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

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

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\ub74% vs 44\ub72%; absolute difference \u20131\ub769 [\u20139\ub758 to 6\ub711] p=0\ub767; 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\u20138] vs 6 [5\u20138] cm H2O; p=0\ub70011). ICU mortality was higher in MICs than in HICs (30\ub75% vs 19\ub79%; p=0\ub70004; adjusted effect 16\ub741% [95% CI 9\ub752\u201323\ub752]; p&lt;0\ub70001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0\ub780 [95% CI 0\ub775\u20130\ub786]; p&lt;0\ub70001). 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. Funding: No funding

The chaos in calibrating crop models

Calibration, the estimation of model parameters based on fitting the model to experimental data, is among the first steps in many applications of system models and has an important impact on simulated values. Here we propose and illustrate a novel method of developing guidelines for calibration of system models. Our example is calibration of the phenology component of crop models. The approach is based on a multi-model study, where all teams are provided with the same data and asked to return simulations for the same conditions. All teams are asked to document in detail their calibration approach, including choices with respect to criteria for best parameters, choice of parameters to estimate and software. Based on an analysis of the advantages and disadvantages of the various choices, we propose calibration recommendations that cover a comprehensive list of decisions and that are based on actual practices.HighlightsWe propose a new approach to deriving calibration recommendations for system modelsApproach is based on analyzing calibration in multi-model simulation exercisesResulting recommendations are holistic and anchored in actual practiceWe apply the approach to calibration of crop models used to simulate phenologyRecommendations concern: objective function, parameters to estimate, software usedCompeting Interest StatementThe authors have declared no competing interest

Long Term Effects of Tillage&ndash;Crop Rotation Interaction on Soil Organic Carbon Pools and Microbial Activity on Wheat-Based System in Mediterranean Semi-Arid Region

Conservation agriculture based on no-tillage (NT) and crop rotation allows to enhance soil health. Based on data collected from long-term trials in a semi-arid region of Tunisia, results showed that NT increased significantly soil organic carbon stock (SOCS), soil microbial biomass carbon (SMBC), arbuscular mycorrhizal fungal (AMF) root colonization, and soil microbial respiration (CO2) at 0&ndash;20 cm topsoil layer compared to conventional tillage (CT). Moreover, triennial rotation (TRI), based on annual succession of Faba bean-Durum wheat-Barley, and biennial rotation (BI), based on annual succession of Faba bean-Durum wheat, increased significatively SMBC, AMF, and CO2. Likewise, a significant benefit of the two-way interactions Tillage &times; Rotation was observed. Furthermore, NT combined with TRI recorded the highest SOCS (2181 g C m&minus;2), SMBC (515 mg C kg&minus;1 soil), AMF (14%), and CO2 which is an indicator of soil microbial respiration (1071 mg CO2 kg&minus;1 soil). The current results highlight the benefit adoption of minimum or (NT)combined with crop diversification on soil health

Long Term Effects of Tillage–Crop Rotation Interaction on Soil Organic Carbon Pools and Microbial Activity on Wheat-Based System in Mediterranean Semi-Arid Region

Conservation agriculture based on no-tillage (NT) and crop rotation allows to enhance soil health. Based on data collected from long-term trials in a semi-arid region of Tunisia, results showed that NT increased significantly soil organic carbon stock (SOCS), soil microbial biomass carbon (SMBC), arbuscular mycorrhizal fungal (AMF) root colonization, and soil microbial respiration (CO2) at 0–20 cm topsoil layer compared to conventional tillage (CT). Moreover, triennial rotation (TRI), based on annual succession of Faba bean-Durum wheat-Barley, and biennial rotation (BI), based on annual succession of Faba bean-Durum wheat, increased significatively SMBC, AMF, and CO2. Likewise, a significant benefit of the two-way interactions Tillage × Rotation was observed. Furthermore, NT combined with TRI recorded the highest SOCS (2181 g C m−2), SMBC (515 mg C kg−1 soil), AMF (14%), and CO2 which is an indicator of soil microbial respiration (1071 mg CO2 kg−1 soil). The current results highlight the benefit adoption of minimum or (NT)combined with crop diversification on soil health

Effect of Wheat Monoculture on Durum Wheat Yield under Rainfed Sub-Humid Mediterranean Climate of Tunisia

Cultivating cereals in monoculture systems contributes to the decrease in grain yield and quality. Currently, under Mediterranean climate conditions of Tunisia, wheat mono-cropping covers more than 70% of cereal areas. In order to reveal the impact of this practice on cereal productivity, five improved durum wheat cultivars (Karim, Khiar, Om Rabiaa, Razzek, and Maali) were conducted under two conditions of previous wheat crop: one-year wheat previous crop (W) and two successive years (W-W). Then, they were assessed for grain yield (GY), yield components (NKS, TKW, NS), straw yield, harvest index (SY, HI), and grain quality parameters during three consecutive cropping seasons (2017, 2018, and 2019). The results showed significant effects of cropping season for all measured parameters, except thousand kernel weight (TKW). A significant effect (p −1) more than after two years (W-W) (3277.3 kg ha−1). Our results show that, based on the three-year experiment, almost all yield related traits were significantly affected by the genotype except HI and NS. The highest GYs were recorded for Om Rabiaa (4010.4 kg ha−1) and Nasr (3765.76 kg ha−1). All grain quality was significantly (p < 0.05) affected by cropping season, but only gluten content (GC) and vitreousness aspect (Vit A) were affected by genotype. On the other hand, the Pre-Crop W-W decreased grain protein concentration (GPC) (12.13%) and GC (22.14%) but no significant effect was observed on the Vit A of grain in our study. Furthermore, GY was positively correlated with HI (r = 0.64), NKS (r = 0.59), SN (r = 0.49), GPC (r = 0.23), and GC (r = 0.23). According to stability analysis, the Karim cultivar is the most stable genotype in wheat mono-cropping for GY and straw yield (SY). Altogether, this study provides useful information for farmers on how to produce a satisfactory yield for durum wheat cultivation under mono-cropping wheat conditions in the sub-humid environment of the Mediterranean climate of Tunisia

Proposal and extensive test of a calibration protocol for crop phenology models

A major effect of environment on crops is through crop phenology, and therefore, the capacity to predict phenology for new environments is important. Mechanistic crop models are a major tool for such predictions, but calibration of crop phenology models is difficult and there is no consensus on the best approach. We propose an original, detailed approach for calibration of such models, which we refer to as a calibration protocol. The protocol covers all the steps in the calibration workflow, namely choice of default parameter values, choice of objective function, choice of parameters to estimate from the data, calculation of optimal parameter values, and diagnostics. The major innovation is in the choice of which parameters to estimate from the data, which combines expert knowledge and data-based model selection. First, almost additive parameters are identified and estimated. This should make bias (average difference between observed and simulated values) nearly zero. These are "obligatory" parameters, that will definitely be estimated. Then candidate parameters are identified, which are parameters likely to explain the remaining discrepancies between simulated and observed values. A candidate is only added to the list of parameters to estimate if it leads to a reduction in BIC (Bayesian Information Criterion), which is a model selection criterion. A second original aspect of the protocol is the specification of documentation for each stage of the protocol. The protocol was applied by 19 modeling teams to three data sets for wheat phenology. All teams first calibrated their model using their "usual" calibration approach, so it was possible to compare usual and protocol calibration. Evaluation of prediction error was based on data from sites and years not represented in the training data. Compared to usual calibration, calibration following the new protocol reduced the variability between modeling teams by 22% and reduced prediction error by 11%