Weekly Ards Research Analysis
This week’s ARDS literature highlights three actionable directions: a large pragmatic RCT protocol (SAVE-ICU) testing inhaled versus intravenous sedation in acute hypoxemic respiratory failure which could change ICU sedation practice; transcriptomic deconvolution of circulating blood identifies endothelial cell signatures that predict mortality and respiratory trajectories across pediatric and adult cohorts; and a systematic review/meta-analysis links higher bronchoscopic grades after smoke inha
Summary
This week’s ARDS literature highlights three actionable directions: a large pragmatic RCT protocol (SAVE-ICU) testing inhaled versus intravenous sedation in acute hypoxemic respiratory failure which could change ICU sedation practice; transcriptomic deconvolution of circulating blood identifies endothelial cell signatures that predict mortality and respiratory trajectories across pediatric and adult cohorts; and a systematic review/meta-analysis links higher bronchoscopic grades after smoke inhalation to increased ARDS and pneumonia risk, arguing for standardized bronchoscopic grading for early risk stratification.
Selected Articles
1. Sedating with volatile anaesthetics for COVID-19 and non-COVID-19 acute hypoxaemic respiratory failure patients in ICU (SAVE-ICU): protocol for a randomised clinical trial.
SAVE-ICU is a multicentre, pragmatic, open-label randomized trial protocol (15 ICUs in Canada and the USA) comparing inhaled volatile anesthetic sedation with standard intravenous sedation in mechanically ventilated adults with acute hypoxemic respiratory failure (including ARDS). The protocol is registered and ethically approved, designed to evaluate patient-centered outcomes and system-level effects of inhaled sedation in routine ICU practice.
Impact: A high-quality pragmatic RCT can change ICU sedation standards; inhaled sedation has mechanistic rationale for lung-protection and resource implications, so a definitive trial has broad clinical and policy impact.
Clinical Implications: If results favor inhaled sedation, ICUs may adopt volatile anesthetics for ventilated ARDS patients to improve ventilator synchrony, reduce intravenous sedative use, and potentially shorten ventilation/ICU stay; centers should prepare logistics and monitoring protocols for inhaled agents.
Key Findings
- Pragmatic, multicentre randomized controlled trial protocol across 15 ICUs comparing inhaled volatile anesthetic sedation vs intravenous sedation.
- Targets mechanically ventilated adults with acute hypoxemic respiratory failure (COVID-19 and non-COVID-19).
- Ethics approvals and trial registration (NCT04415060) in place; predefined dissemination plan.
2. Circulating endothelial signatures correlate with worse outcomes in COVID-19, respiratory failure and ARDS.
Using unsupervised deconvolution of blood transcriptomes across pediatric ventilated and adult COVID-19 cohorts (CAF-PINT, IMPACC), the study quantified circulating endothelial signatures (ECS%) and showed higher baseline ECS% independently associated with 28‑day mortality and worse respiratory trajectories, supporting a noninvasive biomarker of endothelial injury relevant to ARDS pathobiology.
Impact: Provides a scalable, mechanism-linked, noninvasive prognostic biomarker bridging pediatric and adult ARDS cohorts, enabling early endothelial injury detection and trial enrichment for vascular-targeted therapies.
Clinical Implications: ECS% measurement could be integrated into early risk stratification to target high-risk patients for closer monitoring, consideration of endothelial-protective interventions, or inclusion in biomarker-guided trials.
Key Findings
- Baseline ECS% higher in non-survivors in adults with COVID-19 (2.9% vs 2.7%, n=932, p<0.001) and in ventilated pediatric non-survivors (2.8% vs 2.6%, n=244, p<0.05).
- Each 1% increase in baseline ECS% associated with increased mortality (adjusted OR 1.36, 95% CI 1.03–1.79).
- Higher ECS% correlated with worse respiratory trajectories across oxygen-requirement categories.
3. Evaluating the association between bronchoscopic severity of burns-related smoke inhalation injury and clinical outcomes: A systematic review and meta-analysis.
A PRISMA-compliant systematic review and meta-analysis (30 studies, 12 meta-analyzed) found that higher bronchoscopic Abbreviated Injury Score (AIS 3–4) after smoke inhalation is significantly associated with increased risk of pneumonia and ARDS compared to AIS 1–2; mortality trended higher but was not statistically significant. Heterogeneity and inconsistent grading systems were important limitations.
Impact: Provides quantitative evidence that bronchoscopic severity stratifies risk for ARDS and pneumonia after smoke inhalation, supporting early invasive assessment and the need for standardized bronchoscopic scoring in burn care.
Clinical Implications: Patients with higher bronchoscopic grades (AIS 3–4) should be triaged as high risk for ARDS/pneumonia, triggering early lung-protective ventilation, intensified pulmonary hygiene, and heightened monitoring; centers should standardize bronchoscopic reporting to guide care and research.
Key Findings
- AIS 3–4 (severe) BII vs AIS 1–2 associated with higher pneumonia risk (RD 0.319, 95% CI 0.020–0.618, p=0.037).
- AIS 3–4 associated with increased ARDS risk (RD 0.242, 95% CI 0.118–0.367, p<0.001).
- Mortality higher with AIS 3–4 but not statistically significant (RD 0.068, 95% CI -0.017–0.153, p=0.116); heterogeneity limits certainty.