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Background: A profound inflammation-mediated lung injury with long-term acute respiratory distress and high mortality is one of the major complications of critical COVID-19. Immunoglobulin M (IgM)-enriched immunoglobulins seem especially capable of mitigating the inflicted inflammatory harm. However, the efficacy of intravenous IgM-enriched preparations in critically ill patients with COVID-19 is largely unclear., Methods: In this retrospective multicentric cohort study, 316 patients with laboratory-confirmed critical COVID-19 were treated in ten German and Austrian ICUs between May 2020 and April 2021. The primary outcome was 30-day mortality. Analysis was performed by Cox regression models. Covariate adjustment was performed by propensity score weighting using machine learning-based SuperLearner to overcome the selection bias due to missing randomization. In addition, a subgroup analysis focusing on different treatment regimens and patient characteristics was performed., Results: Of the 316 ICU patients, 146 received IgM-enriched immunoglobulins and 170 cases did not, which served as controls. There was no survival difference between the two groups in terms of mortality at 30 days in the overall cohort (HR adj : 0.83; 95% CI: 0.55 to 1.25; p = 0.374). An improved 30-day survival in patients without mechanical ventilation at the time of the immunoglobulin treatment did not reach statistical significance (HR adj : 0.23; 95% CI: 0.05 to 1.08; p = 0.063). Also, no statistically significant difference was observed in the subgroup when a daily dose of ≥ 15 g and a duration of ≥ 3 days of IgM-enriched immunoglobulins were applied (HR adj : 0.65; 95% CI: 0.41 to 1.03; p = 0.068)., Conclusions: Although we cannot prove a statistically reliable effect of intravenous IgM-enriched immunoglobulins, the confidence intervals may suggest a clinically relevant effect in certain subgroups. Here, an early administration (i.e. in critically ill but not yet mechanically ventilated COVID-19 patients) and a dose of ≥ 15 g for at least 3 days may confer beneficial effects without concerning safety issues. However, these findings need to be validated in upcoming randomized clinical trials. Trial registration DRKS00025794 , German Clinical Trials Register, https://www.drks.de . Registered 6 July 2021., (© 2022. The Author(s).)

Purpose: The CIGMA study investigated a novel human polyclonal antibody preparation (trimodulin) containing ~ 23% immunoglobulin (Ig) M, ~ 21% IgA, and ~ 56% IgG as add-on therapy for patients with severe community-acquired pneumonia (sCAP)., Methods: In this double-blind, phase II study (NCT01420744), 160 patients with sCAP requiring invasive mechanical ventilation were randomized (1:1) to trimodulin (42 mg IgM/kg/day) or placebo for five consecutive days. Primary endpoint was ventilator-free days (VFDs). Secondary endpoints included 28-day all-cause and pneumonia-related mortality. Safety and tolerability were monitored. Exploratory post hoc analyses were performed in subsets stratified by baseline C-reactive protein (CRP; ≥ 70 mg/L) and/or IgM (≤ 0.8 g/L)., Results: Overall, there was no statistically significant difference in VFDs between trimodulin (mean 11.0, median 11 [n = 81]) and placebo (mean 9.6; median 8 [n = 79]; p = 0.173). Twenty-eight-day all-cause mortality was 22.2% vs. 27.8%, respectively (p = 0.465). Time to discharge from intensive care unit and mean duration of hospitalization were comparable between groups. Adverse-event incidences were comparable. Post hoc subset analyses, which included the majority of patients (58-78%), showed significant reductions in all-cause mortality (trimodulin vs. placebo) in patients with high CRP, low IgM, and high CRP/low IgM at baseline., Conclusions: No significant differences were found in VFDs and mortality between trimodulin and placebo groups. Post hoc analyses supported improved outcome regarding mortality with trimodulin in subsets of patients with elevated CRP, reduced IgM, or both. These findings warrant further investigation., Trial Registration: NCT01420744.

Purpose: High-frequency oscillatory ventilation (HFOV) is usually considered not indicated for treatment of patients with chronic obstructive pulmonary disease (COPD) because of the theoretical risk of air trapping and hyperinflation. The aim of our study was to establish whether HFOV can be safely applied in patients with acute exacerbation of COPD and hypercapnic respiratory failure., Methods: Ten patients (age, 63-83 years) requiring intensive care treatment who failed on noninvasive ventilation were studied. After initial conventional mechanical ventilation (CMV) of less than 72 hours, all patients were transferred to HFOV for 24 hours and then back to CMV. Arterial blood gases, spirometry, and hemodynamic parameters were repeatedly obtained in all phases of CMV and HFOV at different settings. Regional lung aeration and ventilation were assessed by electrical impedance tomography., Results: High-frequency oscillatory ventilation was tolerated well; no adverse effects or severe hyperinflation and hemodynamic compromise were observed. Effective CO(2) elimination and oxygenation were achieved. Ventilation was more homogeneously distributed during HFOV than during initial CMV. Higher respiratory system compliance and tidal volume were found during CMV after 24 hours of HFOV., Conclusions: Our study indicates that short-term HFOV, using lower mean airway pressures than recommended for acute respiratory distress syndrome, appears safe in patients with COPD while securing adequate pulmonary gas exchange., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background and Objective: The prevalence of difficult or prolonged weaning from mechanical ventilation is increasing because of a growing number of elderly patients with multiple diseases and pulmonary problems requiring mechanical ventilation. Intensive care units (ICU) are inclined to refer to specialized unit those patients who are difficult to wean. A nationwide survey of German facilities was conducted and this article reports the current state of weaning centers staffed by chest physicians., Patients and Methods: 38 centers participated in the survey, which was divided into 10 items, covering characteristics of the hospital, weaning strategies, patients and outcomes during 2006. The survey included 2718 patients in whom weaning was difficult or prolonged. Almost three quarters of patients were transferred to one of the weaning centers from the ICU of another hospital., Results: The weaning success rate was 66.4%. In 31,9 % of patients home mechanical ventilation was started after they had been weaned. The overall hospital mortality rate was 20.8%. There were major differences between individual centres concerning the number of patients, organization of the weaning unit and weaning strategies., Conclusions: Weaning was successful in two thirds of patients who had been on prolonged mechanical ventilation and had then been transferred to weaning facilities staffed by chest physicians. These centres effectively improved the quality of care of patients on prolonged mechanical ventilation by avoiding long-term invasive ventilation and sparing cost-intensive ICU resources. The problems that still exist may be overcome by a network of weaning facilities.

Background: Tracheostomy provides a method for long-term ventilation in intensive care, which reduces the risk of necrotizing lesions of the pharyngeal and laryngeal mucosa. Since the introduction of the percutaneous dilatational tracheostomy, experienced physicians are able to perform bedside tracheostomies. This presentation reviews the complication rate and long-term outcome of percutaneous dilatational tracheostomy., Patients and Method: The method was applied in 57 patients following previous orotracheal intubation averaging 7.8 days (3 to 15 days). Underlying diseases were sepsis/SIRS in 29, stroke in 7, cerebral hypoxemia after cardiopulmonary resuscitation in 10, trauma in 7, prolonged weaning in 2, primary neurological diseases in 2., Results: The following complications occurred during the procedure: 1 major and 7 minor bleedings. 2 subcutaneous emphysemas, 1 mediastinal emphysema following tracheal injury. No complication required surgical intervention. In the follow-up 17 patients (30%) died from their underlying disease, none from complications of the tracheostomy. After removed of the tracheal tube, in 39 patients the stoma closed spontaneously within 7 to 14 days. In 8 patients the tracheostoma persisted for more than 3 months, but no clinically relevant tracheal stenosis was found., Conclusion: Percutaneous dilatational tracheostomy is a safe procedure easy to perform in intensive care units. Bronchoscopic control is necessary to avoid complications.

With extending duration of translaryngeal intubation the rate of lesions in the oral cavity, pharynx and trachea caused by the orotracheal tube increase. To prevent these complications ventilated patients receive early tracheostomy. PDT is an alternative procedure to the conventional, surgically performed tracheostomy. We performed 60 dilatational tracheostomies using the Ciaglia percutaneous tracheostomy set (W. Cook-Critical Care, Bjaeverskov). Complication rate was 17% due to minor bleeding (n = 7), subcutaneous emphysema (n = 2) and fracture of one tracheal cartilage ring (n = 1). This rate is equivalent to that of surgical procedure. Advantage of PDT is that it can be performed by intensive care doctors without a specific surgical background. Further follow up after removal of the tracheal cannula was uneventful. Tracheal stenosis requiring intervention are rare. The remaining scar after PDT is significantly smaller than after conventional tracheostomy.