ARDS is associated with poor clinical outcomes, with a pooled mortality rate of approximately 40% despite best standards of care. Current therapeutic strategies are based on improving oxygenation and pulmonary compliance while minimizing ventilator-induced lung injury. It has been demonstrated that relative hypoxemia can be well tolerated, and improvements in oxygenation do not necessarily translate into survival benefit. Cardiac failure, in particular right ventricular dysfunction (RVD), is commonly encountered in moderate to severe ARDS and is reported to be one of the major determinants of mortality. The prevalence rate of echocardiographically evident RVD in ARDS varies across studies, ranging from 22% to 50%. Although there is no definitive causal relationship between RVD and mortality, severe RVD is associated with increased mortality. Factors that can adversely affect RV function include hypoxic pulmonary vasoconstriction, hypercapnia, and invasive ventilation with high driving pressure. It might be expected that early diagnosis of RVD would be of benefit; however, echocardiographic markers (qualitative and quantitative) used to prospectively evaluate the right ventricle in ARDS have not been tested in adequately powered studies. In this review, we examine the prognostic implications and pathophysiology of RVD in ARDS and discuss available diagnostic modalities and treatment options. We aim to identify gaps in knowledge and directions for future research that could potentially improve clinical outcomes in this patient population.

Decision to insert a PICC should be taken after careful risk stratification. There is lack of high-quality evidence assessing prevention strategies and management of PICC-related thrombosis in the ICU. Well-designed RCTs are required to estimate the prevalence of UEVT in ICU patients with PICCs and evaluate the efficacy and magnitude of clinical benefit and cost-effectiveness of therapeutic strategies.

SummaryThere has been increased interest in the prophylactic and therapeutic use of high‐flow nasal oxygen in patients with, or at risk of, non‐hypercapnic respiratory failure. There are no randomised trials examining the efficacy of high‐flow nasal oxygen in high‐risk cardiac surgical patients. We sought to determine whether routine administration of high‐flow nasal oxygen, compared with standard oxygen therapy, leads to reduced hospital length of stay after cardiac surgery in patients with pre‐existing respiratory disease at high risk for postoperative pulmonary complications. Adult patients with pre‐existing respiratory disease undergoing elective cardiac surgery were randomly allocated to receive high‐flow nasal oxygen (n = 51) or standard oxygen therapy (n = 49). The primary outcome was hospital length of stay and all analyses were carried out on an intention‐to‐treat basis. Median (IQR [range]) hospital length of stay was 7 (6–9 [4–30]) days in the high‐flow nasal oxygen group and 9 (7–16 [4–120]) days in the standard oxygen group (p=0.012). Geometric mean hospital length of stay was 29% lower in the high‐flow nasal group (95%CI 11–44%, p = 0.004). High‐flow nasal oxygen was also associated with fewer intensive care unit re‐admissions (1/49 vs. 7/45; p = 0.026). When compared with standard care, prophylactic postoperative high‐flow nasal oxygen reduced hospital length of stay and intensive care unit re‐admission. This is the first randomised controlled trial examining the effect of prophylactic high‐flow nasal oxygen use on patient‐centred outcomes in cardiac surgical patients at high risk for postoperative respiratory complications.