Background: A large proportion of patients with a SARS-Cov-2-associated respiratory failure develop an acute respiratory distress syndrome (ARDS). It has been recently suggested that SARS-Cov-2-associated ARDS may differ from usual non-SARS-Cov-2-associated ARDS by higher respiratory system compliance (C RS ), lower potential for recruitment with positive end-expiratory pressure (PEEP) contrasting with severe shunt fraction. The purpose of the study was to systematically assess respiratory mechanics and recruitability in SARS-Cov-2-associated ARDS. Methods:Gas exchanges, C RS and hemodynamics were assessed at 2 levels of PEEP (15 cmH 2 O and 5 cmH 2 O) within 36 h (day1) and from 4 to 6 days (day 5) after intubation. The recruited volume was computed as the difference between the volume expired from PEEP 15 to 5 cmH 2 O and the volume predicted by compliance at PEEP 5 cmH 2 O (or above airway opening pressure). The recruitment-to-inflation (R/I) ratio (i.e. the ratio between the recruited lung compliance and C RS at PEEP 5 cmH 2 O) was used to assess lung recruitability. A R/I ratio value higher than or equal to 0.5 was used to define highly recruitable patients. Results:The R/I ratio was calculated in 25 of the 26 enrolled patients at day 1 and in 15 patients at day 5. At day 1, 16 (64%) were considered as highly recruitable (R/I ratio median [interquartile range] 0.7 [0.55-0.94]) and 9 (36%) were considered as poorly recruitable (R/I ratio 0.41 [0.31-0.48]). The PaO 2 /FiO 2 ratio at PEEP 15 cmH 2 O was higher compared to PEEP 5 cmH 2 O only in highly recruitable patients (173 [139-236] vs 135 [89-167] mmHg; p < 0.01). Neither PaO 2 /FiO 2 or C RS measured at PEEP 15 cmH 2 O or at PEEP 5 cmH 2 O nor changes in PaO 2 /FiO 2 or C RS in response to PEEP changes allowed to identify highly or poorly recruitable patients. Conclusion:In this series of 25 patients with SARS-Cov-2 associated ARDS, 64% were considered as highly recruitable and only 36% as poorly recruitable based on the R/I ratio performed on the day of intubation. This observation suggests that a systematic R/I ratio assessment may help to guide initial PEEP titration to limit harmful effect of unnecessary high PEEP in the context of Covid-19 crisis.

Background Differences in physiology of ARDS have been described between COVID-19 and non-COVID-19 patients. This study aimed to compare initial values and longitudinal changes in respiratory system compliance (CRS), oxygenation parameters and ventilatory ratio (VR) in patients with COVID-19 and non-COVID-19 pulmonary ARDS matched on oxygenation. Methods 135 patients with COVID-19 ARDS from two centers were included in a physiological study; 767 non-COVID-19 ARDS from a clinical trial were used for the purpose of at least 1:2 matching. A propensity-matching was based on age, severity score, oxygenation, positive end-expiratory pressure (PEEP) and pulmonary cause of ARDS and allowed to include 112 COVID-19 and 198 non-COVID pulmonary ARDS. Results The two groups were similar on initial oxygenation. COVID-19 patients had a higher body mass index, higher CRS at day 1 (median [IQR], 35 [28–44] vs 32 [26–38] ml cmH2O−1, p = 0.037). At day 1, CRS was correlated with oxygenation only in non-COVID-19 patients; 61.6% and 68.2% of COVID-19 and non-COVID-19 pulmonary ARDS were still ventilated at day 7 (p = 0.241). Oxygenation became lower in COVID-19 than in non-COVID-19 patients at days 3 and 7, while CRS became similar. VR was lower at day 1 in COVID-19 than in non-COVID-19 patients but increased from day 1 to 7 only in COVID-19 patients. VR was higher at days 1, 3 and 7 in the COVID-19 patients ventilated using heat and moisture exchangers compared to heated humidifiers. After adjustment on PaO2/FiO2, PEEP and humidification device, CRS and VR were found not different between COVID-19 and non-COVID-19 patients at day 7. Day-28 mortality did not differ between COVID-19 and non-COVID-19 patients (25.9% and 23.7%, respectively, p = 0.666). Conclusions For a similar initial oxygenation, COVID-19 ARDS initially differs from classical ARDS by a higher CRS, dissociated from oxygenation. CRS become similar for patients remaining on mechanical ventilation during the first week of evolution, but oxygenation becomes lower in COVID-19 patients. Trial registration: clinicaltrials.gov NCT04385004

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Background: Graft Versus Host Disease (GvHD) is a frequent complication of hematopoietic stem cell transplantation (HSCT). Acute GvHD can involve intestinal tract which requires temporary fasting in addition to immunosuppressive treatment. Surgical management of gastrointestinal (GI) GVHD is an unusual approach.Objectives: Diversion stoma can help in healing the digestive tract during the acute phase of GI GvHD by keeping it free from any aggression. We report our experience of 6 adult patients with Gl GvHD who underwent intestinal surgery.Study Design: Medical files of patients who experienced biopsy-proven GI GvHD between 01/01/2011 and 31/12/2019 in Angers University hospital were retrospectively reviewed and patients who underwent GI surgery were analysed. Informed consent was obtained from all patients.Results: Between 2011 and 2019, 354 allogenic HSCT were performed and stage II to IV acute GI GvHD occurred in 42 patients. GI surgery and diversion stomas were required for 6 patients. Two surgeries were performed urgently for colonic perforation, 2 were performed for small bowel occlusion symptoms and 2 for uncontrolled GvHD symptoms despite medical treatment. All surgeries were performed safely. Diversion stomy could not prevent aGvHD progression and death in 2 patients. Additional treatment for GI GvHD was necessary in 1 patient while 3 patients did not receive any further treatment for GI GvHD after long-term follow-up. Two patients had successful bowel continuity restoration. Data from 29 patients who underwent GI surgery for acute GVH published so far are reviewed. Conclusion:GI surgical interventions are rarely required in patients with GI GvHD. There is a lack of data on digestive surgery in GI GVHD, including follow-up data and efficiency on GVHD-related symptoms. The use of digestive surgery as diversion stoma appeared feasible for severe GI GVHD and seems to benefit some patients. This data should be confirmed in a larger study.