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Rationale: The most beneficial positive end-expiratory pressure (PEEP) selection strategy in patients with acute respiratory distress syndrome (ARDS) is unknown, and current practice is variable. Objectives: To compare the relative effects of different PEEP selection strategies on mortality in adults with moderate to severe ARDS. Methods: We conducted a network meta-analysis using a Bayesian framework. Certainty of evidence was evaluated using grading of recommendations assessment, development and evaluation methodology. Measurements and Main Results: We included 18 randomized trials (4,646 participants). Compared with a lower PEEP strategy, the posterior probability of mortality benefit from a higher PEEP without lung recruitment maneuver (LRM) strategy was 99% (risk ratio [RR], 0.77; 95% credible interval [CrI], 0.60-0.96, high certainty), the posterior probability of benefit of the esophageal pressure-guided strategy was 87% (RR, 0.77; 95% CrI, 0.48-1.22, moderate certainty), the posterior probability of benefit of a higher PEEP with brief LRM strategy was 96% (RR, 0.83; 95% CrI, 0.67-1.02, moderate certainty), and the posterior probability of increased mortality from a higher PEEP with prolonged LRM strategy was 77% (RR, 1.06; 95% CrI, 0.89-1.22, low certainty). Compared with a higher PEEP without LRM strategy, the posterior probability of increased mortality from a higher PEEP with prolonged LRM strategy was 99% (RR, 1.37; 95% CrI, 1.04-1.81, moderate certainty). Conclusions: In patients with moderate to severe ARDS, higher PEEP without LRM is associated with a lower risk of death than lower PEEP. A higher PEEP with prolonged LRM strategy is associated with increased risk of death when compared with higher PEEP without LRM.

BACKGROUND: The unifying goal of lung-protective ventilation strategies in ARDS is to minimize the strain and stress applied by mechanical ventilation to the lung to reduce ventilator-induced lung injury (VILI). The relative contributions of the magnitude and frequency of mechanical stress and the end-expiratory pressure to the development of VILI is unknown. Consequently, it is uncertain whether the risk of VILI is best quantified in terms of tidal volume (V(T)), driving pressure (ΔP), or mechanical power. METHODS: The correlation between differences in V(T), ΔP, and mechanical power and the magnitude of mortality benefit in trials of lung-protective ventilation strategies in adult subjects with ARDS was assessed by meta-regression. Modified mechanical power was computed including PEEP (Power(elastic)), excluding PEEP (Power(dynamic)), and using ΔP (Power(driving)). The primary analysis incorporated all included trials. A secondary subgroup analysis was restricted to trials of lower versus higher PEEP strategies. RESULTS: We included 9 trials involving 4,731 subjects in the analysis. Odds ratios for moderation derived from meta-regression showed that variations in V(T), ΔP, and Power(dynamic) were associated with increased mortality with odds ratios of 1.24 (95% CI 1.03–1.49), 1.31 (95% CI 1.03–1.66), and 1.37 (95% CI 1.05–1.78), respectively. In trials comparing higher versus lower PEEP strategies, Power(elastic) was increased in the higher PEEP arm (24 ± 1.7 vs 20 ± 1.5 J/min, respectively), whereas the other parameters were not affected on average by a higher PEEP ventilation strategy. CONCLUSIONS: In trials of lung-protective ventilation strategies, V(T), ΔP, Power(elastic), Power(dynamic), and Power(driving) exhibited similar moderation of treatment effect on mortality. In this study, modified mechanical power did not add important information on the risk of death from VILI in comparison to V(T) or ΔP.

BackgroundThe acute respiratory distress syndrome (ARDS) has high morbidity and mortality. Positive end-expiratory pressure (PEEP) is commonly used in patients with ARDS but the best method to select the optimal PEEP level and reduce all-cause mortality is unclear. The primary objective of this network meta-analysis is to summarize the available evidence and to compare the effect of different PEEP selection strategies on all-cause mortality in adult patients with ARDS.MethodsWe will search MEDLINE, Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and LILACS from inception onwards for randomized controlled trials assessing the effect of PEEP selection strategies in adult patients with moderate to severe ARDS. We will exclude studies that did not use a lung-protective ventilation approach as part of the comparator or intervention strategy. The primary outcome will be all-cause mortality (at the longest available follow-up and up to 90 days). Secondary outcomes will include barotrauma, ventilator-free days, intensive care unit and hospital length of stay, and changes in oxygenation. Two reviewers will independently screen all citations, full-text articles, and extract study-data. We will assess the risk of bias for each of the outcomes using version 2 of the Cochrane risk of bias tool for randomized controlled trials. If feasible, Bayesian network meta-analyses will be conducted to obtain pooled estimates of all potential head-to-head comparisons. We will report pairwise and network meta-analysis treatment effect estimates as risk ratios and risk differences, together with the associated 95% credible intervals. We will assess certainty in effect estimates using GRADE methodology.DiscussionThe present study will inform clinical decision-making for adult patients with ARDS and will improve our understanding of the limitations of the available literature assessing PEEP selection strategies. Finally, this information may also inform the design of future randomized trials, including the selection of interventions, comparators, and predictive enrichment strategies.Trial registrationPROSPERO 2020CRD42020193302.

IntroducciónEl Síndrome de Leak Capilar Idiopático (SLCI) o enfermedad de Clarkson es un entidad rara pero potencialmente letal, caracterizada por episodios recurrentes de shock y anasarca secundarios al aumento idiopático de la permeabilidad capilar. En este contexto, el uso de membrana de oxigenación extracorpórea (ECMO) venoarterial como soporte cardiorrespiratorio, es una medida de rescate que busca generar estabilidad hemodinámica a la espera de la desaparición espontánea del leak capilar con el fin de sortear las complicaciones de la fase de reabsorción. Caso ClínicoSe presenta el caso de un paciente un paciente de 42 años de edad que presentó SLCI y requirió ECMO durante 8 días como soporte hemodinámico. Cursó 20 días de internación en la unidad de terapia intensiva y se otorgó el alta hospitalaria luego de 43 días. ConclusionesEl uso de ECMO en el caso reportado significó una estrategia útil para el manejo del SLCI como puente a la recuperación, tanto en la etapa de leak como en la fase de reabsorción de fluidos. Sin embargo, su indicación se ve limitada a pacientes altamente seleccionados, y todavía requiere un mayor debate entre especialistas sobre los posibles riesgos y beneficios.

Idiopathic systemic capillary leak syndrome (ISCLS) or Clarkson's disease is unusual but potentially lethal, characterized by recurrent shock incidents and anasarca secondary to idiopathic increase of capillary permeability. In such a context, the use of venoarterial Extracorporeal Membrane Oxygenation (ECMO) as cardiorespiratory support is a rescue action that seeks hemodynamic stability generation until spontaneous disappearance of the capillary occurs with the objective of surpassing the complications of resorption phase.A 42 year old patient presented ISCLS and required ECMO as hemodynamic support for 8 days. She remained 20 days in Intensive Care Unit and was given hospital release after 43 days.The use of ECMO in the reported case was a useful strategy in the ISCLS management as a bridge to recovery both in the leak stage and the fluid resorption phase. Notwithstanding its indication is limited to thoroughly selected patients and requires further debate between specialists about its risks and benefits.El Síndrome de Leak Capilar Idiopático (SLCI) o enfermedad de Clarkson es un entidad rara pero potencialmente letal, caracterizada por episodios recurrentes de shock y anasarca secundarios al aumento idiopático de la permeabilidad capilar. En este contexto, el uso de membrana de oxigenación extracorpórea (ECMO) venoarterial como soporte cardiorrespiratorio, es una medida de rescate que busca generar estabilidad hemodinámica a la espera de la desaparición espontánea del leak capilar con el fin de sortear las complicaciones de la fase de reabsorción.Se presenta el caso de un paciente un paciente de 42 años de edad que presentó SLCI y requirió ECMO durante 8 días como soporte hemodinámico. Cursó 20 días de internación en la unidad de terapia intensiva y se otorgó el alta hospitalaria luego de 43 días.El uso de ECMO en el caso reportado significó una estrategia útil para el manejo del SLCI como puente a la recuperación, tanto en la etapa de leak como en la fase de reabsorción de fluidos. Sin embargo, su indicación se ve limitada a pacientes altamente seleccionados, y todavía requiere un mayor debate entre especialistas sobre los posibles riesgos y beneficios.

Rationale Acute hypoxemic respiratory failure is a condition that comprises a wide array of entities. Obtaining a histological lung sample might help reach a diagnosis and direct an appropriate treatment in a select group of patients. Objective To describe our experience in the use of cryobiopsy for the diagnosis of acute hypoxemic respiratory failure of undetermined origin. Methods Retrospective analysis of case series of patients with acute hypoxemic respiratory failure who underwent lung cryobiopsy at the Intensive Care Unit of the Hospital Italiano de Buenos Aires, Argentina. Results Cryobiopsy yielded a histological diagnosis in all patients ( n = 10, 100%). This led to either a change in therapy or continuation of a specific treatment in eight of these patients. Cryobiopsy was found to be contributive in all the patients who did not meet Berlin criteria for acute respiratory distress syndrome. No major complications were associated with the procedure. Conclusions Cryobiopsy is a safe procedure with a high diagnostic yield in a selected group of patients.