Explore the vast range of titles available.

Sevoflurane improves gas exchange, and reduces alveolar edema and inflammation in preclinical studies of lung injury, but its therapeutic effects have never been investigated in acute respiratory distress syndrome (ARDS). To assess whether sevoflurane would improve gas exchange and inflammation in ARDS. We did a parallel, open-label single-center randomized controlled trial at three intensive care units from a French university hospital between April 2014 and February 2016. Adult patients were randomized within 24 hours of moderate-to-severe ARDS onset to receive either intravenous midazolam or inhaled sevoflurane for 48 hours. The primary outcome was the Pa /Fi ratio on Day 2. Secondary endpoints included alveolar and plasma levels of cytokines and soluble form of the receptor for advanced glycation end-products, and safety. Investigators who did the analyses were masked to group allocation. Analysis was by intention to treat. Twenty-five patients were assigned to the sevoflurane group and 25 to the midazolam group. On Day 2, Pa /Fi ratio was higher in the sevoflurane group than in the midazolam group (mean ± SD, 205 ± 56 vs. 166 ± 59, respectively; P = 0.04). There was a significant reduction over time in cytokines and soluble form of the receptor for advanced glycation end-products levels in the sevoflurane group, compared with the midazolam group, and no serious adverse event was observed with sevoflurane. In patients with ARDS, use of inhaled sevoflurane improved oxygenation and decreased levels of a marker of epithelial injury and of some inflammatory markers, compared with midazolam. Clinical trial registered with www.clinicaltrials.gov (NCT 02166853).

Patients with acute hypoxemic respiratory failure were assigned to standard oxygen therapy, high-flow oxygen therapy, or noninvasive ventilation. The intubation rate did not differ significantly among the groups, but 90-day mortality was lower in the high-flow–oxygen group. Noninvasive positive-pressure ventilation (hereafter, noninvasive ventilation) reduces the need for endotracheal intubation and mortality among patients with acute exacerbations of chronic obstructive pulmonary disease 1 – 3 or severe cardiogenic pulmonary edema. 4 The physiological effects of noninvasive ventilation include a decrease in the work of breathing and improvement in gas exchange. In patients with acute hypoxemic respiratory failure, the need for mechanical ventilation is associated with high mortality, 5 but data on the overall effects of noninvasive ventilation with respect to the prevention of intubation and improvement in outcome are conflicting. 6 – 10 Previous studies have often included a heterogeneous population of patients with . . .

[...]the method for assessing the LUS was carefully described. [...]measurement of the LUS as a tool for monitoring lung aeration in critically ill patients requires a short and easy-toimplement training program based on 25 ultrasound examinations supervised by a physician with expertise in bedside lung ultrasound. [...]Affiliated Hospital, Zhejiang University Hangzhou, China Jie Lv, M.D. Youzhong An, M.D., Ph.D. CHU Estaing, University of Auvergne Clermont-Ferrand, France For the APECHO Study Group The APECHO (Apprentissage de l'ECHOgraphie pulmonaire) Study Group members, listed according to their institution, include Charlotte Arbelot, Jean-Jacques Rouby, Hélè ne Brisson, Romain Deransy, Corinne Vezinet, Pierre Garçon, Nabil El Hadj Kacem, Denis Lemesle, Antoine Monsel, Qin Lu, and Olivier Langeron (Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtriè re Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France); Frédérick Gay (Department of Parasitology-Mycology, La Pitié-Salpêtriè re Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France); Bruno Lucena, Luiz Malbouisson, and Maria JoséCarvalho Carmona (Surgical and Trauma Intensive Care Unit, Hospital Das Clinicas, University of São Paulo, São Paulo, Brazil); Julio Neves (Multidisciplinary Intensive Care Unit, Hospital da Bahia, Salvador, Brazil); Paulo de Tarso Roth Dalcin (Intensive Care Unit, Ernesto Dornelles Hospital, Hospital Moinhos de Vento and Programa de Pós Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil); Guilherme de Paula Pinto Schettino (Multidisciplinary Intensive Care Unit, Hospital Albert Einstein, São Paulo, Brazil); Alberto Biestro (Intensive Care Unit, Hospital de Clínicas Dr Manuel Qintela, Faculdade de Medicina, Universidad de la Republica, Montevideo, Uruguay); and Davi Cristovao and Jorge Salluh (Multidisciplinary Intensive Care Unit, Hospital Copa D'Or, Rio de Janeiro, Brazil).

Introduction Severe cardiovascular collapse (CVC) is a life-threatening complication after emergency endotracheal intubation (ETI) in the ICU. Many factors may interact with hemodynamic conditions during ETI, but no study to date has focused on factors associated with severe CVC occurrence. This study assessed the incidence of severe CVC after ETI in the ICU and analyzed the factors predictive of severe CVC. Methods This was a secondary analysis of a prospective multicenter study of 1,400 consecutive intubations at 42 ICUs. The incidence of severe CVC was assessed in patients who were hemodynamically stable (mean arterial blood pressure >65 mmHg without vasoactive drugs) before intubation, and the factors predictive of severe CVC were determined by multivariate analysis based on patient and procedure characteristics. Results Severe CVC occurred following 264 of 885 (29.8 %) intubation procedures. A two-step multivariate analysis showed that independent risk factors for CVC included simple acute physiologic score II regardless of age (odds ratio (OR) 1.02, p < 0.001), age 60–75 years (OR 1.96, p < 0.002 versus <60 years) and >75 years (OR 2.81, p < 0.001 versus <60 years), acute respiratory failure as a reason for intubation (OR 1.51, p = 0.04), first intubation in the ICU (OR 1.61, p = 0.02), noninvasive ventilation as a preoxygenation method (OR 1.54, p = 0.03) and inspired oxygen concentration >70 % after intubation (OR 1.91, p = 0.001). Comatose patients who required ETI were less likely to develop CVC during intubation (OR 0.48, p = 0.004). Conclusions CVC is a frequent complication, especially in old and severely ill patients intubated for acute respiratory failure in the ICU. Specific bundles to prevent CVC may reduce morbidity and mortality related to intubation of these high-risk, critically ill patients. Trial registration clinicaltrials.gov NCT01532063 ; registered 8 February 2012.

Although frequent, little is known about early-onset pneumonia that occurs in the postresuscitation period. Although induced hypothermia is recommended as a method of improving neurological outcome, its influence on the occurrence of early-onset pneumonia is not well defined. To describe the incidence, risk factors, causative agents, and impact on outcome of early-onset pneumonia occurring within 3 days after out-of-hospital cardiac arrest (OHCA). Retrospective analysis of a large cohort study of all patients successfully resuscitated after OHCA and admitted from July 2002 to March 2008 in two medical intensive care units (ICUs). Patients who presented accidental hypothermia or a known pneumonia before OHCA, or patients who died within the first 24 hours, were excluded. During this 6-year period, 845 patients were admitted after OHCA, and 641 consecutive patients were included. A total of 500 patients (78%) were treated with therapeutic hypothermia. In the first 3 days, 419 (65%) presented early-onset pneumonia. Multivariate analysis disclosed therapeutic hypothermia as the single independent risk factor of early-onset pneumonia (odds ratio, 1.90; 95% confidence interval, 1.28-2.80; P = 0.001). Early-onset pneumonia increased length of mechanical ventilation (5.7 ± 5.9 vs. 4.7 ± 6.2 d; P = 0.001) and ICU stay (7.9 ± 7.2 versus 6.7 ± 7.6 d; P = 0.001), but did not influence incidence of ventilator-associated pneumonia (P = 0.25), favorable neurologic outcome (P = 0.35), or ICU mortality (P = 0.26). After OHCA, therapeutic hypothermia is associated with an increased risk of early-onset pneumonia. This complication was associated with prolonged respiratory support and ICU stay, but did not significantly influence ICU mortality.

The main soluble form of the receptor for advanced glycation end-products (sRAGE) is elevated during acute respiratory distress syndrome (ARDS). However other RAGE isoforms and multiple ligands have been poorly reported in the clinical setting, and their respective contribution to RAGE activation during ARDS remains unclear. Our goal was therefore to describe main RAGE isoforms and ligands levels during ARDS. 30 ARDS patients and 30 mechanically ventilated controls were prospectively included in this monocenter observational study. Arterial, superior vena cava and alveolar fluid levels of sRAGE, endogenous-secretory RAGE (esRAGE), high mobility group box-1 protein (HMGB1), S100A12 and advanced glycation end-products (AGEs) were measured in duplicate ELISA on day 0, day 3 and day 6. In patients with ARDS, baseline lung morphology was assessed with computed tomography. ARDS patients had higher arterial, central venous and alveolar levels of sRAGE, HMGB1 and S100A12, but lower levels of esRAGE and AGEs, than controls. Baseline arterial sRAGE, HMGB1 and S100A12 were correlated with nonfocal ARDS (AUC 0.79, 0.65 and 0.63, respectively). Baseline arterial sRAGE, esRAGE, S100A12 and AGEs were associated with severity as assessed by PaO2/FiO2. This is the first kinetics study of levels of RAGE main isoforms and ligands during ARDS. Elevated sRAGE, HMGB1 and S100A12, with decreased esRAGE and AGEs, were found to distinguish patients with ARDS from those without. Our findings should prompt future studies aimed at elucidating RAGE/HMGB1/S100A12 axis involvement in ARDS. clinicaltrials.gov Identifier: NCT01270295.

Rare pathogenic variants in the MYH11 gene are responsible for thoracic aortic aneurysms and dissections. They are usually heterozygous missense variants or in-frame deletions of several amino acids without alteration of the reading frame and mainly affect the coiled-coil domain of the protein. Variants leading to a premature stop codon have been described in patients with another phenotype, megacystis-microcolon-intestinal hypoperistalsis syndrome, with an autosomal recessive inheritance. The physiopathological mechanisms arising from the different genetic alterations affecting the MYH11 gene are still poorly understood. Consequently, variants of unknown significance are relatively frequent in this gene. We have identified a variant affecting the consensus donor splice site of exon 29 in the MYH11 gene in a patient who suddenly died from an aortic type A dissection at the age of 23 years old. A transcript analysis on cultured fibroblasts has highlighted several abnormal transcripts including two in-frame transcripts. The first one is a deletion of the last 78 nucleotides of exon 29, corresponding to the use of a cryptic alternative donor splice site; the second one corresponds to an exon 29 skipping. Familial screening has revealed that this molecular event occurred de novo in the proband. Taken together, these experiments allowed us to classify this variant as pathogenic. This case underlines the challenging aspect of the discovery of variations in the MYH11 gene for which the consequences on splicing should be systematically studied in detail.

Objective To describe current use and diagnostic and therapeutic impacts of point-of-care ultrasound (POCUS) in the intensive care unit (ICU). Background POCUS is of growing importance in the ICU. Several guidelines recommend its use for procedural guidance and diagnostic assessment. Nevertheless, its current use and clinical impact remain unknown. Methods Prospective multicentric study in 142 ICUs in France, Belgium, and Switzerland. All the POCUS procedures performed during a 24-h period were prospectively analyzed. Data regarding patient condition and the POCUS procedures were collected. Factors associated with diagnostic and therapeutic impacts were identified. Results Among 1954 patients hospitalized during the study period, 1073 (55 %) POCUS/day were performed in 709 (36 %) patients. POCUS served for diagnostic assessment in 932 (87 %) cases and procedural guidance in 141 (13 %) cases. Transthoracic echocardiography, lung ultrasound, and transcranial Doppler accounted for 51, 17, and 16 % of procedures, respectively. Diagnostic and therapeutic impacts of diagnostic POCUS examinations were 84 and 69 %, respectively. Ultrasound guidance was used in 54 and 15 % of cases for central venous line and arterial catheter placement, respectively. Hemodynamic instability, emergency conditions, transthoracic echocardiography, and ultrasounds performed by certified intensivists themselves were independent factors affecting diagnostic or therapeutic impacts. Conclusions With regard to guidelines, POCUS utilization for procedural guidance remains insufficient. In contrast, POCUS for diagnostic assessment is of extensive use. Its impact on both diagnosis and treatment of ICU patients seems critical. This study identified factors associated with an improved clinical value of POCUS.

Background Dyspnea is a key symptom of de novo acute hypoxemic respiratory failure. This study explores dyspnea and its association with intubation and mortality in this population. Methods This was a secondary analysis of a multicenter, randomized, controlled trial. Dyspnea was quantified by a visual analog scale (dyspnea-VAS) from zero to 100 mm. Dyspnea was measured in 259 of the 310 patients included. Factors associated with intubation were assessed with a competing risks model taking into account ICU discharge. The Cox model was used to evaluate factors associated with 90-day mortality. Results At baseline (randomization in the parent trial), median dyspnea-VAS was 46 (interquartile range, 16–65) mm and was ≥ 40 mm in 146 patients (56%). The intubation rate was 45%. Baseline variables independently associated with intubation were moderate (dyspnea-VAS 40–64 mm) and severe (dyspnea-VAS ≥ 65 mm) dyspnea at baseline (sHR 1.96 and 2.61, p  = 0.023), systolic arterial pressure (sHR 2.56, p  < 0.001), heart rate (sHR 1.94, p  = 0.02) and PaO 2 /FiO 2 (sHR 0.34, p  = 0.028). 90-day mortality was 20%. The cumulative probability of survival was lower in patients with baseline dyspnea-VAS ≥ 40 mm (logrank test, p  = 0.049). Variables independently associated with mortality were SAPS 2 ≥ 25 ( p  < 0.001), moderate-to-severe dyspnea at baseline ( p  = 0.073), PaO 2 /FiO 2 ( p  = 0.118), and treatment arm ( p  = 0.046). Conclusions In patients admitted to the ICU for de novo acute hypoxemic respiratory failure, dyspnea is associated with a higher risk of intubation and with a higher mortality. Trial registration : clinicaltrials.gov Identifier # NCT 01320384.

Purpose Noninvasive ventilation (NIV) is a treatment option in patients with acute respiratory failure who are good candidates for intensive care but have declined tracheal intubation. The aim of our study was to report outcomes after NIV in patients with a do-not-intubate (DNI) order. Methods Prospective observational cohort study in all patients who received NIV for acute respiratory failure in 54 ICUs in France and Belgium, in 2010/2011. Results Goals of care, comfort, and vital status were assessed daily. On day 90, a telephone interview with patients and relatives recorded health-related quality of life (HRQOL), posttraumatic stress disorder-related symptoms, and symptoms of anxiety and depression. Post-ICU burden was compared between DNI patients and patients receiving NIV with no treatment-limitation decisions (TLD). Of 780 NIV patients, 574 received NIV with no TLD, and 134 had DNI orders. Hospital mortality was 44 % in DNI patients and 12 % in the no-TLD group. Mortality in the DNI group was lowest in COPD patients compared to other patients in the DNI group (34 vs. 51 %, P  = 0.01). In the DNI group, HRQOL showed no significant decline on day 90 compared to baseline; day-90 data of patients and relatives did not differ from those in the no-TLD group. Conclusions Do-not-intubate status was present among one-fifth of ICU patients who received NIV. DNI patients who were alive on day 90 experienced no decrease in HRQOL compared to baseline. The prevalences of anxiety, depression, and PTSD-related symptoms in these patients and their relatives were similar to those seen after NIV was used as part of full-code management (clinicaltrial.govNCT01449331).