BACKGROUND:Th ere are few data regarding mechanical ventilation and ARDS in the ED. Th is could be a vital arena for prevention and treatment.

BACKGROUND: Our Cooling to Help Injured Lungs (CHILL) trial of therapeutic hypothermia in ARDS includes neuromuscular blockade (NMB) as an inclusion criterion to avoid shivering. NMB has been used to facilitate mechanical ventilation in ARDS and was shown to reduce mortality in the ACURASYS trial. To assess the feasibility of a multi-center CHILL trial, we conducted a survey of academic intensivists about their NMB use in patients with ARDS. METHODS: We distributed via email a 16-question survey about NMB use in patients with ARDS including frequency, indications, and dosing strategy. RESULTS: 212 (24.3%) of 871 respondents completed the survey: 94.7% were board-certified in internal medicine, 88% in pulmonary and critical care; 90.3% practiced in academic medical centers, with 87% working in medical ICUs; 96.6% of respondents who treat ARDS use NMB, and 39.7% use NMB in > 50% of these patients. Of 4 listed indications for initiating NMB in ARDS, allowing adherence with lung-protective ventilator strategies and patient-ventilator synchrony were cited as the most important reasons, followed by the results of the ACURASYS trial and facilitating prone positioning. CONCLUSIONS: We conclude that NMB is frequently used by academic intensivists to facilitate mechanical ventilation in patients with moderate to severe ARDS.

The association between inflammatory myopathies anti-synthetase syndrome and interstitial lung disease has been recognized since the 1950s. Patients generally present with gradual onset of symptoms and slow progression of fibrosis over months to years. Herein, we describe a previously well 51-year-old man who presented with three months of progressive small joint arthritis, cough, dyspnea, and eventually hypoxemic respiratory failure following a viral prodrome. He continued to decompensate despite high dose corticosteroids and mycophenolate mofetil, ultimately requiring extracorporeal membranous oxygenation as a bridge to bilateral lung transplantation. Clinically amyopathic dermatomyositis (CADM) was confirmed through serum positivity for anti-Melanoma Differentiation Associated Protein-5 (MDA-5) antibody. Interestingly, his post-operative course was complicated by a zoonotic infection with Bordetella bronchiseptica. This case highlights the importance of identifying rare autoimmune diseases, and the utility of transfer to a lung transplant center.

Background: The current standard of analyzing microcirculatory video microscopy is time-consuming and occurs away from the patient, limiting its clinical utility. Point-of-care assessment with incident dark field (IDF) microscopy, however, may offer greater clinical applicability. We aimed to determine the reproducibility of the Point of Care Microcirculation (POEM) tool when used at the bedside in critically ill patients. Methods: A multinational, multicenter, prospective observational study of adult intubated patients was undertaken during a 9-month period in Germany, the United Kingdom, and the United States. A user recorded a batch of four standardized video clips from each patient, calculated a POEM score and recorded the time for image acquisition. A second user blinded to the first repeated this process. Patients with video clips of poor quality were excluded. At a later date, the two users again blinded themselves to reassess both their own clips and those of the other user. Basic demographic information was recorded. Intrauser reliability (an individual user rescoring the same batch of videos after blinding), interuser reliability (a second user rescoring the other user's video batch after blinding), and test–retest reliability (two users individually capturing videos and recording POEM scores) were assessed using a linearly weighted kappa statistic for ordinal data. Results: Sixty-five patients were included in the final analysis. Observer agreement was substantial for all tests. Intrauser agreement was 0.73 (0.95 CI 0.64–0.81), interuser agreement 0.71 (0.95 CI 0.63–0.79), and test–retest agreement 0.75 (0.95 CI 0.65–0.86). Average time to record videos and assess POEM scores 7:34 ± 3:37 minutes. Conclusions: Point-of-care assessment of the microcirculation using IDF video microscopy and POEM scoring appears to be both a feasible and reproducible approach to microcirculatory assessment. Testing of the score in critically ill patients showed substantial agreement within and between investigators, but further studies should validate its utility as a tool to guide shock resuscitation.

BACKGROUND: Timing of intubation in COVID-19 is controversial. We sought to determine the association of the ROX (Respiratory rate-OXygenation) index defined as S pO 2 divided by F IO 2 divided by breathing frequency at the time of intubation with clinical outcomes. METHODS: We conducted a retrospective cohort study of patients with COVID-19 who were intubated by using a database composed of electronic health record data from patients with COVID-19 from 62 institutions. Multivariable logistic regression was used to evaluate the impact of ROX index score on mortality. We analyzed the ROX index as a continuous variable as well as a categorical variable by using cutoffs previously described as predicting success with high-flow nasal cannula. RESULTS: Of 1,087 subjects in the analysis group, the median age was 64 years, and more than half had diabetes; 55.2% died, 1.8% were discharged to hospice, 7.8% were discharged to home, 27.3% were discharged to another institution, and 7.8% had another disposition. Increasing age and a longer time from admission to intubation were associated with mortality. After adjusting for sex, race, age, comorbidities, and days from admission to intubation, an increasing ROX index score at the time of intubation was associated with a lower risk of death. In a logistic regression model, each increase in the ROX index score by 1 at the time of intubation was associated with an 8% reduction in odds of mortality (odds ratio 0.92, 95% CI 0.88-0.95). We also found an odds ratio for death of 0.62 (95% CI 0.47-0.81) for subjects with an ROX index score 6 4.88 at the time of intubation. CONCLUSIONS: Among a cohort of subjects with COVID-19 who were ultimately intubated, a higher ROX index at the time of intubation was positively associated with survival.

Acute respiratory distress syndrome is treated by utilizing a lung protective ventilation strategy. Obesity presents with additional physiologic considerations, and optimizing ventilator settings may be limited with traditional means. Transpulmonary pressure (P L ) obtained via esophageal manometry may be more beneficial to titrating positive end-expiratory pressure (PEEP) in this population. We sought to determine the feasibility and impact of implementation of a protocol for use of esophageal balloon to set PEEP in obese patients in a community ICU. DESIGN:Retrospective cohort study of obese (body mass index [BMI] ≥ 35 kg/ m 2 ) patients undergoing individualized PEEP titration with esophageal manometry. Data were extracted from electronic health record, and Wilcoxon signed rank test was performed to determine whether there were differences in the ventilatory parameters over time. SETTING:Intensive care unit in a community based hospital system in Newark, Delaware. PATIENTS:Twenty-nine mechanically ventilated adult patients with a median BMI of 45.8 kg/m 2 with acute respiratory distress syndrome (ARDS). INTERVENTION:Individualized titration of PEEP via esophageal catheter obtained transpulmonary pressures. MEASUREMENTS AND MAIN RESULTS:Outcomes measured include PEEP, oxygenation, and driving pressure (DP) before and after esophageal manometry at 4 and 24 hr. Clinical outcomes including adverse events (pneumothorax and pneumomediastinum), increased vasopressor use, rescue therapies (inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, and new prone position), continuous renal replacement therapy, and tracheostomy were also analyzed. Four hours after PEEP titration, median PEEP increased from 12 to 20 cm H 2 O (p < 0.0001) with a corresponding decrease in median DP from 15 to 13 cm H 2 O (p = 0.002). Subsequently, oxygenation improved as median Fio 2 decreased from 0.8 to 0.6 (p < 0.0001), and median oxygen saturation/Fio 2 (S/F) ratio improved from 120 to 165 (p < 0.0001). One patient developed pneumomediastinum. No pneumothoraces were identified. Improvements in oxygenation continued to be seen at 24 hr, compared with the prior 4 hr mark, Fio 2 (0.6-0.45; p < 0.004), and S/F ratio (165-211.11; p < 0.001). Seven patients required an increase in vasopressor support after 4 hours. Norepinephrine and epinephrine were increased by 0.05 (± 0.04) µg/kg/min and 0.02 (± 0.01) µg/kg/min on average, respectively. CONCLUSIONS: P L -guided PEEP titration in obese patients can be used to safely titrate PEEP and decrease DP, resulting in improved oxygenation.

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Background: Chimeric antigen receptor T-cell (CAR-T) therapy is an FDA-approved therapy for relapsed or refractory diffuse large B-cell lymphoma (DLBCL) and acute lymphoblastic leukemia (ALL). A common side effect of CAR-T therapy is cytokine release syndrome (CRS), and its severity ranges from mild to severe, and occasionally resulting in death. Patients at particularly high risk for severe CRS may benefit from earlier supportive care and rescue therapies, such as tocilizumab. Although the median onset of CRS has been reported as two days, no existing prognostic tools adequately assist the bedside clinician with triaging which patients will decompensate and warrant escalation of care. For example, biomarkers such as CRP and ferritin are ineffective in predicting CRS severity. Evaluation of the sublingual microcirculation of patients receiving CAR-T therapy may serve as a valuable surveillance tool. The sublingual microcirculation (defined as blood vessels <20um) has been investigated clinically in various inflammatory settings (e.g., sepsis, hemorrhage, surgery). Persistent alterations in microcirculatory flow correlate with worse clinical outcomes. We have used a handheld dark-field microscope, the Cytocam (Bradeus, Netherlands) to image and analyze the sublingual microcirculation of patients receiving CAR-T therapy. Methods: Video images are collected in real time. Prior to interpretation, all video clips were assessed for quality based on the current microcirculation consensus document. Each acceptable clip was then analyzed by using two point-of-care (POC) scoring systems: 1) the microvascular flow index (MFI) and 2) the point-of-care microcirculation (POEM) score. The MFI is determined by dividing the video monitor into four equal quadrants and grading the overall flow of each quadrant with a score from 0-3 (0 = no flow; 1 = intermittent flow; 2 = sluggish flow; 3 = normal flow). The POEM score utilizes an ordinal 1-5 scale (1 = critically impaired; 2 = impaired; 3 = normal with marked heterogeneity; 4 = normal with mild heterogeneity; 5 = normal) that is a composite of four measurements assessing flow impairment and heterogeneity. For each enrolled patient, a baseline measurement was made immediately prior to CAR-T cell infusion with follow up measurements occurring every six hours beginning at hour 18 after cell infusion until hour 72. After hour 72, measurements were made daily until they were deemed no longer at risk for CRS. Results: At this time there is mature data on 7 patients. All patients received Axicabtagene Ciloleucel- a CD19 directed CAR-T cell therapy (Yescarta, Kite Pharma). All patients had normal baseline microcirculation (MFI > 2.6, POEM=5) and normal or near-normal microcirculation at the end of the study period. No patients developed severe CRS (grade 3 and above). Three patients developed grade 2 CRS that required tocilizumab. Patients #1 and #2 both had significant microcirculatory impairments ≥12 hours prior to developing symptoms severe enough to warrant tocilizumab. Patient #3 had normal microcirculation through the first four days of therapy and developed hypotension on day six. We captured a subtle change from a normal MFI and POEM score to mild impairment with both scoring algorithms on day five, one day prior to clinical manifestations of decompensation. For logistical reasons, subsequent data were unable to be obtained. MFI and POEM scores for all patients are listed below in Table 1. The remaining four patients developed grade 1 CRS with associated mild microcirculatory changes. Conclusions: In this pilot study, POC microcirculatory assessments were successfully used to monitor patients undergoing CAR-T therapy. Patients with more severe CRS manifested lower MFI and POEM scores and maintained their nadir longer than those with milder CRS. Our data suggest that CAR-T patients developing CRS manifest early signs of sublingual microcirculatory dysfunction. Moreover, these microcirculatory defects present prior to the development of standard clinical abnormalities, such as macrocirculatory derangements. While further investigation is ongoing, this tool could be used for earlier identification of patients at risk for CRS in order to deliver earlier appropriate therapies, and ultimately to improve patient outcomes. Disclosures No relevant conflicts of interest to declare.