Daily Ards Research Analysis
Analyzed 9 papers and selected 3 impactful papers.
Summary
Across three impactful studies, fluid balance showed severity-dependent effects in COVID-19 respiratory failure, continuous ventilator waveform data exposed substantial variability missed by routine EHR documentation, and early surgical stabilization of rib fractures was associated with lower mortality in severe polytrauma. These findings emphasize individualized fluid stewardship, high-resolution physiologic monitoring, and timely surgical intervention in critical respiratory care.
Research Themes
- Personalized fluid stewardship across respiratory failure severity
- Continuous ventilator waveform analytics for precision monitoring
- Early surgical stabilization in polytrauma with rib fractures
Selected Articles
1. Fluid balance is Associated with Differential Effects on Respiratory Failure between Critically Ill and Non-Critically Ill Adults with SARS-CoV-2: a Retrospective Cohort Study.
In a 5-hospital cohort of 4,254 adults with SARS-CoV-2, positive daily fluid balance increased next-day odds of invasive ventilation and death among critically ill patients but was associated with improved respiratory status among non-critically ill patients on low-flow oxygen. Findings support severity-tailored fluid strategies in acute respiratory failure.
Impact: Large, well-adjusted analyses reveal severity-dependent effects of fluid balance, refining a core management principle beyond classic ARDS cohorts.
Clinical Implications: Adopt fluid stewardship tailored to illness severity: avoid positive balances in the critically ill, while recognizing that modest positive balance may benefit non-critically ill patients on low-flow oxygen. Prospective validation should guide protocolized fluid targets.
Key Findings
- Among critically ill adults, each liter of positive fluid balance increased next-day odds of invasive ventilation (OR 1.48, 95% CI 1.41–1.55).
- Positive fluid balance increased odds of death among the critically ill (OR 1.15, 95% CI 1.08–1.23).
- In non-critically ill patients on low-flow oxygen, positive fluid balance was associated with improved next-day respiratory status (OR 0.89, 95% CI 0.86–0.92).
Methodological Strengths
- Large multicenter cohort with comprehensive adjustment (demographics, comorbidities, vasopressors, inotropes, RRT).
- Robust modeling using cumulative and adjacent-categories logistic regression across ordered outcomes.
Limitations
- Retrospective design with potential residual confounding and measurement biases (e.g., unmeasured urine outputs).
- Findings limited to SARS-CoV-2 era and a single academic health system, affecting generalizability.
Future Directions: Prospective, severity-stratified trials to test fluid targets and timing; mechanistic studies to elucidate why fluid balance has divergent effects across illness severity.
BACKGROUND: Conservative fluid management improves outcomes in mechanically ventilated adults with ARDS, but its impact across the broader spectrum of acute respiratory failure is less clear. The SARS-CoV-2 pandemic provided an opportunity to assess this relationship in patients with a relatively uniform lung injury mechanism. We examined associations between daily fluid balance and respiratory status in adults hospitalized with SARS-CoV-2 across varying degrees of respiratory impairment. METHODS: Retrospective cohort study of adults hospitalized with SARS-CoV-2 within ±7 days of admission to five hospitals in an academic medical system (March 2020-July 2022). The primary outcome was a modified WHO Clinical Scale (mWHO) from 1 (Hospitalized, no respiratory support) to 5 (Death or discharge to hospice). Associations between daily net fluid balance and next-day mWHO were tested using cumulative logistic regression and adjacent-categories logistic regression, adjusting for demographics, comorbidities, hospital type, vasopressors, inotropes, renal replacement therapy, and unmeasured urine outputs. RESULTS: Among 4,254 patients (median age 58 [41-70]; 52.9% male; median hospital stay 4.5 [2.5-8.1] days), 2,860 (67.2%) required respiratory support, 539 (12.7%) received invasive ventilation, and 571 (13.4%) died. In critically ill adults, positive fluid balance was associated with higher odds of subsequent mechanical ventilation (OR per L 1.48, 95%CI 1.41-1.55) or death (OR 1.15, 95%CI 1.08-1.23). Among non-critically ill patients on low-flow oxygen, positive fluid balance was associated with improved respiratory status (OR 0.89, 95%CI 0.86-0.92). CONCLUSIONS: Positive fluid balance had divergent effects by illness severity, suggesting distinct physiologic or clinical mechanisms across the spectrum of SARS-CoV-2 respiratory failure.
2. Surgical Stabilization of Rib Fractures in Severe Polytrauma: A Potential Indication.
Using the 2013–2021 TQIP registry, early SSRF in severe polytrauma with rib fractures (n=5,020 of 388,091) was associated with a 57% reduction in in-hospital mortality after IPTW adjustment. Outcomes assessed included mortality, pneumonia, ARDS, and duration of mechanical ventilation.
Impact: Findings extend the potential benefits of SSRF beyond isolated chest trauma to severe polytrauma at scale, informing trauma and critical care management.
Clinical Implications: Trauma teams should consider early SSRF (within 72 hours) for selected severe polytrauma patients with rib fractures, with multidisciplinary evaluation. Protocols should incorporate patient selection and timing while awaiting prospective trials.
Key Findings
- Among 388,091 severe polytrauma patients with rib fractures, 1.3% (n=5,020) underwent SSRF.
- SSRF was associated with a 57% decrease in in-hospital mortality after IPTW adjustment.
- Study assessed pneumonia, ARDS, and mechanical ventilation duration in addition to mortality.
Methodological Strengths
- Very large national registry with prespecified inclusion/exclusion criteria and early-intervention focus (≤72 hours).
- Advanced confounding control using IPTW, Poisson, and quantile regression.
Limitations
- Retrospective observational design susceptible to selection bias and residual confounding (e.g., indication bias).
- Administrative registry data may have coding inaccuracies; some clinical details unavailable.
Future Directions: Prospective, randomized or quasi-experimental studies to validate mortality benefit and define optimal patient selection and timing for SSRF in polytrauma.
BackgroundMost studies demonstrating efficacy of surgical stabilization of rib fractures (SSRF) are in patients with isolated severe chest wall injury. Recent evidence suggests SSRF may reduce mortality in polytrauma patients. The present study examines SSRF outcomes in severe polytrauma patients.MethodsThe 2013-2021 Trauma Quality Improvement Project database was used to identify severe polytrauma patients, defined as Injury Severity Score (ISS) ≥15 and abbreviated injury scale (AIS) ≥2 in 2 or more regions, with rib fractures. Exclusion criteria included AIS 6 in any region, death ≤72 hours, or SSRF >72 hours after admission. Outcomes of interest were in-hospital mortality, pneumonia, acute respiratory distress syndrome (ARDS), and length of mechanical ventilation. Adjustment for confounding was achieved using inverse probability of treatment weighting, Poisson regression models and quantile regression models.ResultsA total of 388 091 patients met inclusion criteria, of which 1.3% (N = 5020) underwent SSRF. SSRF was associated with a 57% decreased risk of mortality (
3. Waveform data capture substantial variation in tidal volume and other respiratory parameters.
In 59 IMV encounters over 358 patient-days, continuous ventilator waveform measurements captured markedly more variability than EHR documentation. Tidal volume showed a mean absolute error of 69 mL versus EHR entries (r=0.540), with even poorer agreement in mandatory modes (r=0.454).
Impact: Methodological innovation highlights the limitations of intermittent EHR documentation and underscores the value of waveform analytics for precision ventilation in ARDS research and care.
Clinical Implications: Integrate continuous ventilator waveform data into bedside decision-making and research datasets to more accurately track tidal volume, pressures, and ventilation. Quality metrics should prioritize waveform-derived parameters over intermittent charted values.
Key Findings
- Continuous waveform data captured significantly more variability than EHR-documented ventilator parameters across 358 patient-days.
- Tidal volume had a mean absolute error of 69 mL (95% CI 62–77) compared with EHR entries, with overall correlation r=0.540.
- Agreement for tidal volume was worse in mandatory ventilation modes (r=0.454), indicating limitations of intermittent documentation.
Methodological Strengths
- High-frequency, device-level continuous measurements directly compared to routine EHR documentation.
- Objective agreement metrics (mean absolute error, correlation) across multiple ventilator parameters.
Limitations
- Single-center retrospective study with a modest sample size (59 encounters), limiting generalizability.
- Potential device heterogeneity and documentation practices may influence agreement metrics.
Future Directions: Prospective multicenter studies integrating waveform analytics into clinical decision support; evaluate impact on adherence to lung-protective ventilation and patient outcomes.
RATIONALE: Patients receiving invasive mechanical ventilation (IMV) require accurate assessments of ventilator parameters. Documentation of these parameters in standard practice may fail to capture meaningful variation due to intermittent missingness. OBJECTIVES: To assess variation in continuously-measured ventilator parameters and agreement with measurements documented as part of routine care in the electronic health record (EHR). METHODS: We performed a retrospective cohort study of patients receiving IMV in a medical intensive care unit from November 2024-March 2025. We compared the observed tidal volume, minute ventilation, peak inspiratory pressure, and positive end-expiratory pressure, measured continuously from device waveforms with intermittent EHR documentation. We calculated descriptive statistics and measures of agreement between these sources. MEASUREMENTS AND MAIN RESULTS: For 59 encounters, the median age was 65 (IQR, 59-72), 33 (56%) patients were male and 17 (29%) were Black. 34 (58%) patients died or were discharged to hospice. Among 358 patient-days of data, continuous measurements captured significantly more variation than EHR-documented measurements across all parameters. The largest errors were in observed tidal volume (mean absolute error 69 mL, 95% CI, 62-77 mL; correlation coefficient 0.540). Agreement in tidal volume was worse among patients receiving mandatory modes of ventilation (correlation coefficient 0.454). CONCLUSIONS: Intermittent measurement of ventilator parameters fails to capture large variability observed in continuous, waveform-derived measurements. Poor agreement in parameters like tidal volume, even in mandatory modes of ventilation, highlights the potential for ventilator waveform data to improve care and advance research for patients with acute respiratory distress syndrome and others receiving IMV.