The mechanisms of lung injury in acute respiratory distress syndrome (ARDS) are (1) ventilator-associated lung injury (VALI), in which mechanical ventilation itself causes lung injury, and (2) effort-dependent lung injury, in which vigorous spontaneous effort by the patient causes lung injury. To prevent VALI, lung-protective ventilation strategies have been used, including use of low tidal volumes, low plateau pressures, and positive end-expiratory pressure(PEEP). However, mortality in ARDS has not improved over the past 20 years. To improve the clinical outcomes of patients with ARDS, ventilatory management in ARDS needs to be tailored to patients by identifying subgroups that respond to specific interventions.

“The right patient in the right place at the right time.” This is a phrase coined by Florence Nightingale, a nurse and statistician, in a paper where she consolidated the data of severe trauma patients during the Crimean War, creating one of the first models for the ICU. This motto remains relevant in modern ICUs, emphasizing the need to provide intensive care to acute critically ill patients in the appropriate setting and timing to enhance patient outcomes. Although different countries have different criteria for ICU admission and discharge, the lack of high-quality evidence for the effectiveness of these criteria highlights the need to understand their limitations. This review introduces well-designed studies that utilize big data to assess the impact of ICU admission and discharge, aimed at bridging the current evidence gap. Furthermore, observational studies using the DPC database are presented as valuable evidence for Japan. The goal of this review is to provide healthcare professionals with evidence in relation to ICU admission and discharge so as to empower them in integrating this knowledge into their daily clinical practice, ultimately improving patient care for those facing ICU admission and discharge decisions.

Delirious patients in the ICU are sedated when they exhibit symptoms of agitation and excitement. Patients on mechanical ventilation receive sedatives such as midazolam and propofol as well as antipsychotics such as haloperidol, but dexmedetomidine is now used more frequently. Light and patient-optimized sedation is recommended, and many clinical studies have shown a reduced risk and duration of delirium with dexmedetomidine. Dexmedetomidine is preferred in the ICU due to favorable subjective sedation with nocturnal use; however, the notion that sedation with dexmedetomidine resembles natural sleep lacks rigid neurophysiological evidence. The Japanese Society for Palliative Medicine suggested that a careful consideration of the ethical aspects of continuous sedation in palliative care highlights the importance of sedation being appropriate, clear in purpose to the healthcare provider, consistent with patient and family wishes, and a team decision. This would apply to sedation of delirious patients. We encourage the daily monitoring of sedation and the suitable use of sedative drugs.

Tracheostomy has been used historically to treat airway obstruction. However, since the polio epidemic in the middle of the 20th century, tracheostomy became established as the treatment of choice for long-term airway management during positive pressure ventilation. Tracheostomized patients can be managed in intensive care units, general wards, and at home because of improved survival rates of critically ill patients. Therefore, a comprehensive tracheostomy management strategy that takes into consideration the long-term quality of life of the patients is required. Safety management protocols, including prevention of obstruction and displacement of the tracheal cannula, have not yet been standardized, particularly in general wards, and it is an urgent issue that requires to be immediately addressed. Although successful removal of a tracheal cannula is a time-consuming process, no standard algorithm for decannulation has been established, and it is rarely performed following transfer from acute care hospitals in Japan. It is suggested that patients with a tracheostomy cannula in place have poor outcomes; therefore, establishing a strategy for tracheal cannula removal and promoting safety measures by establishing a multidisciplinary tracheostomy team may improve the patient outcomes and reduce the associated healthcare costs. Overseas, there have been advanced efforts in this field; thus, development of an action plan for long-term systematic management of patients undergoing tracheostomy in Japan is strongly desired.

We report a case of septic shock following pancreatic head cancer surgery with compromised cardiac function, which was successfully treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) and percutaneous left ventricular assist device (Impella^®, Abiomed, USA). A 67-year-old man who had undergone pancreaticoduodenectomy for pancreatic head cancer and postoperative hepatic artery embolization for gastroduodenal artery bleeding returned to the hospital on the 6th day after discharge with a complaint of fever and suspected liver abscess. On the 5th day of admission to our hospital, the patient went into septic shock and was transferred to the ICU. On the 6th day, the patient was complicated by cardiogenic shock due to sepsis-induced cardiomyopathy; consequently, Impella^® CP and VA-ECMO were initiated. The patient’s cardiac function improved within a few days, and both Impella^® CP and VA-ECMO were removed on the 11th day. The patient was discharged from the ICU on the 15th day. In cases of cardiogenic shock due to sepsis-induced cardiomyopathy requiring mechanical circulatory support for lifesaving, the combined use of Impella^® and VA-ECMO may lead to early recovery.

Severe drug-induced pneumonia following Chinese herbal medicine administration is uncommon. Discontinuing the drug often leads to spontaneous recovery; thus, ventilatory management is usually unnecessary. In this report, we describe a case of drug-induced pneumonia attributable to Saireito administration, which necessitated ventilatory management. An 82-year-old man presented to our hospital with fever and dyspnea. He had a 2-month history of Saireito use for sudden onset of sensorineural hearing loss. He developed dyspnea on exertion 10 days before presentation and visited his local physician who referred the patient to our hospital for emergency management of hypoxemia. Hypoxemia progressed, and the patient required ventilatory support. Based on the patient's history and various tests, we suspected drug-induced pneumonia caused by Saireito and initiated steroid therapy. Based on the clinical course and treatment response, the patient was diagnosed with drug-induced pneumonia attributable to Saireito. Drug-induced pneumonia may rarely lead to severe respiratory failure. Drug-induced pneumonia should be considered in the differential diagnosis of patients with severe respiratory failure.