Objective To explore the prognosis of elderly patients suffered from hospital-acquired pneumonia (HAP) by T cell subsets and clinical pulmonary infection score (CPIS).Methods A cohort of 125 elderly patients admitted in ICU & ED (Emergency Department) from Aug,2012 to Jul,2013 were enrolled for a prospective and observational study.The patients were divided into 3 groups:HAP survival group (n =50,group A),HAP death group (n =40,group B) and non-HAP group (n =35,control group).The criteria of exclusion were patients with auto-immune diseases,immunodeficiency,allergic disorders,malignancies,diabetes,trauma,surgical diseases,or patients with recent use of immunosuppressive agents or cyclooxygenase-inhibitors (Aspirin etc.).In the control group,patients with nosocomial pneumonia and other diseases afecting the CPIS were excluded.APACHE Ⅱ scores of all patients were recorded.Blood T cell subsets (including values of CD3,CD4 +,CD8 +,and CD4 +/CD8 +)were measured on the admission day,the 1st day of HAP onset and the 5th day after onset of HAP in HAP patients whereas these measurements were tested only on the admission day in controls.Meanwhile,the CPISs were recorded on the admission day,the 1st day of HAP onset and the 5th day after onset of HAP in HAP patients.Flow cytometer (FCM) was used to detect T cell subsets.Data of statistical analysis were represented as Mean ± SD.The significant differences in T cell subsets and CPIS between survival group and death group were analyzed by independent t test.The paired samples t test was employed in survival group and death group.Linear correlation analysis was made between CD4 +/CD8 + ratio and CPIS in survival and death groups,respectively.Results There were no significant differences in demographics and clinical features (including age,sex,length of stay,APACHE Ⅱ scores) of patients in survivors and non-survivors (P ＞ 0.05).The values of CDs (CD3,CD4 + and CD4 +/CD8 + ratio) between patients of control group and patients of HAP groups were not significantly different on the admission day (P ＞ 0.05).The values of CDs on the admission day were much lower than those on the 1 st day of HAP onset in both survivors and nonsurvivors (P ＜ 0.05).The values of CDs on the 5th day after onset of HAP were higher than those on the 1 st day of HAP onset in the survival group (P ＜ 0.05),while there were no significant differences in CDs between different intervals after HAP onset in the death group (P ＞ 0.05).There were no significant changes in values of CD8 + in any group (P ＞ 0.05).Both survivors and non-survivors had much higher CPIS values on the 1st day of HAP onset than those on the admission day (P ＜0.01).The survival group had higher CPIS on the 5th day after onset of HAP compared to the 1st day of HAP onset (P ＜0.01),while there was no significant change in the death group.Linear correlation analysis showed negative correlation between CD4 +/CD8 + ratio and CPIS on both the 1 st day of HAP onset (survival group:R =-0.740,P =0.004 ; death group:R =-0.613,P =0.035) and the 5th day after onset of HAP (survival group:R =-0.639,P =0.009; death group:R=-0.686,P=0.021).Conclusions The hospital-acquired pneumonia appears as an immune imbalance disorder.The difference in CDs is a promising objective tool,aiding in prediction of prognosis of HAP in the elderly,the lower the CDs,the higher severity.The CD4 + / CD8 + ratio showed a negative correlation with CPIS.Monitoring of T cell subsets and CPIS may provide clinical value for the treatment of hospital-acquired pneumonia in the elderly.

To study the value of lung ultrasound score (LUS) in assessing the clinical outcome of patients with ventilator-associated pneumonia (VAP).A total of 99 VAP patients were enrolled in a prospective study.All patients met the diagnostic criterion of VAP based on the 2013 guidelines and admitted into our ICU from Jun 2013 to Jun 2015.All parameters were recorded on the diagnostic day (day 1) and day 5,including LUS,clinical pulmonary infection score (CPIS),chest X ray (CXR),Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) score,Sequential Organ Failure Assessment (SOFA) score,etc.According to the CPIS,patients were divided into 2 groups(CPIS less than 6 and more or equal to 6).CPIS and LUS were similar on day 1 between two groups (P ＞ 0.05).However,on day 5,significant differences of CPIS and LUS were found between groups with CPIS ＜ 6 and CPIS≥6 (P =0.019 and P ＜ 0.001 respectively).LUS decreased on day 5 in CPIS ＜ 6 group and increased in CPIS ≥6 group.In CPIS ＜ 6 group,there was a positive correlation between LUS and CPIS on day 1 (r =0.375,P =0.003) and day 5 (r =0.590,P ＜ 0.001).CPIS ≥6 groupshowed the same trend on day 1 (r =0.484,P =0.002) and day 5 (r =0.407,P =0.011).LUS can be used to dynamically evaluate the clinical outcome of VAP.

Objective To observe and explore the effects of different tidal volume (VT) ventilation on right ventricular (RV) function in patients with critical respiratory failure.Methods Consecutive respiratory failure patients who were treated with invasive ventilator over 24 h in the Department of Critical Care Medicine at the Fourth Hospital of Hebei Medical University from June to December in 2015 were enrolled in this study.Clinical data including patients′ vital signs, ventilator parameters and RV echocardiography were collected within 6 h (D0), day1(D1), day2 (D2) and day3 (D3) after ventilation started.According to the VT, patients with acute respiratory distress syndrome (ARDS) were assigned to low VT group [S6, ≤6 ml/kg predicted body weight (PBW)] and high VT group (L6, >6 ml/kg PBW), while non-ARDS patients were also assigned to low VT group (S8, ≤8 ml/kg PBW) and high VT group (L8, >8 ml/kg PBW).Results A total of 84 patients were enrolled in this study.44.2% ARDS patients and 58.5% non-ARDS patients were in low VT groups.After ventilation, tricuspid annulus plane systolic excursion(TAPSE)decreased progressively in S6 [from 18.30(16.70,20.70) mm to 17.55(15.70,19.50) mm, P=0.001], L6 [from 19.50(17.00,21.00) mm to 16.30(15.00,18.00) mm P=0.001], S8[from 18.00(16.00,21.00) mm to 16.50(15.50,18.00) mm, P=0.001] and L8 [from 19.00(17.50,21.50) mm to 16.35(15.15,17.00) mm, P=0.001] groups.However, TAPSE decreased less in small VT groups (S6 and S8) than those of in large VT groups (S8 and L8) without significant differences.There were not statistical differences between different VT groups in terms of ventilation days, including right ventricle area/left ventricle area (RVarea/LVarea),TAPSE,peak mitral flow velocity of the early rapid filling wave (E),peak mitral flow velocity of the late rapid filling wave (A),early diastolic velocity of the tricuspid annulus (e′),pulmonary artery systolic pressure,inferior vena cava diameter (all P>0.05).Compared to L6 group, low VT (S6 group) resulted in decreased mortality at 28 days [1/19 vs 37.5%(9/24), P=0.014].There were not statistical differences between different VT groups in terms of ventilation days, length of intensive care unit stay, length of hospital stay (all P>0.05).Logistic regression analysis showed that VT could be the independent factor of TAPSE (OR=1.104,95%CI 0.100-1.003,P=0.049).Conclusions Positive pressure mechanical ventilation resulted in RV systolic dysfunction.Lower VT may have the protective effect on RV function.Trial registration Chinese Clinical Trial Registry,ChiCTR-POC-15007563.

ObjectiveTo evaluate the value of lung ultrasound score (LUS) on assessing the severity and prognosis in patients with acute respiratory distress syndrome (ARDS), and to investigate its correlation with oxygenation index, acute physiology and chronic health evaluationⅡ (APACHEⅡ) score, sequential organ failure assessment (SOFA) score, and clinical pulmonary infection score (CPIS), and other traditional parameters.Methods A prospective double-blind cohort study was conducted. Sixty-two ARDS patients conformed to the Berlin diagnostic criteria admitted to intensive care unit (ICU) of Beijing Huaxin Hospital from October 2013 to December 2014 were enrolled, including 14 cases with mild, 18 moderate, and 30 severe ARDS; among them 37 cases were of ARDS with pulmonary origin, and 25 non-pulmonary ARDS; 35 patients survived, and 27 died. The clinical data and scores of all patients were recorded by one specialized observer, including baseline data, hemodynamic parameters, lactate, respiratory parameters, and APACHEⅡ, SOFA and CPIS scores. Another observer of recording was responsible for the results of lung ultrasound, LUS, and echocardiogram. The correlation between LUS and oxygenation index as well as APACHEⅡ, SOFA and CPIS scores was analyzed by bivariate correlation analysis. Receiver operator characteristic curve (ROC) was plotted, and the predictive value, sensitivity and specificity of mild ARDS, moderate ARDS, severe ARDS and mortality by LUS were calculated. Results LUS had a negative correlation with oxygenation index (r = -0.755,P< 0.001), a good positive correlation with APACHEⅡ (r = 0.504,P< 0.001), SOFA (r = 0.461,P< 0.001) and CPIS (r = 0.571,P< 0.001) was found. LUS in the pulmonary ARDS group had a positive correlation with CPIS (r = 0.399,P< 0.05), and a positive correlation was found in non-pulmonary ARDS group (r = 0.350,P< 0.05), which indicated that the correlation in pulmonary ARDS was more satisfactory than that in non-pulmonary ARDS. LUS in the pulmonary ARDS group was significantly higher than that in non-pulmonary ARDS group (22.1±4.9 vs. 11.3±2.1,t = 11.667,P< 0.001); LUS in mild, moderate, severe ARDS groups was 9.9±1.7, 14.0±1.4, 23.6±4.1. The predictive value for mild ARDS by LUS was 7.0, sensitivity of 87.0%, specificity of 89.0%; that for moderate ARDS was 11.0, sensitivity of 89.0%, specificity of 87.0%; that for severe ARDS was 8.0, sensitivity of 90.0%, specificity of 88.5%. LUS was 24.3±3.8 in the death group, and 12.7±2.9 in the survival group. Area under ROC curve (AUC) was calculated, and the patients with LUS> 19.0 had a high mortality, sensitivity for predicting death was 84.0%, and specificity of 89.0%.Conclusion Bedside LUS, which is simple and easily available, could evaluate the changes in pulmonary ventilation area of ARDS, and its degree of severity, and prognosis including prediction of mortality of the patients.

Objective To investigate the effect of non invasive cardiac output monitoring(NICO)system in pig model with acute respiratory distress syndrome(ARDS),and to provide experimental basis for clinical application. Methods Eleven anaesthetized and ventilated ARDS male pig models were induced by intravenously infusing 0.2 mL/kg oleic acid. Lung recruitment was condocted by pressure control ventilation on pigs with ARDS. The optimal positive end-expiratory pressure(PEEP)was determined by optimal dead space fraction〔the ratio of dead space to tidal volume(VD/VT)〕. Cardiac output(CO)was determined by NICO,the respiratory function was monitored, and the VD/VT,dynamic compliance(Cdyn),oxygenation index(PaO2/FiO2),the volume of alveolar ventilation(Valv) and arterial blood oxygen saturation(SaO2)were recorded before infusing oleic acid,after stabilization of ARDS model and at optimal PEEP level,and the intrapulmonary shunt fraction(Qs/Qt)was calculated. CO was also determined by application of pulse indicated continuous cardiac output(PiCCO),and the linear regression analysis between CO determined by NICO and CO determined by PiCCO was conducted. Results Seven experimental ARDS pigs model were successfully established. The optimal PEEP identified by the lowest VD/VT method was(15.71±1.80)cmH2O (1 cmH2O=0.098 kPa). Compared with before infusing oleic acid,VD/VT and Qs/Qt after stabilization of ARDS model were significantly increased〔VD/VT:(72.29±8.58)% vs.(56.00±11.06)%,Qs/Qt:(21.04±15.05)%vs.(2.00±1.32)%,both P<0.05〕,and SaO2 and Valv were significantly decreased〔SaO2:0.888±0.108 vs. 0.999±0.053,Valv(mL):92.06±35.22 vs. 146.11±45.43,both P<0.05〕. VD/VT,Qs/Qt,SaO2 and Cdyn at optimal PEEP level were improved to the levels before infusing oleic acid〔(61.07±9.30)%,(3.21±6.10)%, 0.989±0.025,(117.14±41.14)mL〕. Cdyn and PaO2/FiO2 after stabilization of ARDS model were significantly lowered compared with those before infusing oleic acid〔Cdyn (mL/cmH2O):14.43±5.50 vs. 38.14±6.72, PaO2/FiO2 (mmHg, 1 mmHg=0.133 kPa):78.71±23.22 vs. 564.37±158.85, both P<0.05〕. Cdyn and PaO2/FiO2 at optimal PEEP level〔(19.71±4.86)%,(375.49±141.30)mmHg〕were elevated compared with the levels after stabilization of ARDS model(both P<0.05),but still lower than those before infusing oleic acid(both P<0.05). Compared with the levels after stabilization of ARDS model,CO at optimal PEEP level showed obvious decrease from(4.18±2.46)L/min to(3.95±2.69)L/min without significant difference(P>0.05). There was linear correlation between CO determined by NICO and CO determined by PiCCO(r2=0.925,P<0.001). Conclusions NICO technique provides a useful and accurate non invasive estimation of CO and respiratory function.VD/VT provided by NICO can titrate the optimal PEEP in patients with ARDS.

Acute respiratory and circulatory disorders are the most common critical syndromes, the essence of which is damage to the organs/systems of the heart and lungs. These comprise the essential manifestation of disease and injury progression to the severe stage. Its development involves the following components: individual specificity, primary disease strike, dysregulation of the host′s response, and systemic disorders. Admission for acute respiratory and circulatory disorders is a clinical challenge. Based on a previously proposed flow, a critical care ultrasound-based stepwise approach (PIEPEAR) as a standard procedure to manage patients with acute cardiorespiratory compromise and practical experience in recent years, a modified seven-step analysis and treatment process has been developed to help guide clinicians with rational thinking and standardized treatment when faced with acute respiratory and circulatory disorders. The process consists of seven steps: problem-based clinical analysis, intentional information acquisition, evaluation of core disorder based on critical care ultrasound, pathophysiology and host response phenotype identification, etiology diagnosis, act treatment through pathophysiology-host response and etiology, and re-check. The modified seven-step approach is guided by a “modular analysis” style of thinking and visual monitoring. This approach can strengthen the identification of clinical problems and facilitate a three-in-one analysis. It focuses on pathophysiological disorders, body reactions, and primary causes to more accurately understand the condition′s key points, and make treatment more straight forward, to finally achieve the aim of “comprehensive cognition and refined treatment”.

Objective To investigate the characteristics of lung ultrasound images in critical care postoperative patients using BLUE-plus protocol . Methods Two hundred and twenty-two patients who were performed lung ultrasound measurements according to the BLUE-plus protocol within 24 hours admitted to the Department of critical care were included in this study . Data was collected and retrospectively analyzed to compare the proportion of different lung ultrasound signs at different speculate regions ,and to compare the lung ultrasound characteristics of patients undergo different surgeries . Results Excluding A lines ,the most common abnormal lung ultrasound signs at the diaphragmatic points were B7 lines (13 .06％ ) ,and the most common abnormal lung ultrasound signs at the posterior blue points were C signs (28 .60％ ) . The rate of C signs was significantly higher in post spinal cord surgery patients than those in other groups ( P =0 .032) . The rate of B3 lines was significantly higher at bilateral PLAPS points in oxygenation index 100-200 group compared with that in oxygenation index>300 group ( P =0 .011) . The rate of C signs was significantly higher at the left posterior blue point in oxygenation index 200-300 group , and at bilateral posterior blue point in oxygenation index 100-200 and <100 groups compared with those in oxygenation index >300 group ( P =0 .011 , P <0 .001 and P =0 .002) . The rate of pleural effusion was significantly higher at the right posterior blue point in oxygenation index 200 -300 group ,and at bilateral posterior blue point in oxygenation index 100 -200 group compared with those in oxygenation index >300 group ( P = 0 .001 , P < 0 .001 ) . Conclusions Screen with the BLUE-plus protocol can help to find abnormal signs including B3 lines ,B7 lines ,C signs and pleural effusion ,therefore instructs individualized treatment for postoperative patients . Pulmonary edema ,lung consolidation and pleural effusion are three main reasons responsible for hypoxemia in postoperative patients . Intensivists should avoid fluid overload , strengthen airway management ,postural therapy and encourage early mobility in postoperative patients .

Critical ultrasonography is widely used in ICU and has become an indispensable tool for clinicians. However, besides operator-dependency of critical ultrasonography, lack of standardized training mainly result in the physicians′ heterogenous ultrasonic skill. Therefore, standardized training as well as strict quality control plays the key role in the development of critical ultrasonography. We present this quality control standards to promote better development of critical ultrasonography.

Severe patients with coronaviras disease 2019 (COVID-19) are characterized by persistent lung damage, causing respiratory failure, secondary circulatory changes and multiple organ dysfunction after virus invasion. Because of its dynamic, real-time, non-invasive, repeatable and other advantages, critical ultrasonography can be widely used in the diagnosis, assessment and guidance of treatment for severe patients. Based on the recommendations of critical care experts from all over the country who fight against the epidemic in Wuhan, this article summarizes the guidelines for the treatment of COVID-19 based on critical ultrasonography, hoping to provide help for the treatment of severe patients. The recommendations mainly cover the following aspects: (1) lung ultrasound in patients with COVID-19 is mainly manifested by thickened and irregular pleural lines, different types of B-lines, shred signs, and other consolidation like dynamic air bronchogram; (2) Echocardiography may show right heart dysfunction, diffuse cardiac function enhancement, stress cardiomyopathy, diffuse cardiac depression and other multiple abnormalities; (3) Critical ultrasonography helps with initiating early treatment in the suspect patient, screening confirmed patients after intensive care unit admission, early assessment of sudden critical events, rapid grading assessment and treatment based on it; (4) Critical ultrasonography helps to quickly screen for the etiology of respiratory failure in patients with COVID-19, make oxygen therapeutic strategy, guide the implementation of lung protective ventilation, graded management and precise off-ventilator; (5) Critical ultrasonography is helpful for assessing the circulatory status of patients with COVID-19, finding chronic cardiopulmonary diseases and guiding extracorporeal membrane oxygenation management; (6) Critical ultrasonography contributes to the management of organs besides based on cardiopulmonary oxygen transport; (7) Critical ultrasonography can help to improve the success of operation; (8) Critical ultrasonography can help to improve the safety and quality of nursing; (9) When performing critical ultrasonography for patients with COVID-19, it needs to implement three-level protection standard, pay attention to disinfect the machine and strictly obey the rules from nosocomial infection. (10) Telemedicine and artificial intelligence centered on critical ultrasonography may help to improve the efficiency of treatment for the patients with COVID-19. In the face of the global spread of the epidemic, all we can do is to share experience, build a defense line, We hope this recommendations can help COVID-19 patients therapy.

Objective:To describe the features of point-of-care cardiopulmonary ultrasound (POCUS) in the critically ill patients and analyze the independent factors associated with treatment changes after POCUS assessment.Methods:This was a prospective multicentric observational study from January to December 2018 in 13 intensive care units (ICU) in China. Consecutive patients admitted to the ICU were enrolled, POCUS were performed within the first 24 h of admission. The POCUS parameters included acute or chronic cardiac abnormality, diameter of inferior vena cava (IVC) at end-expiration, right ventricular systolic function, systolic and diastolic function of left ventricle (LV) and lung ultrasound score. The general features of patients and performers were recorded. Based on the treatment proposed by the performer before and after POCUS assessment, the patients were divided into treatment changed and unchanged groups. Factors associated with treatment changes were identified by multiple logistic regression analysis.Results:Totally 1 913 patients were enrolled including 322 (16.8%) patients with shock, 638 (33.3%) patients with respiratory failure, 139 (7.3%) patients with both shock and respiratory failure and 814 (42.6%) perioperative patients. POCUS had contributed to treatment changes in 1 204 (62.9%) patients, including 867 (72.0%) cases involved fluid management. Univariate analysis showed that there were significant differences in general characteristics of patients, performers and POCUS parameters between groups(all P<0.05). Logistic regression analysis showed that independent factors of treatment changes included ministry of education or university affiliated teaching hospitals (vs.general hospitals, OR=1.891, 95% CI=1.314-2.722, P<0.001 and OR=1.644, 95% CI=1.152-2.347, P=0.006 separately), middle and senior title performers (vs.primary title, OR=2.112, 95% CI=1.358-3.284, P=0.001, OR=3.271, 95% CI=2.129-5.025, P<0.001 separately), mechanical ventilation (vs.without, OR=0.488, 95% CI 0.381-0.626, P<0.001), IVC diameter ≤1 cm (vs.1-2 cm, OR=0.317, 95% CI 0.231-0.434, P<0.001), LV ejecting fraction <50% (vs.≥50%, OR=0.328, 95% CI=0.210-0.512, P<0.001), lung ultrasound score of 6-12 and >12 points(vs.score ≤ 6 points, OR=0.237, 95% CI=0.178-0.315, P<0.001 and OR=0.619, 95% CI=0.457-0.837, P=0.002 separately). Conclusions:POCUS assessment contributes to treatment changes, most of which involves fluid management strategy, in 62.9% critical patients. The independent influencing factors associated with POCUS parameters includes IVC diameter at end-expiratory, LV systolic function and lung ultrasound score. The performers′ title and hospital grade also have a noticeable effect.