Prone Positioning in Coronavirus Disease 2019 Patients with Acute Respiratory Distress Syndrome: How and When is the Best Way to do it?

A narrative review on the future of ARDS: evolving definitions, pathophysiology, and tailored management

Acute respiratory distress syndrome (ARDS) is a severe complication of critical illness, characterized by bilateral lung infiltrates and hypoxemia. Its clinical and pathophysiological heterogeneity poses challenges for both diagnosis and treatment. This review outlines the evolution of ARDS definitions, discusses the underlying pathophysiology of ARDS, and examines the clinical implications of its heterogeneity. Traditional ARDS definitions required invasive mechanical ventilation and relied on arterial blood gas measurements to calculate the PaO2/FiO2 ratio. Recent updates have expanded these criteria to include patients receiving noninvasive respiratory support, such as high-flow nasal oxygen, and the adoption of the SpO2/FiO2 ratio as an alternative to the PaO2/FiO2 ratio. While these changes broaden the diagnostic criteria, they also introduce additional complexity. ARDS heterogeneity-driven by varying etiologies, clinical subphenotypes, and underlying biological mechanisms-highlights the limitations of a uniform management approach. Emerging evidence highlights the presence of distinct ARDS subphenotypes, each defined by unique molecular and clinical characteristics, offering a pathway to more precise therapeutic targeting. Advances in omics technologies-encompassing genomics, proteomics, and metabolomics-are paving the way for precision-medicine approaches with the potential to revolutionize ARDS management by tailoring interventions to individual patient profiles. This paradigm shift from broad diagnostic categories to precise, subphenotype-driven care holds promise for redefining the landscape of treatment for ARDS and, ultimately, improving outcomes in this complex, multifaceted syndrome.

Development of the ARDS-derived gene panel for lung adenocarcinoma prognosis stratification and experiment validation of CCL20 expression

Acute respiratory distress syndrome (ARDS) is a life-threatening condition characterized by lung inflammation and high mortality rates. Lung cancer, specifically lung adenocarcinoma (LUAD), is a major cause of cancer-related deaths worldwide. Patients with LUAD, particularly those undergoing chemotherapy, are more likely to develop ARDS. ARDS inflicts major malfunctioning in the immune system. We suspected a certain shared pathogenic mechanism between these diseases. This study analyzed 503 LUAD patients from the TCGA-LUAD cohort as the training set, 85 LUAD cases from the GSE30219 cohort as the validation set, and 24 RNA-seq samples from ARDS mice model and control groups in the GSE2411 cohort. The differentially expressed genes (DEGs) of ARDS were analyzed using the limma package and screened by Cox and Lasso analysis. ssGSEA and xCell algorithms were utilized for immune landscaping. RT-qPCR analysis was used to determine the mRNA levels of key genes in both the LPS-induced ARDS model and human LUAD cell lines. We identified DEGs between ARDS and control groups, which were highly associated with cytokine production and leukocyte migration. A prognosis model for LUAD patients was developed based on the expressions of the key genes in the ARDS-derived DEGs, including FMO3, IL1R2, CCL20, CFTR, and GADD45G. A satisfactory efficacy was observed in both the training and validation cohorts. The model demonstrated increased effectiveness in predicting the intratumor immune profile and mutation status of LUAD. Moreover, we utilized LPS to induce the ARDS model, which resulted in elevated expressions of IL1R2 and CCL20. Additionally, CCL20 was upregulated in cancerous LUAD cell lines. We developed an ARDS-based model for stratifying LUAD prognosis. CCL20 was found to be elevated in both the ARDS model and LUAD, suggesting a shared underlying mechanism of these two diseases.

Evaluating the Effects of a General Anesthesia and Prone Position Nursing Checklist and Training Course on Posterior Lumbar Surgery: A Randomized Controlled Trial

BACKGROUND

While general anesthesia in the prone position is one of the most utilized surgical positions, it predisposes to multiple types of complications. Existing studies on this topic are mostly literature reviews or focus on solving one complication, which limits their clinical use.

OBJECTIVE

The aims of the study were to evaluate the effectiveness of a 22-item general anesthesia and prone position nursing checklist and specific training course at preventing complications related to general anesthesia in the prone position.

DESIGN

The study used a randomized controlled trial.

SETTINGS AND PARTICIPANTS

Convenience sampling was used to recruit patients who underwent general anesthesia during posterior lumbar surgery from July 2021 to December 2021 at the Run Run Shaw Hospital, Zhejiang University School of Medicine Hospital.

METHODS

Patients involved in the study were randomly assigned to the control (standard general anesthesia and prone position care) or experimental group (general anesthesia and prone position nursing checklist combined with specific training course in addition to standard general anesthesia and prone position care). Outcomes were pressure injuries, peripheral nerve injuries, ocular complications, and length of stay (LOS). Patient satisfaction, Numeric Pain Rating Scale (NRS) and the Oswestry Disability Scale were also measured.

RESULTS

Compared with the control group, pressure injury, brachial plexus injury, and two ocular findings (foreign body sensation and blurry vision) were significantly less common in the intervention group ( P ≤ 0.01). Participants who received standard general anesthesia and prone position care had lower self-reported satisfaction than those managed with the general anesthesia and prone position nursing checklist plus specific training course ( P = 0.002). The checklist-based intervention also significantly reduced LOS ( P = 0.000) and NRS ( P = 0.000).

CONCLUSIONS

The intervention group had significant fewer general anesthesia in the prone position-related complications, improved satisfaction, reduced LOS, and lower NRS. These findings suggest that a general anesthesia and prone position nursing checklist in addition to a specific training course are beneficial to standardizing prone position nursing care during posterior lumbar surgery.