Daily Ards Research Analysis
Across ARDS care, a large binational cohort found no association between ECMO center volume and 6‑month death or disability, suggesting coordinated regional networks may offset traditional volume–outcome effects. In COVID‑19 ARDS, high-sensitivity troponin T on the day of extubation independently predicted extubation failure. In neonatal RDS, a meta-analysis of 26 RCTs indicates surfactant plus budesonide lowers BPD risk and resource use, though overall certainty is mostly low.
Summary
Across ARDS care, a large binational cohort found no association between ECMO center volume and 6‑month death or disability, suggesting coordinated regional networks may offset traditional volume–outcome effects. In COVID‑19 ARDS, high-sensitivity troponin T on the day of extubation independently predicted extubation failure. In neonatal RDS, a meta-analysis of 26 RCTs indicates surfactant plus budesonide lowers BPD risk and resource use, though overall certainty is mostly low.
Research Themes
- ECMO organization and long-term outcomes
- Biomarkers for extubation readiness in ARDS
- Pharmacotherapy to prevent BPD in neonatal RDS
Selected Articles
1. Hospital-level volume in extracorporeal membrane oxygenation cases and death or disability at 6 months.
In a binational registry-embedded cohort (n=1,232), ECMO center volume (>30 vs ≤30 cases/year) was not associated with death or new disability at 6 months across VV-, VA-, and ECPR-ECMO after multivariable adjustment. Sensitivity analyses, including exclusion of inter-hospital transfers, confirmed the null association, implicating coordinated regional care and training.
Impact: Provides high-quality, long-term, patient-centered outcomes that challenge the assumption that higher ECMO volume necessarily yields better results. Informs regionalization, transfer policies, and training strategies.
Clinical Implications: Health systems should prioritize coordinated networks, standardized protocols, and inter-hospital transfers/training over rigid volume thresholds when organizing ECMO services and benchmarking outcomes.
Key Findings
- No difference in 6‑month death or new disability between high- and low-volume centers for VV-ECMO (OR 1.09, 95% CI 0.65–1.83; p=0.744).
- No difference for VA-ECMO (OR 1.10, 95% CI 0.66–1.84; p=0.708) or ECPR (OR 1.38, 95% CI 0.37–5.08; p=0.629).
- Findings were consistent across sensitivity analyses, including exclusion of transferred patients; total n=1,232 (663 high-volume, 569 low-volume).
Methodological Strengths
- Registry-embedded, multicenter binational cohort with pre-specified 6‑month patient-centered outcome.
- Multivariable analyses across ECMO subgroups with sensitivity analyses including transfer exclusions.
Limitations
- Observational design leaves potential residual confounding.
- Generalizability may be limited to regions with coordinated ECMO networks (Australia/New Zealand).
Future Directions: Prospective multicenter studies to identify which components of coordinated networks (e.g., protocols, simulation training, transfer timing) drive outcome equivalence; incorporation of patient-reported outcomes and cost-effectiveness.
2. The prognostic role of cardiac and inflammatory biomarkers in extubation failure in patients with COVID-19 acute respiratory distress syndrome.
Among 297 extubated C-ARDS patients, 21.5% failed extubation. On the day of extubation, Hs‑TnT, NT‑proBNP, and PCT were associated with failure in univariable analyses; only Hs‑TnT remained independently associated after adjusting for age, ventilation days, and SOFA (adjusted OR 1.38, 95% CI 1.02–1.90). Combined elevation of Hs‑TnT and PCT identified a 46% failure risk vs 13% when both were normal.
Impact: Identifies a readily available cardiac biomarker (Hs‑TnT) that independently stratifies extubation risk in C‑ARDS, enabling more objective liberation decisions.
Clinical Implications: Consider incorporating Hs‑TnT into extubation readiness assessments in C‑ARDS, alongside clinical variables; patients with elevated Hs‑TnT (± elevated PCT) may benefit from enhanced monitoring, optimization, or delayed extubation.
Key Findings
- Extubation failure occurred in 21.5% of 297 C‑ARDS patients.
- On extubation day, Hs‑TnT (OR 1.72), NT‑proBNP (OR 1.24), and PCT (OR 1.38) were associated with failure in univariable analyses.
- After multivariable adjustment, only Hs‑TnT remained independently associated (adjusted OR 1.38, 95% CI 1.02–1.90). Combined elevated Hs‑TnT (≥14 ng/mL) and PCT (≥0.25 ng/mL) conferred a 46% failure risk vs 13% when both normal.
Methodological Strengths
- Clearly defined endpoint (reintubation or death within 7 days) and adjustment for key clinical confounders (age, ventilation duration, SOFA).
- Real-world single-center cohort with standardized biomarker measurements on the day of extubation.
Limitations
- Single-center retrospective design limits generalizability and causal inference.
- Focused on C‑ARDS; applicability to non-COVID ARDS requires validation.
Future Directions: Prospective multicenter validation and integration of Hs‑TnT with clinical indices and physiologic weaning tests to build multivariable risk models; assessment of biomarker-guided extubation strategies.
3. Efficacy of pulmonary surfactant with budesonide in premature infants: A systematic review and meta-analysis.
Across 26 RCTs (n=2,701), adding budesonide to pulmonary surfactant reduced bronchopulmonary dysplasia (RR 0.61) and shortened ventilation days (−2.21), oxygen days (−5.86), and hospital stay (−5.61) versus surfactant alone, without short-term adverse events. Overall certainty was mostly low to very low by GRADE, with moderate certainty supporting reductions in moderate-to-severe BPD.
Impact: Synthesizes a large RCT evidence base suggesting a widely available steroid added to surfactant may reduce BPD and resource use in preterm infants, informing practice while highlighting the need for higher-quality trials.
Clinical Implications: Consider budesonide with surfactant for high-risk preterm infants in settings with protocols and monitoring, while recognizing the low certainty and prioritizing enrollment in ongoing high-quality trials and long-term safety follow-up.
Key Findings
- 26 RCTs (n=2,701) compared PS+budesonide vs PS alone.
- PS+budesonide reduced BPD incidence (RR 0.61; 95% CI 0.51–0.73).
- Shortened mechanical ventilation (MD −2.21 days), oxygen requirement (MD −5.86 days), and hospital stay (MD −5.61 days); no increase in short-term adverse events; overall evidence certainty mostly low to very low.
Methodological Strengths
- Comprehensive multi-database search with random-effects meta-analysis and GRADE assessment.
- Large aggregate sample size across randomized trials enabling precise estimates for key clinical outcomes.
Limitations
- Overall evidence certainty rated mostly low to very low due to study quality and heterogeneity.
- Limited data on long-term neurodevelopmental outcomes and standardized dosing/administration protocols.
Future Directions: Large pragmatic multicenter RCTs with standardized dosing/administration, stratification by BPD risk, and long-term neurodevelopmental and safety outcomes; implementation studies in diverse care settings.