Acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) are serious complications of acute illness and injury, associated with an inpatient mortality of up to 40%. Despite considerable basic science and clinical research, therapeutic options for established ALI are limited. Survivors of ARDS are often faced with poor health-related quality of life, depressive-anxiety disorders, cognitive deficits, and financial strain. An attractive approach toward managing ALI lies in its prevention and early treatment. In addition to improving recognition of at-risk patients, it is necessary to identify novel treatments targeting the pathways that may prevent or ameliorate lung injury. The rationale and animal and clinical evidence for aspirin, systemic and inhaled steroids, β-agonists, renin-angiotensin axis blockers, statins, peroxisome proliferator agonist receptor ligands, curcumin, and inhaled heparin are included in this narrative review. Randomized, controlled trials are currently being designed and implemented to address their efficacy in populations at risk for ALI.

Purpose Inhaled corticosteroids (ICS) attenuated lung injury in animal studies. We investigated the association between pre-hospital ICS and incidence of acute lung injury (ALI) among patients at-risk. Methods In this ancillary analysis of the large multicenter Lung Injury Prediction Study (LIPS) cohort, we developed a propensity score for pre-hospital ICS use followed by matching, for all patients and for a subgroup of patients with at least one risk factor for direct pulmonary injury. The primary outcome was ALI, secondary outcomes included ARDS, need for invasive mechanical ventilation and hospital mortality. Results Of the 5126 patients, 401 (8%) were using ICS. ALI developed in 343 (7%). The unadjusted incidence of ALI was 4.7% vs. 6.9% (p=0.12) among those in ICS compared to non-ICS group. In the “direct” lung injury subgroup, the unadjusted incidence of ALI was 4.1% vs. 10.6% (p=0.006). After propensity matching, the estimated effect for ALI in the whole cohort was 0.69 (95% CI 0.39–1.2; p=0.18) and in the “direct” subgroup was 0.56 (95% CI 0.22–1.46; p=0.24). Conclusions Pre-admission use of ICS in a hospitalized population of patients at-risk for ALI was not significantly associated with a lower incidence of ALI once controlled by comprehensive propensity matched analysis.

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Intra-abdominal hypertension/abdominal compartment syndrome (IAH/ACS) is a well-recognized entity among surgical subspecialties. Nevertheless, it has been proven to be present in the medical critically ill population. Prospective and retrospective observational studies have found medical patients with IAH/ACS to be associated with death in the intensive care unit and other poor outcomes. Frequently, it is underdiagnosed and undertreated in this patient group. Limitations encountered in these observational studies are their small population size and single-center design. In addition, most studies target consecutive intensive care unit admissions instead of limiting IAH/ACS screening to a predefined population confined by their risk factors (unspecified ascites, mechanical ventilation, positive fluid balance, etc.). Generally, medical patients with IAH/ACS are more severely ill compared with surgical patients. Furthermore, they are less likely to receive treatment targeted at lowering intra-abdominal pressure. Medical treatment of IAH/ACS has not been demonstrated to be specifically effective to avoid decompressive surgery. Identifying medical patients at risk of IAH represents an underresearched area for which training in measurement of abdominal pressure surrogates, awareness of its prevalence, and prevention and treatment of such condition could further improve outcomes in critically ill medical patients.

Pulmonary manifestations of hyperthyroidism not only include pulmonary hypertension and hydrostatic pulmonary oedema, but also treatment/drug-associated pulmonary diseases have to be considered as an exclusion diagnosis. A 27-year-old woman with hypoxaemic respiratory failure under an arterial-venous extra-corporeal membrane oxygenator (AV-ECMO) was admitted to the intensive care unit (ICU). The patient had progressive dyspnoea with haemoptysis, palpitations and failure to thrive. The patient had Graves' disease treated previously with propylthiouracil (PTU). Diffuse alveolar haemorrhage is a non-specific syndrome characterised by evidence of diffuse alveolar damage, exclusion of infectious aetiology and progressively bloodier bronchoalveolar lavage (and/or 20% hemosiderin laden macrophages on cytological examination). PTU associated perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) vasculitis appears to be more common in younger female patients presenting with leukocytoclastic vasculitis, myalgias and arthralgias. The latter compared to non-drug associated ANCA vasculitis which are more common in older males with visceral involvement. PTU-induced ANCA vasculitis prognosis appears to be better compared to primary ANCA syndromes.