Background Little information is available about the geo-economic variations in demographics, management, and outcomes of patients with acute respiratory distress syndrome (ARDS). We aimed to characterise the effect of these geo-economic variations in patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE). Methods LUNG SAFE was done during 4 consecutive weeks in winter, 2014, in a convenience sample of 459 intensivecare units in 50 countries across six continents. Inclusion criteria were admission to a participating intensive-care unit (including transfers) within the enrolment window and receipt of invasive or non-invasive ventilation. One of the trial's secondary aims was to characterise variations in the demographics, management, and outcome of patients with ARDS. We used the 2016 World Bank countries classification to define three major geo-economic groupings, namely European high-income countries (Europe-High), high-income countries in the rest of the world (rWORLD-High), and middle-income countries (Middle). We compared patient outcomes across these three groupings. LUNG SAFE is registered with ClinicalTrials.gov, number NCT02010073. Findings Of the 2813 patients enrolled in LUNG SAFE who fulfilled ARDS criteria on day 1 or 2, 1521 (54%) were recruited from Europe-High, 746 (27%) from rWORLD-High, and 546 (19%) from Middle countries. We noted significant geographical variations in demographics, risk factors for ARDS, and comorbid diseases. The proportion of patients with severe ARDS or with ratios of the partial pressure of arterial oxygen (PaO 2) to the fractional concentration of oxygen in inspired air (F I O 2) less than 150 was significantly lower in rWORLD-High countries than in the two other regions. Use of prone positioning and neuromuscular blockade was significantly more common in Europe-High countries than in the other two regions. Adjusted duration of invasive mechanical ventilation and length of stay in the intensive-care unit were significantly shorter in patients in rWORLD-High countries than in Europe-High or Middle countries. High gross national income per person was associated with increased survival in ARDS; hospital survival was significantly lower in Middle countries than in Europe-High or rWORLD-High countries. Interpretation Important geo-economic differences exist in the severity, clinician recognition, and management of ARDS, and in patients' outcomes. Income per person and outcomes in ARDS are independently associated.

Chronic kidney disease (CKD) is an important and common noncommunicable condition globally. In national and international guidelines, CKD is defined and staged according to measures of kidney function that allow for a degree of risk stratification using commonly available markers. It is often asymptomatic in its early stages, and early detection is important to reduce future risk. The risk of cardiovascular outcomes is greater than the risk of progression to end-stage kidney disease for most people with CKD. CKD also predisposes to acute kidney injury – a major cause of morbidity and mortality worldwide. Although only a small proportion of people with CKD progress to end-stage kidney disease, renal replacement therapy (dialysis or transplantation) represents major costs for health care systems and burden for patients. Efforts in primary care to reduce the risks of cardiovascular disease, acute kidney injury, and progression are therefore required. Monitoring renal function is an important task, and primary care clinicians are well placed to oversee this aspect of care along with the management of modifiable risk factors, particularly blood pressure and proteinuria. Good primary care judgment is also essential in making decisions about referral for specialist nephrology opinion. As CKD commonly occurs alongside other conditions, consideration of comorbidities and patient wishes is important, and primary care clinicians have a key role in coordinating care while adopting a holistic, patient-centered approach and providing continuity. This review aims to summarize the vital role that primary care plays in predialysis CKD care and to outline the main considerations in its identification, monitoring, and clinical management in this context.

Intra-and inter-hospital transport is common due to the need for advanced diagnostics and procedures, and to provide access to specialized care. Risks are inherent during transport, so the anticipated benefits of transport must be weighed against the possible negative outcome during the transport. Adverse events are common in both in and out of hospital transports, the most common being equipment malfunctions. During inter-hospital transport, increased transfer time is associated with worse patient outcomes. The use of specialized teams with the transport of children has been shown to decrease adverse events. Intra-hospital transports often involve critically ill patients, which increases the likelihood of adverse events. Radiographic diagnostics are the most common in-hospital transport destination and the results often change the course of care. It is recommended that portable ventilators be used for transport, because studies show that use of a manual resuscitator alters blood gas values due to inconsistent ventilation. The performance of new generation transport ventilators has improved greatly and now allows for seamless transition from ICU ventilators. Diligent planning for and monitoring during transport may decrease adverse events and reduce risk.

INTRODUCTION:A mass-casualty respiratory failure event where patients exceed available ventilators has spurred several proposed solutions. One proposal is use of a single ventilator to support 4 patients. METHODS: A ventilator was modified to allow attachment of 4 circuits. Each circuit was connected to one chamber of 2 dual-chambered, test lungs. The ventilator was set at a tidal volume (V T ) of 2.0 L, respiratory frequency of 10 breaths/min, and PEEP of 5 cm H 2 O. Tests were repeated with pressure targeted breaths at 15 cm H 2 O. Airway pressure, volume, and flow were measured at each chamber. The test lungs were set to simulate 4 patients using combinations of resistance (R) and compliance (C). These included equivalent C and R, constant R and variable C, constant C and variable R, and variable C and variable R. Results. When R and C were equivalent the V T distributed to each chamber of the test lung was similar during both volume (range 428 -442 mL) and pressure (range 528 -544 mL) breaths. Changing C while R was constant resulted in large variations in delivered V T (volume range 257-621 mL, pressure range 320 -762 mL). Changing R while C was constant resulted in a smaller variation in V T (volume range 418 -460 mL, pressure range 502-554 mL) compared to only C changes. When R and C were both varied, the range of delivered V T in both volume (336 -517 mL) and pressure (417-676 mL) breaths was greater, compared to only R changes. CONCLUSIONS: Using a single ventilator to support 4 patients is an attractive concept; however, the V T cannot be controlled for each subject and V T disparity is proportional to the variability in compliance. Along with other practical limitations, these findings cannot support the use of this concept for mass-casualty respiratory failure.

SummaryPatient-ventilator synchrony and patient comfort are assumed to go hand in hand, yet few studies provide support for this common sense idea. In reality, synchrony between the patient and ventilator is complex and can be affected by the ventilator settings, type of ventilator, patient-ventilator interface, and sedation. Inspections of airway pressure and flow waveforms are reliable methods for detecting asynchrony, and automated detection seems accurate. A number of types of asynchronies have been defined, and asynchrony during invasive and noninvasive ventilation have different calling cards. There is a clear association between asynchrony, ventilator-induced diaphragmatic dysfunction, and duration of mechanical ventilation. Whether these are cause and effect or simply associated remains to be determined.