Acute respiratory distress syndrome (ARDS) continues to be one of the most life-threatening conditions for patients in the intensive care unit (ICU). The 2023 European Society of Intensive Care Medicine guidelines on ARDS: definition, phenotyping and respiratory support strategies (2023 Guideline) update the 2017 An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: mechanical ventilation in adult patients with ARDS (2017 Guideline), including 7 aspects of 3 topics of definitions, phenotyping, and respiratory support strategies [including high flow nasal cannula oxygen (HFNO), non-invasive ventilation (NIV), neuromuscular blocking agents (NMBA), extracorporeal life support (ECLS), positive end-expiratory pressure (PEEP) with recruitment maneuvers (RM), tidal volume (VT), and prone positioning]. 2023 Guideline review and summarize the literature since the publication of the 2017 Guideline, covering ARDS and acute hypoxemic respiratory failure, as well as ARDS caused by novel coronavirus infection. Based on the most recent medical evidence, the 2023 Guideline provide clinicians with new ideas and approaches for nonpharmacologic respiratory support strategies for adults with ARDS. This article provides interpretation of the new concepts, the new approaches, the new recommended grading and new levels of evidence for ARDS in the 2023 Guideline.
Adult ; Humans ; COVID-19 ; Respiration, Artificial ; Positive-Pressure Respiration ; Respiratory Distress Syndrome/therapy* ; Noninvasive Ventilation

OBJECTIVE: To explore the changes of serum procalcitonin (PCT) level in patients with moderate and severe acute respiratory distress syndrome (ARDS) after cardiac surgery under cardiopulmonary bypass (CPB), and try to find out the best cut-off of PCT to predict the progression to moderate and severe ARDS. METHODS: Medical records of patients undergoing cardiac surgery with CPB in Fujian Provincial Hospital from January 2017 to December 2019 were retrospectively analyzed. Adult patients who were admitted in intensive care unit (ICU) for more than 1 day and had PCT values on the first postoperative day were enrolled. Clinical data such as patient demographics, past history, diagnosis, and New York Heart Association (HYHA) classification, and the operation mode, procedure duration, CPB duration, aortic clamp duration, intraoperative fluid balance, calculation of 24 hours postoperative fluid balance and vasoactive-inotropic score (VIS); 24 hours postoperative C-reactive protein (CRP), N-terminal B-type natriuretic peptide precursor (NT-proBNP) and PCT levels were collected. Two clinicians independently made the diagnosis of ARDS according to the Berlin definition, and the diagnosis was established only in patients with a consistent diagnosis. The differences in each parameter were compared between patients with moderate to severe ARDS and those without or with mild ARDS. Analysis of the ability of PCT to predict moderate to severe ARDS was evaluated by receiver operator characteristic curve (ROC curve). Multivariate Logistic regression was conducted to determine the risk factors of the development of moderate to severe ARDS. RESULTS: 108 patients were finally enrolled, including 37 patients with mild ARDS (34.3%), 35 patients with moderate ARDS (32.4%), 2 patients with severe ARDS (1.9%), and 34 patients without ARDS. Compared with patients with no or mild ARDS, patients with moderate to severe ARDS were older (years old: 58.5±11.1 vs. 52.8±14.8, P < 0.05), with a higher proportion of combined hypertension [45.9% (17/37) vs. 25.4% (18/71), P < 0.05], longer operative time (minutes: 363.2±120.6 vs. 313.5±97.6, P < 0.05), and higher mortality (8.1% vs. 0, P < 0.05), but there were no differences in the VIS score, incidence of acute renal failure (ARF), CPB duration, aortic clamp duration, and intraoperative bleeding, transfusion volume, and fluid balance between the two groups. Serum PCT and NT-proBNP levels in patients with moderate to severe ARDS at postoperative day 1 were significantly higher than those in patients with no or mild ARDS [PCT (μg/L): 16.33 (6.96, 32.56) vs. 2.21 (0.80, 5.76), NT-proBNP (ng/L): 2 405.0 (1 543.0, 6 456.5) vs. 1 680.0 (1 388.0, 4 667.0), both P < 0.05]. ROC curve analysis showed that the area under the curve (AUC) for PCT to predict the occurrence of moderate to severe ARDS was 0.827 [95% confidence interval (95%CI) was 0.739-0.915, P < 0.05]. When PCT cut-off value was 7.165 μg/L, the sensitivity was 75.7% and the specificity was 84.5%, for differentiating patients who developed moderate to severe ARDS from who did not. Multivariate Logistic regression showed that age and the elevated PCT concentration were independent risk factors for the development of moderate to severe ARDS [age: odds ratio (OR) = 1.105, 95%CI was 1.037-1.177, P = 0.002; PCT: OR = 48.286, 95%CI was 10.282-226.753, P < 0.001]. CONCLUSIONS Patients with moderate to severe ARDS undergoing CPB cardiac surgery have a higher serum concentration of PCT than patients with no or mild ARDS. Serum PCT level may be a promising biomarker to predict the development of moderate to severe ARDS, the cut-off value is 7.165 μg/L.
Adult ; Humans ; Cardiopulmonary Bypass ; Procalcitonin ; Retrospective Studies ; Heart ; Respiratory Distress Syndrome

Adult ; Aged ; Betacoronavirus ; Coronavirus Infections ; complications ; therapy ; Critical Care ; Female ; Humans ; Length of Stay ; Male ; Middle Aged ; Pandemics ; Patient Positioning ; Pneumonia, Viral ; complications ; therapy ; Prone Position ; Respiratory Distress Syndrome, Adult ; therapy ; virology ; Respiratory Function Tests ; Retrospective Studies ; Treatment Outcome

BACKGROUND: Critical patients with the coronavirus disease 2019 (COVID-19), even those whose nucleic acid test results had turned negative and those receiving maximal medical support, have been noted to progress to irreversible fatal respiratory failure. Lung transplantation (LT) as the sole therapy for end-stage pulmonary fibrosis related to acute respiratory distress syndrome has been considered as the ultimate rescue therapy for these patients. METHODS: From February 10 to March 10, 2020, three male patients were urgently assessed and listed for transplantation. After conducting a full ethical review and after obtaining assent from the family of the patients, we performed three LT procedures for COVID-19 patients with illness durations of more than one month and extremely high sequential organ failure assessment scores. RESULTS: Two of the three recipients survived post-LT and started participating in a rehabilitation program. Pearls of the LT team collaboration and perioperative logistics were summarized and continually improved. The pathological results of the explanted lungs were concordant with the critical clinical manifestation, and provided insight towards better understanding of the disease. Government health affair systems, virology detection tools, and modern communication technology all play key roles towards the survival of the patients and their rehabilitation. CONCLUSIONS LT can be performed in end-stage patients with respiratory failure due to COVID-19-related pulmonary fibrosis. If confirmed positive-turned-negative virology status without organ dysfunction that could contraindicate LT, LT provided the final option for these patients to avoid certain death, with proper protection of transplant surgeons and medical staffs. By ensuring instant seamless care for both patients and medical teams, the goal of reducing the mortality rate and salvaging the lives of patients with COVID-19 can be attained.
Aged ; Betacoronavirus ; Coronavirus Infections ; complications ; mortality ; Extracorporeal Membrane Oxygenation ; Humans ; Lung Transplantation ; methods ; Male ; Middle Aged ; Pandemics ; Pneumonia, Viral ; complications ; mortality ; Pulmonary Fibrosis ; mortality ; surgery ; Respiratory Distress Syndrome, Adult ; mortality ; surgery

The 2019 novel coronavirus disease (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has occurred in China and around the world. SARS-CoV-2-infected patients with severe pneumonia rapidly develop acute respiratory distress syndrome (ARDS) and die of multiple organ failure. Despite advances in supportive care approaches, ARDS is still associated with high mortality and morbidity. Mesenchymal stem cell (MSC)-based therapy may be an potential alternative strategy for treating ARDS by targeting the various pathophysiological events of ARDS. By releasing a variety of paracrine factors and extracellular vesicles, MSC can exert anti-inflammatory, anti-apoptotic, anti-microbial, and pro-angiogenic effects, promote bacterial and alveolar fluid clearance, disrupt the pulmonary endothelial and epithelial cell damage, eventually avoiding the lung and distal organ injuries to rescue patients with ARDS. An increasing number of experimental animal studies and early clinical studies verify the safety and efficacy of MSC therapy in ARDS. Since low cell engraftment and survival in lung limit MSC therapeutic potentials, several strategies have been developed to enhance their engraftment in the lung and their intrinsic, therapeutic properties. Here, we provide a comprehensive review of the mechanisms and optimization of MSC therapy in ARDS and highlighted the potentials and possible barriers of MSC therapy for COVID-19 patients with ARDS.
Adoptive Transfer ; Alveolar Epithelial Cells ; pathology ; Animals ; Apoptosis ; Betacoronavirus ; Body Fluids ; metabolism ; CD4-Positive T-Lymphocytes ; immunology ; Clinical Trials as Topic ; Coinfection ; prevention & control ; therapy ; Coronavirus Infections ; complications ; immunology ; Disease Models, Animal ; Endothelial Cells ; pathology ; Extracorporeal Membrane Oxygenation ; Genetic Therapy ; methods ; Genetic Vectors ; administration & dosage ; therapeutic use ; Humans ; Immunity, Innate ; Inflammation Mediators ; metabolism ; Lung ; pathology ; physiopathology ; Mesenchymal Stem Cell Transplantation ; methods ; Mesenchymal Stem Cells ; physiology ; Multiple Organ Failure ; etiology ; prevention & control ; Pandemics ; Pneumonia, Viral ; complications ; immunology ; Respiratory Distress Syndrome, Adult ; immunology ; pathology ; therapy ; Translational Medical Research

Adult ; Capillary Permeability ; Extracorporeal Membrane Oxygenation ; Extravascular Lung Water ; Humans ; Lung/diagnostic imaging* ; Prognosis ; Respiratory Distress Syndrome/therapy*

Mycoplasma pneumoniae (MP) is the most common causative agent of community-acquired pneumonia in school-aged children. An 8-year-old boy who had been diagnosed with autism looked severely ill when he presented to our hospital due to dyspnea and lethargy. He had fever and cough 7 days prior to hospitalization. He had signs and symptoms of severe respiratory distress. The percutaneous oxygen saturation was 88% at high oxygen supply. Chest radiography showed diffusely increased opacity with moderate pleural effusion. He was intubated immediately and admitted to the intensive care unit. Under the clinical impression of mycoplasmal pneumonia, intravenous clarithromycin was started. Laboratory findings showed leukocytosis, hepatitis, decreased renal function, and presence of serum MP immunoglobulin (Ig) M (+) IgG (+) and sputum MP polymerase chain reaction (+). On hospital day 2, the patient developed multiple organ failure with acute respiratory distress syndrome (ARDS). Veno-venous extracorporeal membrane oxygenation (ECMO) was performed with continuous renal replacement therapy (CRRT) and was weaned successfully. This is the first reported case of an ARDS due to MP infection complicated by multiple organ failure that was successfully treated with ECMO and CRRT in South Korea.
Autistic Disorder ; Child ; Clarithromycin ; Cough ; Dyspnea ; Extracorporeal Membrane Oxygenation ; Fever ; Hepatitis ; Hospitalization ; Humans ; Immunoglobulin G ; Immunoglobulins ; Intensive Care Units ; Korea ; Lethargy ; Leukocytosis ; Male ; Multiple Organ Failure ; Mycoplasma pneumoniae ; Mycoplasma ; Oxygen ; Pleural Effusion ; Pneumonia ; Pneumonia, Mycoplasma ; Polymerase Chain Reaction ; Radiography ; Renal Replacement Therapy ; Respiratory Distress Syndrome, Adult ; Sputum ; Thorax

BACKGROUND/AIMS: The relationship between nonpulmonary organ failure and the development of acute respiratory distress syndrome (ARDS) in patients with sepsis has not been well studied. METHODS: We retrospectively reviewed the medical records of patients with septic bacteremia admitted to the medical intensive care unit (ICU) of a tertiary academic hospital between January 2013 and December 2016. RESULTS: The study enrolled 125 patients of median age 73.0 years. Urinary (n = 47), hepatobiliary (n = 30), and pulmonary infections (n = 28) were the most common causes of sepsis; the incidence of ARDS was 17.6%. The total number of nonpulmonary organ failures at the time of ICU admission was higher in patients with ARDS than in those without (p = 0.011), and the cardiovascular, central nervous system (CNS), and coagulation scores were significantly higher in ARDS patients. On multivariate analysis, apart from pneumonia sepsis, the CNS (odds ratio [OR], 1.917; 95% confidence interval [CI], 1.097 to 3.348) and coagulation scores (OR, 2.669; 95% CI, 1.438 to 4.954) were significantly associated with ARDS development. The 28-day and in-hospital mortality rates were higher in those with ARDS than in those without (63.6 vs. 8.7%, p < 0.001; 72.7% vs. 11.7%, p < 0.001), and ARDS development was found to be an independent risk factor for 28-day mortality. CONCLUSIONS: Apart from pneumonia, CNS dysfunction and coagulopathy were significantly associated with ARDS development, which was an independent risk factor for 28-day mortality.
Bacteremia ; Central Nervous System ; Hospital Mortality ; Humans ; Incidence ; Intensive Care Units ; Medical Records ; Mortality ; Multivariate Analysis ; Pneumonia ; Respiratory Distress Syndrome, Adult* ; Retrospective Studies ; Risk Factors* ; Sepsis

A 37-year-old male visited the hospital with multiple trauma after traffic accident. Fractures of ribs, left femur, and right humerus and spleen rupture with hemoperitoneum were founded on image studies. He was moved to operation room and general anesthesia was performed for splenectomy. During the operation, excessive high peak inspiratory pressure was observed. After abdominal closure, hypoxia, hypercapnia, and respiratory acidosis were worsened. Veno-venous extracorporeal membrane oxygenation (ECMO) was initiated after the operation. Status of the patient were improved after the application of ECMO. The patient was discharged without significant complication. Despite of several limitations in applying ECMO to patients with abdominal compartment syndrome (ACS) and multiple trauma, severe pulmonary dysfunction in ACS patients may be rescued without open abdomen treatment.
Abdomen ; Accidents, Traffic ; Acidosis, Respiratory ; Adult ; Anesthesia, General ; Anoxia ; Extracorporeal Membrane Oxygenation* ; Femur ; Hemoperitoneum ; Humans ; Humerus ; Hypercapnia ; Intra-Abdominal Hypertension ; Male ; Multiple Trauma ; Respiratory Distress Syndrome, Adult ; Ribs ; Rupture ; Spleen ; Splenectomy

Patients undergoing thoracic surgery show various lesions such as chronic obstructive lung diseases, pleural adhesion, pneumonia, acute respiratory distress syndrome, atelectasis, pleural effusion, pulmonary edema, and pneumothorax throughout preoperative, operative, and recovery periods. Therefore, lung ultrasonography has potential for perioperative use in thoracic surgery. Benefits of lung ultrasonography over conventional chest X-ray are convincing. First, ultrasonography has higher sensitivity than X-ray in various lesions. Second, it can be performed at bed side to obtain diagnosis immediately. Third, it does not expose patients to radiologic hazard. If anesthesiologists can obtain necessary skills and perform lung ultrasonography as a routine evaluation process for patients, territory of anesthesia would become broader and patients would obtain more benefit.
Anesthesia ; Diagnosis ; Humans ; Lung Diseases, Obstructive ; Lung* ; Pleural Effusion ; Pneumonia ; Pneumothorax ; Pulmonary Atelectasis ; Pulmonary Edema ; Respiratory Distress Syndrome, Adult ; Thoracic Surgery* ; Thorax ; Ultrasonography*