Daily Ards Research Analysis
A large multicenter randomized clinical trial (SESAR) shows inhaled sevoflurane sedation results in fewer ventilator‑free days and lower 90‑day survival than intravenous propofol in adults with ARDS. Pediatric data reveal that right atrial dysfunction is common within 24 hours of PARDS onset and correlates with pulmonary hypertension and RV dysfunction. In neonates with early respiratory distress, delivering bedside nCPAP in the delivery room shortens CPAP duration and hospital stay while preven
Summary
A large multicenter randomized clinical trial (SESAR) shows inhaled sevoflurane sedation results in fewer ventilator‑free days and lower 90‑day survival than intravenous propofol in adults with ARDS. Pediatric data reveal that right atrial dysfunction is common within 24 hours of PARDS onset and correlates with pulmonary hypertension and RV dysfunction. In neonates with early respiratory distress, delivering bedside nCPAP in the delivery room shortens CPAP duration and hospital stay while preventing many NICU transfers.
Research Themes
- Sedation strategies and outcomes in ARDS
- Cardiopulmonary interactions and right heart function in PARDS
- Neonatal respiratory support and care pathway optimization
Selected Articles
1. Inhaled Sedation in Acute Respiratory Distress Syndrome: The SESAR Randomized Clinical Trial.
Among 687 adults with moderate-to-severe ARDS, sevoflurane sedation resulted in fewer ventilator-free days through day 28 (median difference −2.1; 95% CI, −3.6 to −0.7) and lower 90-day survival (47.1% vs 55.7%; HR, 1.31; 95% CI, 1.05–1.62) compared with propofol. Sevoflurane also increased 7-day mortality (19.4% vs 13.5%; RR, 1.44) and reduced ICU-free days.
Impact: This large, assessor-blinded RCT provides definitive comparative evidence that challenges the use of inhaled sevoflurane for ARDS sedation, with clinically important harms.
Clinical Implications: Propofol should be preferred over sevoflurane for sedation in moderate-to-severe ARDS. Centers using volatile sedation should re-evaluate protocols and monitor outcomes closely.
Key Findings
- Sevoflurane led to fewer ventilator-free days through day 28 (median difference −2.1; 95% CI, −3.6 to −0.7) versus propofol.
- Ninety-day survival was lower with sevoflurane (47.1% vs 55.7%; hazard ratio 1.31; 95% CI, 1.05–1.62).
- Sevoflurane increased 7-day mortality (19.4% vs 13.5%; relative risk 1.44; 95% CI, 1.02–2.03) and reduced ICU-free days.
Methodological Strengths
- Phase 3 multicenter randomized, assessor-blinded design with protocolized sedation strategies
- Prospective registration (NCT04235608) with clinically meaningful endpoints and 90-day follow-up
Limitations
- Open-label to treating clinicians, which may influence co-interventions
- Inhaled sedation logistics and device availability may limit generalizability
Future Directions: Mechanistic analyses to understand why volatile sedation worsens outcomes, subgroup analyses (e.g., etiologies of ARDS), and trials of alternative sedation strategies.
IMPORTANCE: Whether the use of inhaled or intravenous sedation affects outcomes differentially in mechanically ventilated adults with acute respiratory distress syndrome (ARDS) is unknown. OBJECTIVE: To determine the efficacy and safety of inhaled sevoflurane compared with intravenous propofol for sedation in patients with ARDS. DESIGN, SETTING, AND PARTICIPANTS: Phase 3 randomized, open-label, assessor-blinded clinical trial conducted from May 2020 to October 2023 with 90-day follow-up. Adults with early moderate to severe ARDS (defined by a ratio of Pao2 to the fraction of inspired oxygen of <150 mm Hg with a positive end-expiratory pressure of ≥8 cm H2O) were enrolled in 37 French intensive care units. INTERVENTIONS: Patients were randomized to a strategy of inhaled sedation with sevoflurane (intervention group) or to a strategy of intravenous sedation with propofol (control group) for up to 7 days. MAIN OUTCOMES AND MEASURES: The primary end point was the number of ventilator-free days at 28 days; the key secondary end point was 90-day survival.
2. Portable Bedside Nasal Continuous Positive Airway Pressure in the Delivery Room Reduces Length of Stay.
In 410 infants ≥35 weeks’ gestation with early respiratory distress, delivery-room bedside nCPAP shortened CPAP duration (4.4 vs 7.3 hours; p<0.001) and hospital length of stay (7.2 vs 20.2 hours; p<0.001) compared to NICU nCPAP. Notably, 72% avoided NICU transfer, preventing mother–infant separation.
Impact: Demonstrates system-level benefits of delivering respiratory support in the delivery room, with meaningful reductions in treatment time, hospital stay, and NICU transfers.
Clinical Implications: Implementing bedside nCPAP in delivery rooms for late-preterm/term infants with early respiratory distress can reduce NICU utilization and promote family-centered care.
Key Findings
- Bedside nCPAP shortened CPAP treatment duration (4.4 vs 7.3 hours; p<0.001).
- Hospital length of stay was reduced (7.2 vs 20.2 hours; p<0.001) with bedside nCPAP.
- NICU transfer was avoided in 72% of infants treated with bedside nCPAP.
Methodological Strengths
- Relatively large single-center cohort over a 9-year period
- Clear, clinically relevant outcomes (treatment duration, length of stay, transfer rates)
Limitations
- Retrospective design with potential confounding and selection bias
- Single-center experience may limit generalizability; lack of randomized allocation
Future Directions: Prospective multicenter implementation trials assessing safety, cost-effectiveness, and long-term neurodevelopmental outcomes.
AIM: Portable bedside nasal continuous positive airway pressure in the delivery room (bedside nCPAP) allows the newborn infant to remain with the mother in the delivery room while receiving nCPAP. This study aimed to evaluate the duration of nCPAP treatment and length of stay (LOS) in newborn infants with respiratory distress receiving bedside nCPAP compared to nCPAP in the neonatal intensive care unit (NICU). METHODS: This retrospective cohort study comprised newborn infants born at ≥ 35 weeks of gestation requiring nCPAP treatment within the first 2 h of life due to respiratory distress. Data were collected from October 2011 to October 2020 at Aalborg University Hospital, Denmark. RESULTS: Bedside nCPAP was administered to 225 newborn infants, while 185 newborn infants received nCPAP at the NICU. Newborn infants receiving bedside nCPAP had a shorter duration of CPAP treatment (4.4 vs. 7.3 h, p < 0.001) and LOS (7.2 vs. 20.2 h, p < 0.001). Transfer to the NICU was avoided in 72% of newborn infants receiving bedside nCPAP. CONCLUSION: Bedside nCPAP reduces the duration of CPAP treatment and LOS compared to nCPAP in the NICU. About 72% of newborn infants receiving bedside nCPAP avoided transfer to the NICU and avoided separation from their mothers.
3. Right Atrial Dysfunction Is Prevalent in Pediatric Acute Respiratory Distress Syndrome and Reflects Pulmonary Hypertension and Right Ventricular Dysfunction.
In a single-center cohort of 92 PARDS patients vs 55 controls, 49% had right atrial dysfunction by predefined thresholds. Maximal reservoir-phase RA strain was reduced (40.2% vs 53.7%; p<0.001) and was lower in those with pulmonary hypertension (31.7% vs 40.5%; p<0.05). RA function correlated with RV systolic function and BNP.
Impact: Introduces right atrial strain as an early, sensitive marker of cardiopulmonary interaction in PARDS, linking it to pulmonary hypertension and RV dysfunction.
Clinical Implications: Early RA strain assessment may help identify PARDS patients at risk of pulmonary hypertension and RV dysfunction, informing monitoring and cardiopulmonary management.
Key Findings
- RA dysfunction was present in 49% of PARDS patients using thresholds >2 SDs from controls.
- Maximal reservoir-phase RA strain was reduced vs controls (40.2% vs 53.7%; p<0.001).
- RA strain was lower with pulmonary hypertension (31.7% vs 40.5%; p<0.05) and correlated with RV systolic function and BNP.
Methodological Strengths
- Use of speckle-tracking echocardiography with predefined thresholds
- Inclusion of a contemporaneous healthy control group
Limitations
- Retrospective, single-center design limits causal inference and generalizability
- Outcomes beyond early echocardiographic measures were not assessed
Future Directions: Prospective multicenter studies to validate RA strain thresholds, track trajectories, and link to hard outcomes (e.g., mortality, ventilator duration).
IMPORTANCE: Right atrial (RA) dysfunction is associated with worse outcomes in some populations with pulmonary hypertension or respiratory failure but the prevalence and correlates of RA dysfunction in pediatric acute respiratory distress syndrome (PARDS) are unknown. OBJECTIVES: The aim of this study was to evaluate RA function by characterizing the prevalence and pattern of RA dysfunction within the first 24 hours of PARDS onset. We hypothesized that RA dysfunction would be common and correlate with the presence of pulmonary hypertension and right ventricular (RV) systolic dysfunction. DESIGN, SETTING, AND PARTICIPANTS: Retrospective, single-center cohort study at a tertiary care PICU of children (< 18 yr) with a clinically obtained echocardiogram within 24 hours following PARDS diagnosis and healthy controls without cardiopulmonary disease. MAIN OUTCOMES AND MEASURES: Echocardiograms were evaluated for conventional and speckle-tracking (or strain) echocardiographic measures of RA and RV systolic function. Nonparametric summary statistics, comparisons, and correlational analyses were completed. RESULTS: Ninety-two PARDS patients and 55 controls were included. Using a priori thresholds (> 2 sds of control values), 49% (n = 45) of PARDS patients demonstrated RA dysfunction in at least one RA functional metric. The maximal RA strain during the reservoir phase was reduced in PARDS compared with controls (median 40.2% vs. 53.7%; p < 0.001). Patients with echocardiographic evidence of pulmonary hypertension had lower maximal RA strain during the reservoir phase (31.7%) compared with patients without (40.5%; p < 0.05). Patients with higher brain-type natriuretic peptide plasma concentrations had worse RA function. RA function significantly correlated with conventional and strain measures of RV systolic function. CONCLUSIONS AND RELEVANCE: RA dysfunction is common within the first 24 hours of PARDS onset. RA dysfunction during the reservoir phase is associated with pulmonary hypertension and RV systolic dysfunction. Future studies investigating trajectories of RA function and their association with outcomes in PARDS patients are needed.