Spontaneous Breathing in Early Acute Respiratory Distress Syndrome: Insights From the Large Observational Study to UNderstand the Global Impact of Severe Acute Respiratory FailurE Study

OBJECTIVES: To describe the characteristics and outcomes of patients with acute respiratory distress syndrome with or without spontaneous breathing and to investigate whether the effects of spontaneous breathing on outcome depend on acute respiratory distress syndrome severity. DESIGN: Planned secondary analysis of a prospective, observational, multicentre cohort study. SETTING: International sample of 459 ICUs from 50 countries. PATIENTS: Patients with acute respiratory distress syndrome and at least 2 days of invasive mechanical ventilation and available data for the mode of mechanical ventilation and respiratory rate for the 2 first days. INTERVENTIONS: Analysis of patients with and without spontaneous breathing, defined by the mode of mechanical ventilation and by actual respiratory rate compared with set respiratory rate during the first 48 hours of mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: Spontaneous breathing was present in 67% of patients with mild acute respiratory distress syndrome, 58% of patients with moderate acute respiratory distress syndrome, and 46% of patients with severe acute respiratory distress syndrome. Patients with spontaneous breathing were older and had lower acute respiratory distress syndrome severity, Sequential Organ Failure Assessment scores, ICU and hospital mortality, and were less likely to be diagnosed with acute respiratory distress syndrome by clinicians. In adjusted analysis, spontaneous breathing during the first 2 days was not associated with an effect on ICU or hospital mortality (33% vs 37%; odds ratio, 1.18 [0.92-1.51]; p = 0.19 and 37% vs 41%; odds ratio, 1.18 [0.93-1.50]; p = 0.196, respectively ). Spontaneous breathing was associated with increased ventilator-free days (13 [0-22] vs 8 [0-20]; p = 0.014) and shorter duration of ICU stay (11 [6-20] vs 12 [7-22]; p = 0.04). CONCLUSIONS: Spontaneous breathing is common in patients with acute respiratory distress syndrome during the first 48 hours of mechanical ventilation. Spontaneous breathing is not associated with worse outcomes and may hasten liberation from the ventilator and from ICU. Although these results support the use of spontaneous breathing in patients with acute respiratory distress syndrome independent of acute respiratory distress syndrome severity, the use of controlled ventilation indicates a bias toward use in patients with higher disease severity. In addition, because the lack of reliable data on inspiratory effort in our study, prospective studies incorporating the magnitude of inspiratory effort and adjusting for all potential severity confounders are required

Identifying associations between diabetes and acute respiratory distress syndrome in patients with acute hypoxemic respiratory failure: an analysis of the LUNG SAFE database

Background: Diabetes mellitus is a common co-existing disease in the critically ill. Diabetes mellitus may reduce the risk of acute respiratory distress syndrome (ARDS), but data from previous studies are conflicting. The objective of this study was to evaluate associations between pre-existing diabetes mellitus and ARDS in critically ill patients with acute hypoxemic respiratory failure (AHRF). Methods: An ancillary analysis of a global, multi-centre prospective observational study (LUNG SAFE) was undertaken. LUNG SAFE evaluated all patients admitted to an intensive care unit (ICU) over a 4-week period, that required mechanical ventilation and met AHRF criteria. Patients who had their AHRF fully explained by cardiac failure were excluded. Important clinical characteristics were included in a stepwise selection approach (forward and backward selection combined with a significance level of 0.05) to identify a set of independent variables associated with having ARDS at any time, developing ARDS (defined as ARDS occurring after day 2 from meeting AHRF criteria) and with hospital mortality. Furthermore, propensity score analysis was undertaken to account for the differences in baseline characteristics between patients with and without diabetes mellitus, and the association between diabetes mellitus and outcomes of interest was assessed on matched samples. Results: Of the 4107 patients with AHRF included in this study, 3022 (73.6%) patients fulfilled ARDS criteria at admission or developed ARDS during their ICU stay. Diabetes mellitus was a pre-existing co-morbidity in 913 patients (22.2% of patients with AHRF). In multivariable analysis, there was no association between diabetes mellitus and having ARDS (OR 0.93 (0.78-1.11); p = 0.39), developing ARDS late (OR 0.79 (0.54-1.15); p = 0.22), or hospital mortality in patients with ARDS (1.15 (0.93-1.42); p = 0.19). In a matched sample of patients, there was no association between diabetes mellitus and outcomes of interest. Conclusions: In a large, global observational study of patients with AHRF, no association was found between diabetes mellitus and having ARDS, developing ARDS, or outcomes from ARDS. Trial registration: NCT02010073. Registered on 12 December 2013

Epidemiology and patterns of tracheostomy practice in patients with acute respiratory distress syndrome in ICUs across 50 countries

Background: To better understand the epidemiology and patterns of tracheostomy practice for patients with acute respiratory distress syndrome (ARDS), we investigated the current usage of tracheostomy in patients with ARDS recruited into the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG-SAFE) study. Methods: This is a secondary analysis of LUNG-SAFE, an international, multicenter, prospective cohort study of patients receiving invasive or noninvasive ventilation in 50 countries spanning 5 continents. The study was carried out over 4 weeks consecutively in the winter of 2014, and 459 ICUs participated. We evaluated the clinical characteristics, management and outcomes of patients that received tracheostomy, in the cohort of patients that developed ARDS on day 1-2 of acute hypoxemic respiratory failure, and in a subsequent propensity-matched cohort. Results: Of the 2377 patients with ARDS that fulfilled the inclusion criteria, 309 (13.0%) underwent tracheostomy during their ICU stay. Patients from high-income European countries (n = 198/1263) more frequently underwent tracheostomy compared to patients from non-European high-income countries (n = 63/649) or patients from middle-income countries (n = 48/465). Only 86/309 (27.8%) underwent tracheostomy on or before day 7, while the median timing of tracheostomy was 14 (Q1-Q3, 7-21) days after onset of ARDS. In the subsample matched by propensity score, ICU and hospital stay were longer in patients with tracheostomy. While patients with tracheostomy had the highest survival probability, there was no difference in 60-day or 90-day mortality in either the patient subgroup that survived for at least 5 days in ICU, or in the propensity-matched subsample. Conclusions: Most patients that receive tracheostomy do so after the first week of critical illness. Tracheostomy may prolong patient survival but does not reduce 60-day or 90-day mortality. Trial registration: ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013

Coupled aquaponics systems

Coupled aquaponics is the archetype form of aquaponics. The technical complexity increases with the scale of production and required water treatment, e.g. filtration, UV light for microbial control, automatic controlled feeding, computerization and biosecurity. Upscaling is realized through multiunit systems that allow staggered fish production, parallel cultivation of different plants and application of several hydroponic subsystems. The main task of coupled aquaponics is the purification of aquaculture process water through integration of plants which add economic benefits when selecting suitable species like herbs, medicinal plants or ornamentals. Thus, coupled aquaponics with closed water recirculation systems has a particular role to fulfil. Under fully closed recirculation of nutrient enriched water, the symbiotic community of fish, plants and bacteria can result in higher yields compared with stand-alone fish production and/or plant cultivation. Fish and plant choices are highly diverse and only limited by water quality parameters, strongly influenced by fish feed, the plant cultivation area and component ratios that are often not ideal. Carps, tilapia and catfish are most commonly used, though more sensitive fish species and crayfish have been applied. Polyponics and additional fertilizers are methods to improve plant quality in the case of growth deficiencies, boosting plant production and increasing total yield. The main advantages of coupled aquaponics are in the most efficient use of resources such as feed for nutrient input, phosphorous, water and energy as well as in an increase of fish welfare. The multivariate system design approach allows coupled aquaponics to be installed in all geographic regions, from the high latitudes to arid and desert regions, with specific adaptation to the local environmental conditions. This chapter provides an overview of the historical development, general system design, upscaling, saline and brackish water systems, fish and plant choices as well as management issues of coupled aquaponics especially in Europe

Isoscalar quadrupole strength in Ca-40 from the (p,p 'alpha(0)) reaction at E-p = 100 MeV

The Ca-40(p,p'alpha) reaction has been studied at an incident proton energy E-p,= 99.5 MeV for proton laboratory scattering angles Theta(p)(lab) = 17 degrees, 23 degrees and 27 degrees. Emission of alpha particles coincident with the scattered proton has been measured for an angular range Theta(alpha), similar or equal to 0 degrees - 180 degrees relative to the recoil axis. A multipole decomposition for the alpha(0)-decay channel to the Ar-36 ground state has been performed from the angular-correlation functions. The energy distribution of the dominating E2 strength deduced in the excitation energy range E-x = 11-21 MeV agrees reasonably well with the results from electron and alpha-induced alpha(0)-decay investigations. The exhaustion of the E? energy weighted sum rule in this channel up to an energy of 17 MeV is 16.1(4.0)%, in accord with the study of the (alpha, alpha' alpha(0)) reaction. However, this value is twice what is found in the (e,e' alpha(0)) experiment in the same energy region. Thus, the puzzling discrepancy in the E2 strengths derived from electromagnetic and hadronic probes remains unsolved. (C) 1998 Elsevier Science B.V

Assessing the effectiveness of low-cost air quality monitors for identifying volcanic SO2 and PM downwind from Masaya volcano, Nicaragua

Gas and particulate matter (PM) emissions from Masaya volcano, Nicaragua, cause substantial regional volcanic air pollution (VAP). We evaluate the suitability of low-cost SO2 and PM sensors for a continuous air-quality network. The network was deployed for six months in five populated areas (4–16 km from crater). The SO2 sensors failed and recorded erroneous values on multiple occasions, likely due to corrosion, requiring significant maintenance commitment. The PM sensors were found to be robust but data required correction for humidity. SO2 measurements could not be used as stand-alone tools to detect occurrence of VAP episodes (VAPE), but an SO2/PM correlation reliably achieved this at near-field stations, as confirmed by meteorological forecasts and satellite imagery. Above-background PM concentrations reliably identified VAPE at both near-field and far-field stations. We suggest that a continuous network can be built from a combination of low-cost PM and SO2 sensors with a greater number of PM-only sensors

Effectiveness of low-cost air quality monitors for identifying volcanic SO₂ and PM downwind from Masaya volcano, Nicaragua

Gas and particulate matter (PM) emissions from Masaya volcano, Nicaragua, cause substantial regional volcanic air pollution (VAP). We evaluate the suitability of low-cost SO2 and PM sensors for a continuous air-quality network. The network was deployed for six months in five populated areas (4-16 km from crater). The SO2 sensors failed and recorded erroneous values on multiple occasions, likely due to corrosion, requiring significant maintenance commitment. The PM sensors were found to be robust but data required correction for humidity. SO2 measurements could not be used as stand-alone tools to detect occurrence of VAP episodes (VAPE), but SO2/PM correlation reliably achieved this at near-field stations, as confirmed by meteorological forecasts and satellite imagery. Above-background PM concentrations reliably identified VAPE at both near-field and far-field stations. We suggest that a continuous network can be built from a combination of low-cost PM and SO2 sensors with a greater number of PM-only sensors