were associated with HFNC use.HFNC O2 therapy is feasible and safe and may decrease the need for MV in LTx recipients readmitted to the ICU because of ARF.

BACKGROUND: Primary graft dysfunction (PGD) remains a significant cause of lung transplant postoperative morbidity and mortality. The underlying mechanisms of PGD development are not completely understood. This study analyzed the effect of right ventricular function (RVF) on PGD development. METHODS: A retrospective analysis of a prospectively assessed cohort was performed at a single institution between July 2010 and June 2013. The primary outcome was development of PGD grade 3 (PGD3). Conventional echocardiographic parameters and speckle-tracking echocardiography, performed during the pre-transplant evaluation phase up to 1 year before surgery, were used to assess preoperative RVF./nRESULTS: Included were 120 lung transplant recipients (LTr). Systolic pulmonary arterial pressure (48 ± 20 vs 41 ± 18 mm Hg; p = 0.048) and ischemia time (349 ± 73 vs 306 ± 92 minutes; p < 0.01) were higher in LTr who developed PGD3. Patients who developed PGD3 had better RVF estimated by basal free wall longitudinal strain (BLS; -24% ± 9% vs -20% ± 6%; p = 0.039) but had a longer intensive care unit length of stay and mechanical ventilation and higher 6-month mortality. BLS ≥ -21.5% was the cutoff that best identified patients developing PGD3 (area under the receiver operating characteristic curve, 0.70; 95% confidence interval, 0.54-0.85; p = 0.020). In the multivariate analysis, a BLS ≥ -21.5% was an independent risk factor for PGD3 development (odds ratio, 4.56; 95% confidence interval, 1.20-17.38; p = 0.026), even after adjusting for potential confounding. CONCLUSIONS: A better RVF, as measured by BLS, is a risk factor for severe PGD. Careful preoperative RVF assessment using speckle-tracking echocardiography may identify LTrs with the highest risk of developing PGD. Dr. Pérez-Terán is granted by a “Rio Hortega”grant (Ref. CM12/00216)from the Instituto de Salud Carlos III, Ministerio de Ciencia e Innovación.

Introduction We investigated the effects on hemodynamics and gas exchange of a lipid emulsion enriched with omega-3 fatty acids in patients with ARDS. Methods The design was a prospective, randomized, double-blind, parallel group study in our Intensive Medicine Department of Vall d'Hebron University Hospital (Barcelona-Spain). We studied 16 consecutive patients with ARDS and intolerance to enteral nutrition (14 men and 2 women; mean age: 58 ± 13 years; APACHE II score: 17.8 ± 2.3; Lung Injury Score: 3.1 ± 0.5; baseline PaO2/FiO2 ratio: 149 ± 40). Patients were randomized into 2 groups: Group A (n = 8) received the study emulsion Lipoplus® 20%, B.Braun Medical (50% MCT, 40% LCT, 10% ω-3); Group B (n = 8) received the control emulsion Intralipid® Fresenius Kabi (100% LCT). Lipid emulsions were administered during 12 h at a dose of 0.12 g/kg/h. Measurements of the main hemodynamic and gas exchange parameters were made at baseline (immediately before administration of the lipid emulsions), every hour during the lipid infusion, at the end of administration, and six hours after the end of administration lipid infusion. Results No statistically significant changes were observed in the different hemodynamic values analyzed. Likewise, the gas exchange parameters did not show statistically significant differences during the study. No adverse effect attributable to the lipid emulsions was seen in the patients analyzed. Conclusion The lipid emulsion enriched with omega-3 fatty acids was safe and well tolerated in short-term administration to patients with ARDS. It did not cause any significant changes in hemodynamic and gas exchange parameters. Trial registration ISRCTN63673813

OBJETIVO. Analizar la frecuencia del síndrome de distrés respiratorio agudo (SDRA) en pacientes ingresados en un Servicio de Medicina Intensiva (SMI) y los factores pronósticos de mortalidad en estos pacientes. DISEÑO. Estudio prospectivo de todos los pacientes ingresados de forma consecutiva en el SMI desde enero de 1998 a febrero de 2003. ÁMBITO. SMI de un centro universitario de tercer nivel con 32 camas en su Área General y 10 camas en el Área de Traumatología. PACIENTES. Pacientes que cumplieron los criterios de SDRA de la Conferencia de Consenso Europeo-Norteamericana en cualquier momento durante el ingreso en el SMI. VARIABLES DE INTERÉS. Mortalidad a los 28 días. RESULTADOS. Ciento noventa y un pacientes (3,4% del total de ingresos en el SMI) cumplieron criterios de SDRA. El origen del SDRA fue intrapulmonar en el 63%. Un 77% de los pacientes presentaron disfunción multiorgánica y un 26% sobreinfección respiratoria. La mediana de la estancia en el SMI fue de 20 días. La mortalidad a los 28 días fue del 48% y la mortalidad hospitalaria del 58%. El análisis multivariante mostró que las variables asociadas de manera independiente con un aumento de la mortalidad fueron las siguientes: APACHE II > 22 (odds ratio [OR] 2,7; IC 95%: 1,3-5,8; p = 0,007), PaO2/F I O2 mínima durante la evolución del SDRA < 81 mmHg (OR 5,5; IC 95%: 2,6-11,9; p < 0,0001), disfunción ≥ 3 órganos (OR 11,8; IC 95%: 2,5-55,4; p = 0,002). CONCLUSIONES. El SDRA es una entidad de elevada mortalidad, cuyo pronóstico se asocia no sólo a la gravedad del deterioro de la función pulmonar, sino también sistémica, sobre la que algún tratamiento podría modular su evolución. OBJETIVE. Analyze acute respiratory distress syndrome (ARDS) in patients admitted to an Intensive Care Medicine Service (ICMS) and prognostic factors of mortality in these patients. DEDIGN. Prospective study of all the patients admitted consecutively in the ICMS from January 1998 to February 2003. SCOPE. ICMS of a third level university site with 32 beds in its General Area and 10 beds in the Traumatology Area. PATIENTS. Patients who met the ARDS criteria of the European-North American Consensus Conference at any time during admission in ICMS. ENDPOINTS OF INTEREST. Mortality at 28 days. RESULTS. One hundred and ninety-one patients (3.4 of all the admissions in ICMS) had ARDS criteria. The origin of ARDS was intrapulmonary in 63%. A total of 77% of the patients had multiorgan dysfunction and 26% respiratory superinfection. Median stay in the ICMS was 20 days. Mortality at 28 days was 48% and hospital mortality 58%. Multivariant analysis showed that the variables associated independently with an increase in mortality were the following: APACHE II > 22 (odds ratio [OR] 2.7; 95% CI: 1.3-5.8; p = 0.007), minimum PaO2/F I O2 during evolution of ARDS < 81 mmHg (odds ratio 5.5; 95% CI: 2.6-11.9; p < 0.0001), dysfunction ≥ 3 organs (odds ratio 11.8; 95% CI: 2.5-55.4; p = 0.002). CONCLUSIONS: ARDS is an entity with elevated mortality whose prognosis is associated not only with the seriousness of pulmonary function deterioration but also of systemic function, on which some treatment could modulate its evolution.