Daily Ards Research Analysis
Across neonatal and adult critical care, three papers advance respiratory management: a meta-analysis suggests inhaled nitric oxide modestly lowers death or bronchopulmonary dysplasia in preterm infants; a pragmatic UK RCT protocol (SINFONIA) will test whether sugammadex reduces postoperative pulmonary complications versus neostigmine; and a narrative review synthesizes how bedside electrical impedance tomography can personalize weaning and positioning in ventilated ICU patients.
Summary
Across neonatal and adult critical care, three papers advance respiratory management: a meta-analysis suggests inhaled nitric oxide modestly lowers death or bronchopulmonary dysplasia in preterm infants; a pragmatic UK RCT protocol (SINFONIA) will test whether sugammadex reduces postoperative pulmonary complications versus neostigmine; and a narrative review synthesizes how bedside electrical impedance tomography can personalize weaning and positioning in ventilated ICU patients.
Research Themes
- Neonatal respiratory therapy and outcomes (iNO in preterm infants)
- Perioperative pulmonary complication prevention (sugammadex vs neostigmine)
- Bedside functional lung imaging for personalized ventilation (EIT)
Selected Articles
1. Inhaled nitric oxide in preterm infants with respiratory disease: a systematic review and meta-analysis.
This meta-analysis of 31 trials in preterm infants suggests inhaled nitric oxide modestly reduces the composite of death or bronchopulmonary dysplasia and lowers BPD in randomized subgroups, with improved oxygenation indices in limited studies. No clear effects on other morbidities were observed, and long-term respiratory/neurodevelopmental outcomes remain unclear.
Impact: Provides an updated quantitative synthesis indicating potential benefit of iNO in a population where routine use has been controversial, informing neonatal respiratory care and future trial design.
Clinical Implications: Clinicians may consider iNO as an adjunct in select preterm infants at risk of BPD, while balancing the modest effect size and lack of long-term outcome data; systematic follow-up and eligibility criteria should be refined.
Key Findings
- Across 31 trials, iNO reduced death or BPD (RR 0.94, 95% CI 0.88–0.99; 6 studies; 1954 infants).
- In RCT subgroups, iNO reduced BPD (RR 0.91, 95% CI 0.84–0.99; 8 studies; 2196 infants).
- Oxygenation improved in limited studies (oxygenation index SMD −0.62, 95% CI −0.81 to −0.43; 2 studies; 441 infants).
- No clear effect on other morbidities or adverse events; long-term outcomes remain unknown.
Methodological Strengths
- Inclusion of randomized and cohort studies with predefined primary outcomes
- Multiple databases searched up to May 2025 with subgroup analyses
Limitations
- Heterogeneity in study designs and iNO indications/dosing
- Limited data on long-term respiratory and neurodevelopmental outcomes and few studies contributing to oxygenation endpoints
Future Directions: Large, well-stratified RCTs in extremely low birth weight infants with standardized iNO protocols and long-term follow-up are needed to confirm efficacy and safety.
2. Sugammadex or Neostigmine for prevention of post-operative pulmonary complications after major abdominal or thoracic surgery: study protocol for the SINFONIA (Sugammadex for preventioN oF pOst-operative pulmonary complIcAtions) randomised controlled superiority trial.
SINFONIA is a pragmatic, multicentre, open-label RCT protocol comparing sugammadex versus neostigmine in 2500 older adults undergoing major abdominal or thoracic surgery, with DAH-30 as the primary endpoint and key secondary endpoints including PPCs, quality of life, and 180-day mortality. An embedded observational study will quantify allergic sensitization after sugammadex exposure.
Impact: Addresses a high-burden perioperative problem with a patient-centred primary outcome and cost-effectiveness assessment, potentially shaping anaesthetic reversal practices.
Clinical Implications: If sugammadex improves DAH-30 and reduces PPCs without excessive allergic sensitization, it could become the preferred reversal agent in high-risk surgical populations.
Key Findings
- Pragmatic, multicentre, open-label RCT randomizing 2500 patients ≥50 years after major abdominal or non-cardiac thoracic surgery.
- Primary endpoint: days alive and out of hospital at 30 days (DAH-30); secondary endpoints include PPC incidence, quality of life, and mortality up to 180 days.
- Embedded observational study to measure allergic sensitization after sugammadex exposure.
- Trial registered on ISRCTN (15109717) before recruitment.
Methodological Strengths
- Large pragmatic design with patient-centred primary outcome (DAH-30)
- Prospective registration and multicentre UK network with embedded safety evaluation
Limitations
- Open-label design may introduce performance bias
- Protocol paper without outcomes; real-world practice variability could confound effects
Future Directions: Completion and reporting of the trial will clarify comparative effectiveness, safety (allergic sensitization), and cost-effectiveness; subgroup analyses may identify populations with greatest benefit.
3. Lung electrical impedance tomography during positioning, weaning and chest physiotherapy in mechanically ventilated critically ill patients: a narrative review.
This narrative review synthesizes EIT applications beyond PEEP titration, showing dorsal ventilation benefits in prone positioning, EIT-derived indices that can predict SBT failure, and frequent pendelluft during weaning linked to worse outcomes. It highlights gaps: heterogeneous responses, moderate predictive performance, and a lack of randomized evidence for chest physiotherapy or alternative positions.
Impact: It operationalizes EIT as a bedside tool to personalize ventilation and weaning, consolidating metrics clinicians can monitor while outlining research priorities to link EIT to outcomes.
Clinical Implications: EIT can inform positioning strategies and identify patients at risk of weaning failure via indices like global inhomogeneity and pendelluft, supporting individualized ventilatory management while awaiting outcome-driven trials.
Key Findings
- Prone positioning enhances dorsal ventilation and preserves perfusion compared with supine, though responses are heterogeneous.
- EIT-derived indices (global inhomogeneity, end-expiratory lung impedance, ventral–dorsal impedance differences, temporal skew) predict SBT failure in some observational studies.
- Pendelluft occurs frequently during weaning, is associated with poorer outcomes, but has only moderate predictive performance for SBT failure.
- RCTs comparing SBT techniques showed no differences in EIT indices; effects of other positions and chest physiotherapy remain under-studied.
Methodological Strengths
- Integrates physiologic imaging concepts with practical ICU applications across positioning, weaning, and physiotherapy
- Highlights unique EIT capabilities (e.g., pendelluft detection) unavailable by other bedside tools
Limitations
- Narrative (non-systematic) review with potential selection bias
- Limited randomized evidence linking EIT-guided strategies to improved clinical outcomes
Future Directions: Conduct prospective trials integrating EIT with measures of lung aeration and patient effort to test outcome benefits of EIT-guided weaning, positioning (including prone), and physiotherapy.