Daily Respiratory Research Analysis

RATIONALE: Myocardial injury is common in acute respiratory distress syndrome (ARDS) and sepsis and associated with increased mortality. Two latent class analysis derived subphenotypes are associated with differential risk of mortality in these populations, though the association of troponin-I with mortality within each subphenotype is unknown. METHODS: The derivation (n = 597 in EARLI) and validation (n = 452 in VALID) cohorts consisted of patients with sepsis or ARDS admitted to the ICU and enrolled in two separate prospective observational studies. Patients with troponin-I measured between hospital presentation and within 24 h of ICU admission were included. A parsimonious classifier model using interleukin-8, soluble tumor necrosis factor receptor-1, and vasopressor use assigned patients to subphenotype. Association between peak troponin-I concentration and 60-day in-hospital mortality within each subphenotype was assessed through logistic regression adjusting for age, admission laboratory values, vasopressor use, invasive ventilation use, and cardiac comorbidities. RESULTS: Median peak troponin-I was significantly higher in the hyperinflammatory vs hypoinflammatory subphenotype in both cohorts (0.07 vs 0.04 ng/mL and 0.17 vs 0.07 ng/mL, both p < 0.05). The association between peak troponin-I and mortality differed between inflammatory subphenotypes (p-interaction 0.004, EARLI). In EARLI, each doubling of peak troponin-I was associated with increased adjusted odds of 60-day mortality (aOR 1.14, 95% CI 1.02-1.28) in the hypoinflammatory subphenotype only. These findings were corroborated in VALID (aOR 1.11, 95% CI 1.03-1.21 in hypoinflammatory). CONCLUSIONS: Admission peak troponin-I is significantly associated with 60-day mortality in patients with sepsis or ARDS. This association was distinctly driven by the hypoinflammatory subphenotype.

OBJECTIVE: To develop PerAIDE, an AI-driven system for automated analysis of pulmonary perfusion blood volume (PBV) using dual-energy computed tomography pulmonary angiography (DE-CTPA) in patients with chronic pulmonary thromboembolism (CPE). MATERIALS AND METHODS: In this prospective observational study, 32 patients with chronic thromboembolic pulmonary disease (CTEPD) and 151 patients with chronic thromboembolic pulmonary hypertension (CTEPH) were enrolled between January 2022 and July 2024. PerAIDE was developed to automatically quantify three distinct perfusion patterns-normal, reduced, and defective-on DE-CTPA images. Two radiologists independently assessed PBV scores. Follow-up imaging was conducted 3 months after balloon pulmonary angioplasty (BPA). RESULTS: PerAIDE demonstrated high agreement with the radiologists (intraclass correlation coefficient = 0.778) and reduced analysis time significantly (31 ± 3 s vs. 15 ± 4 min, p < 0.001). CTEPH patients had greater perfusion defects than CTEPD (0.35 vs. 0.29, p < 0.001), while reduced perfusion was more prevalent in CTEPD (0.36 vs. 0.30, p < 0.001). Perfusion defects correlated positively with pulmonary vascular resistance (ρ = 0.534) and mean pulmonary artery pressure (ρ = 0.482), and negatively with oxygenation index (ρ = -0.441). PerAIDE effectively differentiated CTEPH from CTEPD (AUC = 0.809, 95% CI: 0.745-0.863). At the 3-month post-BPA, a significant reduction in perfusion defects was observed (0.36 vs. 0.33, p < 0.01). CONCLUSION: CTEPD and CTEPH exhibit distinct perfusion phenotypes on DE-CTPA. PerAIDE reliably quantifies perfusion abnormalities and correlates strongly with clinical and hemodynamic markers of CPE severity. TRIAL REGISTRATION: ClinicalTrials.gov, NCT06526468. Registered 28 August 2024- Retrospectively registered, https://clinicaltrials.gov/study/NCT06526468?cond=NCT06526468&rank=1 . CRITICAL RELEVANCE STATEMENT: PerAIDE is a dual-energy computed tomography pulmonary angiography (DE-CTPA) AI-driven system that rapidly and accurately assesses perfusion blood volume in patients with chronic pulmonary thromboembolism, effectively distinguishing between CTEPD and CTEPH phenotypes and correlating with disease severity and therapeutic response. KEY POINTS: Right heart catheterization for definitive diagnosis of chronic pulmonary thromboembolism (CPE) is invasive. PerAIDE-based perfusion defects correlated with disease severity to aid CPE-treatment assessment. CTEPH demonstrates severe perfusion defects, while CTEPD displays predominantly reduced perfusion. PerAIDE employs a U-Net-based adaptive threshold method, which achieves alignment with and faster processing relative to manual evaluation.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) is increasingly performed. Nationwide data comparing its outcomes with nonoperative management (NOM) and defining the best timing for SSRF are scarce. METHODS: We analyzed data from the American College of Surgeons Trauma Quality Improvement Program, 2017-2021. Adults with three or more blunt rib fractures and no major extrathoracic injury were included. Surgical fixation was compared with risk-weighted NOM using inverse probability of treatment weighting. Primary outcome was in-hospital mortality. Secondary outcomes were hospital and intensive care length of stay, ventilator duration, ventilator-free days, acute respiratory distress syndrome, and ventilator-associated pneumonia. Subgroup analyses examined flail chest and the impact of timing of fixation, which was modeled as a continuous exposure with a generalized additive spline; its discriminatory performance was evaluated with receiver-operating-characteristic curve analysis to calculate the Youden's index. RESULTS: A total of 3,806 patients underwent SSRF, and 3,753 weighted controls received NOM. After weighting, an association of SSRF with lower mortality (1.5% vs. 2.7%, p < 0.001) but longer hospital (median, 10 vs. 5 days) and intensive care stays (5 vs. 3 days, both p < 0.001) were observed. In the flail chest subgroup, SSRF was associated with a mortality of 4.2% compared with 10.1% with NOM ( p = 0.002). In the nonflail group, mortality was 1.3% after SSRF versus 2.0% in NOM ( p = 0.003). Early SSRF within 82 hours had similar mortality to delayed fixation (1.6% vs. 1.4%, p = 0.647). However, early SSRF was associated with lower rates of acute respiratory distress syndrome (0.5% vs. 1.5%), ventilator-associated pneumonia (0.9% vs. 2.3%), and shorter hospital stays compared with delayed SSRF. CONCLUSION: Nationwide data demonstrated that SSRF is associated with higher survival, particularly in patients with flail chest, at the cost of increased resource utilization. Surgical stabilization of rib fractures performed within 82 hours is associated with higher survival, lower pulmonary morbidity, and additional resource utilization. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.