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Evaluate current recommendation for the use of noninvasive ventilation (Bi-level positive airway pressure- BiPAP modality) in hypoxemic acute respiratory failure, excluding chronic obstructive pulmonary disease. Electronic searches in MEDLINE, Web of Science, Clinical Trials, and The Cochrane Central Register of Controlled Clinical Trials. We searched for randomized controlled trials comparing BiPAP to a control group in patients with hypoxemic acute respiratory failure. Endotracheal intubation and death were the assessed outcomes. Of the 563 studies found, nine met the inclusion criteria for this systematic review. The pooled RR (95% CI) for intubation in patients with acute pulmonary edema (APE)/community acquired pneumonia (CAP) and in immunosuppressed patients (cancer and transplants) were 0.61 (0.39–0.84) and 0.77 (0.60–0.93), respectively. For Intensive Care Units (ICU) mortality, the RR (95% CI) in patients with APE/CAP was 0.51 (0.22–0.79). The heterogeneity was low in all comparisons. NIV showed a significant protective effect for intubation in immunosuppressed patients (cancer and transplants) and in patients with APE/CAP. However, the benefits of NIV for other etiologies are not clear and more trials are needed to prove these effects. •Noninvasive ventilation reduces the risk of intubation in subgroups of acute hypoxemic patients.•Immunosuppressed, acute pulmonary edema and pneumonia patients may benefit most from NIV.•Well designed randomized clinical trials are required to address the benefit in other populations.

Background Sodium-glucose cotransport-2 inhibitors (SGLT2i) have established benefits in diabetes mellitus, heart failure, and chronic kidney disease, but their physiological effects during critical illness remain unclear. We explored whether dapagliflozin affected urinary output, fluid balance, and other physiological parameters in critically ill patients with acute organ dysfunction. Methods This secondary analysis of the DEFENDER trial included 401 critically ill patients with acute organ dysfunction randomized to receive dapagliflozin 10 mg daily or standard care. We analyzed urinary output, fluid balance, electrolytes, acid–base status, glycemia, and vasopressor requirements over the first five days using Bayesian models. Results Dapagliflozin progressively increased urinary output (day 5: + 157 mL/day, 95% CrI -90 to 386, probability 90%) and decreased fluid balance (day 5: -290 mL/day, 95% CrI -564 to -27, probability 98%). Furosemide use was lower in the dapagliflozin group (overall -3%, 95% CrI -7% to 1%, probability 90%). Dapagliflozin had minimal effects on creatinine and electrolytes but was associated with progressive small decreases in pH (day 5: -0.02, probability 96%). Maximum glucose levels were consistently lower with dapagliflozin (-9 mg/dL overall, probability 83%). Norepinephrine requirements showed a time-dependent increase in the dapagliflozin group, with the expected dose difference reaching 0.034 mcg/kg/min by day 5 (probability 94%), and heterogeneity analysis revealed larger effects in patients with sepsis or on mechanical ventilation. Conclusion This exploratory analysis suggests dapagliflozin may enhance diuresis and reduce loop diuretic requirements in critically ill patients, potentially at the cost of increased vasopressor needs. Glucose levels were likely slightly lower with dapagliflozin. Given the study's limitations and heterogeneous treatment effects, these findings should be considered hypothesis-generating pending confirmation in prospective trials.