Daily Ards Research Analysis

BACKGROUND: Inhaled nitric oxide (iNO) has been shown to be effective in term and near-term infants with specific respiratory diseases. The effects and potential risks of iNO differ substantially in preterm infants with special pathophysiology. Specific study in this population is necessary. PURPOSE: To assess the short-term and long-term effects of iNO in preterm infants with respiratory diseases such as respiratory failure and respiratory distress syndrome. METHODS: We conducted a meta-analysis of randomized controlled trials and cohort studies comparing iNO with placebo or blank control in preterm infants with respiratory diseases.Databases including PubMed, the Cochrane Library, Scopus, and Web of Science were searched from their inception until May 2025. The primary outcomes were death before discharge, death at 36 weeks' postmenstrual age (PMA), bronchopulmonary dysplasia (BPD) and death or BPD. RESULTS: Thirty-one trials met the inclusion criteria. iNO reduced the incidence of death or BPD (risk ratio [RR] 0.94, 95% confidence interval [CI] 0.88 to 0.99, 6 studies, 1954 infants) and BPD in the RCT subgroup (RR 0.91, 95% CI 0.84 to 0.99, 8 studies, 2196 infants).Increases of oxygenation index (Standardized mean difference (SMD)  - 0.62, 95% CI - 0.81 to - 0.43, 2 studies, 441 infants) and Partial pressure of oxygen (PaO CONCLUSIONS: iNO was associated with a reduced risk of death or BPD and a probably reduction of BPD. There was no effect on other morbidities or adverse events. Data on long-term respiratory and neurodevelopment outcomes are critically needed to further evaluate NO's efficacy in preterm infants, particularly Extremely low birth weight infants.

BACKGROUND: Post-operative pulmonary complications (PPCs) are an important source of morbidity and mortality after major abdominal and thoracic surgery. The use of neuromuscular blocking drugs in general anaesthesia is an important risk factor for PPCs. The incomplete reversal of this neuromuscular blockade at the end of surgery leads to residual weakness of respiratory muscles and predisposes to aspiration of pharyngeal contents, hypoventilation, and thus to PPCs such as atelectasis and pneumonia. Two reversal drugs for neuromuscular blocking agents are available: neostigmine and sugammadex. Compared with neostigmine, sugammadex use results in more rapid reversal of neuromuscular blockade, and small clinical efficacy studies have suggested an associated lower incidence of PPCs. The comparative clinical effectiveness of the two drugs in reducing length of hospital stay or mortality is uncertain. Moreover, a potential safety concern with sugammadex is the relatively high incidence of life-threatening allergic reactions in countries where this drug has been widely used over the last decade. METHODS: SINFONIA is a pragmatic, randomised, open-label, parallel group, superiority trial with an internal pilot which aims to compare the clinical and cost effectiveness of the two available drugs for reversal of neuromuscular blockade, sugammadex and neostigmine, in patients aged 50 years or older undergoing major abdominal or non-cardiac thoracic surgery. The trial will randomise 2500 patients from approximately 40 centres in the UK. The primary outcome will be days alive and out of hospital at 30 days (DAH-30), with key secondary outcomes of PPC incidence, quality of life, and mortality up to 180 days. An embedded observational study will investigate the rate of allergic sensitisation following exposure to sugammadex. DISCUSSION: The SINFONIA trial addresses an important question for anaesthetists and for patients undergoing major abdominal and thoracic surgery. The choice of reversal agent for neuromuscular blockade between sugammadex and neostigmine is currently largely a matter of anaesthetist preference. A growing body of evidence suggests that sugammadex may reduce the incidence of post-operative pulmonary complications relative to neostigmine. This pragmatic clinical effectiveness trial will provide robust evidence as to the effects of the two drugs on patient-centred outcomes such as DAH-30, as well as on cost effectiveness and the incidence of allergic sensitisation. TRIAL REGISTRATION: The trial was registered on the ISRCTN database ( https://www.isrctn.com ) prior to opening to recruitment (registration no 15109717).

BACKGROUND: Electrical impedance tomography (EIT) is a non-invasive, radiation free, lung imaging technique of lung ventilation with a low spatial but a high temporal resolution available at the bedside. Lung perfusion, and hence ventilation-to-perfusion ratios, can also be assessed with EIT. Most of the EIT studies in intensive care units (ICU) are dedicated to positive end expiratory pressure selection in patients with acute respiratory distress syndrome receiving invasive mechanical ventilation. This narrative review explores the use of EIT during change in body position, weaning and chest physiotherapy in adult intubated ICU patients. MAIN BODY: EIT findings confirm a better ventilation and the persistence of lung perfusion in the dorsal lung regions in prone as compared to supine position. However, the response of the ventilation distribution to prone is heterogeneous across patients. For the weaning, global inhomogeneity index, end-expiratory lung impedance, absolute ventral-to-dorsal difference of the change in lung impedance and temporal skew of aeration had a good performance to predict spontaneous breathing trial (SBT) failure in some observational studies. Pendelluft that measures the risk of overstretching in dependent lung regions can only be assessed with EIT. It occurs frequently during weaning and is associated with poor patient outcome. However, its performance to predict SBT failure was moderate. Randomized controlled trials comparing SBT techniques did not find a difference in EIT indexes. The effects of other body positions and chest physiotherapy have been less investigated with EIT. CONCLUSION: EIT offers the possibility to monitor lung ventilation and perfusion at the bedside and hence to deliver a personalized ventilatory management. Further designed EIT studies coupled with measurement of lung aeration and patient breathing effort are warranted during weaning to check if the technique is useful to clinical outcome. The same is true regarding the optimal use of body position including prone, and of chest physiotherapy in ICU patients.