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

Bioeconomic evaluation of beef cow-calf systems intensified with pasture irrigation

A cria é a etapa de menor eficiência biológica devido ao alto custo energético de mantença da vaca. Além disso, é um sistema que depende basicamente de tecnologias de processos, pois o uso de insumos não produz grandes impactos na produtividade final. Contudo, em decorrência da maior concorrência pelo uso de terras, a cria também passa por questionamentos com relação ao uso de processos mais intensivos de produção. Neste contexto, uma das formas de aumentar a produtividade é mantendo mais estável a produção de forragens, favorecendo variedades de elevado potencial de crescimento (p.e., capim sudão), sendo isto possível através do uso da irrigação de pastagens, que também ajuda a mitigar os efeitos dos fenômenos climáticos como El Niño Oscilação Sul. No entanto, a intensificação pode ter algumas desvantagens, frequentemente associadas a um maior consumo de insumos. Portanto, acima de um certo nível de intensificação, questiona-se o potencial de mitigação das mudanças climáticas sobre o aumento de produtividade. Assim, a proposta deste estudo foi desenvolver um modelo de simulação para avaliar os efeitos da intensificação em sistemas de cria, utilizando níveis de produção de energia por meio de pastagens cultivadas e a irrigação, sobre parâmetros bioeconômicos. A análise do sistema e sua síntese, através da relação dos submodelos de produção de energia, estrutura de rebanho, exigências de energia dos animais e o econômico, permitiu entender as respostas da intensificação sobre parâmetros bioeconômicos Este estudo revela que a intensificação com irrigação pode aumentar a produtividade em 66%, intensificando no máximo 20% da área. Isto considerando os efeitos dos eventos climáticos que podem ocorrer nos sistemas de produção em um horizonte de 10 anos. Não obstante, os impactos biofísicos não compensaram o custo total associado à produção, indicando a descapitalização do sistema ao longo do tempo. Contudo, a irrigação minimizou o risco econômico, frente às mudanças climáticas, ao estabilizar a produção de energia no sistema. Em um contexto holístico do sistema, os resultados supracitados podem sinalizar outras perspectivas sobre a configuração deste sistema de produção. A primeira é a necessidade de avaliar as respostas bioeconômicas da intensificação, exclusivamente, no complexo campo natural. A segunda, avaliar a intensificação integrando outras fases produtivas de melhor eficiência biológica. como a recria, a terminação ou o ciclo completo. E a terceira, avaliar cenários alternativos que aumentam a eficiência bioeconômica da cria por meio de relações de eficiência entre o custo da terra, o custo de produção, a produção por área e o preço do produto.Cow-calf production is the least biologically efficient stage due to the high energy cost of maintaining the cow. In addition, it is a system that depends basically on process technologies, since the use of inputs does not produce great impacts on the final productivity. However, because of the greater competition for land use, the cow-calf production systems are being pressured to further intensify its production processes. In this context, one of the ways is to keep pasture production more stable, favoring varieties with high potential growth (e.g., sudangrass). This is possible through pasture irrigation, which also helps to mitigate the effects of climatic phenomena as El Niño Southern Oscillation. However, intensification may have some drawbacks, often associated with increased consumption of inputs. Therefore, above a certain level of intensification, the potential of climate change mitigation on productivity increase is questioned. Thus, the proposal of this study was to develop a simulation model to evaluate the effects of intensification in a cow-calf production system, using levels of energy production through cultivated pastures and irrigation, on bioeconomic parameters. The analysis of the system and its synthesis, through the relation of submodels energy production, herd structure, animal energy requirements and economic, allowed to understand the intensification responses on bioeconomic parameters. This study reveals that intensification with irrigation can increase productivity by 66%, intensifying at most 20% of the area This considering the effects of climatic events that can occur in production systems over a 10-year horizon. However, these biophysical impacts could not afford the total cost associated with production, indicating the decapitalization of the system over time. Although, in this situation, irrigation proved to minimize the economic risk to climate change by stabilizing the energy production in the system. In a holistic ownership context, the above results may be signaling other perspectives on the configuration of the production system. The first is the need to evaluate the bioeconomic responses of intensification, exclusively, in the complex natural grassland. The second is to evaluate intensification by integrating other productive phases of better biological efficiency, such as rearing, finishing or whole cycle. And third, to evaluate alternative scenarios that increase the bioeconomic efficiency of the cow-calf through efficiency relations between the cost of land, the cost of production, the production per area and the price of the product

Effect of supplementation on growth and development of brangus heifers

O objetivo deste estudo foi avaliar a resposta de crescimento e desenvolvimento tecidual de gordura e músculo, através de medidas seriadas obtidas por ultrassom em fêmeas Brangus após desmama, até os 16 meses de idade em diferentes manejos alimentares. O trabalho envolveu 43 fêmeas da raça Brangus. No início do estudo os animais apresentavam uma média de peso vivo (PV) ajustado aos 205 dias de idade de 172.9 ± 18.45 kg e foram distribuídos aleatoriamente em quatro tratamentos de manejo alimentar (MA). O tratamento 1 (T1, n = 9) com média de PV e erro padrão de 160.1 ± 2.5 kg, respectivamente. O tratamento 2 (T2, n = 9) 158.1 ± 4.4 kg, tratamento 3 (T3, n = 9) 167.3 ± 3.8 kg e tratamento 4 (T4, n = 16) 170.8 ± 3.6 kg. As características peso vivo, área do músculo longissimus (AOL) e espessura de gordura subcutânea (EGS) foram mensuradas dos 205 até os 485 dias de idade, enquanto que espessura de gordura na picanha (EGP) foi mensurada dos 261 até os 485 dias de idade. O peso vivo, AOL, EGS e EGP foram avaliados a cada 56 dias. O ganho médio diário (GMD) de PV apresentou uma grande influência no crescimento e na deposição dos tecidos muscular e adiposo, sendo necessários ganhos acima de 0.566 kg/dia, para que possa ocorrer o crescimento destes tecidos. A deposição de gordura de cobertura pode ser comprometida em animais que experimentam ganhos médios diários menores que 0.401 kg/dia na fase de recria, culminando com perda de escore corporal. Nas condições deste estudo, o manejo alimentar T4 mostrou impacto no aumento do peso vivo e deposição tecidual de gordura e músculo aos 16 meses de idade. O manejo alimentar com suplementação energética diária por um período de 112 dias durante o inverno sob condições de pastoreio, afetou positivamente a percentagem do peso vivo maduro aos 16 meses de idade, o crescimento e o desenvolvimento da área do músculo longissimus, espessura de gordura na costela e espessura de gordura na picanha. As magnitudes das taxas de ganho de peso vivo são determinantes na deposição tecidual de gordura e músculo. A ultrassonografia em tempo real é uma tecnologia que pode ser utilizada para estimar o desenvolvimento tecidual da gordura e músculo com medidas repetidas no tempo, para ser utilizada como ferramenta de manejo e método de seleção de novilhas de reposição para obtenção de eficiência no sistema de produção.The objective of this study was to evaluate the growth and tissue development of fat and muscle through serial measurements obtained by ultrasound in Brangus females after weaning until 16 months of age under different feeding management. The study involved 43 Brangus breed females. At the begin of study the animals had an average body weight (BW) set at 205 days of age of 172.9 ± 18.45 kg and were randomized into four feeding management treatments (MA). Treatment 1 (T1, n = 9) with an average of BW and standard error of 160.1 ± 2.5 kg, respectively. Treatment 2 (T2, n = 9) 158.1 ± 4.4 kg, treatment 3 (T3, n = 9) 167.3 ± 3.8 kg and Treatment 4 (T4 n = 16) 170.8 ± 3.6 kg. The characteristics BW, rib eye area (REA), back fat thickness (BF), were measured from 205 to 485 days of age, while rump fat (RF) was measured from 261 to 485 days age. Body weight, REA, BF and RF were evaluated every 56 days. The average daily gain (ADG) had a strong influence on growth and deposition of muscle and fat tissues, requiring gains above of 0.566 kg/day, to occur growth of these tissues. The deposition of fat cover may be compromised in animals with average daily gain lower than 0.401 kg/day in the growing phase, culminating in loss of body score condition. In our study, feeding management T4 showed impact on the increase of body weight and tissue deposition of fat and muscle to 16 months of age. The feeding regime with daily energy supplementation for a period of 112 days during the winter under grazing conditions, positively affected the percentage of mature body weight at 16 months of age, growth and development of rib eye area, back fat thickness and rump fat. The magnitudes of live weight gain rates are crucial in tissue deposition of fat and muscle. The real-time ultrasound is a technology that can be used to estimate the tissue development of fat and muscle with repeated measures over time, to be used as a management tool and replacement heifer selection method for obtaining efficient production system

Effect of supplementation on growth and development of brangus heifers

O objetivo deste estudo foi avaliar a resposta de crescimento e desenvolvimento tecidual de gordura e músculo, através de medidas seriadas obtidas por ultrassom em fêmeas Brangus após desmama, até os 16 meses de idade em diferentes manejos alimentares. O trabalho envolveu 43 fêmeas da raça Brangus. No início do estudo os animais apresentavam uma média de peso vivo (PV) ajustado aos 205 dias de idade de 172.9 ± 18.45 kg e foram distribuídos aleatoriamente em quatro tratamentos de manejo alimentar (MA). O tratamento 1 (T1, n = 9) com média de PV e erro padrão de 160.1 ± 2.5 kg, respectivamente. O tratamento 2 (T2, n = 9) 158.1 ± 4.4 kg, tratamento 3 (T3, n = 9) 167.3 ± 3.8 kg e tratamento 4 (T4, n = 16) 170.8 ± 3.6 kg. As características peso vivo, área do músculo longissimus (AOL) e espessura de gordura subcutânea (EGS) foram mensuradas dos 205 até os 485 dias de idade, enquanto que espessura de gordura na picanha (EGP) foi mensurada dos 261 até os 485 dias de idade. O peso vivo, AOL, EGS e EGP foram avaliados a cada 56 dias. O ganho médio diário (GMD) de PV apresentou uma grande influência no crescimento e na deposição dos tecidos muscular e adiposo, sendo necessários ganhos acima de 0.566 kg/dia, para que possa ocorrer o crescimento destes tecidos. A deposição de gordura de cobertura pode ser comprometida em animais que experimentam ganhos médios diários menores que 0.401 kg/dia na fase de recria, culminando com perda de escore corporal. Nas condições deste estudo, o manejo alimentar T4 mostrou impacto no aumento do peso vivo e deposição tecidual de gordura e músculo aos 16 meses de idade. O manejo alimentar com suplementação energética diária por um período de 112 dias durante o inverno sob condições de pastoreio, afetou positivamente a percentagem do peso vivo maduro aos 16 meses de idade, o crescimento e o desenvolvimento da área do músculo longissimus, espessura de gordura na costela e espessura de gordura na picanha. As magnitudes das taxas de ganho de peso vivo são determinantes na deposição tecidual de gordura e músculo. A ultrassonografia em tempo real é uma tecnologia que pode ser utilizada para estimar o desenvolvimento tecidual da gordura e músculo com medidas repetidas no tempo, para ser utilizada como ferramenta de manejo e método de seleção de novilhas de reposição para obtenção de eficiência no sistema de produção.The objective of this study was to evaluate the growth and tissue development of fat and muscle through serial measurements obtained by ultrasound in Brangus females after weaning until 16 months of age under different feeding management. The study involved 43 Brangus breed females. At the begin of study the animals had an average body weight (BW) set at 205 days of age of 172.9 ± 18.45 kg and were randomized into four feeding management treatments (MA). Treatment 1 (T1, n = 9) with an average of BW and standard error of 160.1 ± 2.5 kg, respectively. Treatment 2 (T2, n = 9) 158.1 ± 4.4 kg, treatment 3 (T3, n = 9) 167.3 ± 3.8 kg and Treatment 4 (T4 n = 16) 170.8 ± 3.6 kg. The characteristics BW, rib eye area (REA), back fat thickness (BF), were measured from 205 to 485 days of age, while rump fat (RF) was measured from 261 to 485 days age. Body weight, REA, BF and RF were evaluated every 56 days. The average daily gain (ADG) had a strong influence on growth and deposition of muscle and fat tissues, requiring gains above of 0.566 kg/day, to occur growth of these tissues. The deposition of fat cover may be compromised in animals with average daily gain lower than 0.401 kg/day in the growing phase, culminating in loss of body score condition. In our study, feeding management T4 showed impact on the increase of body weight and tissue deposition of fat and muscle to 16 months of age. The feeding regime with daily energy supplementation for a period of 112 days during the winter under grazing conditions, positively affected the percentage of mature body weight at 16 months of age, growth and development of rib eye area, back fat thickness and rump fat. The magnitudes of live weight gain rates are crucial in tissue deposition of fat and muscle. The real-time ultrasound is a technology that can be used to estimate the tissue development of fat and muscle with repeated measures over time, to be used as a management tool and replacement heifer selection method for obtaining efficient production system

Average daily gain rates determine eye muscle area and rump fat depth of beef heifers

In cow-calf beef production systems, the growth and development of replacement heifers deserve special attention because they affect the age at puberty and the onset of reproductive activity. Therefore, the objective of this study was to test if changes in average daily gain (ADG) have an effect on eye muscle area, rump fat depth and back-fat thickness in developing beef heifers. These traits of 42 beef heifers were measured over time. The results of the current study allow inferring that heifers older than 385 days and with high rates of ADG (above 0.950 kg per day) have the greatest impact on longissimus muscle area growth (above 57 cm2). On the other hand, it is observed that younger heifers (less than 230 days old) do not exceed 48 cm2 of the longissimus muscle area, even with ADGs around 1.25 kg. A positive relationship between the rate of ADG and rump fat depth was also evidenced, observing that rump fat depth deposition is influenced by the rate of ADG. The results of the current study show a linear trajectory of rump fat depth, indicating that for every 0.10 kg of ADG during a period exceeding 56 days, an increase of 1.09 mm of rump fat depth occurs. In conclusion, this study illustrates a simple way on how ADG and age affect the body composition traits in beef heifers and shows that changes in average daily gain affect muscle and fat tissue growth, as determined by longissimus muscle area and rump fat depth in growing beef heifers

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