Daily Ards Research Analysis

UNLABELLED: The present open-label, non-inferiority randomized controlled trial aimed to determine the efficacy and safety of RAM cannula as compared to nasal mask on the need for mechanical ventilation within 72 h of initiation of nCPAP. Preterm neonates (< 34 weeks) with Silverman-Anderson Score ≥ 3/10 were allocated to either RAM cannula or nasal mask for providing nCPAP. Two hundred and ten neonates were enrolled in the study, 105 each in the RAM cannula group and nasal mask group, respectively. Baseline characteristics were similar between the two groups. The proportion of neonates who needed mechanical ventilation within 72 h of initiation of nCPAP support allocated to the RAM cannula group and nasal mask group were 22 (21%) and 13 (12%), respectively (risk difference 8.57%, 95% CI -1.44 to 18.59). The non-inferiority of RAM cannula could not be established as the upper bound of 95% CI crossed the pre-specified non-inferiority margin of 15%. Other clinical parameters like incidence and severity of nasal injury, duration of CPAP support, mortality, and common neonatal morbidities were comparable. CONCLUSION: RAM cannula is not non inferior as compared to nasal mask in reducing the need for mechanical ventilation within 72 h of initiation of CPAP support in preterm neonates (< 34 weeks) with RDS. TRIAL REGISTRATION: www.ctri.nic.in , id CTRI/2024/06/068826, registered on 12/06/2024. WHAT IS KNOWN: • RAM cannula is not non-inferior to short binasal prongs (SBP) in providing CPAP to preterm infants with RDS. • RAM cannula causes less nasal trauma than SBP. WHAT IS NEW: • RAM cannula is not non-inferior as compared to nasal mask in reducing the need for mechanical ventilation within 72 h of initation of CPAP support in preterm neonates (< 34 weeks) with RDS. • The incidence of nasal injury is comparable between RAM cannula and nasal mask.

IMPORTANCE: Evidence for prone positioning in post-cardiac surgery acute respiratory distress syndrome (ARDS), especially after acute type A aortic dissection (ATAAD) repair, is extremely limited. Clinicians remain uncertain about its safety, feasibility, and the optimal timing of initiation in this hemodynamically vulnerable population. OBJECTIVES: To evaluate the effectiveness and safety of prone positioning for moderate-to-severe ARDS (MS-ARDS) after ATAAD repair, and to determine whether early initiation (≤ 48 hr) provides additional clinical benefit. DESIGN, SETTING, AND PARTICIPANTS: A retrospective, single-center cohort study conducted in a tertiary cardiovascular center. Seventy-eight adults with MS-ARDS after ATAAD surgery were included: 58 received prone positioning and 20 remained supine. MAIN OUTCOMES AND MEASURES: Primary outcomes were duration of mechanical ventilation (MV) and postoperative ICU length of stay (LOS). Secondary outcomes included hospital LOS, hospitalization cost, and 28- and 90-day mortality. Adverse events were systematically captured using prespecified hemodynamic and respiratory categories. RESULTS: Preoperative and perioperative characteristics were comparable between groups. In the prone cohort, the Pao2/Fio2 improved from 92.67 ± 21.04 to 152.45 ± 64.28 mm Hg at 4 hours (p < 0.001), demonstrating rapid oxygenation gain. Patients were further stratified by timing of intervention: early prone positioning (EPP: ≤ 48 hr from ARDS onset) and delayed prone positioning (DPP). EPP was associated with a significantly shorter duration of MV 5.03 ± 1.87 days compared with DPP 8.32 ± 4.73 days and the supine group 7.51 ± 4.08 days (p = 0.002). No increase in adverse events was observed, and no episodes of malignant arrhythmia or cardiac arrest occurred. CONCLUSIONS AND RELEVANCE: Prone positioning for MS-ARDS after ATAAD repair was feasible, safe, and rapidly improved oxygenation. Initiation within 48 hours was associated with a clinically meaningful reduction in ventilation duration. These findings support early, protocolized prone positioning in selected postoperative ATAAD patients and justify further evaluation in prospective trials.

BACKGROUND: Fetal growth restriction (FGR) diagnosed in mid-pregnancy is associated with substantial perinatal risk. However, the prognostic significance of FGR identified at the time of the second-trimester anatomy ultrasound that subsequently resolves later in pregnancy remains incompletely understood. OBJECTIVES: To evaluate the association between early FGR with subsequent growth normalization and severe neonatal morbidity (SNM), and to compare neonatal outcomes across pregnancies with persistent early FGR, resolved early FGR, and normal fetal growth. STUDY DESIGN: This retrospective cohort study included singleton pregnancies that underwent a routine second-trimester fetal anatomy ultrasound between 18 weeks 0 days and 23 weeks 6 days of gestation and had one or more follow-up third-trimester ultrasound examinations with fetal biometry performed at 28 weeks' gestation or later, delivering at two tertiary care hospitals in New York between January 2019 and December 2023. FGR was defined as estimated fetal weight or abdominal circumference <10th percentile. Pregnancies with FGR first diagnosed after 24 weeks' gestation were excluded. Pregnancies were categorized into three groups: no FGR, early FGR that persisted into the third trimester (persistent early FGR), and early FGR that subsequently normalized (resolved early FGR), with classification based on the last third-trimester ultrasound with fetal biometry performed prior to delivery. The primary outcome was SNM, defined as a composite of life-threatening neonatal diagnoses and procedures. Secondary outcomes included respiratory distress syndrome (RDS), neonatal intensive care unit (NICU) admission, preterm birth, need for parenteral nutrition, and need for phototherapy. Multivariable logistic regression was used to estimate adjusted odds ratios (aORs) controlling for demographic and clinical covariates. RESULTS: Among 20,022 pregnancies, 636 (3.2%) were diagnosed with early FGR at the mid-pregnancy anatomy ultrasound, of which 181 (28.5%) subsequently demonstrated resolution and 455 (71.5%) remained persistent. Compared with pregnancies without FGR, resolved early FGR was associated with increased odds of SNM (aOR 1.80, 95% CI 1.10-2.83), RDS (aOR 3.30, 95% CI 1.01-8.90), preterm birth (aOR 2.04, 95% CI 1.18-3.34), and need for parenteral nutrition (aOR 3.66, 95% CI 1.71-7.17). NICU admission and phototherapy did not differ significantly. Persistent early FGR was associated with increased odds of SNM and secondary outcomes. Neonatal risk followed a graded pattern across groups, with lowest risk among pregnancies without FGR, intermediate risk among those with resolved early FGR, and highest risk among those with persistent early FGR, with findings largely reflecting respiratory and prematurity-related morbidity. CONCLUSIONS: FGR diagnosed at the time of the second-trimester anatomy ultrasound is associated with increased neonatal morbidity even when fetal growth subsequently normalizes. Resolution of early FGR is associated with reduced but persistent risk, supporting consideration of early FGR as a marker of residual neonatal vulnerability. Further prospective studies are needed to refine risk stratification and determine whether specific management strategies modify outcomes in pregnancies complicated by early FGR with subsequent growth normalization.