Daily Ards Research Analysis

OBJECTIVE: To evaluate the ability of the criteria "At-risk for PARDS" to identify patients with acute respiratory infection hospitalized outside the pediatric intensive care unit (PICU) who are at high risk of developing pediatric acute respiratory distress syndrome (PARDS) and describe the timing for the identification. The secondary aim was to explore clinical outcome differences between patients with and without risk for PARDS. METHODS: We conducted an observational prospective cohort study from June to August 2019. Children under 15 years old hospitalized in a pediatric ward due to an acute respiratory tract infection were included. MAIN RESULTS: A total of 177 patients with a median age of 12 (IQR 5; 25) months were included. Registered data included demographics, respiratory support, at-risk for PARDS and PARDS diagnosis according to PALICC consensus. PICU admission, hospital length of stay (LOS) and intrahospital mortality were the outcomes compared between children with and without risk for PARDS. The at-risk criteria, within 48 h of admission, showed an overall accuracy, sensitivity, and specificity of 82.5%, 100%, and 81.9% respectively, to detect patients that progress to PARDS. The at-risk for PARDS criteria was met in 37 cases (20.9%), which also were more likely to developed PARDS (6/37 [16.2%] vs. 0/140 [0%]; p < 0.001), had higher admission to PICU (16/37 [43.2%] vs. 0 [0%]; p < 0.001) and hospital LOS (7 [6; 12] days vs. 5 [3-6] days; p < 0.001), compared with the group without at-risk for PARDS. CONCLUSIONS: The at-risk for PARDS criteria within 48 h of admission demonstrated an adequate ability to identify patients with a respiratory infection at increased risk of developing PARDS. Patients who met the at-risk for PARDS criteria before PICU admission presented with unfavorable clinical outcomes compared with those without risk.

OBJECTIVES: To evaluate the effects of positive end-expiratory pressure (PEEP) on pulse pressure variation (PPV) in patients with moderate/severe acute respiratory distress syndrome (ARDS). DESIGN: Prospective interventional self-controlled study. SETTING: University Hospital of Larissa. PATIENTS: ARDS patients admitted intubated in the ICU (from August 2020 to March 2022). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: PPV and inferior vena cava (IVC) respiratory variability were evaluated at two PEEP levels (first value mainly based on PEEP/Fio2 and second value based on respiratory system compliance). Additionally, respiratory mechanics, hemodynamics, and echocardiographic indices assessing right ventricular (RV) size (RV end-diastolic area/left ventricular end-diastolic area [RVEDA/LVEDA]), RV systolic function, and RV afterload (pulmonary artery systolic pressure [PASP] and PASP/left ventricular outflow tract velocity time integral [PASP/VTILVOT]) were recorded. Ninety-five patients were evaluated. PPV decreased after PEEP reduction (11.7 ± 0.2 to 7.9% ± 0.2%), whereas IVC respiratory variability increased (9.1 ± 0.9 to 14.6% ± 0.1%) and central venous pressure decreased (all p < 0.0001). RV afterload indices decreased (p < 0.0001), simultaneously with RV size (< 0.0001) and systolic function indices' improvements (< 0.05); shock warranted less noradrenaline doses. The change in PPV correlated significantly to respiratory variability in IVC diameter distensibility (p < 0.0001) and moderately to changes in RV size and systolic function (change in RVEDA/change in LVEDA, change in tricuspid annular plane systolic excursion); RV afterload (change in PASP [ΔPASP], ΔPASP/VTILVOT); and change in Paco2 (all p < 0.05). CONCLUSIONS: PPV alteration with PEEP decrease, associated with IVC distensibility increases, may indicate the presence of RV dysfunction and increased pulmonary vascular resistances. Whether the patients are in need for fluid loading, fluid responsiveness assessment may be further warranted.

Soluble Delta-like ligand 1 (sDLL1) has demonstrated promising results as an early biomarker of bacterial sepsis, but its role in viral infections remains unclear. This study investigated the association between sDLL1 levels and clinical outcomes in patients hospitalized for COVID-19. In this secondary analysis of a single-center prospective observational trial, we measured plasma sDLL1 levels in 46 patients admitted with PCR-confirmed SARS-CoV2 infection between December 2020 and April 2021. Patients were divided into a high-sDLL1 group, upper quartile of patients with the highest measured sDLL1 levels, and low-sDLL1 group, lower three quartiles of patients. Clinical outcomes, including secondary infections, organ dysfunction, and mortality, were compared between groups. Patients in the high-sDLL1 group (n = 11, 24%) showed higher rates of secondary infections (63% vs. 20%, OR 7, CI 1.6 to 31, p = 0.01) with higher odds of pulmonary secondary infections (46% vs. 11%, OR 6.5, CI 1.3 to 31, p = 0.03). Organ dysfunction was more prevalent in the high-sDLL1-group, indicated by a higher maximal Sequential Organ-Failure Assessment (SOFA) score (median (IQR) 11 (8.5-14) vs. 3 (0.5-8), p < 0.01) as well as higher rates of vasopressor support (64% vs. 26%, OR 5.1, CI 1.2 to 21, p = 0.03) and renal replacement therapy (36% vs. 9%, OR 6.1, CI 1.1 to 3.6, p < 0.05). The high-sDLL1 group also showed increased 90-day mortality (45% vs. 11%, OR 6.5, CI 1.3 to 31, p = 0.03). These findings suggest that high levels of sDLL1 are associated with adverse outcomes in viral sepsis, warranting further investigation in larger, prospective studies.