Driving pressure (DP) has recently gained attention as a meaningful variable in lung-protective ventilation, particularly in studies of adult acute respiratory distress syndrome. Its role in neonates, particularly regarding bronchopulmonary dysplasia (BPD), is poorly defined. This single-center retrospective study included 145 neonates who received invasive conventional mechanical ventilation (CMV) for ≥ 72 h between January 1, 2020 and December 31, 2024. In this study, DP was obtained by subtracting the applied positive end-expiratory pressure (PEEP) from the peak inspiratory pressure(PIP), following common clinical practice in pressure-controlled ventilation. Patients were grouped into High DP (≥ 10 cmH2O) and Low DP (< 10 cmH2O). The primary outcome was a composite of BPD, severe intraventricular hemorrhage (IVH grade ≥ III), need for surgical intervention, or death. A subgroup analysis of preterm infants < 32 weeks with neonatal respiratory distress syndrome (NRDS) assessed DP and the Clinical Risk Index for Babies II (CRIB II) score as predictors of BPD. The composite adverse outcome rate was higher in the High DP group than in the Low DP group (44.7 vs. 21.7%; P = 0.03), primarily driven by increased BPD incidence (25.0 vs. 8.7%; P = 0.009). Multivariate analysis identified High DP (adjusted odds ratio [aOR] = 5.30; 95% CI, 2.20-12.74) and gestational age < 32 weeks (aOR = 11.11; 95% CI, 4.35-28.36) as independent risk factors. In the NRDS subgroup (n = 61), both High DP (aOR = 5.80; 95% CI, 1.61-20.90) and higher CRIB II score (aOR = 4.44; 95% CI, 1.28-15.42) independently predicted BPD, with comparable discriminatory ability (DP AUC = 0.707; CRIB II AUC = 0.733). Lower DP was protective against progression to more severe BPD (aOR = 0.20; P = 0.008). Elevated DP is an independent, modifiable risk factor for adverse outcomes-particularly BPD-in mechanically ventilated neonates. The effect is most pronounced in very preterm infants. Routine DP monitoring combined with clinical scoring (e.g., CRIB II) may improve early risk stratification and facilitate individualized lung-protective ventilation.

Pediatric acute respiratory distress syndrome (PARDS) is a critical condition associated with considerable morbidity and mortality. Trials in adults showed controversial results about neuromuscular blocking agents (NMBAs) use in adult acute respiratory distress syndrome. With limited data in PARDS, we sought to compare the outcomes of continuous cisatracurium infusion versus intermittent bolus administration in children with PARDS. This multicenter randomized controlled study was performed on patients with PARDS. Enrolled patients were categorized into: group I: patients treated with intermittent boluses of cisatracurium and group II: patients treated with intravenous infusion of cisatracurium for 24h. The primary outcome was the duration on mechanical ventilator (MV). Additional results included changes in ventilatory parameters, and length of pediatric intensive care unit (PICU) stay. Group II was associated with a significantly higher extubation from MV compared to group I, after accounting for death as a competing event. This association was confined to moderate-to-severe PARDS (subdistribution hazard ratio (SHR) 3.25, 95% CI 1.69-6.25, p<0.001) and not observed in mild PARDS. Similar with earlier PICU discharge, with stronger effect in moderate-to-severe disease (SHR 3.16, 95% CI 1.64-6.11, p<0.001). By day 7, patients with moderate-to-severe PARDS in group II showed lower fraction of inspired oxygen, mean airway pressure, and oxygenation index. In PARDS, cisatracurium infusion was associated with better oxygenation, earlier extubation from MV and shorter PICU stay compared to intermittent boluses, with benefits limited to moderate-to-severe disease. Outcomes were similar in mild PARDS.

An adult with seropositive rheumatoid arthritis (RA) receiving methotrexate (MTX) and tofacitinib, a Janus kinase (JAK) inhibitor, developed rapidly progressive hypoxemic respiratory failure following a brief coryzal prodrome. High-resolution CT showed diffuse bilateral ground-glass opacities with dependent consolidation. An upper-airway syndromic multiplex PCR detected human rhinovirus (HRV)/Enterovirus, while other pathogens were excluded. The clinical tempo, virologic confirmation, and imaging pattern favored viral acute respiratory distress syndrome (ARDS); drug-related pneumonitis and RA-associated interstitial lung disease remained key differentials. Management included temporary withdrawal of disease-modifying therapy, high-flow nasal oxygen with prolonged awake proning, intermittent non-invasive ventilation during episodes of worsening dyspnoea, a conservative fluid strategy, early de-escalation of empiric antibiotics when cultures remained negative, and a short course of systemic corticosteroids. The patient improved without intubation, was weaned from oxygen, and was discharged in stable condition. MTX was reintroduced without pulmonary relapse; leflunomide was added for residual articular activity. After shared decision-making and due to the patient's aversion to injectables, tofacitinib was restarted, resulting in continued respiratory stability and radiographic resolution on follow-up. This case underscores practical diagnostic discriminators and a stepwise approach to temporarily withholding and safely reintroducing immunosuppression in HRV-ARDS complicating RA treatment.

Prone position has been well recognized for the treatment of adult acute respiratory distress syndrome (ARDS). We aimed to evaluate the role of prone position in the mechanical ventilation in children with ARDS, to provide evidence to the treatment and care of children with ARDS. We searched the Pubmed et al. databases by computer until January 23, 2024 for randomized controlled trials (RCTs) on the role of prone position in the mechanical ventilation in children with ARDS. We evaluated the quality of included studies according to the quality evaluation criteria recommended by the Cochrane library. RevMan 5.3 software was used for meta-analysis. 7 RCTs involving 433 children with ARDS were included. Meta-analysis indicated that prone position is beneficial to improve the arterial oxygenation pressure [MD = 4.27 mmHg, 95% CI (3.49, 5.06)], PaO2/FiO2 [MD = 26.97, 95% CI (19.17, 34.77)], reduced the oxygenation index [MD = -3.52, 95% CI (-5.41, -1.64)], mean airway pressure [MD = -1.91 cmH2O, 95% CI (-2.27, -1.55)] and mortality [OR = 0.33, 95% CI (0.15, 0.73), all P < 0.05]. There were no statistical differences in the duration of mechanical ventilation between the prone position group and control group [MD = -17.01, 97.27, 95% CI (-38.28, 4.26), P = 0.12]. Egger test results showed that no significant publication bias was found (all P > 0.05). Prone position ventilation has obvious advantages in improving oxygenation, but there is no significant improvement in the time of mechanical ventilation in the treatment of children with ARDS. In the future, more large-sample, high-quality RCTs are still needed to further analyze the role of prone position in the mechanical ventilation in children with ARDS.

Background/Objectives: SARS-CoV-2 was responsible for the global pandemic. Approximately 10-15% of patients with COVID-19 developed respiratory failure with adult acute respiratory distress syndrome (ARDS), which required treatment in the Intensive Care Unit (ICU). The cytokine storm observed in severe COVID-19 was frequently handled with steroids. Synergically, tocilizumab, an anti-interleukin-6 receptor monoclonal antibody, gained popularity as a cytokine storm-suppressing agent. However, immunosuppression was proven to increase the predisposition to infections with resistant bacteria. Our study aimed to assess the relationship between positive tests for secondary infections and the survival of patients with severe COVID-19-attributed ARDS treated with immunosuppressive agents. Methods: This study included 342 patients qualified for the ICU and mechanical ventilation (MV). The patients were divided based on the type of immunomodulating therapy and the culture tests results. Results: The results showed the highest survival rate among patients <61 years, favoring the combined treatment (tocilizumab + steroids). Atrial fibrillation (AF) and coronary heart disease (CHD) correlated with a lower survival rate than other comorbidities. Tocilizumab was associated with an increased risk of positive pathogen cultures, which could potentially cause secondary infections; however, the survival rate among these patients was higher. Conclusions: MV and ICU procedures as well as the application of tocilizumab significantly decreased the mortality rate in patients with severe COVID-19-related ARDS. The suppression of cytokine storms played a crucial role in survival. Tocilizumab was found to be both efficient and safe despite the 'side effect' of the increased risk of positive results for secondary infections.