Daily Ards Research Analysis
Among ARDS-related studies, a multicenter cohort suggests empirical antifungal therapy in influenza-associated ARDS lowers IAPA incidence without improving short-term survival. A large MIMIC-IV analysis shows the Gustave Roussy immune score enhances mortality risk prediction in ARDS, while an esophagectomy series highlights anastomotic leakage and ARDS as major drivers of postoperative deaths.
Summary
Among ARDS-related studies, a multicenter cohort suggests empirical antifungal therapy in influenza-associated ARDS lowers IAPA incidence without improving short-term survival. A large MIMIC-IV analysis shows the Gustave Roussy immune score enhances mortality risk prediction in ARDS, while an esophagectomy series highlights anastomotic leakage and ARDS as major drivers of postoperative deaths.
Research Themes
- Empirical antifungal strategies in viral ARDS
- Immune-metabolic prognostic scoring for ARDS
- Postoperative complications (anastomotic leak and ARDS) after esophagectomy
Selected Articles
1. Empirical antifungal treatment of critically ill patients with influenza-associated acute respiratory distress syndrome: A propensity score weighted observational study.
In a multicenter cohort of influenza-associated ARDS, empirical antifungal therapy (mostly posaconazole) significantly reduced 30-day IAPA incidence (7.7% vs 20.4%; sHR 0.21) but did not improve 30-day ICU survival. Findings support early fungal risk mitigation while underscoring the need for randomized trials to evaluate efficacy, safety, and survival impact.
Impact: This study provides actionable evidence that empiric antifungal therapy can prevent IAPA in influenza ARDS, quantifying effect size with propensity weighting in a multicenter setting.
Clinical Implications: Consider early fungal surveillance and targeted empiric antifungal therapy in high-risk influenza ARDS settings with substantial IAPA prevalence, alongside stewardship and adverse event monitoring; routine use should await RCT confirmation.
Key Findings
- Empirical antifungal therapy was given to 35% of patients (94% posaconazole).
- 30-day IAPA incidence was lower with empirical treatment (7.7%) versus no treatment (20.4%; p=0.002).
- Sub-distributional hazard ratio for IAPA with empirical therapy was 0.21 (95% CI 0.10–0.92; p=0.045).
- No significant difference in 30-day ICU survival between groups.
- IAPA typically occurred early (median 2 days after ICU admission).
Methodological Strengths
- Multicenter, consecutive ICU cohort with predefined inclusion window.
- Propensity score weighting to mitigate baseline imbalances.
- Standardized IAPA classification using FUNDICU consensus criteria.
Limitations
- Observational design with potential residual confounding and indication bias.
- Empiric regimen was predominantly posaconazole, limiting generalizability across antifungals.
- No observed survival benefit; adverse effects and resistance were not detailed.
Future Directions: Conduct adequately powered, registered RCTs to test empiric antifungal strategies stratified by IAPA risk, with safety, resistance, and patient-centered outcomes including survival and organ support.
BACKGROUND: Influenza-associated pulmonary aspergillosis (IAPA) is a significant fungal complication in patients with influenza-induced acute-respiratory-distress-syndrome (ARDS). The impact of empirical antifungal treatment on IAPA incidence and outcomes remains unclear. METHODS: In this observational multicenter study (9 treatment centers), we included all consecutive patients admitted to intensive care units (ICUs) with influenza-associated ARDS between September 1, 2016, and March 1, 2025. We compared patients receiving empirical antifungal treatment with those who did not, focusing on 30-day IAPA incidence (primary outcome) and survival (secondary outcome). Propensity score weighting was used to account for baseline characteristic imbalances. IAPA cases were classified based on the Fungal-Infections-in-Adult-Patients-in-ICU (FUNDICU) consensus criteria. RESULTS: We included 172 patients, 61 (35%) of whom received empirical antifungal therapy (94% posaconazole). IAPA was diagnosed in 24 cases, with a median onset of 2 days after ICU admission. Of these, 20 occurred in the non-treatment group and 4 in the empirical treatment group. The 30-day IAPA incidence was 7.7% in the treatment group and 20.4% in the non-treatment group (p=0.002). The sub-distributional hazard ratio (sHR) for IAPA incidence in the empirical treatment group compared to the non-treatment group was 0.21 (95% CI 0.10-0.92, p=0.045). However, there was no significant difference in 30-day ICU survival. CONCLUSION: In ICU patients with influenza ARDS, empirical antifungal treatment was associated with significantly reduced IAPA incidence, but this did not translate into improved survival. Randomized controlled trials are warranted to evaluate the efficacy and safety of patients' specific empirical antifungal treatment with regard to IAPA incidence and outcomes.
2. Association of Gustave Roussy immune score and the risk of in-hospital mortality in patients with acute respiratory distress syndrome: A retrospective cohort study from MIMIC-IV database.
Using 1,238 ARDS cases from MIMIC-IV, higher GRIm-s (albumin, NLR, LDH) was associated with increased in-hospital mortality and outperformed NLR. Adding GRIm-s improved the discriminative performance of SOFA, SAPS II, and CURB-65 for mortality prediction.
Impact: Repurposes a simple immune-metabolic score for ARDS and demonstrates additive prognostic value beyond widely used ICU scores.
Clinical Implications: GRIm-s may aid early risk stratification and inform triage and monitoring intensity in ARDS, but requires external validation and impact assessment before integration into protocols.
Key Findings
- Among 1,238 ARDS patients, in-hospital mortality was 34.25%.
- Higher GRIm-s was independently associated with increased in-hospital mortality.
- GRIm-s outperformed NLR and significantly improved the AUC of SOFA, SAPS II, and CURB-65.
Methodological Strengths
- Large ICU database cohort with predefined variables enabling multivariable adjustment.
- Robust discrimination analyses (ROC/AUC) and comparison with established scores.
Limitations
- Single-center retrospective database (MIMIC-IV) without external validation.
- Potential residual confounding; calibration and clinical utility analyses were not detailed.
Future Directions: Externally validate GRIm-s-based models across diverse ARDS populations, assess calibration and net clinical benefit, and test decision-impact in prospective studies.
BACKGROUND: There has been a lack of studies to describe the relationship between Gustave Roussy immune score (GRIm-s) and the risk of in-hospital mortality in patients with acute respiratory distress syndrome (ARDS) so far. This study aimed to investigate the relationship between GRIm-s and hospital mortality in patients with ARDS and to compare the predictive ability of GRIm-s with common scoring systems for predicting mortality risk based on MIMIC-IV database. METHODS: GRIm-s was calculated based on albumin, neutrophil-to-lymphocyte ratio (NLR) and lactate dehydrogenase (LDH). The univariate and multivariate logistic regression analysis were used to explore association between GRIm-s and in-hospital mortality, with odds ratio (OR) and 95 % confidence intervals (CIs). The receiver operator characteristic (ROC) analysis was performed to verity the predictive power and the enhancement the predictive power of GRIm-s to NLR and sequential organ failure assessment (SOFA), simplified acute physiology score II (SAPSII) and confusion, uremia, respiratory rate, blood pressure, age ≥65 years (CURB-65), with area under the curve (AUC) and 95 %CI. RESULTS: Totally 1238 eligible ARDS patients were included with the in-hospital mortality was 34.25 %. High GRIm-s was associated with higher risk of in-hospital mortality. The predictive value of GRIm-s was superior to NLR. GRIm-s can significantly improve the predictive power of a single score prediction system including SOFA, SAPSII, and CURB-65. CONCLUSIONS: High GRIm-s was associated with high risk of in-hospital mortality in ARDS patients. GRIm-s has a good predictive ability for the prognosis of ARDS patients.
3. Analysis of in-hospital mortality following transthoracic esophagectomy for cancer.
Across 3,899 esophagectomies, in-hospital mortality was 3.1%; anastomotic leakage was frequent (53.7%) and the leading cause of death (36.4%), followed by ARDS (12.4%). Most care was adjudicated adequate, but delayed recognition/treatment of anastomotic leakage explained most non-adequate postoperative management.
Impact: Identifies modifiable postoperative processes (early detection and management of anastomotic leakage) and underscores ARDS as a significant contributor to mortality after esophagectomy.
Clinical Implications: Implement standardized pathways for early anastomotic leak detection (e.g., protocols, biomarkers, imaging) and aggressive source control to mitigate sepsis and ARDS risk; coordinate surgical–ICU teams to optimize lung-protective strategies when ARDS develops.
Key Findings
- Among 3,899 esophagectomies, 121 patients died in-hospital (3.1%).
- Anastomotic leakage occurred in 53.7% and was the leading cause of death (36.4%).
- ARDS accounted for 12.4% of deaths after esophagectomy.
- Most preoperative selection and intraoperative management were adequate; postoperative non-adequate management (6.6%) often involved delayed recognition/treatment of leakage.
- Median time to death was 32 days post-surgery.
Methodological Strengths
- Multicenter analysis using prospective institutional databases with standardized data elements.
- Structured retrospective adjudication of care adequacy across perioperative phases.
Limitations
- Descriptive analysis limited to fatal cases without a comparator cohort.
- Retrospective adjudication may be subject to reviewer bias; generalizability limited to expert centers.
Future Directions: Prospective implementation studies testing enhanced anastomotic leak surveillance and rapid response bundles to reduce postoperative ARDS and mortality.
In-hospital mortality following esophagectomy for cancer has markedly decreased over the last few decades, with reported death rates below 5% considered a benchmark for quality of care. Although large registry studies have focused on reaching this benchmark, little is known about the underlying cause of death and the possibility of preventing a lethal outcome. The aim of this multicenter study was to perform an in-depth analysis of in-hospital mortality following esophagectomy for cancer. Data were obtained from four European esophageal cancer centers analyzing their prospective databases between January 2010 and June 2020. All patients with an in-hospital lethal postoperative course (Clavien-Dindo V) following elective transthoracic esophagectomy were included. Data collection comprised baseline characteristics, preoperative comorbidities, surgical procedures, postoperative complications, and their management. In each participating center, cases were retrospectively assessed for (1) the selection of patients for esophagectomy based on their individual comorbidities, (2) intraoperative, and (3) postoperative complications and their management to finally classify the management of each section as adequate, non-adequate, or undetermined. One hundred and twenty-one out of 3899 patients died following esophagectomy, amounting to an in-hospital mortality rate of 3.1%. Patients deceased on a median of 32 days after surgery (IQR: 18-60). Following surgery, a total of 294 major complications were identified in the 121 patients (mean 2.4 ± 1.2) with anastomotic leakage (AL) reported most often in 65 patients (53.7%). AL was considered as leading cause of death in 44 patients (36.4%) followed by acute respiratory distress syndrome (ARDS) in 15 patients (12.4%). Assessment of preoperative patient selection revealed a non-adequate workup in only two patients (1.4%). During surgery, six patients (4.6%) suffered complications, which were deemed adequately treated in retrospective assessment. In eight patients (6.6%), postoperative management was deemed non-adequate; in seven of eight cases, recognition and initiation of treatment for AL were considered delayed. Despite technical advances, AL remains the leading cause of death following esophagectomy, contributing to a significantly prolonged clinical course and lethal outcome. In contrast to other published series, assessment of this homogenous patient cohort in expert centers revealed only a low rate of preventable mortality with respect to the preoperative patient selection and postoperative complication management. However, modification of AL management might be considered to reduce the overall death rate.