Daily Ards Research Analysis
Analyzed 5 papers and selected 3 impactful papers.
Summary
A meta-analysis suggests extending prone positioning to at least 24 hours in moderate-to-severe ARDS reduces mortality but increases pressure injuries. A prospective cohort links a rare HIF-1α TT genotype to lower 30-day mortality in COVID-19-related ARDS. A retrospective study indicates that foregoing routine train-of-four monitoring for cisatracurium infusions may reduce drug use and costs, though clinical outcomes were not assessed.
Research Themes
- Ventilatory strategies and positioning in ARDS
- Genetic and hypoxia signaling determinants of ARDS outcomes
- Sedation/paralysis monitoring and resource utilization in ICU care
Selected Articles
1. Extended Prone Positioning in ARDS: A Systematic Review and Meta-Analysis.
This meta-analysis of 10 studies (n=2,412), all in COVID-19-related ARDS, found that extending prone positioning to ≥24 hours was associated with lower mortality compared with 16–24 hours (RR 0.76; 95% CI 0.66–0.86). Pressure injuries increased, and there was no effect on ventilator duration or ICU length of stay.
Impact: Provides quantitative evidence that longer prone sessions may improve survival in ARDS, informing protocol optimization. Registration on PROSPERO enhances credibility and reproducibility.
Clinical Implications: Consider implementing prone sessions ≥24 hours in moderate-to-severe ARDS with robust pressure injury prevention and nursing protocols. Await further RCTs to define optimal duration and patient selection.
Key Findings
- Extended prone positioning (≥24 h) reduced mortality versus 16–24 h (RR 0.76; 95% CI 0.66–0.86).
- Increased risk of pressure injuries with extended prone positioning.
- No significant impact on ventilator duration or ICU length of stay.
- Meta-analysis included 10 studies (n=2,412), predominantly observational and all in COVID-19 ARDS.
Methodological Strengths
- Prospero-registered systematic review and meta-analysis.
- Included randomized and observational evidence with consistent mortality signal.
- Clear comparison of predefined prone duration categories.
Limitations
- Predominantly observational data; residual confounding likely.
- All studies were in COVID-19 ARDS, limiting generalizability to non-COVID ARDS.
- Heterogeneity and protocol differences across studies may influence estimates.
Future Directions: Conduct multicenter RCTs to define optimal prone duration, balance skin injury risks, and assess generalizability beyond COVID-19 ARDS.
BACKGROUND: Prone positioning is a recommended therapy for patients with moderate-to-severe ARDS; however, the optimal duration of this maneuver is still unknown. METHODS: We performed a systematic review and meta-analysis comparing clinical outcomes of extended (≥24 h) versus traditional prone positioning (16-24 h) of adults with moderate-to-severe ARDS receiving invasive mechanical ventilation. RESULTS: Ten studies involving 2,412 subjects met the inclusion criteria, including one randomized controlled trial and 9 observational studies, all with COVID-19-related ARDS. Extended prone positioning was associated with reduced mortality compared with the traditional approach (risk ratio [RR]: 0.76, 95% CI 0.66-0.86, CONCLUSIONS: Extended prone positioning was associated with reduced mortality in ARDS but increased risk of pressure injuries, without impact on ventilator duration or ICU stay. While this strategy appears feasible and potentially beneficial, further randomized trials are warranted to confirm its role in routine practice. TRIAL REGISTRATION: PROSPERO no. CRD42024529311.
2. HIF-1α is Associated with Improved Survival in Acute Respiratory Distress Syndrome due to COVID-19: A Prospective Study.
In a prospective cohort of 297 ICU patients with COVID-19-related ARDS, the HIF-1α TT genotype (2.36%) was associated with reduced needs for mechanical ventilation, vasopressors, and dialysis, and with lower 30-day mortality. APACHE II and SOFA scores were similar across genotypes; PHD2 polymorphisms showed no outcome associations.
Impact: Identifies a potential genetic determinant of ARDS outcomes linked to hypoxia signaling, supporting precision prognostication and mechanistic hypotheses. The rare TT genotype’s strong association warrants validation.
Clinical Implications: Routine genotyping is premature, but HIF-1α variants may inform risk stratification and future targeted therapies modulating hypoxia pathways in ARDS.
Key Findings
- HIF-1α TT genotype frequency was 2.36% and was associated with lower 30-day mortality (P<0.05).
- TT genotype had reduced needs for mechanical ventilation, vasopressors, and dialysis (P<0.05).
- APACHE II and SOFA scores did not differ by genotype; PHD2 polymorphisms showed no association with outcomes.
Methodological Strengths
- Prospective cohort design with predefined ICU outcomes including 30-day mortality.
- Standardized DNA isolation and genotyping across all participants.
- Comparative analysis across genotype groups with clinical severity scores reported.
Limitations
- Very small number of TT genotype subjects limits precision and generalizability.
- Adjustment for confounders and multivariable analyses were not detailed in the abstract.
- Findings derive from COVID-19 ARDS and may not generalize to non-COVID ARDS.
Future Directions: Validate associations in larger, multi-center cohorts with diverse ARDS etiologies and perform mechanistic studies on HIF signaling in hypoxemia.
BACKGROUND: Acute respiratory distress syndrome (ARDS) due to coronovirus disease 2019 (COVID-19) is accompanied by severe hypoxemia and hyperinflammation. Hypoxia-inducible factor (HIF) pathway plays a fundamental role in detecting the hypoxia and developing appropriate responses. AIM: The aim of this study was to evaluate the role of HIF-1α and PHD2 (prolyl hydroxylase domain2) genes in the pathophysiology of severe hypoxemia in COVID-19 patients. METHODS: The study included 297 patients who developed ARDS due to COVID-19 infection and were admitted into the intensive care unit. APACHEII score, SOFA, vasopressor, dialysis and mechanical ventilation need during treatment, and 30-day mortality were recorded. DNA was isolated from the blood samples by the spin colon method with the QIAamp DNA MiniKit (Cat.No. 51106, QIAGEN, Germany). RESULTS: Patients were divided into three groups according to their Hypoxia Inducible Factor-1α (C/T SNP [11549465]) genotypes. The frequencies were 71.13% for the homozygous CC genotype, 26.4% heterozygous CT genotype, and 2.36% for the homozygous TT genotype. The median age (P = 0.631), APACHE II (P = 0.205), and SOFA (P = 0.077) scores were similar in all three groups. However, the need for dialysis, mechanical ventilation, and vasopressor was less in the homozygous TT-genotype group than in the other groups (P < 0.05). The mortality rate was also lower in this group compared to other groups (P < 0.05). CONCLUSION: In conclusion, we revealed the polymorphism in HIF-lα and PHD2 genes in ARDS patients due to COVID-19. The rate of HIF-lα polymorphism was 26.4% for heterozygous CT-genotype and 2.36% for homozygous TT-genotype. The 30-day mortality and adverse outcome (dialysis, vasopressor use, MV need) were significantly lower in TT homozygous. However, none of the polymorphisms in the PHD2 genes affected mortality and adverse outcome.
3. Comparison of Train-of-Four Versus No Train-of-Four Monitoring of Neuromuscular Blockade on Drug Consumption for Acute Respiratory Distress Syndrome.
In a retrospective comparison of cisatracurium infusions for ARDS, clinical assessment without train-of-four monitoring reduced cumulative drug use versus TOF-guided titration (median 536 mg vs 665 mg). Costs decreased, but effects on oxygenation or clinical outcomes were not evaluated.
Impact: Challenges routine TOF monitoring by showing lower drug utilization with clinical assessment alone, with potential cost savings—a relevant consideration for ICU resource stewardship.
Clinical Implications: Institutions may reevaluate routine TOF monitoring for continuous cisatracurium in ARDS, balancing drug savings against potential safety and efficacy considerations pending prospective outcome data.
Key Findings
- Clinical assessment without TOF monitoring reduced cumulative cisatracurium dose compared with TOF-guided titration (median 536 mg vs 665 mg).
- Screened 1,600 patients; analyzed 99 (TOF) and 65 (non-TOF) after exclusions.
- Study excluded ECMO and COVID-19 cases to focus on contemporary ARDS practice.
Methodological Strengths
- Clearly defined inclusion/exclusion criteria with contemporaneous ARDS context.
- Direct comparison of two titration strategies with quantifiable primary outcome (drug utilization).
Limitations
- Retrospective, noncontemporaneous cohorts increase risk of confounding and practice drift.
- No assessment of clinical outcomes (oxygenation, ventilator days, safety events).
- Single-center data and relatively small sample size limit generalizability.
Future Directions: Prospective, randomized comparisons of TOF-guided versus clinical assessment-only titration assessing oxygenation, ventilator duration, safety, and cost-effectiveness.
BACKGROUND: There is limited data regarding the use of clinical assessment alone for neuromuscular blockade (NMB) titrations in the setting of acute respiratory distress syndrome (ARDS). OBJECTIVE: To compare the amount of cisatracurium (CIS) consumed when utilizing train-of-four (TOF)-guided NMB titrations or clinical assessment alone without TOF for continuous infusion (CI) administration. METHODS: A retrospective analysis was performed evaluating TOF-guided titrations compared with clinical assessment alone (non-TOF) for CI NMB with CIS. Individuals within the TOF group were assessed from January 2013 to December 2018 while those within the clinical assessment alone group were assessed from January 2021 to December 2024. Patients were excluded if they were less than 18 years old, had documentation of COVID-19 infection, were receiving extracorporeal membrane oxygenation, or had NMB initiated at an outside hospital. The primary objective was assessing drug utilization between groups. RESULTS: A total of 1047 and 553 individuals were screened resulting in 99 and 65 included for analysis in the TOF and non-TOF groups, respectively. The median cumulative CIS dose was 665 (472, 927) mg in the TOF group and 536 (400, 699) mg in the clinical assessment alone group, CONCLUSION AND RELEVANCE: This study assesses drug utilization when comparing TOF-guided NMB titration with clinical assessment alone in the modern ARDS era. Utilization of clinical assessment alone without TOF monitoring for CI CIS resulted in significantly reduced drug utilization and costs. Further studies are needed to assess the impact of clinical assessment alone on improvement of oxygenation.