Hyperoxemia and excess oxygen use in early acute respiratory distress syndrome : Insights from the LUNG SAFE study

Publisher Copyright: © 2020 The Author(s). Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Background: Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patients with acute respiratory distress syndrome (ARDS). We examined this issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. Methods: In this secondary analysis of the LUNG SAFE study, we wished to determine the prevalence and the outcomes associated with hyperoxemia on day 1, sustained hyperoxemia, and excessive oxygen use in patients with early ARDS. Patients who fulfilled criteria of ARDS on day 1 and day 2 of acute hypoxemic respiratory failure were categorized based on the presence of hyperoxemia (PaO2 > 100 mmHg) on day 1, sustained (i.e., present on day 1 and day 2) hyperoxemia, or excessive oxygen use (FIO2 ≥ 0.60 during hyperoxemia). Results: Of 2005 patients that met the inclusion criteria, 131 (6.5%) were hypoxemic (PaO2 < 55 mmHg), 607 (30%) had hyperoxemia on day 1, and 250 (12%) had sustained hyperoxemia. Excess FIO2 use occurred in 400 (66%) out of 607 patients with hyperoxemia. Excess FIO2 use decreased from day 1 to day 2 of ARDS, with most hyperoxemic patients on day 2 receiving relatively low FIO2. Multivariate analyses found no independent relationship between day 1 hyperoxemia, sustained hyperoxemia, or excess FIO2 use and adverse clinical outcomes. Mortality was 42% in patients with excess FIO2 use, compared to 39% in a propensity-matched sample of normoxemic (PaO2 55-100 mmHg) patients (P = 0.47). Conclusions: Hyperoxemia and excess oxygen use are both prevalent in early ARDS but are most often non-sustained. No relationship was found between hyperoxemia or excessive oxygen use and patient outcome in this cohort. Trial registration: LUNG-SAFE is registered with ClinicalTrials.gov, NCT02010073publishersversionPeer reviewe

Caracterização das ligas Ni-Ti-Mo, Ni-Ti-Ta e Ni-Ti-Mo-Zr obtidas por moagem de alta energia e prensagem a quente

O Brasil ainda não produz a liga Ni – Ti em escala comercial, importando grande parte dos produtos à base de Ni – Ti voltados à área médica. O grande custo envolvido na importação destes produtos estimula a tentativa de desenvolvimento nacional desta liga. Assim, esta pesquisa objetivou a caracterização de ligas Ni-Ti-Mo, Ni-Ti-Ta e Ni-Ti-Mo-Zr produzidas por meio de moagem de alta energia e subseqüente prensagem a quente. A caracterização dos produtos moídos e prensados a quente foi realizada por meio de microscopia eletrônica de varredura, difração de raios X, espectrometria por dispersão de energia. Os resultados indicaram que a formação dos compostos intermetálicos, como o Ni3Ti, NiTi e NiTi2, ocorreram nos estágios iniciais de moagem. Em todas as misturas constituídas de pós, os tamanhos de suas respectivas partículas foram aumentados, e a distância entre as lamelas foram reduzidas para longos períodos de moagem. Este fato ocorreu devido ao mecanismo de solda fria entre as partículas dúcteis, que foram totalmente revestidas em suas superfícies esféricas. O rendimento da mistura de Ni-Ti-Mo, Ni-Ti-Ta e Ni-Ti-Mo-Zr aumentou após a moagem molhada. A prensagem a quente contribuiu para a obtenção de estruturas homogêneas e a consolidação dos pós de Ni-Ti-Mo, Ni-Ti-Ta e Ni-Ti-Mo-Zr moídos. No caso das ligas Ni-45Ti-5Mo e Ni-40Ti-10Mo, o composto Ni-Ti foi identificado na estrutura de ambas as ligas, enquanto que as fases Ni3Ti e NiTi2 foram formadas nas microestruturas das ligas Ni-45Ti-5Mo e Ni-40Ti-10Mo. Estas fases intermetálicas dissolveram teores de molibdênio inferiores a 2,1 %-at. Além disso, foi encontrada a presença de precipitados ricos em molibdênio com teores (%-at) próximos de 16Ni-25Ti-59Mo.Não foi encontrada variação significativa dos valores médios de dureza Vickers relacionadas a estas ligas ternárias, após o aumento da...The Brazil not yet product the Ni – Ti alloy commercially, importing the most products of the Ni-Ti of the medical area. The high cust to wrap up in the importation this products encourage the development national this alloy. In this way, this work aimed the characterization of Ni-Ti-Mo, Ni-Ti-Ta and Ni-Ti-Mo-Zr alloys produced by high-energy ball milling and subsequent hot pressing. The milled and hot-pressed materials were characterized by, scanning electron microscopy, X-ray diffraction, energy dispersive spectrometry. Results indicated that the formation of intermetallic compounds such as Ni3Ti, NiTi and NiTi2 occurred at the initial milling stages. For all the powder mixtures, it was noted that the powder sizes were increased and the distance between lamellas were reduced for longer milling times. This fact occurred due to excessive cold welding mechanism between ductile particles, which were coated fully the vial and balls surfaces. The yield of Ni-Ti-Mo, Ni-Ti-Ta and Ni-Ti-Mo-Zr powders was increased after wet milling. The hot pressing of milled Ni-Ti-Mo, Ni-Ti-Ta and Ni-Ti-Mo-Zr powders contributed for obtainment of homogeneous structures containing amounts of pores lower than 1%. In Ni-45Ti-5Mo and Ni-40Ti-10Mo alloys, the NiTi compound was identified in structure of both the alloys while that the Ni3Ti and NiTi2 were formed in microstructures of the Ni-45Ti-5Mo and Ni-40Ti-10Mo, respectively. These intermetallic phases dissolved molibdenum contents lower than 2.1 at-%. Moreover, it was noted the presence of Mo-rich precipitates with contents close to 16Ni-25Ti-59Mo (at-%). No significant variation of average Vickers hardness values was noted in Ni-Ti-Mo alloys for increased Mo addition up to 10 at-%. In Ni-Ti-Ta alloys, the NiTi and Ni3Ti phases were formed in microstructures of the hot-pressed Ni-48Ti-2Ta and Ni-45Ti-5Ta alloys, while that the Ni3Ti phase was found in ... (Complete abstract click electronic access below)Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES

Preparation of Ni-Ti-Mo and Ni-Ti-Mo-Zr Alloys by High-Energy Ball Milling and Subsequent Hot Pressing

This work discusses on the preparation of Ni-45Ti-5Mo, Ni-40Ti-10Mo and Ni-46Ti-2Mo-2Zr (at-%) alloys by high-energy ball milling and hot pressing, which are potentially attractive for dental and medical applications. The milling process was performed in stainless steel balls (19mm diameter) and vials (225 mL) using a rotary speed of 300rpm and a ball-to-powder weight ratio of 10:1. Hot pressing under vacuum was performed in a BN-coated graphite crucible at 900 degrees C for 1 h using a load of 20 MPa. The milled and hot-pressed materials were characterized by X-ray diffraction, electron scanning microscopy, and electron dispersive spectrometry. Peaks of B2-NiTi and Ni4Ti3 were identified in XRD patterns of Ni-45Ti-5Mo, Ni-40Ti-10Mo and Ni-46Ti-2Mo-2Zr powders milled for 1h. The NiTi compound dissolved small Mo amounts lower than 4 at%, which were measured by EDS analysis. Moreover, it was identified the existence of an unknown Mo-rich phase in microstructures of the hot-pressed Ni-Ti-Mo alloys

Immunocompromised patients with acute respiratory distress syndrome: Secondary analysis of the LUNG SAFE database

Background: The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients. Methods: We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents. Results: Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p &lt; 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27.1% vs 18.6%; p &lt; 0.0001). Use of noninvasive ventilation (NIV) as first-line treatment was higher in immunocompromised patients (20.9% vs 15.9%; p = 0.0048), and immunodeficiency remained independently associated with the use of NIV after adjustment for confounders. Forty-eight percent of the patients treated with NIV were intubated, and their mortality was not different from that of the patients invasively ventilated ab initio. Conclusions: Immunosuppression is frequent in patients with ARDS, and infections are the main risk factors for ARDS in these immunocompromised patients. Their management differs from that of immunocompetent patients, particularly the greater use of NIV as first-line ventilation strategy. Compared with immunocompetent subjects, they have higher mortality regardless of ARDS severity as well as a higher frequency of limitation of life-sustaining measures. Nonetheless, nearly half of these patients survive to hospital discharge. Trial registration: ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013

Outcomes of Patients Presenting with Mild Acute Respiratory Distress Syndrome Insights from the LUNG SAFE Study

BACKGROUND: Patients with initial mild acute respiratory distress syndrome are often underrecognized and mistakenly considered to have low disease severity and favorable outcomes. They represent a relatively poorly characterized population that was only classified as having acute respiratory distress syndrome in the most recent definition. Our primary objective was to describe the natural course and the factors associated with worsening and mortality in this population. METHODS: This study analyzed patients from the international prospective Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) who had initial mild acute respiratory distress syndrome in the first day of inclusion. This study defined three groups based on the evolution of severity in the first week: "worsening" if moderate or severe acute respiratory distress syndrome criteria were met, "persisting" if mild acute respiratory distress syndrome criteria were the most severe category, and "improving" if patients did not fulfill acute respiratory distress syndrome criteria any more from day 2. RESULTS: Among 580 patients with initial mild acute respiratory distress syndrome, 18% (103 of 580) continuously improved, 36% (210 of 580) had persisting mild acute respiratory distress syndrome, and 46% (267 of 580) worsened in the first week after acute respiratory distress syndrome onset. Global in-hospital mortality was 30% (172 of 576; specifically 10% [10 of 101], 30% [63 of 210], and 37% [99 of 265] for patients with improving, persisting, and worsening acute respiratory distress syndrome, respectively), and the median (interquartile range) duration of mechanical ventilation was 7 (4, 14) days (specifically 3 [2, 5], 7 [4, 14], and 11 [6, 18] days for patients with improving, persisting, and worsening acute respiratory distress syndrome, respectively). Admissions for trauma or pneumonia, higher nonpulmonary sequential organ failure assessment score, lower partial pressure of alveolar oxygen/fraction of inspired oxygen, and higher peak inspiratory pressure were independently associated with worsening. CONCLUSIONS: Most patients with initial mild acute respiratory distress syndrome continue to fulfill acute respiratory distress syndrome criteria in the first week, and nearly half worsen in severity. Their mortality is high, particularly in patients with worsening acute respiratory distress syndrome, emphasizing the need for close attention to this patient population.status: publishe

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p&lt;0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p&lt;0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status