Objective: Mechanical power (MP) is a promising parameter that may guide lung-protective ventilation strategies. The MP equation encompasses all variables involved in the pathogenesis of ventilator-induced lung injury (VILI), as well as the inspiratory-to-expiratory (I:E) ratio. Shortening the inspiratory time-by altering the I:E ratio-increases gas flow and may lead to lung injury. The optimal I:E ratio for preventing VILI remains uncertain. The present study aimed to investigate the effects of different I:E ratios on inspiratory gas flow and MP in patients with acute respiratory distress syndrome (ARDS). Materials and Methods: This study was conducted on 19 adult patients diagnosed with moderate ARDS who were admitted to the intensive care unit and received mechanical ventilation. Patients were ventilated at a PEEP level of 10 cmH2O, a tidal volume of 6 mL/kg, and three sequentially applied I:E ratios (1:2, 1:1, and 1.5:1), each maintained for 10 minutes. MP and respiratory parameters across the three I:E groups were compared using repeated-measures ANOVA. Results: Compared with the I:E ratio of 1:2, ventilation with an I:E ratio of 1:1 resulted in slower inspiratory gas flow, lower inspiratory resistance and peak inspiratory pressure, higher dynamic compliance, and lower MP values. Plateau pressure and driving pressure did not differ significantly. When comparing I:E 1:1 with I:E 1.5:1, a persistent slowing of inspiratory gas flow was observed, but no significant difference in MP was detected. Conclusion: In patients with ARDS, transitioning the I:E ratio from the conventional 1:2 to 1:1 or 1.5:1 resulted in progressively slower inspiratory gas flow and lower resistive and total mechanical power, suggesting that reducing inspiratory flow may enhance lung-protective ventilation.

This study aims to develop the most accurate machine learning model to predict the success of ventilator weaning by classifying weaning trials and identifying the most influential predictive parameters. To classify weaning trials, a novel hybrid bagged light gradient boosting machine model (B-LGBM) was developed, trained, and validated using dataset collected from a cohort of 3,215 patients over a monitoring period of the last 1-hour record prior to the patient’s attempt to wean from the ventilator in the intensive care unit (ICU) employing a bagging approach. The dataset encompasses a total of 69 features, including demographic data, clinical indicators, ventilator settings, respiratory parameters, and patient outcomes. Model performance was evaluated based on accuracy, precision, recall, F1-score, specificity, and area under the receiver operating characteristic curve (AUC-ROC). Results revealed that the B-LGBM model outperformed other algorithms, achieving an AUC-ROC of 91.45%, accuracy of 89.08%, precision of 95.64%, and specificity of 83.33%. Key predictive parameters for successful weaning included pulse oximetry saturation, fraction of inspired oxygen, respiratory rate, expiratory minute volume, total ventilated hours, peak pressure, and partial pressure of arterial carbon dioxide. Accurate weaning predictions with a high AUC-ROC rate can be achieved for the clinical decision-making process with the B-LGBM model developed using ensemble techniques.

RATIONALE: A routine clinical practice in adult critically ill patients receiving invasive mechanical ventilation (IMV) may be difficult to define. Our goal was to report updated global, and country-specific estimates of incidence, mortality, and case-fatality rates. METHODS: An observational prospective cohort of consecutive adult patients admitted between October 1, 2022, and April 30, 2023 to 457 intensive care units (ICU) from 42 countries who received IMV longer than 12 hours. Data were collected on each patient at initiation of mechanical ventilation and daily throughout the course of IMV for up to 28 days. RESULTS: During the period of recruitment, 8,350 patients were enrolled. A total of 6,998 patients from lower-middle income countries (1,428 patients), upper-middle countries (1930 patients) and high-income countries (3,640 patients) were included. Patients were predominantly males (63%) with a median age of 64 years (IQR 50,74) and median SAPS3 64 points (IQR 52-77). Main reasons for IMV were: neurologic disease (20%), postoperative respiratory insufficiency (16%), community acquired pneumonia (10%), sepsis (9%), cardiac failure (7%), ARDS (6%), COPD (5%), nosocomial pneumonia (5%), COVID (3%). Ventilator setting registered were: Tidal volume (median, IQR 7.4; 6.6-8.3 ml/kgPBW), plateau pressure (18; 15-22 cmH2O), applied PEEP (6; 5-8 cmH2O), driving pressure (12; 9-15 cmH2O), mechanical power (15.7; 11.9-20.8 joules/min). A lung protective strategy was applied on 79% of monitoring days and an open Lung Approach on 25% of monitoring days. Patients received sedation on 80% of the monitored days, analgesia on 77% and neuromuscular blocking on 9%. Most prevalent complications during the course of mechanical ventilation were sepsis (17%), delirium (14%), ventilator-associated pneumonia (8%), ARDS (8%) and ICU acquired weakness (8%). Other complications as thromboembolic events, tracheobronchitis, bleeding ulcus stress or Clostridium infection had a prevalence lower than 2%. 73% of the patients had at least one organ dysfunction, the most frequent of which were cardiovascular failure (66%), renal failure (24%), hematological failure (12%) and hepatic failure (9%). Comparison of outcomes according to income country is shown in table 1. CONCLUSIONS: After the pandemic COVID-19, we found significant geo-economic differences in the clinical outcomes of critically ill patients requiring IMV. Further adjusted models will provide information about the usual care of mechanically ventilated patients and variables related with poor outcomes.

This retrospective study of 2,624 COVID-19 inpatients treated at Koç University and American Hospital in Istanbul, between March 2020 and April 2022 provides critical insights into factors influencing patient outcomes. The extensive follow-up captured detailed disease progression, essential for optimizing regional treatment strategies and improving patient care during ongoing and future pandemics.Using SPSS and Python for data analysis, we identified risk factors for mortality, including hypertension (p=0.003), coronary artery disease (p<0.001), diabetes mellitus (p=0.013), COPD (p<0.001), chronic kidney disease (p<0.001), active hematological malignancy (p<0.001), active solid cancer (p<0.001), and immunosuppressive treatment (p<0.001).We also assessed markers such as IL-6, procalcitonin, C-reactive protein, and the CRP/PCT ratio for predicting mortality. Procalcitonin emerged as the most reliable predictor of mortality within the first two weeks (AUC: 0.870) and sepsis in the first week (AUC:0.853). Unvaccinated patients had a 2.646-fold higher risk of in-hospital death compared to those with at least one vaccine dose (CI: 1.800-3.890, p<0.001). Partial vaccination was associated with more favorable outcomes (OR: 0.346, CI: 0.191-0.626, p<0.001). Multiple doses of the same vaccine showed the best outcomes (p<0.001), with +3 doses of mixed vaccines being the next best (p=0.048). Notably, 23.8% of patients with +3 Biontech doses had severe/critical disease compared to 50% with +3 Sinovac doses, potentially due to selection bias. These findings underscore the importance of personalized care and strategic vaccination in managing COVID-19. By identifying early mortality predictors and analyzing vaccination effects, this study aids in improving outcomes for COVID-19 patients in Turkey and beyond.

The trend over time and across different geographical areas of outcomes and management with noninvasive ventilation or invasive mechanical ventilation in patients admitted for acute exacerbations of chronic obstructive pulmonary disease and treated with ventilatory support is unknown. The purpose of this study was to describe outcomes and identify variables associated with survival for patients admitted to an intensive care unit (ICU) with acute exacerbation of chronic obstructive pulmonary disease [aeCOPD] who received noninvasive or invasive mechanical ventilation worldwide. Retrospective, multi-national, and multicenter studies, including four observational cohort studies, were carried out in 1998, 2004, 2010, and 2016 for the VENTILAGROUP following the same methodology. A total of 1,848 patients from 1,253 ICUs in 38 countries admitted for aeCOPD and need of ventilatory support were identified in the four study cohorts and included in the study. The overall incidence of aeCOPD as a cause for ventilatory support at ICU admission significantly decreased over time and varied widely according to the gross national income. The mortality of patients admitted to ICU for aeCOPD and ventilatory support significantly decreased over time regardless of the geographical area and gross national income; however, there is a remarkable variability in ICU mortality according to geographical area and gross national income. The use of NPPV as the first attempt at ventilatory support has significantly increased over time, with a parallel reduction of invasive mechanical ventilation regardless of gross national income. In this worldwide observational study, including four sequential cohorts of patients over 18 years from 1998 to 2016, the mortality of patients admitted to ICU for aeCOPD and ventilatory support significantly decreased regardless of the geographical area and gross national income. Future research will need to investigate the reason for the remarkable variability in ICU mortality according to the geographical area, gross national income, and methods to select patients for the appropriate ventilatory support.

BACKGROUND Mechanical power (MP) is the amount of energy transferred from the ventilator to the patient within a unit of time. It has been emphasized in ventilation-induced lung injury (VILI) and mortality. However, its measurement and use in clinical practice are challenging. "Electronic recording systems (ERS)" using mechanical ventilation parameters provided by the ventilator can be helpful to measure and record the MP. The MP (J/minutes) formula is 0.098 x tidal volume x respiratory rate x (Ppeak - ½ ∆P), in which ∆P is the driving pressure and Ppeak is the peak pressure. We aimed to define the association between MP values and ICU mortality, mechanical ventilation days, and intensive care unit length of stay (ICU-LOS). The secondary outcome was to determine the most potent or essential component of power in the equation that has a role in mortality. METHODS This retrospective study was performed in two centers (VKV American Hospital and Bakırköy Sadi Konuk Hospital ICUs) that used ERS (Metavision IMDsoft) between 2014 and 2018. We uploaded the power formula (MP (J/minutes)=0.098×VT×RR×(Ppeak - ½ ∆P) to ERS (METAvision, iMDsoft, and Consult Orion Health) and calculated the MP value by using MV parameters automatically sent from the ventilator. (∆P; driving pressure, VT; tidal volume, RR; respiratory rate and Ppeak; peak pressure). RESULTS A total of 3042 patients were included in the study. The median value of MP was 11.3 J/min. Mortality in MP<11.3 J/min was 35.4%, and 49.1% in MP>11.3J/min.; P<0.001. Mechanical ventilation days and ICU-LOS were also statistically longer in the MVP>11.3 J/min group. CONCLUSIONS The first 24 h MP maybe a predictive value for the ICU patients' prognosis. This implies that MP may be used as a decision-making system to define the clinical approach and as a scoring system to predict patient prognosis.

We described the secondary bacterial infections (SBI) among COVID-19 patients in comparison with non-COVID-19 patients. We performed a retrospective case–control study between January 01, 2020 and April 01, 2022. Including the adult patients, who stayed ≥ 72 h in intensive care unit (ICU). In total 405 patients were included, 135 had (33.3%) COVID-19, with similar age and gender. The length of stay in ICU was not different (11.4 vs 8.2, p = 0.109), however mean intubation days were higher among COVID-19 cases (6.5 vs 3.8, p = 0.005), SBI were more common among COVID-19 cases (34% vs 10.7%, p < 0.001). Among the patients with pneumonia, the rate of gram-positive bacteria was higher in COVID-19 group than the control group (39% vs 5%, p = 0.006). The predictors for SBI were having COVID-19 (OR: 2.3, Cl 1.25–4.32, p = 0.008), days of intubation (OR: 1.05, Cl 1.01–1.10, p = 0.004), and being male (OR: 2, Cl 1.12–3.58, p = 0.018). The predictors of mortality were COVID-19 (OR: 2.38, Cl 1.28–4.42, p = 0.006), days of intubation (OR: 1.06, Cl 1.03–1.09, p < 0.001), active hematologic malignancy (OR: 3.1, Cl: 1.33–7.28, p = 0.09), active solid tumors (OR: 2.44, Cl 1.21–4.91, p = 0.012), and coronary artery diseases (OR: 1.8, Cl 1.01–3.52, p = 0.045). The most common SBI in COVID-19 patients were methicillin-sensitive Staphylococcus aureus. No carbapenem-resistant Enterobacterales related infections were detected in COVID-19 patients.

International collaborative consultations are significantly beneficial in combatting pandemics, although such opportunities were quite limited during the COVID-19 pandemic. We had the chance to convene with the experts to share experiences and review the practices in Kosova. Two days of expert consultation hybrid meeting […]

Despite the need for specific weaning strategies in neurological patients, evidence is generally insufficient or lacking. We aimed to describe the evolution over time of weaning and extubation practices in patients with acute brain injury compared with patients who are mechanically ventilated (MV) due to other reasons. We performed a secondary analysis of three prospective, observational, multicenter international studies conducted in 2004, 2010, and 2016 in adults who had need of invasive MV for more than 12 h. We collected data on baseline characteristics, variables related to management ventilator settings, and complications while patients were ventilated or until day 28. Among the 20,929 patients enrolled, we included 12,618 (60

BACKGROUND:Mechanical power (MP) is a promising tool for guidance of lung protective ventilation. Different equations have been proposed to calculate MP in pressure control ventilation (PCV). The aim of this study is to introduce an easy to use MP equation MPpcv(m-simpl) and compare it to an equation proposed by Van der Meijden et al. (MPpcv) which considered as the reference equation in PCV. METHODS:Ventilatory parameters of 206 Covid-19 ARDS patients recorded between 24-72 hours after admission to intensive care unit. The PCV data from these patients were retrospectively investigated. MP in PCV was calculated with a modified equation (MPpcv(m-simpl)) derived from the equation (MPpcv) of Van der Meijden et al.: 0.098xRRx∆Vx(PEEP+∆Pinsp - 1). The results from MPpcv(slope), MPpcv(simpl), and MPpcv(m-simpl) were compared to MPpcv at 15 cmH2O ∙ s/L inspiratory resistance levels by univariable regression and Bland-Altman analysis. RESULTS:Inspiratory resistance levels at 15 cmH2O s/L was found to be correlated between the power values calculated by MPpcv(simpl)/MPpcv(m-simpl) and the MPpcv(slope)/MPpcv based on univariable logistic regression (R2≥98) analyses. In the comparison of all patients average MP values computed by the MPpcv(m-simpl) equation and the MPpcv reference equation. Bland-Altman analysis mean difference and p values at 15 cmH2O s/L inspiratory resistance values (J/min) were found to be MPpcv(m-simpl) vs MPpcv=-0,04 (P=0.014); MPpcv(slope) vs. MPpcv=0.63 (P<0.0001); MPpcv(simpl) vs. MPpcv=0.64 J/min (P<0.0001), respectively. CONCLUSIONS:The results of this study confirmed that the MPpcv(m-simpl) equation can be used easily to calculate MP at bedside in pressure control ventilated COVID-19 ARDS patients.

We aimed to describe the increased rate of Acinetobacter baumannii infections during the COVID-19 pandemic and define its significance within the last five years. This study was performed in a tertiary hospital with 280 beds and included all patients infected with A. baumannii in the intensive care unit between January 1, 2018, and June 30, 2022. A. baumannii-infected patients in the intensive care unit 27 months before the pandemic and 27 months during the pandemic were included. Pulsed-field gel electrophoresis was performed to assess clonal relatedness. The infection control measures were specified based on the findings and targeted elimination. In total, 5718 patients were admitted to the intensive care unit from January 1st, 2018, to June 30th, 2022. A. baumannii infection was detected in 81 patients. Compared to the pre-pandemic era, the rate of A. baumannii infection during the pandemic was 1.90 times higher (OR: 1.90, 95% CI: [1.197, 3.033]). Clonality assessment of multidrug-resistant A. baumannii samples revealed eight clusters with one main cluster comprising 14/27 isolates between 2021 and 2022. The case fatality rate of the pre-pandemic and pandemic era was not different statistically (83.33% vs. 81.48%, p = 0.835). Univariate analysis revealed the association of mechanical ventilation (p = 0.002) and bacterial growth in tracheal aspirate (p = 0.001) with fatality. During the COVID-19 pandemic, potential deficits in infection control measures may lead to persistent nosocomial outbreaks. In this study, the introduction of enhanced and customized infection control measures has resulted in the containment of an A. baumannii outbreak.

BACKGROUND: The growing proportion of elderly intensive care patients constitutes a public health challenge. The benefit of critical care in these patients remains unclear. We compared outcomes in elderly versus very elderly subjects receiving mechanical ventilation. METHODS: In total, 5,557 mechanically ventilated subjects were included in our post hoc retrospective analysis, a subgroup of the VENTILA study. We divided the cohort into 2 subgroups on the basis of age: very elderly subjects (age >= 80 y; n = 1,430), and elderly subjects (age 65-79 y; n = 4,127). A propensity score on being very elderly was calculated. Evaluation of associations with 28-d mortality was done with logistic regression analysis. RESULTS: Very elderly subjects were clinically sicker as expressed by higher SAPS II scores (53 +/- 18 vs 50 +/- 18, P < .001), and their rates of plateau pressure < 30 cm H2O were higher, whereas other parameters did not differ. The 28-d mortality was higher in very elderly subjects (42% vs 34%, P < .001) and remained unchanged after propensity score adjustment (adjusted odds ratio 1.31 [95% CI 1.16-1.49], P < .001). CONCLUSIONS: Age was an independent and unchangeable risk factor for death in mechanically ventilated subjects. However, survival rates of very elderly subjects were > 50%. Denial of critical care based solely on age is not justified.

Background: COVID-19 can cause a clinical spectrum from asymptomatic disease to life-threatening respiratory failure and acute respiratory distress syndrome (ARDS).There is an ongoing discussion whether the clinical presentation and ventilatory parameters are the same as typical ARDS or not.There is no clear understanding of how the hemodynamic parameters have been affected in COVID-19 ARDS patients. We aimed to compare hemodynamic and respiratory parameters of moderate and severe COVID-19 and non-COVID-19 ARDS patients.These patients were monitored with an advanced hemodynamic measurement system by the transpulmonary thermodilution method in prone and supine positions. Patients and methods: Data of 17 patients diagnosed with COVID-19 and 16 patients diagnosed with other types of diseases with moderate and severe ARDS, mechanically ventilated, placed in a prone position, had advanced hemodynamic measurements with PICCO, and stayed in the intensive care unit for more than a week were analyzed retrospectively. Patient characteristics and arterial blood gases analysis recorded at admission and respiratory and advanced hemodynamic parameters during the first week were compared in prone and supine positions. Results: No difference was observed in the respiratory parameters including respiratory system compliance between COVID-19 and non-COVD-19 patients in prone and supine positions. In comparison of advanced hemodynamic parameters in the first week of intensive care, the extravascular lung water and pulmonary vascular permeability indexes measured in supine position of COVID-19 ARDS patients were found to be significantly higher than non-COVID-19 patients. Duration of prone position was significantly longer in patients diagnosed with COVID-19 ARDS. Conclusions: The results of this study suggested that COVID-19 ARDS is a variant of typical ARDS with a different pathophysiology.

OBJECTIVES:To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality.DESIGN:Secondary analysis of three prospective, observational, multicenter studies.SETTING:Cohort studies conducted in 2004, 2010, and 2016.PATIENTS:Adult patients who received mechanical ventilation for more than 12 hours.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma.CONCLUSIONS:More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease.

BACKGROUND:The risk of muscle weakness is high in the survivors of acute respiratory distress syndrome with COVID-19 following discharge from intensive care unit.AIM:To evaluate the effects of early rehabilitation program in intensive care unit in patients with acute respiratory distress syndrome secondary to COVID-19.DESIGN:The design of the study is observational.SETTING:The setting of the study is inpatient.POPULATION:Thirty-five patients with acute respiratory distress syndrome secondary to COVID-19 were enrolled.METHODS:This study was performed in an intensive care unit of a university hospital. Early rehabilitation program consisting of passive or active range of motion exercises and neuromuscular electrical stimulation in addition to standard intensive care (N.=18) compared to standard intensive care (N.=17). Primary outcome was hand grip strength following discharge.RESULTS:Rehab group had higher prevalence of chronic pulmonary diseases and neurologic diseases. There was no difference in hand grip or manual muscle strength following discharge between rehab and non-rehab groups. No adverse event was noted.CONCLUSIONS:The results did not support the beneficial effects of early rehabilitation in intensive care unit on improving muscle strength. More patients with pulmonary and neurologic diseases in rehab group might impede the impact of rehabilitation on outcomes. On the other hand, these comorbidities underline the role and need of rehabilitation. It is safe both for the patients and the health care workers when necessary precautions are taken.CLINICAL REHABILITATION IMPACT:This study guide how to rehabilitate patients with acute respiratory distress syndrome with COVID-19 during intensive care unit in a safe way.

BACKGROUND:We aimed to assess the feasibility and short-term clinical outcomes of surgical procedures for cancer at an institution using a coronavirus disease 2019 (COVID-19)-free surgical pathway during the peak phase of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.MATERIALS AND METHODS:This was a single-center study, including cancer patients from all surgical departments, who underwent elective surgical procedures during the first peak phase between March 10 and June 30, 2020. The primary outcomes were the rate of postoperative SARS-CoV-2 infection and 30-day pulmonary or non-pulmonary related morbidity and mortality associated with SARS-CoV-2 disease.RESULTS:Four hundred and four cancer patients fulfilling inclusion criteria were analyzed. The rate of patients who underwent open and minimally invasive procedures was 61.9% and 38.1%, respectively. Only one (0.2%) patient died during the study period due to postoperative SARS-CoV2 infection because of acute respiratory distress syndrome. The overall non-SARS-CoV2 related 30-day morbidity and mortality rates were 19.3% and 1.7%, respectively; whereas the overall SARS-CoV2 related 30-day morbidity and mortality rates were 0.2% and 0.2%, respectively.CONCLUSIONS:Under strict institutional policies and measures to establish a COVID-19-free surgical pathway, elective and emergency cancer operations can be performed with acceptable perioperative and postoperative morbidity and mortality.

Background Mechanical Ventilation (MV) is a complex and central treatment process in the care of critically ill patients. It influences acid–base balance and can also cause prognostically relevant biotrauma by generating forces and liberating reactive oxygen species, negatively affecting outcomes. In this work we evaluate the use of a Recurrent Neural Network (RNN) modelling to predict outcomes of mechanically ventilated patients, using standard mechanical ventilation parameters. Methods We performed our analysis on VENTILA dataset, an observational, prospective, international, multi-centre study, performed to investigate the effect of baseline characteristics and management changes over time on the all-cause mortality rate in mechanically ventilated patients in ICU. Our cohort includes 12,596 adult patients older than 18, associated with 12,755 distinct admissions in ICUs across 37 countries and receiving invasive and non-invasive mechanical ventilation. We carry out four different analysis. Initially we select typical mechanical ventilation parameters and evaluate the machine learning model on both, the overall cohort and a subgroup of patients admitted with respiratory disorders. Furthermore, we carry out sensitivity analysis to evaluate whether inclusion of variables related to the function of other organs, improve the predictive performance of the model for both the overall cohort as well as the subgroup of patients with respiratory disorders. Results Predictive performance of RNN-based model was higher with Area Under the Receiver Operating Characteristic (ROC) Curve (AUC) of 0.72 (± 0.01) and Average Precision (AP) of 0.57 (± 0.01) in comparison to RF and LR for the overall patient dataset. Higher predictive performance was recorded in the subgroup of patients admitted with respiratory disorders with AUC of 0.75 (± 0.02) and AP of 0.65 (± 0.03). Inclusion of function of other organs further improved the performance to AUC of 0.79 (± 0.01) and AP 0.68 (± 0.02) for the overall patient dataset and AUC of 0.79 (± 0.01) and AP 0.72 (± 0.02) for the subgroup with respiratory disorders. Conclusion The RNN-based model demonstrated better performance than RF and LR in patients in mechanical ventilation and its subgroup admitted with respiratory disorders. Clinical studies are needed to evaluate whether it impacts decision-making and patient outcomes. Trial registration : NCT02731898 ( https://clinicaltrials.gov/ct2/show/NCT02731898 ), prospectively registered on April 8, 2016.

BACKGROUND: Driving pressure (Delta P) has been described as a risk factor for mortality in patients with ARDS. However, the role of Delta P in the outcome of patients without ARDS and on mechanical ventilation has received less attention. Our objective was to evaluate the association between Delta P on the first day of mechanical ventilation with the development of ARDS. METHODS: This was a post hoc analysis of a multicenter, prospective, observational, international study that included subjects who were on mechanical ventilation for > 12 h. Our objective was to evaluate the association between Delta P on the first day of mechanical ventilation with the development of ARDS. To assess the effect of Delta P, a logistic regression analysis was performed when adjusting for other potential risk factors. Validation of the results obtained was performed by using a bootstrap method and by repeating the same analyses at day 2. RESULTS: A total of 1,575 subjects were included, of whom 65 (4.1%) developed ARDS. The Delta P was independently associated with ARDS (odds ratio [OR] 1.12, 95% CI 1.07-1.18 for each cm H2O of Delta P increase, P < .001). The same results were observed at day 2 (OR 1.14, 95% CI 1.07-1.21; P < .001) and after bootstrap validation (OR 1.13, 95% CI 1.04-1.22; P < .001). When taking the prevalence of ARDS in the lowest quartile of Delta P (<= 9 cm H2O) as a reference, the subjects with Delta P > 12-15 cm H2O and those with Delta P > 15 cm H2O presented a higher probability of ARDS (OR 3.65, 95% CI 1.32-10.04 [P 5.01] and OR 7.31, 95% CI, 2.89-18.50 [P < .001], respectively). CONCLUSIONS: In the subjects without ARDS, a higher level of Delta P on the first day of mechanical ventilation was associated with later development of ARDS.

Variations in clinical characteristics and management and in the mortality of mechanically ventilated patients have not been sufficiently evaluated. We hypothesized that mortality shows a variability associated with country after adjustment for clinical characteristics and management. Analysis of four studies carried out at 6-year intervals over an 18-year period. The studies included 26,024 patients (5183 in 1998, 4968 in 2004, 8108 in 2010, and 7765 in 2016) admitted to 1253 units from 38 countries. The primary outcome was 28-day mortality. We performed analyses using multilevel logistic modeling with mixed-random effects, including country as a random variable. To evaluate the effect of management strategies on mortality, a mediation analysis was performed. Adjusted 28-day mortality decreased significantly over time (first study as reference): 2004: odds ratio 0.82 (95% confidence interval [CI] 0.72–0.93); 2010: 0.63 (95% CI 0.53–0.75); 2016: 0.49 (95% CI 0.39–0.61). A protective ventilatory strategy and the use of continuous sedation mediated a moderate fraction of the effect of time on mortality in patients with moderate hypoxemia and without hypoxemia, respectively. Logistic multilevel modeling showed a significant effect of country on mortality: median odds ratio (MOR) in 1998: 2.02 (95% CI 1.57–2.48); in 2004: 1.76 (95% CI 1.47–2.06); in 2010: 1.55 (95% CI 1.37–1.74), and in 2016: 1.39 (95% CI 1.25–1.54). These findings suggest that country could contribute, independently of confounder variables, to outcome. The magnitude of the effect of country decreased over time. Clinical trials registered with http://www.clinicaltrials.gov (NCT02731898).

Objective: This study aimed to describe the effectiveness and optimum use of tocilizumab (TCZ) treatment by the support of clinical, laboratory and radiologic observations. Methods: All patients were followed up in the hospital with daily interleukin-6 (IL-6), C-reactive protein (CRP), ferritin, d-dimer, full blood count, and procalcitonin. Thoracic computed tomography (CT) was performed on admission, when oxygen support was necessary, and seven days after TCZ started. Disease course of the patients was grouped as severe or critical, according to their clinical, laboratory and radiologic evaluations. Results: Forty-three patients were included: 70% were male; the median age was 64 years (minimum–maximum: 27–94); and six (14%) patients died. The median duration of oxygen support before the onset of TCZ was shorter among the severe patient group than the critical patient group (1 vs. 4 days, p < 0.001). Three cases of 21 (14%) who received TCZ in the ward were transferred to ICU, and none of them died. The levels of IL-6, CRP, ferritin, d-dimer, and procalcitonin were significantly lower in the severe cases group than the critical cases group (p = 0.025, p = 0.002, p = 0.008, p = 0.002, and p = 0.001, respectively). Radiological improvement was observed in severe cases on the seventh day of TCZ. Secondary bacterial infection was detected in 41% of critical cases, but none of the severe ones. Conclusion: Earlier use of TCZ in COVID-19 infection was beneficial for survival, length of hospitalization and duration of oxygen support. The recommendation for administration of TCZ was based on an increase in requirement of oxygen support, progression in thoracic CT, and elevation of inflammation markers, including IL-6, CRP, ferritin, and d-dimer, and decrease in % lymphocytes.