Lung ultrasound is associated with distinct clinical phenotypes in COVID-19 ARDS: A retrospective observational study.

BACKGROUND: ARDS is a heterogeneous syndrome with distinct clinical phenotypes. Here we investigate whether the presence or absence of large pulmonary ultrasonographic consolidations can categorize COVID-19 ARDS patients requiring mechanical ventilation into distinct clinical phenotypes. METHODS: This is a retrospective study performed in a tertiary-level intensive care unit in Israel between April and September 2020. Data collected included lung ultrasound (LUS) findings, respiratory parameters, and treatment interventions. The primary outcome was a composite of three ARDS interventions: prone positioning, high PEEP, or a high dose of inhaled nitric oxide. RESULTS: A total of 128 LUS scans were conducted among 23 patients. The mean age was 65 and about two-thirds were males. 81 scans identified large consolidation and were classified as "C-type", and 47 scans showed multiple B-lines with no or small consolidation and were classified as "B-type". The presence of a "C-type" study had 2.5 times increased chance of receiving the composite primary outcome of advanced ARDS interventions despite similar SOFA scores, Pao2/FiO2 ratio, and markers of disease severity (OR = 2.49, %95CI 1.40-4.44). CONCLUSION: The presence of a "C-type" profile with LUS consolidation potentially represents a distinct COVID-19 ARDS subphenotype that is more likely to require aggressive ARDS interventions. Further studies are required to validate this phenotype in a larger cohort and determine causality, diagnostic, and treatment responses.

Personalized mechanical ventilation guided by ultrasound in patients with acute respiratory distress syndrome (PEGASUS): study protocol for an international randomized clinical trial.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is a frequent cause of hypoxemic respiratory failure with a mortality rate of approximately 30%. Identifying ARDS subphenotypes based on "focal" or "non-focal" lung morphology has the potential to better target mechanical ventilation strategies of individual patients. However, classifying morphology through chest radiography or computed tomography is either inaccurate or impractical. Lung ultrasound (LUS) is a non-invasive bedside tool that can accurately distinguish "focal" from "non-focal" lung morphology. We hypothesize that LUS-guided personalized mechanical ventilation in ARDS patients leads to a reduction in 90-day mortality compared to conventional mechanical ventilation. METHODS: The Personalized Mechanical Ventilation Guided by UltraSound in Patients with Acute Respiratory Distress Syndrome (PEGASUS) study is an investigator-initiated, international, randomized clinical trial (RCT) that plans to enroll 538 invasively ventilated adult intensive care unit (ICU) patients with moderate to severe ARDS. Eligible patients will receive a LUS exam to classify lung morphology as "focal" or "non-focal". Thereafter, patients will be randomized within 12 h after ARDS diagnosis to receive standard care or personalized ventilation where the ventilation strategy is adjusted to the morphology subphenotype, i.e., higher positive end-expiratory pressure (PEEP) and recruitment maneuvers for "non-focal" ARDS and lower PEEP and prone positioning for "focal" ARDS. The primary endpoint is all-cause mortality at day 90. Secondary outcomes are mortality at day 28, ventilator-free days at day 28, ICU length of stay, ICU mortality, hospital length of stay, hospital mortality, and number of complications (ventilator-associated pneumonia, pneumothorax, and need for rescue therapy). After a pilot phase of 80 patients, the correct interpretation of LUS images and correct application of the intervention within the safe limits of mechanical ventilation will be evaluated. DISCUSSION: PEGASUS is the first RCT that compares LUS-guided personalized mechanical ventilation with conventional ventilation in invasively ventilated patients with moderate and severe ARDS. If this study demonstrates that personalized ventilation guided by LUS can improve the outcomes of ARDS patients, it has the potential to shift the existing one-size-fits-all ventilation strategy towards a more individualized approach. TRIAL REGISTRATION: The PEGASUS trial was registered before the inclusion of the first patient, https://clinicaltrials.gov/ (ID: NCT05492344).

Imaging the pulmonary vasculature in acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is characterized by a redistribution of regional lung perfusion that impairs gas exchange. While speculative, experimental evidence suggests that perfusion redistribution may contribute to regional inflammation and modify disease progression. Unfortunately, tools to visualize and quantify lung perfusion in patients with ARDS are lacking. This review explores recent advances in perfusion imaging techniques that aim to understand the pulmonary circulation in ARDS. Dynamic contrast-enhanced computed tomography captures first-pass kinetics of intravenously injected dye during continuous scan acquisitions. Different contrast characteristics and kinetic modeling have improved its topographic measurement of pulmonary perfusion with high spatial and temporal resolution. Dual-energy computed tomography can map the pulmonary blood volume of the whole lung with limited radiation exposure, enabling its application in clinical research. Electrical impedance tomography can obtain serial topographic assessments of perfusion at the bedside in response to treatments such as inhaled nitric oxide and prone position. Ongoing technological improvements and emerging techniques will enhance lung perfusion imaging and aid its incorporation into the care of patients with ARDS.

[The value of point-of-care ultrasound in the diagnosis and management of acute respiratory distress syndrome].

Acute respiratory distress syndrome (ARDS) continues to cause significant morbidity and mortality worldwide. However, there are currently no corresponding specific medications. Lung, right heart, and diaphragm protective therapy is the cornerstone of ARDS management. Non-invasive, radiation-free, and transportation-free point-of-care ultrasound enables for real-time dynamic evaluation of the lung, right heart, and diaphragm. It is an essential tool for the diagnosis, monitoring, and clinical decision-making of ARDS patients. However, ultrasound has several limitations, and its clinical application must be carefully evaluated in conjunction with clinical symptoms and other monitoring techniques. Further research is needed to determine whether clinical decision-making based on point-of-care ultrasound examination can improve the prognosis of ARDS patients.

Long-term outcomes of survivors with influenza A H1N1 virus-induced severe pneumonia and ARDS: a single-center prospective cohort study.

Introduction: Systematic evaluation of long-term outcomes in survivors of H1N1 is still lacking. This study aimed to characterize long-term outcomes of severe H1N1-induced pneumonia and acute respiratory distress syndrome (ARDS). Method: This was a single-center, prospective, cohort study. Survivors were followed up for four times after discharge from intensive care unit (ICU) by lung high-resolution computed tomography (HRCT), pulmonary function assessment, 6-minute walk test (6MWT), and SF-36 instrument. Result: A total of 60 survivors of H1N1-induced pneumonia and ARDS were followed up for four times. The carbon monoxide at single breath (DLCO) of predicted values and the 6MWT results didn't continue improving after 3 months. Health-related quality of life didn't change during the 12 months after ICU discharge. Reticulation or interlobular septal thickening on HRCT did not begin to improve significantly until the 12-month follow-up. The DLCO of predicted values showed negative correlation with the severity degree of primary disease and reticulation or interlobular septal thickening, and a positive correlation with physical functioning. The DLCO of predicted values and reticulation or interlobular septal thickening both correlated with the highest tidal volume during mechanical ventilation. Levels of fibrogenic cytokines had a positive correlation with reticulation or interlobular septal thickening. Conclusion: The improvements in pulmonary function and exercise capacity, imaging, and health-related quality of life had different time phase and impact on each other during 12 months of follow-up. Long-term outcomes of pulmonary fibrosis might be related to the lung injury and excessive lung fibroproliferation at the early stage during ICU admission.

Portal hypertension-like pattern in coronavirus disease 2019 acute respiratory distress syndrome.

OBJECTIVES: Although respiratory failure is the most common feature in coronavirus disease 2019 (COVID-19), abdominal organ involvement is likewise frequently observed. To investigate visceral and thoracic circulation and abdominal organ damage in COVID-19 patients. MATERIALS AND METHODS: A monocentric observational study was carried on. In COVID-19 patients affected by acute respiratory distress syndrome (ARDS) (n = 31) or mild pneumonia (n = 60) thoracoabdominal circulation was evaluated using Doppler-ultrasound and computed tomography. The study also included non-COVID-19 patients affected by ARDS (n = 10) or portal hypertension (n = 10) for comparison of the main circulatory changes. RESULTS: Patients affected by COVID-19 ARDS showed hyperdynamic visceral flow and increased portal velocity, hepatic artery resistance-index, and spleen diameter relative to those with mild-pneumonia (p = 0.001). Splanchnic circulatory parameters significantly correlated with the main respiratory indexes (p < 0.001) and pulmonary artery diameter (p = 0.02). The chest and abdominal vascular remodeling pattern of COVID-19 ARDS patients resembled the picture observed in the PH group, while differed from that of the non-COVID ARDS group. A more severe COVID-19 presentation was associated with worse liver dysfunction and enhanced inflammatory activation; these parameters both correlated with abdominal (p = 0.04) and chest imaging measures (p = 0.03). CONCLUSION: In COVID-19 ARDS patients there are abdominal and lung vascular modifications that depict a portal hypertension-like pattern. The correlation between visceral vascular remodeling, pulmonary artery enlargement, and organ damage in these critically ill patients is consistent with a portal hyperlfow-like syndrome that could contribute to the peculiar characteristics of respiratory failure in these patients. CLINICAL RELEVANCE STATEMENT: our data suggest that the severity of COVID-19 lung involvement is directly related to the development of a portal hyperflow-like syndrome. These observations should help in defining the need for a closer monitoring, but also to develop dedicated therapeutic strategies.

Automatic ARDS surveillance with chest X-ray recognition using convolutional neural networks.

OBJECTIVE: This study aims to design, validate and assess the accuracy a deep learning model capable of differentiation Chest X-Rays between pneumonia, acute respiratory distress syndrome (ARDS) and normal lungs. MATERIALS AND METHODS: A diagnostic performance study was conducted using Chest X-Ray images from adult patients admitted to a medical intensive care unit between January 2003 and November 2014. X-ray images from 15,899 patients were assigned one of three prespecified categories: "ARDS", "Pneumonia", or "Normal". RESULTS: A two-step convolutional neural network (CNN) pipeline was developed and tested to distinguish between the three patterns with sensitivity ranging from 91.8% to 97.8% and specificity ranging from 96.6% to 98.8%. The CNN model was validated with a sensitivity of 96.3% and specificity of 96.6% using a previous dataset of patients with Acute Lung Injury (ALI)/ARDS. DISCUSSION: The results suggest that a deep learning model based on chest x-ray pattern recognition can be a useful tool in distinguishing patients with ARDS from patients with normal lungs, providing faster results than digital surveillance tools based on text reports. CONCLUSION: A CNN-based deep learning model showed clinically significant performance, providing potential for faster ARDS identification. Future research should prospectively evaluate these tools in a clinical setting.

Evaluation of the Prognosis of Patients With Acute Respiratory Distress Syndrome at the Emergency Department Based on the Lung Ultrasound Score.

OBJECTIVES: Acute respiratory distress syndrome (ARDS) is a respiratory disease characterized by a high rate of mortality. Determining the prognosis of this disease is therefore important. Lung ultrasonography has found increased use, especially in the recent years. This study aimed to score patients diagnosed with ARDS at the emergency department using point-of-care ultrasound (POCUS)-Lung and to investigate the prognosis of patients with ARDS using a scoring system. METHODS: This study was designed as a single-center prospective study. The study was performed in patients admitted to the emergency department and were diagnosed with ARDS pursuant to the Berlin criteria for ARDS and who met the inclusion criteria. The patients underwent lung ultrasonography at the emergency department and were scored (A line: 0; B1 line: 1; B2 line: 2; and C line: 3 points) accordingly. RESULTS: The study included 100 patients with ARDS. The mortality rate was 52% in the patients in the study. The lung ultrasonography score in the mortality group (25.48 ± 3.64) was higher than that in the survivors (8.46 ± 3.61). For a cut-off value of 17.5 for the lung ultrasonography score, the sensitivity and specificity with regard to mortality indicators were 92.8% and 90.9%, respectively (the area under the curve: 0.901; 95% confidence interval: 0.945-0.985: P < .001). CONCLUSION: The findings suggested that scoring based on POCUS-Lung at the time of initial presentation at the emergency department in patients diagnosed with ARDS according to the Berlin criteria could help determine the prognosis. As POCUS-Lung proved to be an important imaging method in investigating the affected alveolar capacity, we recommend its possible use as a prognostic indicator.

Regional pulmonary perfusion, blood volume, and their relationship change in experimental early ARDS.

Regional pulmonary perfusion (Q) has been investigated using blood volume (Fb) imaging as an easier-to-measure surrogate. However, it is unclear if changing pulmonary conditions could affect their relationship. We hypothesized that vascular changes in early acute respiratory distress syndrome (ARDS) affect Q and Fb differently. Five sheep were anesthetized and received lung protective mechanical ventilation for 20 h while endotoxin was continuously infused. Using dynamic 18F-FDG and 13NN Positron Emission Tomography (PET), regional Fb and Q were analysed in 30 regions of interest (ROIs) and normalized by tissue content (Fbn and Qn, respectively). After 20 h, the lung injury showed characteristics of early ARDS, including gas exchange and lung mechanics. PET images of Fbn and Qn showed substantial differences between baseline and lung injury. Lung injury caused a significant change in the Fbn-Qn relationship compared to baseline (p < 0.001). The best models at baseline and lung injury were Fbn = 0.32 + 0.690Qn and Fbn = 1.684Qn-0.538Qn2, respectively. Endotoxine-associated early ARDS changed the relationship between Fb and Q, shifting from linear to curvilinear. Effects of endotoxin exposure on the vasoactive blood flow regulation were most likely the key factor for this change limiting the quantitative accuracy of Fb imaging as a surrogate for regional Q.

[Relationship between the lung ultrasound and the clinical severity of the patient with seasonal flu]. / Lien entre l'aspect échographique du poumon et la sévérité́ clinique du patient atteint d'une grippe saisonnière.

INTRODUCTION: The seasonal flu is a very important reason for consultation every winter. Symptoms can quickly progress to severe pneumonia. Currently, few tools exist to assess the clinical severity of patients. The aim of this study is to demonstrate the role of lung ultrasound as a marker of severity in patients with influenza. METHODS: 79 patients who arrived at the emergency department with flu-like symptoms were included. A pulmonary ultrasound looking for an interstitial syndrome or consolidation was performed. The qSOFA, the SOFA, the saturation, the PaO2/FiO2 ratio, the oxygen needs, the destination of the patient made it possible to establish the seriousness of the pathology of the patient. Ultrasound was then compared to these different tools. RESULTS: The more the ultrasound became pathological, the more we observed a proportion of qSOFA (p = 0.001) and pathological SOFA (p = 0.009). Most patients with acute respiratory distress syndrome have pathological ultrasound (p < 0.001). The average admission saturation is 89.2 % in the "pathological ultrasound" group compared to 95.8 % in the "normal ultrasound" group (p < 0.001). Patients who required invasive therapies had pathological ultrasound (p < 0.001). Of the 28 patients with pathological ultrasound, 24 required hospitalization (p < 0.001). CONCLUSION: Lung ultrasound is a major asset for assessing the severity of the patient with seasonal flu. In addition, ultrasound allows better monitoring of the patient by being able to influence the destination of the latter towards a return home or monitoring in intensive care.

INTRODUCTION: La grippe saisonnière représente chaque hiver un motif de consultation très important. La symptomatologie peut rapidement évoluer vers une pneumonie sévère. Actuellement, peu d'outils existent pour évaluer la sévérité clinique des patients. Le but de cette étude est de démontrer le rôle de l'échographie pulmonaire comme marqueur de sévérité́ chez les patients atteints d'une grippe. Méthodes : L'étude a comporté 79 patients arrivés aux urgences pour grippe. Une échographie pulmonaire a été réalisée à la recherche d'un syndrome interstitiel ou d'une consolidation. Le qSOFA, le SOFA, la saturation, le rapport PaO2/FiO2, les besoins en oxygène, la destination du patient ont permis d'établir la gravité de la pathologie du patient. L'échographie a alors été comparée à ces différents outils. Résultats : Plus l'échographie devient pathologique, plus on observe une proportion de qSOFA (p = 0,001) et de SOFA pathologiques (p = 0,009). La majorité́ des patients ayant un syndrome de détresse respiratoire aiguë ont une échographie pathologique (p < 0,001). La moyenne des saturations d'admission est de 89,2 % dans le groupe «échographie pathologique¼ contre 95,8 % dans le groupe «échographie normale¼ (p < 0,001). Les patients ayant eu recours à des thérapies invasives ont une échographie pathologique (p < 0,001). Sur les 28 patients ayant une échographie pathologique, 24 ont nécessité́ une hospitalisation (p < 0,001). CONCLUSION: L'échographie pulmonaire est un atout majeur pour l'évaluation de la sévérité du patient atteint d'une grippe saisonnière. De plus, l'échographie permet une meilleure surveillance du patient en pouvant influencer la destination de celui-ci vers un retour à̀ domicile ou une surveillance aux soins intensifs.

Diagnostic role of thoracic ultrasound in patients with acute respiratory failure at emergency service.

BACKGROUND AND AIM: This study aimed to elucidate the effectiveness of bedside thoracic ultrasound according to BLUE protocol and to investigate its superiority over other imaging methods in the emergency service. METHODS: A total of 120 patients admitted to our institution's emergency care department due to respiratory distress have been enrolled in this prospective research. Thorax USG has been performed in the right and left hemithorax at the points specified in the BLUE protocol for each patient. Pleural sliding motion, A-lines, B-lines, consolidation, effusion, and the presence of barcode signs were evaluated individually. Age, sex, comorbid diseases, other radiological examination findings, laboratory findings, final clinical diagnosis, and hospitalization-discharge status of the patients were recorded. RESULTS: When a correct diagnosis of pneumonia has been analyzed for imaging techniques, the diagnostic rate of chest radiography was 83.3%, CT was 100.0%, and USG was 66.6%. The correct diagnostic rate of chest radiography was 94.5%; CT and USG were 100.0%. The correct diagnosis of pulmonary edema on chest radiography was 94.5%; CT and USG were 100.0%. While the correct diagnosis of pleural effusion on chest radiography and CT was 100.0%, it was 92.3% in USG imaging. Finally, CT and USG imaging performed better than chest radiography in patients with pneumothorax (chest radiography 80.0%, CT and USG 100%). CONCLUSION: USG imaging could be preferred in the diagnosis of pneumonia, pulmonary edema, pleural effusion, pneumothorax, pulmonary embolism, and differential diagnosis at the emergency service.

Macklin Effect: From Pathophysiology to Clinical Implication.

Air leak syndromes (such as pneumomediastinum, pneumothorax, or subcutaneous emphysema) are frequent complications of acute respiratory distress syndrome (ARDS). Unfortunately, the development of air leaks is associated with worse outcomes. In addition, it has been hypothesized that the development of pneumomediastinum could be a marker of disease severity in patients with respiratory failure receiving noninvasive respiratory support or assisted ventilation. The so-called Macklin effect (or pulmonary interstitial emphysema) is the air dissection of the lung bronchovascular tree from peripheral to central airways following injury to distal alveoli. Ultimately, the progression of the Macklin effect leads to the development of pneumomediastinum, subcutaneous emphysema, or pneumothorax. The Macklin effect is identifiable on a chest computed tomography (CT) scan. The Macklin effect could be an accurate predictor of barotrauma in patients with ARDS (sensitivity = 89.2% [95% CI: 74.6-96.9]; specificity = 95.6% [95% CI: 90.6-98.4]), and may be a marker of disease severity. Accordingly, the detection of the Macklin effect on a chest CT scan could be used to select which patients with ARDS might benefit from different treatment algorithms, including advanced respiratory monitoring, early intubation, or, potentially, the institution of early extracorporeal support with or without invasive ventilation. In this video, the authors summarize the pathophysiology and potential clinical significance and applications of the Macklin effect in patients with acute respiratory failure.

Quantifying heterogeneity in an animal model of acute respiratory distress syndrome, a comparison of inspired sinewave technique to computed tomography.

The inspired sinewave technique (IST) is a non-invasive method to measure lung heterogeneity indices (including both uneven ventilation and perfusion or heterogeneity), which reveal multiple conditions of the lung and lung injury. To evaluate the reproducibility and predicted clinical outcomes of IST heterogeneity values, a comparison with a quantitative lung computed tomography (CT) scan is performed. Six anaesthetised pigs were studied after surfactant depletion by saline-lavage. Paired measurements of lung heterogeneity were then taken with both the IST and CT. Lung heterogeneity measured by the IST was calculated by (a) the ratio of tracer gas outputs measured at oscillation periods of 180 s and 60 s, and (b) by the standard deviation of the modelled log-normal distribution of ventilations and perfusions in the simulation lung. In the CT images, lungs were manually segmented and divided into different regions according to voxel density. A quantitative CT method to calculate the heterogeneity (the Cressoni method) was applied. The IST and CT show good Pearson correlation coefficients in lung heterogeneity measurements (ventilation: 0.71, and perfusion, 0.60, p < 0.001). Within individual animals, the coefficients of determination average ventilation (R2 = 0.53) and perfusion (R2 = 0.68) heterogeneity. Strong concordance rates of 98% in ventilation and 89% when the heterogeneity changes were reported in pairs measured by CT scanning and IST methods. This quantitative method to identify heterogeneity has the potential to replicate CT lung heterogeneity, and to aid individualised care in ARDS.

Inspiratory-expiratory variation of pleural line thickness in neonates with and without acute respiratory failure.

BACKGROUND: There are relatively few data about the ultrasound evaluation of pleural line in patients with respiratory failure. We measured the pleural line thickness during different phases of the respiratory cycle in neonates with and without acute respiratory failure as we hypothesized that this can significantly change. METHODS: Prospective, observational, cohort study performed in an academic tertiary neonatal intensive care unit recruiting neonates with transient tachypnoea of the neonate (TTN), respiratory distress syndrome (RDS) or neonatal acute respiratory distress syndrome (NARDS). Neonates with no lung disease (NLD) were also recruited as controls. Pleural line thickness was measured with high-frequency ultrasound at end-inspiration and end-expiration by two different raters. RESULTS: Pleural line thickness was slightly but significantly higher at end-expiration (0.53 [0.43-0.63] mm) than at end-inspiration (0.5 [0.4-0.6] mm; p = 0.001) for the whole population. End-inspiratory (NLD: 0.45 [0.38-0.53], TTN: 0.49 [0.43-0.59], RDS: 0.53 [0.41-0.62], NARDS: 0.6 [0.5-0.7] mm) and -expiratory (NLD: 0.47 [0.42-0.56], TTN: 0.48 [0.43-0.61], RDS: 0.53 [0.46-0.65], NARDS: 0.61 [0.54-0.72] mm) thickness were significantly different (overall p = 0.021 for both), between the groups although the absolute differences were small. The inter-rater agreement was optimal (ICC: 0.95 (0.94-0.96)). Coefficient of variation was 2.8% and 2.5% for end-inspiratory and end-expiratory measurements, respectively. These findings provide normative data of pleural line thickness for the most common forms of neonatal acute respiratory failure and are useful to design future studies to investigate possible clinical applications.

Lung ultrasound score and in-hospital mortality of adults with acute respiratory distress syndrome: a meta-analysis.

BACKGROUND: Lung ultrasound (LUS) score could quantitatively reflect the lung aeration, which has been well applied in critically ill patients. The aim of the systematic review and meta-analysis was to evaluate the association between LUS score at admission and the risk of in-hospital mortality of adults with acute respiratory distress syndrome (ARDS). METHODS: Toachieve the objective of this meta-analysis, we conducted a thorough search of PubMed, Embase, Cochrane Library, and the Web of Science to identify relevant observational studies with longitudinal follow-up. We employed random-effects models to combine the outcomes, considering the potential influence of heterogeneity. RESULTS: Thirteen cohort studies with 1,022 hospitalized patients with ARDS were included. Among them, 343 patients (33.6%) died during hospitalization. The pooled results suggested that the LUS score at admission was higher in non-survivors as compared to survivors (standardized mean difference = 0.73, 95% confidence interval [CI]: 0.55 to 0.91, p < 0.001; I2 = 25%). Moreover, a high LUS score at admission was associated with a higher risk of in-hospital mortality of patients with ARDS (risk ratio: 1.44, 95% CI: 1.14 to 1.81, p = 0.002; I2 = 46%). Subgroup analyses showed consistent results in studies with LUS score analyzed with 12 or 16 lung regions, and in studies reporting mortality during ICU or within 1-month hospitalization. CONCLUSION: Our findings suggest that a high LUS score at admission may be associated with a high risk of in-hospital mortality of patients with ARDS.

Structural Brain Injury on Brain Magnetic Resonance Imaging in Acute Respiratory Distress Syndrome.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is an acute inflammatory respiratory failure condition that may be associated with brain injury. We aimed to describe the types of structural brain injuries detected by brain magnetic resonance imaging (MRI) among patients with ARDS. METHODS: We retrospectively reviewed and collected data on brain injuries as detected by brain MRI during index hospitalization of all patients with ARDS at a single tertiary center in the United States from January 2010 to October 2018 (pre-COVID era). Structural brain injuries were classified as cerebral ischemia (ischemic infarct and hypoxic-ischemic brain injury) or cerebral hemorrhage (intraparenchymal hemorrhage, cerebral microbleeds, subarachnoid hemorrhage, and subdural hematoma). Descriptive statistics were conducted. RESULTS: Of the 678 patients with ARDS, 66 (9.7%) underwent brain MRI during their ARDS illness. The most common indication for brain MRI was encephalopathy (45.4%), and the median time from hospital admission to MRI was 10 days (interquartile range 4-17). Of 66 patients, 29 (44%) had MRI evidence of brain injury, including cerebral ischemia in 33% (22 of 66) and cerebral hemorrhage in 21% (14 of 66). Among those with cerebral ischemia, common findings were bilateral globus pallidus infarcts (n = 7, 32%), multifocal infarcts (n = 5, 23%), and diffuse hypoxic-ischemic brain injury (n = 3, 14%). Of those with cerebral hemorrhage, common findings were cerebral microbleeds (n = 12, 86%) and intraparenchymal hemorrhage (n = 2, 14%). Patients with ARDS with cerebral hemorrhage had significantly greater use of rescue therapies, including prone positioning (28.6% vs. 5.8%, p = 0.03), inhaled vasodilator (35.7% vs. 11.5%, p = 0.046), and recruitment maneuver (14.3% vs. 0%, p = 0.04). CONCLUSIONS: Structural brain injury was not uncommon among selected patients with ARDS who underwent brain MRI. The majority of brain injuries seen were bilateral globus pallidus infarcts and cerebral microbleeds.

Causes of Hypoxemia in COVID-19 Acute Respiratory Distress Syndrome: A Combined Multiple Inert Gas Elimination Technique and Dual-energy Computed Tomography Study.

BACKGROUND: Despite the fervent scientific effort, a state-of-the art assessment of the different causes of hypoxemia (shunt, ventilation-perfusion mismatch, and diffusion limitation) in COVID-19 acute respiratory distress syndrome (ARDS) is currently lacking. In this study, the authors hypothesized a multifactorial genesis of hypoxemia and aimed to measure the relative contribution of each of the different mechanism and their relationship with the distribution of tissue and blood within the lung. METHODS: In this cross-sectional study, the authors prospectively enrolled 10 patients with COVID-19 ARDS who had been intubated for less than 7 days. The multiple inert gas elimination technique (MIGET) and a dual-energy computed tomography (DECT) were performed and quantitatively analyzed for both tissue and blood volume. Variables related to the respiratory mechanics and invasive hemodynamics (PiCCO [Getinge, Sweden]) were also recorded. RESULTS: The sample (51 ± 15 yr; Pao2/Fio2, 172 ± 86 mmHg) had a mortality of 50%. The MIGET showed a shunt of 25 ± 16% and a dead space of 53 ± 11%. Ventilation and perfusion were mismatched (LogSD, Q, 0.86 ± 0.33). Unexpectedly, evidence of diffusion limitation or postpulmonary shunting was also found. In the well aerated regions, the blood volume was in excess compared to the tissue, while the opposite happened in the atelectasis. Shunt was proportional to the blood volume of the atelectasis (R2 = 0.70, P = 0.003). V˙A/Q˙T mismatch was correlated with the blood volume of the poorly aerated tissue (R2 = 0.54, P = 0.016). The overperfusion coefficient was related to Pao2/Fio2 (R2 = 0.66, P = 0.002), excess tissue mass (R2 = 0.84, P < 0.001), and Etco2/Paco2 (R2 = 0.63, P = 0.004). CONCLUSIONS: These data support the hypothesis of a highly multifactorial genesis of hypoxemia. Moreover, recent evidence from post-mortem studies (i.e., opening of intrapulmonary bronchopulmonary anastomosis) may explain the findings regarding the postpulmonary shunting. The hyperperfusion might be related to the disease severity.

Lung ultrasound score for monitoring the withdrawal of extracorporeal membrane oxygenation on neonatal acute respiratory distress syndrome.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is considered an efficient and life-saving treatment for neonatal severe acute respiratory distress syndrome (ARDS). Bedside lung ultrasound (LUS) is an attractive and feasible method for evaluating neonatal ARDS. OBJECTIVE: To evaluate the value of LUS score at veno-arterial (V-A) ECMO withdrawal in neonatal patients with severe acute ARDS. METHODS: A retrospective preliminary study was conducted in our cardiac intensive care unit from June 2021 to June 2022. Eight severe ARDS neonates who received V-A ECMO were enroled in this study. LUS was measured daily during ECMO and when weaning off ECMO. The relationships between the LUS score and ECMO parameters (blood flow and the sweep gas of FiO2) were assessed. RESULTS: (1) There was a significant improvement in LUS score by ECMO treatment. And, various diagnostic signs of lung ultrasound were detected during ECMO, including pulmonary edema (7 neonates) and lung consolidation (4 neonates), followed by pleural effusion (1 neonate) and bilateral white lung (1 neonate). (2) A total of 12 trials for weaning off ECMO were carried out, of which four failed, but all eight neonates finally succeeded in passing the weaning trial. LUS score of 21 or less was defined as a cut-off value for predicting ECMO weaning success. During ECMO treatment, LUS score was positively correlated with ECMO blood flow (r = 0.866, P < 0.05). CONCLUSIONS: LUS can be used to evaluate the various lung diagnostic signs in ARDS neonatal patients during ECMO treatment, and the LUS score under ECMO treatment decreases over time. The reduction in LUS score is associated with lower ECMO blood flow. LUS score is regarded as a predictor of ECMO weaning success.