Effect of EIT-guided PEEP titration on prognosis of patients with moderate to severe ARDS: study protocol for a multicenter randomized controlled trial.

BACKGROUND: Acute respiratory syndrome distress (ARDS) is a clinical common syndrome with high mortality. Electrical impedance tomography (EIT)-guided positive end-expiratory pressure (PEEP) titration can achieve the compromise between lung overdistension and collapse which may minimize ventilator-induced lung injury in these patients. However, the effect of EIT-guided PEEP titration on the clinical outcomes remains unknown. The objective of this trial is to investigate the effects of EIT-guided PEEP titration on the clinical outcomes for moderate or severe ARDS, compared to the low fraction of inspired oxygen (FiO2)-PEEP table. METHODS: This is a prospective, multicenter, single-blind, parallel-group, adaptive designed, randomized controlled trial (RCT) with intention-to-treat analysis. Adult patients with moderate to severe ARDS less than 72 h after diagnosis will be included in this study. Participants in the intervention group will receive PEEP titrated by EIT with a stepwise decrease PEEP trial, whereas participants in the control group will select PEEP based on the low FiO2-PEEP table. Other ventilator parameters will be set according to the ARDSNet strategy. Participants will be followed up until 28 days after enrollment. Three hundred seventy-six participants will be recruited based on a 15% decrease of 28-day mortality in the intervention group, with an interim analysis for sample size re-estimation and futility assessment being undertaken once 188 participants have been recruited. The primary outcome is 28-day mortality. The secondary outcomes include ventilator-free days and shock-free days at day 28, length of ICU and hospital stay, the rate of successful weaning, proportion requiring rescue therapies, compilations, respiratory variables, and Sequential Organ Failure Assessment (SOFA). DISCUSSION: As a heterogeneous syndrome, ARDS has different responses to treatment and further results in different clinical outcomes. PEEP selection will depend on the properties of patients and can be individually achieved by EIT. This study will be the largest randomized trial to investigate thoroughly the effect of individual PEEP titrated by EIT in moderate to severe ARDS patients to date. TRIAL REGISTRATION: ClinicalTrial.gov NCT05207202. First published on January 26, 2022.

New development: Administrative accountability and early responses during public health crises—lessons from Covid-19 in China

The administrative accountability system in China has evolved during public health crises. By holding public officials accountable, the system hopes to improve their performance during emergencies. However, Covid-19 exposed an unexpected effect of the system. Instead of incentivizing public officials to take responsibility, it may have discouraged them from making timely, but potentially risky, decisions. Based on a holistic case analysis of the early response in Wuhan city, the authors demonstrate the lessons learnt and a way to improve the system. The case adds to an increasing academic literature on responsible risk-taking behaviours and decisions under uncertainties, extending the academic discussion by providing the critical contextual information for such behaviours and decisions in China.

A Ventilator-associated Pneumonia Prediction Model in Patients With Acute Respiratory Distress Syndrome.

BACKGROUND: Mechanical ventilation is crucial for acute respiratory distress syndrome (ARDS) patients and diagnosis of ventilator-associated pneumonia (VAP) in ARDS patients is challenging. Hence, an effective model to predict VAP in ARDS is urgently needed. METHODS: We performed a secondary analysis of patient-level data from the Early versus Delayed Enteral Nutrition (EDEN) of ARDSNet randomized controlled trials. Multivariate binary logistic regression analysis established a predictive model, incorporating characteristics selected by systematic review and univariate analyses. The model's discrimination, calibration, and clinical usefulness were assessed using the C-index, calibration plot, and decision curve analysis (DCA). RESULTS: Of the 1000 unique patients enrolled in the EDEN trials, 70 (7%) had ARDS complicated with VAP. Mechanical ventilation duration and intensive care unit (ICU) stay were significantly longer in the VAP group than non-VAP group (P < .001 for both) but the 60-day mortality was comparable. Use of neuromuscular blocking agents, severe ARDS, admission for unscheduled surgery, and trauma as primary ARDS causes were independent risk factors for VAP. The area under the curve of the model was .744, and model fit was acceptable (Hosmer-Lemeshow P = .185). The calibration curve indicated that the model had proper discrimination and good calibration. DCA showed that the VAP prediction nomogram was clinically useful when an intervention was decided at a VAP probability threshold between 1% and 61%. CONCLUSIONS: The prediction nomogram for VAP development in ARDS patients can be applied after ICU admission, using available variables. Potential clinical benefits of using this model deserve further assessment.

Clinical Characteristics and Outcomes of Patients With Severe COVID-19 Induced Acute Kidney Injury.

BACKGROUND: The incidence and outcome of Coronavirus disease 2019 (COVID-19)-induced kidney injury have been variably described. We aimed to describe the clinical characteristics, correlates and outcomes of critically ill patients with severe COVID-19 complicated by acute kidney injury (AKI). METHODS: We performed a multicenter retrospective cohort study of 671 critically ill adults with laboratory-confirmed COVID-19 from 19 hospitals in China between January 1 to February 29, 2020. Data were captured on demographics, comorbidities, symptoms, acute physiology, laboratory parameters, interventions, and outcomes. The primary exposure was ICU admission for confirmed COVID-19 related critically illness. The primary outcome was 28-day mortality. Secondary outcomes included factors associated with AKI, organ dysfunction, treatment intensity, and health services use. MEASUREMENTS AND MAIN RESULTS: Of 671 severe COVID-19 patients (median [IQR] 65 [56-73] years; male sex 65% (n = 434); hypertension 43% (n = 287) and APACHE II score 10 [7-14]), 39% developed AKI. Patients with AKI were older, had greater markers of inflammation and coagulation activation, and had greater acuity and organ dysfunction as presentation. Despite similar treatment with antivirals, patients with AKI had lower viral conversion negative rates than those without AKI. The 28-day mortality was much higher in AKI patients than patients without AKI (72% vs. 42%), and there was an increase in 28-day mortality according to the severity of AKI. Non-survivors were less likely to receive antiviral therapy [132 (70%) vs. 65 (88%)] compared with survivors and have lower viral negative conversion rate [17 (9%) vs. 47 (64%)]. CONCLUSIONS: Acute kidney injury was quite common in severe COVID-19 pneumonia, which associated with higher mortality.