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Papers by imed chouchene

World Academy of Science, Engineering and Technology, International Journal of Medical and Health Sciences, Jul 20, 2017

The Pan African medical journal, 2018

Introduction: intensive care unit (ICU) beds are a scarce resource, and admissions may require pr... more Introduction: intensive care unit (ICU) beds are a scarce resource, and admissions may require prioritization when demand exceeds supply. However, there are few data regarding both outcomes of admitted patients to intensive care unit (ICU) in comparison with outcomes of not admitted patients. The aim of this study was to assess reasons and factors associated to refusal of admission to ICU as well as the impact on mortality at 28 days and patients' outcomes. Methods: Single-center, cross-sectional descriptive study conducted in 8-bed Medical ICU at a Tunisian University hospital. All consecutive adult patients referred for admission to ICU during 6 months were included. We collected demographic data, ICU admission/refusal reasons, co-morbidity and diagnosis at time of admission, mortality probability model (MPMII0) score, day and time of admission, request for admission and mortality at 28 days. Results: 327 patients were evaluated for ICU admission and 260 were refused to ICU (79.5%). Patients refused because of unavailability of beds represented 50% and patients considered "too sick to benefit" represented 22%. Multivariate analysis showed that the presence of acute respiratory failure and request by direct contact in the unit were independently associated to admission to ICU (OR: 0.15; 95% CI: 0.07-0.31 and OR: 0.16; 95% CI: 0.08-0.31, respectively). Higher mortality rates were shown in patients "too sick to benefit" (80.7%) and unavailable beds (26.56%). Conclusion: Refusal of ICU admission was correlated with the severity of acute illness, lack of ICU beds and reasons for admission request. ICU clinicians should evaluate their triage decisions and, if possible, routinely solicit patient preferences during medical emergencies, taking steps to ensure that ICU admission decisions are in line with the goals of the patient. Ultimately, these efforts will help ensure that scarce ICU resources are used most effectively and efficiently.

Journal of Intensive Care

Background Patients with acute respiratory failure caused by cardiogenic pulmonary edema (CPE) ma... more Background Patients with acute respiratory failure caused by cardiogenic pulmonary edema (CPE) may require mechanical ventilation that can cause further lung damage. Our aim was to determine the impact of ventilatory settings on CPE mortality. Methods Patients from the LUNG SAFE cohort, a multicenter prospective cohort study of patients undergoing mechanical ventilation, were studied. Relationships between ventilatory parameters and outcomes (ICU discharge/hospital mortality) were assessed using latent mixture analysis and a marginal structural model. Results From 4499 patients, 391 meeting CPE criteria (median age 70 [interquartile range 59–78], 40% female) were included. ICU and hospital mortality were 34% and 40%, respectively. ICU survivors were younger (67 [57–77] vs 74 [64–80] years, p < 0.001) and had lower driving (12 [8–16] vs 15 [11–17] cmH2O, p < 0.001), plateau (20 [15–23] vs 22 [19–26] cmH2O, p < 0.001) and peak (21 [17–27] vs 26 [20–32] cmH2O, p < 0.001) pr...

The Lancet Respiratory Medicine, 2022

Two acute respiratory distress syndrome (ARDS) subphenotypes (hyperinflammatory and hypoinflammat... more Two acute respiratory distress syndrome (ARDS) subphenotypes (hyperinflammatory and hypoinflammatory) with distinct clinical and biological features and differential treatment responses have been identified using latent class analysis (LCA) in seven individual cohorts. To facilitate bedside identification of subphenotypes, clinical classifier models using readily available clinical variables have been described in four randomised controlled trials. We aimed to assess the performance of these models in observational cohorts of ARDS. In this observational, multicohort, retrospective study, we validated two machine-learning clinical classifier models for assigning ARDS subphenotypes in two observational cohorts of patients with ARDS: Early Assessment of Renal and Lung Injury (EARLI; n=335) and Validating Acute Lung Injury Markers for Diagnosis (VALID; n=452), with LCA-derived subphenotypes as the gold standard. The primary model comprised only vital signs and laboratory variables, and the secondary model comprised all predictors in the primary model, with the addition of ventilatory variables and demographics. Model performance was assessed by calculating the area under the receiver operating characteristic curve (AUC) and calibration plots, and assigning subphenotypes using a probability cutoff value of 0·5 to determine sensitivity, specificity, and accuracy of the assignments. We also assessed the performance of the primary model in EARLI using data automatically extracted from an electronic health record (EHR; EHR-derived EARLI cohort). In Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE; n=2813), a multinational, observational ARDS cohort, we applied a custom classifier model (with fewer variables than the primary model) to determine the prognostic value of the subphenotypes and tested their interaction with the positive end-expiratory pressure (PEEP) strategy, with 90-day mortality as the dependent variable. The primary clinical classifier model had an area under receiver operating characteristic curve (AUC) of 0·92 (95% CI 0·90-0·95) in EARLI and 0·88 (0·84-0·91) in VALID. Performance of the primary model was similar when using exclusively EHR-derived predictors compared with manually curated predictors (AUC=0·88 [95% CI 0·81-0·94] vs 0·92 [0·88-0·97]). In LUNG SAFE, 90-day mortality was higher in patients assigned the hyperinflammatory subphenotype than in those with the hypoinflammatory phenotype (414 [57%] of 725 vs 694 [33%] of 2088; p<0·0001). There was a significant treatment interaction with PEEP strategy and ARDS subphenotype (p=0·041), with lower 90-day mortality in the high PEEP group of patients with the hyperinflammatory subphenotype (hyperinflammatory subphenotype: 169 [54%] of 313 patients in the high PEEP group vs 127 [62%] of 205 patients in the low PEEP group; hypoinflammatory subphenotype: 231 [34%] of 675 patients in the high PEEP group vs 233 [32%] of 734 patients in the low PEEP group). Classifier models using clinical variables alone can accurately assign ARDS subphenotypes in observational cohorts. Application of these models can provide valuable prognostic information and could inform management strategies for personalised treatment, including application of PEEP, once prospectively validated. US National Institutes of Health and European Society of Intensive Care Medicine.

The Lancet Global Health, 2021

Summary Background Geoeconomic variations in epidemiology, the practice of ventilation, and outco... more Summary Background Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001). Interpretation Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding No funding.

Background: To determine the frequency of, and factors associated with, death in hospital followi... more Background: To determine the frequency of, and factors associated with, death in hospital following ICU discharge to the ward.Methods: The Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study was an international, multicenter, prospective cohort study of patients with severe respiratory failure, conducted across 459 ICUs from 50 countries globally. This study aimed to understand the frequency and factors associated with death in hospital in patients who survived their ICU stay. We examined outcomes in the subpopulation discharged with no limitations of life sustaining treatments (‘treatment limitations’), and the subpopulations with treatment limitations.Results: 2,186 (94%) patients with no treatment limitations discharged from ICU survived, while 142 (6%) died in hospital. 118 (61%) of patients with treatment limitations survived while 77 (39%) patients died in hospital. Patients without treatment limitations that died in ...

World Academy of Science, Engineering and Technology, International Journal of Medical and Health Sciences, 2017

Pan African Medical Journal, 2018

Critical Care, 2020

Background Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patien... more Background Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patients with acute respiratory distress syndrome (ARDS). We examined this issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. Methods In this secondary analysis of the LUNG SAFE study, we wished to determine the prevalence and the outcomes associated with hyperoxemia on day 1, sustained hyperoxemia, and excessive oxygen use in patients with early ARDS. Patients who fulfilled criteria of ARDS on day 1 and day 2 of acute hypoxemic respiratory failure were categorized based on the presence of hyperoxemia (PaO2 > 100 mmHg) on day 1, sustained (i.e., present on day 1 and day 2) hyperoxemia, or excessive oxygen use (FIO2 ≥ 0.60 during hyperoxemia). Results Of 2005 patients that met the inclusion criteria, 131 (6.5%) were hypoxemic (PaO2 < 55 mmHg), 607 (30%) had hyperoxemia on day 1, and 2...

Santé Publique, 2015

Imed Chouchene et al., « Incidence des infections associées aux dispositifs médicaux dans un serv... more Imed Chouchene et al., « Incidence des infections associées aux dispositifs médicaux dans un service de réanimation tunisien »,

Anesthesiology, 2018

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New... more Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Patients with initial mild acute respiratory distress syndrome are often underrecognized and mistakenly considered to have low disease severity and favorable outcomes. They represent a relatively poorly characterized population that was only classified as having acute respiratory distress syndrome in the most recent definition. Our primary objective was to describe the natural course and the factors associated with worsening and mortality in this population. Methods This study analyzed patients from the international prospective Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) who had initial mild acute respiratory distress syndrome in the first day of inclusion. This study defined three groups based on the evolution of severity in the first week: “worsening” if moderate or severe acute respiratory distress syndrome cri...

Critical care (London, England), Jan 17, 2018

To better understand the epidemiology and patterns of tracheostomy practice for patients with acu... more To better understand the epidemiology and patterns of tracheostomy practice for patients with acute respiratory distress syndrome (ARDS), we investigated the current usage of tracheostomy in patients with ARDS recruited into the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG-SAFE) study. This is a secondary analysis of LUNG-SAFE, an international, multicenter, prospective cohort study of patients receiving invasive or noninvasive ventilation in 50 countries spanning 5 continents. The study was carried out over 4 weeks consecutively in the winter of 2014, and 459 ICUs participated. We evaluated the clinical characteristics, management and outcomes of patients that received tracheostomy, in the cohort of patients that developed ARDS on day 1-2 of acute hypoxemic respiratory failure, and in a subsequent propensity-matched cohort. Of the 2377 patients with ARDS that fulfilled the inclusion criteria, 309 (13.0%) underwent tracheostomy ...

Critical care (London, England), Jan 12, 2018

The aim of this study was to describe data on epidemiology, ventilatory management, and outcome o... more The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients. We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents. Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p < 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27...

Intensive care medicine, May 9, 2018

To evaluate patients with resolved versus confirmed ARDS, identify subgroups with substantial mor... more To evaluate patients with resolved versus confirmed ARDS, identify subgroups with substantial mortality risk, and to determine the utility of day 2 ARDS reclassification. Our primary objective, in this secondary LUNG SAFE analysis, was to compare outcome in patients with resolved versus confirmed ARDS after 24 h. Secondary objectives included identifying factors associated with ARDS persistence and mortality, and the utility of day 2 ARDS reclassification. Of 2377 patients fulfilling the ARDS definition on the first day of ARDS (day 1) and receiving invasive mechanical ventilation, 503 (24%) no longer fulfilled the ARDS definition the next day, 52% of whom initially had moderate or severe ARDS. Higher tidal volume on day 1 of ARDS was associated with confirmed ARDS [OR 1.07 (CI 1.01-1.13), P = 0.035]. Hospital mortality was 38% overall, ranging from 31% in resolved ARDS to 41% in confirmed ARDS, and 57% in confirmed severe ARDS at day 2. In both resolved and confirmed ARDS, age, non...

The Lancet. Respiratory medicine, Aug 14, 2017

Little information is available about the geo-economic variations in demographics, management, an... more 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). LUNG SAFE was done during 4 consecutive weeks in winter, 2014, in a convenience sample of 459 intensive-care 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-...

Annals of Intensive Care, 2017

Competing interests None. O2 Eligibility for and feasibility of donation after circulatory death ... more Competing interests None. O2 Eligibility for and feasibility of donation after circulatory death Maastricht III (DCD MIII) process in post-anoxic patients: a retrospective analysis

Intensive care medicine experimental, 2016

La Tunisie médicale, 2015

Intensive care unit -acquired infections constitute an important worldwide health problem. Our ai... more Intensive care unit -acquired infections constitute an important worldwide health problem. Our aim was to determine the incidence and risk factors of device-associated infection and those of mortality in a Tunisia ICU. We conducted a prospective observational cohort study over a six months period in the adult medical intensive care unit of University Hospital-Farhat Hached (Sousse-Tunisia). Patients admitted to the unit were included in the study if they stayed in the ICU for more than 48 hours. During the study period, 105 patients were surveyed; 16 of them (15.2%) developed 17 episodes of device associated infections (16.9 DAI/1000 days of hospitalization). The most frequently identified infections were central and peripheral venous catheter -associated infection (respectively, 21.4 CVC-AI/ 1000 CVC-days and 10.2 PVCAI / 1000 PVC-days). At ICU discharge, overall mortality was 40%. Independent risk factors for acquiring infection in ICU were the use of central venous catheter (p=0....

European Respiratory Journal, 2015

Introduction: A limited number of observational studies have reported that NIV can be an effectiv... more Introduction: A limited number of observational studies have reported that NIV can be an effective treatment in IPF. We aimed to investigate outcomes in IPF patients receiving NIV for ARF and to identify risk factors for its failure. Methods: A retrospective analysis of outcome in IPF patients being administered NIV for ARF in an 8-bed medical ICU. 28 IPF patients who were administered NIV between January 1st, 2007and December 31st, 2014, were included. The outcome measures were, need for endotracheal intubation, length of stay and ICU mortality. Multivariate analysis was performed to identify factors associated to NIV failure. Results: Patients were 64±15,62 years mean-aged. Disease duration was 3,55±3 years. 53% have poor baseline functional status(NYHA ≥III). Diagnoses at admission were, fibrosis exacerbation, 16; infectious decompensation, 2 and cardiac decompensation, 8. SAPSII score was 34.85±11. NIV was successful in 12 patients and failed in 16. All the patients in the NIV failure group died within 5.53±6.05 days. The patients in the NIV success group spent 7.75±6.01 days in the ICU and all survived. At admission, the patients in the failure group had significantly higher plasma NT-proBNPlevels (2847±2004vs 600±660 pg/mL;p=0.032) and significantly lower PaO2/FiO2ratio (135.62±67.75 vs 300.5±82.82; p=0.031). NIV failure was associated to the plasma NT-proBNP levels (OR, 5.81;95%CI, [4.20 , 10.08] ; p=0.032). Conclusion: The outcome of IPF patients who were administered NIV was quite poor. The use of NIV was, nevertheless, found to be associated with clinical benefits. Elevated plasma NT-proBNP levels may be a simple marker for poor NIV outcome.

European Respiratory Journal, 2015

Introduction: Patients with hematological malignancies who develop severe pulmonary complications... more Introduction: Patients with hematological malignancies who develop severe pulmonary complications and require admission to ICU have a poor hospital outcome.We studied etiology, outcome and prognostic factors in respiratory critically-ill patients with hematological malignancies admitted to ICU. Methods: A retrospective cohort study in an 8-bed medical ICU of a university hospital. 105 critically-ill patients with hematological malignancies and pulmonary complications treated within a 10 year period were included. Were analyzed, patients clinical characteristics and outcome. Multivariate analysis was performed to identify prognostic factors. Results: The underlying malignancies were predominantly acute leukaemia, 67% ; non-Hodgkin lymphoma, 19% ; Hodgkin lymphoma, 5.8% ; myelodysplasia syndrome, 6.7% and multiple myeloma, 1.9%.Length of stay in the ICU was 4.77±6.14 days. All were ventilated (84%, invasive ventilation and 16%,NIV). Overall ICU mortality was 73.3%, with significantly higher mortality in invasive-ventilated patients (74%)vsNIV patients(12%), p Conclusion: The outcome of respiratory critically-ill patients with hematological malignancies was overall poor. SAPSII, catecholamine use and mechanical ventilation revealed independent prognostic factors.

World Academy of Science, Engineering and Technology, International Journal of Medical and Health Sciences, Jul 20, 2017

The Pan African medical journal, 2018

Introduction: intensive care unit (ICU) beds are a scarce resource, and admissions may require pr... more Introduction: intensive care unit (ICU) beds are a scarce resource, and admissions may require prioritization when demand exceeds supply. However, there are few data regarding both outcomes of admitted patients to intensive care unit (ICU) in comparison with outcomes of not admitted patients. The aim of this study was to assess reasons and factors associated to refusal of admission to ICU as well as the impact on mortality at 28 days and patients' outcomes. Methods: Single-center, cross-sectional descriptive study conducted in 8-bed Medical ICU at a Tunisian University hospital. All consecutive adult patients referred for admission to ICU during 6 months were included. We collected demographic data, ICU admission/refusal reasons, co-morbidity and diagnosis at time of admission, mortality probability model (MPMII0) score, day and time of admission, request for admission and mortality at 28 days. Results: 327 patients were evaluated for ICU admission and 260 were refused to ICU (79.5%). Patients refused because of unavailability of beds represented 50% and patients considered "too sick to benefit" represented 22%. Multivariate analysis showed that the presence of acute respiratory failure and request by direct contact in the unit were independently associated to admission to ICU (OR: 0.15; 95% CI: 0.07-0.31 and OR: 0.16; 95% CI: 0.08-0.31, respectively). Higher mortality rates were shown in patients "too sick to benefit" (80.7%) and unavailable beds (26.56%). Conclusion: Refusal of ICU admission was correlated with the severity of acute illness, lack of ICU beds and reasons for admission request. ICU clinicians should evaluate their triage decisions and, if possible, routinely solicit patient preferences during medical emergencies, taking steps to ensure that ICU admission decisions are in line with the goals of the patient. Ultimately, these efforts will help ensure that scarce ICU resources are used most effectively and efficiently.

Journal of Intensive Care

Background Patients with acute respiratory failure caused by cardiogenic pulmonary edema (CPE) ma... more Background Patients with acute respiratory failure caused by cardiogenic pulmonary edema (CPE) may require mechanical ventilation that can cause further lung damage. Our aim was to determine the impact of ventilatory settings on CPE mortality. Methods Patients from the LUNG SAFE cohort, a multicenter prospective cohort study of patients undergoing mechanical ventilation, were studied. Relationships between ventilatory parameters and outcomes (ICU discharge/hospital mortality) were assessed using latent mixture analysis and a marginal structural model. Results From 4499 patients, 391 meeting CPE criteria (median age 70 [interquartile range 59–78], 40% female) were included. ICU and hospital mortality were 34% and 40%, respectively. ICU survivors were younger (67 [57–77] vs 74 [64–80] years, p < 0.001) and had lower driving (12 [8–16] vs 15 [11–17] cmH2O, p < 0.001), plateau (20 [15–23] vs 22 [19–26] cmH2O, p < 0.001) and peak (21 [17–27] vs 26 [20–32] cmH2O, p < 0.001) pr...

The Lancet Respiratory Medicine, 2022

Two acute respiratory distress syndrome (ARDS) subphenotypes (hyperinflammatory and hypoinflammat... more Two acute respiratory distress syndrome (ARDS) subphenotypes (hyperinflammatory and hypoinflammatory) with distinct clinical and biological features and differential treatment responses have been identified using latent class analysis (LCA) in seven individual cohorts. To facilitate bedside identification of subphenotypes, clinical classifier models using readily available clinical variables have been described in four randomised controlled trials. We aimed to assess the performance of these models in observational cohorts of ARDS. In this observational, multicohort, retrospective study, we validated two machine-learning clinical classifier models for assigning ARDS subphenotypes in two observational cohorts of patients with ARDS: Early Assessment of Renal and Lung Injury (EARLI; n=335) and Validating Acute Lung Injury Markers for Diagnosis (VALID; n=452), with LCA-derived subphenotypes as the gold standard. The primary model comprised only vital signs and laboratory variables, and the secondary model comprised all predictors in the primary model, with the addition of ventilatory variables and demographics. Model performance was assessed by calculating the area under the receiver operating characteristic curve (AUC) and calibration plots, and assigning subphenotypes using a probability cutoff value of 0·5 to determine sensitivity, specificity, and accuracy of the assignments. We also assessed the performance of the primary model in EARLI using data automatically extracted from an electronic health record (EHR; EHR-derived EARLI cohort). In Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE; n=2813), a multinational, observational ARDS cohort, we applied a custom classifier model (with fewer variables than the primary model) to determine the prognostic value of the subphenotypes and tested their interaction with the positive end-expiratory pressure (PEEP) strategy, with 90-day mortality as the dependent variable. The primary clinical classifier model had an area under receiver operating characteristic curve (AUC) of 0·92 (95% CI 0·90-0·95) in EARLI and 0·88 (0·84-0·91) in VALID. Performance of the primary model was similar when using exclusively EHR-derived predictors compared with manually curated predictors (AUC=0·88 [95% CI 0·81-0·94] vs 0·92 [0·88-0·97]). In LUNG SAFE, 90-day mortality was higher in patients assigned the hyperinflammatory subphenotype than in those with the hypoinflammatory phenotype (414 [57%] of 725 vs 694 [33%] of 2088; p<0·0001). There was a significant treatment interaction with PEEP strategy and ARDS subphenotype (p=0·041), with lower 90-day mortality in the high PEEP group of patients with the hyperinflammatory subphenotype (hyperinflammatory subphenotype: 169 [54%] of 313 patients in the high PEEP group vs 127 [62%] of 205 patients in the low PEEP group; hypoinflammatory subphenotype: 231 [34%] of 675 patients in the high PEEP group vs 233 [32%] of 734 patients in the low PEEP group). Classifier models using clinical variables alone can accurately assign ARDS subphenotypes in observational cohorts. Application of these models can provide valuable prognostic information and could inform management strategies for personalised treatment, including application of PEEP, once prospectively validated. US National Institutes of Health and European Society of Intensive Care Medicine.

The Lancet Global Health, 2021

Summary Background Geoeconomic variations in epidemiology, the practice of ventilation, and outco... more Summary Background Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001). Interpretation Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding No funding.

Background: To determine the frequency of, and factors associated with, death in hospital followi... more Background: To determine the frequency of, and factors associated with, death in hospital following ICU discharge to the ward.Methods: The Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study was an international, multicenter, prospective cohort study of patients with severe respiratory failure, conducted across 459 ICUs from 50 countries globally. This study aimed to understand the frequency and factors associated with death in hospital in patients who survived their ICU stay. We examined outcomes in the subpopulation discharged with no limitations of life sustaining treatments (‘treatment limitations’), and the subpopulations with treatment limitations.Results: 2,186 (94%) patients with no treatment limitations discharged from ICU survived, while 142 (6%) died in hospital. 118 (61%) of patients with treatment limitations survived while 77 (39%) patients died in hospital. Patients without treatment limitations that died in ...

World Academy of Science, Engineering and Technology, International Journal of Medical and Health Sciences, 2017

Pan African Medical Journal, 2018

Critical Care, 2020

Background Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patien... more Background Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patients with acute respiratory distress syndrome (ARDS). We examined this issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. Methods In this secondary analysis of the LUNG SAFE study, we wished to determine the prevalence and the outcomes associated with hyperoxemia on day 1, sustained hyperoxemia, and excessive oxygen use in patients with early ARDS. Patients who fulfilled criteria of ARDS on day 1 and day 2 of acute hypoxemic respiratory failure were categorized based on the presence of hyperoxemia (PaO2 > 100 mmHg) on day 1, sustained (i.e., present on day 1 and day 2) hyperoxemia, or excessive oxygen use (FIO2 ≥ 0.60 during hyperoxemia). Results Of 2005 patients that met the inclusion criteria, 131 (6.5%) were hypoxemic (PaO2 < 55 mmHg), 607 (30%) had hyperoxemia on day 1, and 2...

Santé Publique, 2015

Imed Chouchene et al., « Incidence des infections associées aux dispositifs médicaux dans un serv... more Imed Chouchene et al., « Incidence des infections associées aux dispositifs médicaux dans un service de réanimation tunisien »,

Anesthesiology, 2018

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New... more Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Patients with initial mild acute respiratory distress syndrome are often underrecognized and mistakenly considered to have low disease severity and favorable outcomes. They represent a relatively poorly characterized population that was only classified as having acute respiratory distress syndrome in the most recent definition. Our primary objective was to describe the natural course and the factors associated with worsening and mortality in this population. Methods This study analyzed patients from the international prospective Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) who had initial mild acute respiratory distress syndrome in the first day of inclusion. This study defined three groups based on the evolution of severity in the first week: “worsening” if moderate or severe acute respiratory distress syndrome cri...

Critical care (London, England), Jan 17, 2018

To better understand the epidemiology and patterns of tracheostomy practice for patients with acu... more To better understand the epidemiology and patterns of tracheostomy practice for patients with acute respiratory distress syndrome (ARDS), we investigated the current usage of tracheostomy in patients with ARDS recruited into the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG-SAFE) study. This is a secondary analysis of LUNG-SAFE, an international, multicenter, prospective cohort study of patients receiving invasive or noninvasive ventilation in 50 countries spanning 5 continents. The study was carried out over 4 weeks consecutively in the winter of 2014, and 459 ICUs participated. We evaluated the clinical characteristics, management and outcomes of patients that received tracheostomy, in the cohort of patients that developed ARDS on day 1-2 of acute hypoxemic respiratory failure, and in a subsequent propensity-matched cohort. Of the 2377 patients with ARDS that fulfilled the inclusion criteria, 309 (13.0%) underwent tracheostomy ...

Critical care (London, England), Jan 12, 2018

The aim of this study was to describe data on epidemiology, ventilatory management, and outcome o... more The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients. We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents. Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p < 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27...

Intensive care medicine, May 9, 2018

To evaluate patients with resolved versus confirmed ARDS, identify subgroups with substantial mor... more To evaluate patients with resolved versus confirmed ARDS, identify subgroups with substantial mortality risk, and to determine the utility of day 2 ARDS reclassification. Our primary objective, in this secondary LUNG SAFE analysis, was to compare outcome in patients with resolved versus confirmed ARDS after 24 h. Secondary objectives included identifying factors associated with ARDS persistence and mortality, and the utility of day 2 ARDS reclassification. Of 2377 patients fulfilling the ARDS definition on the first day of ARDS (day 1) and receiving invasive mechanical ventilation, 503 (24%) no longer fulfilled the ARDS definition the next day, 52% of whom initially had moderate or severe ARDS. Higher tidal volume on day 1 of ARDS was associated with confirmed ARDS [OR 1.07 (CI 1.01-1.13), P = 0.035]. Hospital mortality was 38% overall, ranging from 31% in resolved ARDS to 41% in confirmed ARDS, and 57% in confirmed severe ARDS at day 2. In both resolved and confirmed ARDS, age, non...

The Lancet. Respiratory medicine, Aug 14, 2017

Little information is available about the geo-economic variations in demographics, management, an... more 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). LUNG SAFE was done during 4 consecutive weeks in winter, 2014, in a convenience sample of 459 intensive-care 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-...

Annals of Intensive Care, 2017

Competing interests None. O2 Eligibility for and feasibility of donation after circulatory death ... more Competing interests None. O2 Eligibility for and feasibility of donation after circulatory death Maastricht III (DCD MIII) process in post-anoxic patients: a retrospective analysis

Intensive care medicine experimental, 2016

La Tunisie médicale, 2015

Intensive care unit -acquired infections constitute an important worldwide health problem. Our ai... more Intensive care unit -acquired infections constitute an important worldwide health problem. Our aim was to determine the incidence and risk factors of device-associated infection and those of mortality in a Tunisia ICU. We conducted a prospective observational cohort study over a six months period in the adult medical intensive care unit of University Hospital-Farhat Hached (Sousse-Tunisia). Patients admitted to the unit were included in the study if they stayed in the ICU for more than 48 hours. During the study period, 105 patients were surveyed; 16 of them (15.2%) developed 17 episodes of device associated infections (16.9 DAI/1000 days of hospitalization). The most frequently identified infections were central and peripheral venous catheter -associated infection (respectively, 21.4 CVC-AI/ 1000 CVC-days and 10.2 PVCAI / 1000 PVC-days). At ICU discharge, overall mortality was 40%. Independent risk factors for acquiring infection in ICU were the use of central venous catheter (p=0....

European Respiratory Journal, 2015

Introduction: A limited number of observational studies have reported that NIV can be an effectiv... more Introduction: A limited number of observational studies have reported that NIV can be an effective treatment in IPF. We aimed to investigate outcomes in IPF patients receiving NIV for ARF and to identify risk factors for its failure. Methods: A retrospective analysis of outcome in IPF patients being administered NIV for ARF in an 8-bed medical ICU. 28 IPF patients who were administered NIV between January 1st, 2007and December 31st, 2014, were included. The outcome measures were, need for endotracheal intubation, length of stay and ICU mortality. Multivariate analysis was performed to identify factors associated to NIV failure. Results: Patients were 64±15,62 years mean-aged. Disease duration was 3,55±3 years. 53% have poor baseline functional status(NYHA ≥III). Diagnoses at admission were, fibrosis exacerbation, 16; infectious decompensation, 2 and cardiac decompensation, 8. SAPSII score was 34.85±11. NIV was successful in 12 patients and failed in 16. All the patients in the NIV failure group died within 5.53±6.05 days. The patients in the NIV success group spent 7.75±6.01 days in the ICU and all survived. At admission, the patients in the failure group had significantly higher plasma NT-proBNPlevels (2847±2004vs 600±660 pg/mL;p=0.032) and significantly lower PaO2/FiO2ratio (135.62±67.75 vs 300.5±82.82; p=0.031). NIV failure was associated to the plasma NT-proBNP levels (OR, 5.81;95%CI, [4.20 , 10.08] ; p=0.032). Conclusion: The outcome of IPF patients who were administered NIV was quite poor. The use of NIV was, nevertheless, found to be associated with clinical benefits. Elevated plasma NT-proBNP levels may be a simple marker for poor NIV outcome.

European Respiratory Journal, 2015

Introduction: Patients with hematological malignancies who develop severe pulmonary complications... more Introduction: Patients with hematological malignancies who develop severe pulmonary complications and require admission to ICU have a poor hospital outcome.We studied etiology, outcome and prognostic factors in respiratory critically-ill patients with hematological malignancies admitted to ICU. Methods: A retrospective cohort study in an 8-bed medical ICU of a university hospital. 105 critically-ill patients with hematological malignancies and pulmonary complications treated within a 10 year period were included. Were analyzed, patients clinical characteristics and outcome. Multivariate analysis was performed to identify prognostic factors. Results: The underlying malignancies were predominantly acute leukaemia, 67% ; non-Hodgkin lymphoma, 19% ; Hodgkin lymphoma, 5.8% ; myelodysplasia syndrome, 6.7% and multiple myeloma, 1.9%.Length of stay in the ICU was 4.77±6.14 days. All were ventilated (84%, invasive ventilation and 16%,NIV). Overall ICU mortality was 73.3%, with significantly higher mortality in invasive-ventilated patients (74%)vsNIV patients(12%), p Conclusion: The outcome of respiratory critically-ill patients with hematological malignancies was overall poor. SAPSII, catecholamine use and mechanical ventilation revealed independent prognostic factors.