Daily Ards Research Analysis

BACKGROUND: Although inhaled nitric oxide (iNO) is used as a rescue therapy in patients with acute respiratory distress syndrome (ARDS), its impact on patient-centered outcomes remains uncertain. To address this gap, we conducted a systematic review of randomized controlled trials (RCTs) to test the hypothesis that the addition of iNO to standard care improves survival in adult patients with ARDS. METHODS: We searched PubMed, Embase, Cochrane Library, ClinicalTrials.gov, and WHO ICTRP for RCTs evaluating iNO in adult patients with ARDS through October 28, 2025. The primary outcome was mortality at the longest follow-up. Secondary outcomes included acute kidney injury (AKI), receipt of renal replacement therapy (RRT), duration of mechanical ventilation, length of intensive care unit stay, length of hospital stay, receipt of extracorporeal membrane oxygenation (ECMO), mean pulmonary artery pressure, partial pressure of arterial oxygen/fraction of inspiratory oxygen (PaO RESULTS: We included 11 RCTs comprising 1302 patients. Only one study was of low risk of bias. iNO therapy may result in no difference in mortality at the longest follow-up (relative risk [RR], 1.07; 95% confidence interval [CI], 0.93-1.23; I CONCLUSIONS: Although iNO may improve oxygenation slightly, it may not confer survival or other patient-centered benefits and may increase the need for RRT. High-quality randomized evidence is needed to guide the optimal patient selection for this therapeutic option. TRIAL REGISTRATION: PROSPERO (registration number: CRD42024573383).

BACKGROUND: Acute respiratory distress syndrome (ARDS) is the acute hypoxemic respiratory failure that presents with non-cardiogenic pulmonary opacities. Patients receiving non-invasive respiratory support might present with high transpulmonary pressure, pulmonary strain, and pendelluft, which contribute to the development of patient self-inflicted lung injury (P-SILI). Experimental studies have identified that continuous positive airway pressure (CPAP) is successful in attenuating P-SILI effectors compared to high-flow nasal oxygenation (HFNO). However, it remains uncertain whether this attenuation is associated with a reduction in lung injury and improved clinical outcomes. METHODS: This is a multicenter, randomized, open-label, controlled trial. One hundred and twenty non-intubated patients with established ARDS will be randomly assigned to receive non-invasive respiratory support with either CPAP 12 cmH DISCUSSION: This study will assess the potential role of CPAP in attenuating P-SILI effectors and inflicting less biological lung injury compared to HFNO. This physiologic effect may lead to lower rates of tracheal intubation and mortality. This project will provide new knowledge on the respiratory management of non-intubated ARDS patients, a subject where evidence is lacking. TRIAL REGISTRATION: ClinicalTrials.gov NCT06694311. Registered on 18 November 2024 as HCB/2023/1105.

BACKGROUND: Prone positioning is recommended for patients with acute respiratory distress syndrome not only to improve oxygenation, but also to reduce lung stress, and lower mortality. The association between improved oxygenation during prone position and reduced mortality is still controversial. In previous studies, oxygenation improvement during the first prone positioning cycle was linked to lower intensive care unit (ICU) mortality, especially with prolonged duration. However, physiological data during subsequent cycles were lacking. This study aims to explore the association between ICU mortality and physiological responses to prone positioning-such as arterial oxygenation, dead space, and respiratory mechanics-and to assess how the cumulative time spent in prone or supine positions across all studied cycles influences outcomes. METHODS: International registry including adult patients who underwent prone positioning for acute hypoxemic respiratory failure due to COVID-19. We measured the difference for arterial partial pressure of oxygen to inspired fraction of oxygen ratio (PaO2/FiO2) and ventilatory ratio between baseline supine position and at either the end of cycle of prone position (Delta-PP) or re-supination (Delta-PostPP), focusing on the cycles following the first one. RESULTS: We included 1523 patients from 53 centers. Both Delta-PP and Delta-PostPP for PaO2/FiO2 were significantly higher in ICU survivors than in ICU non-survivors for all the analyzed prone positioning cycles (p ≤ 0.001 for all comparisons). Delta-PP and Delta-PostPP for ventilatory ratio were significantly lower in ICU survivors than in ICU non-survivors for all the analyzed prone positioning cycles (p < 0.05 for all comparisons). No difference in the overall time spent in prone position was found between ICU survivors and non-survivors [61 (38, 84) h vs 58 (32, 85) h, respectively, p = 0.175]. The cumulative length of prone position was associated with ICU mortality only for the second prone positioning cycle [OR (95% CI) 0.986 (0.978, 0.994)]. No significant association was observed between the time spent in supine position and ICU mortality for all the analyzed prone positioning cycles. CONCLUSIONS: ICU survivors consistently demonstrated better oxygenation and more stable ventilatory ratio across studied prone positioning cycles, whereas non-survivors showed worsening oxygenation when returning supine and increased ventilatory ratio. Additionally, extending the duration of prone position beyond the second cycle may not significantly impact mortality.