Asia Ventilation Forum: Recent Episodes

AVF

The Asia Ventilation Forum (AVF) is a not-for-profit organisation comprising members from different Asian countries. We share our knowledge and experience in respiratory care and critical care with intensive care unit (ICU) workers across the continent with the aim of improving care and outcomes for the critically ill. There are two AVF Podcast series. "Behind-The-Scenes ICU Stories" invites colleagues to share anything and everything on their personal experiences. Expect heart-to-heart discussions on topics that may or may not have been widely described in the medical literature. "The Challenges of Airway Management During the Pandemic" invites colleagues to share anything and everything on how they deal with various clinical situations. Expect discussions on how experts personalise evidence-based medicine for the patient at the bedside. These Podcasts are hosted by Dr Jason Phua, respiratory physician and intensivist at Alexandra Hospital, National University Health System, Singapore, and Dr Jose Emmanuel Palo, intensivist at The Medical City, the Philippines.

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In this AVF Podcast: Behind-The-Scenes ICU Stories episode, Dr Daren Heyland shares key takeaways from large-scale randomised trials on critical care nutrition led by him and published in the last year, a culmination of his impressive career. Dr Heyland is a Professor of Medicine and Epidemiology at Queen’s University, Kingston, Ontario Canada. He is trained in internal medicine, critical care medicine, and clinical epidemiology. He currently serves as the Director of the Clinical Evaluation Research Unit at the Kingston General Hospital. Overall, Dr Heyland has published approximately 450 peer-reviewed papers, raised more than $120 million in external grant support, and given more than 350 international presentations.

Issues discussed in this interview:

· What inspired Dr Heyland to do research in nutrition in critical illness

· The RE-ENERGIZE trial on enteral glutamine for burn injuries (NEJM 2022)

· The SUSTAIN CSX trial on high-dose selenium for cardiac surgery (JAMA Surgery 2023)

· The LOVIT trial on intravenous vitamin C for sepsis (NEJM 2022)

· The EFFORT Protein trial on higher protein dosing for critical illness (Lancet 2023)

· Future areas for research in nutrition in critical illness?

· Thoughts on clinical trial designs for the future

· Reflections on Dr Heyland’s life’s work

Selected further reading:

  1. Heyland DK, Wibbenmeyer L, Pollack JA, et al. A randomized trial of enteral glutamine for treatment of burn injuries. N Engl J Med 2022;387:1001-1010.

  2. Stoppe C, McDonald B, Meybohm P, et al. Effect of high-dose selenium on postoperative organ dysfunction and mortality in cardiac surgery patients: the SUSTAIN CSX randomized clinical trial. JAMA Surg 2023;158:235-244.

  3. Lamontagne F, Masse MH, Menard J, et al. Intravenous vitamin C in adults with sepsis in the intensive care unit. N Engl J Med 2022;386:2387-2398.

  4. Heyland DK, Patel J, Compher C, et al. The effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein): an international, multicentre, pragmatic, registry-based randomised trial. Lancet.2023;401:568-576.

  5. Lee ZY, Ortiz-Reyes L, Lew CCH, et al. Intravenous vitamin C monotherapy in critically ill patients: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis. Ann Intensive Care 2023;13:14.

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The AVF Podcast: ICU Tips & Tricks invites colleagues to share anything and everything on how they deal with various clinical situations. Expect discussions on how experts personalise evidence-based medicine for the patient at the bedside.

In this episode, Professor Hodgson discusses the findings and implications of the landmark TEAM study on early active mobilisation during mechanical ventilation in the ICU, which was published in the New England Journal of Medicine in November 2022. Professor Hodgson is the Head of the Division of Clinical Trials and Cohort Studies in the School of Public Health and Preventive Medicine and Deputy Director of the Australian and New Zealand Intensive Care-Research Centre at Monash University, a specialist ICU physiotherapist at The Alfred, and the lead author of the TEAM study.

Issues discussed in this interview:
· Prevalence and impact of ICU-acquired weakness
· Rationale, methods, and findings of the TEAM study
· Comparisons with other studies
· Recommended timing and intensity of mobilisation in the ICU in 2023
· Future research

Selected further reading:

  1. TEAM Study Investigators and the ANZICS Clinical Trials Group, Hodgson CL, Bailey M, et al. Early active mobilization during mechanical ventilation in the ICU. N Engl J Med 10;387:1747-1758.
  2. Puthucheary ZA, Rawal J, McPhail M, et al. Acute skeletal muscle wasting in critical illness. JAMA 2013 16;310:1591-1600.
  3. Hermans G, Van Mechelen H, Clerckx B, et al. Acute outcomes and 1-year mortality of intensive care unit-acquired weakness. A cohort study and propensity-matched analysis. Am J Respir Crit Care Med 2014;190:410-420.
  4. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 373:1874-1882.
  5. Patel BK, Wolfe KS, Patel SB, et al. Effect of early mobilisation on long-term cognitive impairment in critical illness in the USA: a randomised controlled trial. Lancet Respir Med 2023 Jan 20:S2213-2600(22)00489-1. Epub ahead of print.

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In this AVF Podcast: ICU Tips & Tricks episode, Professor Professor Laffey discusses the findings and implications of the landmark WEAN SAFE study on the epidemiology and outcomes of weaning from invasive mechanical ventilation across 50 countries, which was published in The Lancet Respiratory Medicine in January 2023. Dr Laffey is Professor of Anaesthesia and Intensive Care Medicine at the School of Medicine of the National University of Ireland, a Consultant in Anaesthesia and Intensive Care Medicine at Galway University Hospitals, and corresponding author of the WEAN SAFE study.

Issues discussed in this interview:

·         Key findings of the WEAN SAFE study

·         Implications of delaying weaning in patients on invasive mechanical ventilation

·         Rewards and challenges of performing large multi-country studies

Selected further reading:

1.       Pham T, Heunks L, Bellani G, et al. Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study. Lancet Respir Med. 2023 Jan 20:S2213-2600(22)00449-0. Epub ahead of print.

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In this AVF Podcast: Behind-The-Scenes ICU Stories episode, Dr Andrew Li discusses MOSAICS II, the largest ever study on sepsis in Asian ICUs, and one that was completed before the COVID-19 pandemic. Dr Li is the lead author of the MOSAICS II study, and a consultant respiratory physician and intensivist from Singapore’s National University Hospital and Woodlands Health. 

Issues discussed in this interview: 

·       Key findings of the MOSAICS II study 

·       Brief comparison with the MOSAICS I study published in 2011

·       Challenges and rewards from multinational research collaboration

Selected further reading:

1.       Li A, Ling L, Qin H, et al. Epidemiology, management, and outcomes of sepsis in ICUs among countries of differing national wealth across Asia. Am J Respir Crit Care Med 2022;206:1107-1116.

2.       Phua J, Koh Y, Du B, et al. Management of severe sepsis in patients admitted to Asian intensive care units: prospective cohort study. BMJ 2011;342:d3245.

3.       Vincent JL, Sakr Y, Singer M, et al. Prevalence and outcomes of infection among patients in intensive care units in 2017. JAMA 2020;323:1478-1487. 

4.       Phua J, Faruq MO, Kulkarni AP, et al. Critical care bed capacity in Asian countries and regions. Crit Care Med 2020;48:654-662.

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In this AVF Podcast: Behind-The-Scenes ICU Stories episode, Professor Carolyn Calfee shares her journey on and discusses the science behind precision medicine in the acute respiratory distress syndrome (ARDS) and intensive care. Dr Calfee is Professor in Residence of Medicine and Anesthesia at the University of California, San Francisco (UCSF), where she attends in the intensive care units (ICUs) at Moffitt-Long Hospital. Her primary academic focus is the prevention, diagnosis, prognosis, and treatment of ARDS, and she is a key international leader with multiple high impact publications on molecular phenotyping of ARDS and precision medicine in the ICU.

Issues discussed in this interview:

• What precision medicine is

• The rationale for precision medicine in ARDS

• How Dr Calfee entered this field of research

• Selected landmark studies that reflect the potential of precision medicine in ARDS

• Challenges to overcome

• Implications for practising clinicians today

Selected further reading:

  1. Beitler JR, Thompson BT, Baron RM, et al. Advancing precision medicine for acute respiratory distress syndrome. Lancet Respir Med 2022;10:107-20.

  2. Bos LDJ, Artigas A, Constantin JM, et al. Precision medicine in acute respiratory distress syndrome: workshop report and recommendations for future research. Eur Respir Rev 2021;30.

  3. Reddy K, Sinha P, O'Kane CM, Gordon AC, Calfee CS, McAuley DF. Subphenotypes in critical care: translation into clinical practice. Lancet Respir Med 2020;8:631-43.

  4. Sinha P, Delucchi KL, Thompson BT, et al. Latent class analysis of ARDS subphenotypes: a secondary analysis of the statins for acutely injured lungs from sepsis (SAILS) study. Intensive Care Med 2018;44:1859-69.

  5. Calfee CS, Delucchi KL, Sinha P, et al. Acute respiratory distress syndrome subphenotypes and differential response to simvastatin: secondary analysis of a randomised controlled trial. Lancet Respir Med 2018;6:691-8.

  6. Famous KR, Delucchi K, Ware LB, et al. Acute respiratory distress syndrome subphenotypes respond differently to randomized fluid management strategy. Am J Respir Crit Care Med 2017;195:331-8.

  7. Calfee CS, Delucchi K, Parsons PE, et al. Subphenotypes in acute respiratory distress syndrome: latent class analysis of data from two randomised controlled trials. Lancet Respir Med 2014;2:611-20.

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In this AVF Podcast: ICU Tips & Tricks episode, Professor Paul Young discusses the evidence behind oxygen targets in the intensive care unit (ICU). Professor Young is Deputy Director and Intensive Care Programme Director at the Medical Research Institute of New Zealand, Co-Clinical Lead of the ICU at Wellington Hospital, and the Medical Director of Wakefield Hospital in Wellington, New Zealand. His high-impact studies include the SPLIT trial (JAMA 2015), the HEAT trial (N Engl J Med 2015), the ICU-ROX trial (N Engl J Med 2020), the PEPTIC trial (JAMA 2020), and the VITAMINS trial (JAMA 2020).

Issues discussed in this interview:

  • The potential risks of hyperoxia in ICU patients
  • Oxygenation targets in the general ICU population as well as for specific patient subsets
  • The implications of studies such as ICU-ROX (2020), HOT-ICU (2021), and the ongoing Mega-ROX trial
  • Strategies (and the limitations of knowledge) for fine-tuning targets in complicated populations

For more about the Mega-ROX trial, please visit:

  1. https://www.anzics.com.au/current-active-endorsed-research/mega-rox/

  2. https://www.youtube.com/watch?v=dMOrOPahXTw

  3. https://ccr.cicm.org.au/journal-editions/2022/june/24/original-articles/article-8

Work cited:

  1. Young PJ, Hodgson CL, Rasmussen BS. Oxygen targets. Intensive Care Med 2022;48:732-5.

  2. The ICU-ROX Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group et al. Conservative oxygen therapy during mechanical ventilation in the ICU. N Engl J Med 2020;382:989-98.

  3. Schjorring OL, Klitgaard TL, Perner A, et al. Lower or higher oxygenation targets for acute hypoxemic respiratory failure. N Engl J Med 2021;384:1301-11.

  4. Girardis M, Busani S, Damiani E, et al. Effect of conservative vs conventional oxygen therapy on mortality among patients in an intensive care unit: the Oxygen-ICU randomized clinical trial. JAMA 2016;316:1583-9.

  5. Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet 2018;391:1693-705.

  6. Asfar P, Schortgen F, Boisrame-Helms J, et al. Hyperoxia and hypertonic saline in patients with septic shock (HYPERS2S): a two-by-two factorial, multicentre, randomised, clinical trial. Lancet Respir Med 2017;5:180-90.

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In this AVF Podcast: ICU Tips & Tricks episode, Professor Anders Perner discusses how he provides fluid therapy in patients with sepsis. Professor Perner is a senior staff specialist and professor in intensive care at Rigshospitalet, University of Copenhagen and an honorary professor of the George Institute in Sydney. He chairs the Danish National Centre for Research in Intensive Care and the Scandinavian Critical Care Trials Group. He was the chair of three land-mark trials, the 6S, TRISS, and CLASSIC trials, the results of which have improved the fluid and transfusion therapy of patients with sepsis.

Issues discussed in this interview:

· What to look out for when deciding on fluid therapy

· Restrictive versus standard fluid therapy

· Whether the guideline of 30 mL/kg of crystalloids remains valid

· When to start vasopressors

· Buffered crystalloids or 0.9% saline or albumin

· Limitations of markers of pre-load responsiveness

· Removal of fluid after stabilisation

· Importance of evidenced-based medicine and randomised controlled trials

Work cited:

  1. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021;47:1181-247.

  2. Meyhoff TS, Hjortrup PB, Wetterslev J, et al. Restriction of intravenous fluid in ICU patients with septic shock. N Engl J Med 2022;386:2459-70.

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In this AVF Podcast: ICU Tips & Tricks episode, Dr Brenda Pun discusses what how healthcare workers should look after family members and loved ones of critically ill patient. Dr Pun is an advanced practice nurse with a special interest in critical care, who serves as the Director of Data Quality at the Vanderbilt Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center. She is a key leader of the 2018 clinical practice guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility and Sleep Disruption in Adult Patients in the ICU (PADIS) and in the implementation of the ABCDEF bundle. Her research has focused on improving the care and outcomes of critically ill patients with a special emphasis on delirium, sedation, long-term outcomes and teamwork.

Issues discussed in this interview:

· Impact of critical illness on family members and loved ones of patients in the ICU

· Post-intensive care syndrome-family (PICS-F)

· The ABCDEF bundle

· Care for family members and loved ones in the ICU

· Care for family members and loved ones after the ICU stay

· Care for family members and loved ones of dying and deceased patients

· COVID-19 and its impact on family members and loved ones of patients in the ICU

Work cited:

  1. Devlin JW, Skrobik Y, Gelinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 2018;46:e825-e73.

  2. Davidson JE, Aslakson RA, Long AC, et al. Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Crit Care Med 2017;45:103-28.

  3. Pun BT, Balas MC, Barnes-Daly MA, et al. Caring for critically ill patients with the ABCDEF bundle: results of the ICU Liberation Collaborative in over 15,000 adults. Crit Care Med 2019;47:3-14.

  4. Pun BT, Badenes R, Heras La Calle G, et al. Prevalence and risk factors for delirium in critically ill patients with COVID-19 (COVID-D): a multicentre cohort study. Lancet Respir Med 2021;9:239-50.

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In this AVF Podcast: ICU Tips & Tricks episode, Professor Margaret Herridge discusses what patients and their loved ones go through after surviving ARDS and how we can help them. Dr. Herridge is a Professor in the Department of Medicine, a Senior Scientist in the Toronto General Hospital Research Institute, Director of the RECOVER Program/Grace RECOVER Program for Chronic Critical Illness, and co-lead (with Dr. Angela Cheung) of CANCOV (Canadian multi-centre 2-year follow-up of patients/caregivers after COVID-19). She has been the lead or co-lead on 5 publications in the New England Journal of Medicine and has published over 200 articles and book chapters on patient and caregiver outcomes after critical illness.

Issues discussed in this interview:

· Long-term physical, cognitive, and psychological complications of ARDS and critical
illness
· Evidence-based interventions to minimise such complications
· Care for ARDS survivors and their loved ones

Work cited:

  1. Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med 2008;358:1327-35.

  2. Puthucheary ZA, Rawal J, McPhail M, et al. Acute skeletal muscle wasting in critical illness. JAMA 2013;310:1591-600.

  3. Herridge MS, Cheung AM, Tansey CM, et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med 2003;348:683-93.

  4. Herridge MS, Tansey CM, Matte A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011;364:1293-304.

  5. Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med 2013;369:1306-16.

  6. Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Crit Care Med 2012;40:502-9.

  7. Brummel NE, Girard TD, Pandharipande PP, et al. Prevalence and course of frailty in survivors of critical illness. Crit Care Med 2020;48:1419-26.

  8. Azoulay E, Resche-Rigon M, Megarbane B, et al. Association of COVID-19 acute respiratory distress syndrome with symptoms of posttraumatic stress disorder in family members after ICU discharge. JAMA 2022;327:1042-50.

  9. Huang C, Huang L, Wang Y, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet 2021;397:220-32.

  10. Hermans G, Wilmer A, Meersseman W, et al. Impact of intensive insulin therapy on neuromuscular complications and ventilator dependency in the medical intensive care unit. Am J Respir Crit Care Med 2007;175:480-9.

  11. Schaller SJ, Anstey M, Blobner M, et al. Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial. Lancet 2016;388:1377-88.

  12. Hughes CG, Mailloux PT, Devlin JW, et al. Dexmedetomidine or propofol for sedation in mechanically ventilated adults with sepsis. N Engl J Med 2021;384:1424-36.

  13. Goligher EC, Jonkman AH, Dianti J, et al. Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort. Intensive Care Med 2020;46:2314-26.

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In this AVF Podcast: Behind-The-Scenes ICU Stories episode, Professor Jean-Louis Vincent paints his vision for the future of intensive care. Professor Vincent is Professor of intensive care medicine at the University of Brussels. He is Past-President of the World Federation of Societies of Intensive and Critical Care Medicine and the European Society of Intensive Care Medicine. He is the editor-in-chief of Critical Care, Current Opinion in Critical Care, and ICU Management & Practice, and member of the editorial boards of about 30 other journals. He has authored more than 1000 original articles, and his H index is 193.

Issues discussed in this interview:

  • Critical care medicine outside the intensive care unit (ICU)
  • Mixed versus medical or surgical ICU
  • Multidisciplinary teams
  • Protocolised versus personalised care with artificial intelligence
  • Outcomes beyond mortality
  • Telemedicine and pre-hospital care
  • Humanity and diversity in medicine
  • Noninvasive monitoring and extracorporeal organ support
  • Passion and inspiration

Work cited:

  1. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021;47:1181-247.
  2. Alam N, Oskam E, Stassen PM, et al. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. Lancet Respir Med 2018;6:40-50.
  3. Vincent JL. Antibiotic administration in the ambulance? Lancet Respir Med 2018;6:5-6.
  4. Lane DJ, Wunsch H, Saskin R, et al. Association between early intravenous fluids provided by paramedics and subsequent in-hospital mortality among patients with sepsis. JAMA Netw Open 2018;1:e185845.
  5. Ranieri VM, Brodie D, Vincent JL. Extracorporeal organ support: from technological tool to clinical strategy supporting severe organ failure. JAMA 2017;318:1105-6.
  6. Mang S, Reyher C, Mutlak H, et al. Awake extracorporeal membrane oxygenation for COVID-19-induced acute respiratory distress syndrome. Am J Respir Crit Care Med 2022;205:847-51.

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In this AVF Podcast: Behind-The-Scenes ICU Stories episode, Dr Maksym Pylypenko discusses the human impact of the Russia-Ukraine war on intensive care and hospital care. Together with Dr Oleg Loskutov, Dr Pylypenko is co-author of a recent article in Intensive Care Medicine, titled "The courage of Ukrainian hospitals and intensive care units in the first months of the Russia–Ukraine war".  Dr Pylypenko is Head of the Intensive Care and Anaesthesia Department at Romodanov Neurosurgery Institute, National Academy of Medical Sciences of Ukraine, and Associate Professor of the Department of Anaesthesiology and Intensive Care, Shupyk National Healthcare University of Ukraine.

Issues discussed in this interview:

·         The situation for intensive care unit (ICU) healthcare workers in Ukraine

·         How ICUs fit into the picture painted by the war

·         Challenges faced by ICU healthcare workers and leaders

·         Ways the international community can help

Work cited:

1.       Loskutov OA, Pylypenko MM. The courage of Ukrainian hospitals and Intensive Care Units in the first months of the Russia-Ukraine war. Intensive Care Med. 2022 Apr 13. doi: 10.1007/s00134-022-06694-1. Epub ahead of print.

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In this AVF Podcast: ICU Tips & Tricks episode, Professor Stephane Gaudry discusses his evidence-based approach to kidney-replacement therapy (KRT). Professor Gaudry is a physician in the critical care department at Assistance Publique-Hopitaux de Paris and at Sorbonne Paris Nord Universite. He is the first author of the landmark Artificial Kidney Initiation in Kidney Injury (AKIKI) and AKIKI 2 studies, of a systematic review on timing of KRT published in The Lancet, and of a recent narrative review on KRT published in the New England Journal of Medicine.

Issues discussed in this interview:

  • What acute kidney injury is
  • When to start KRT
  • Intermittent versus continuous KRT
  • Intensity of KRT
  • When to stop KRT
  • Future research areas for KRT and acute kidney injury

Work cited:

  1. Gaudry S, Palevsky PM, Dreyfuss D. Extracorporeal kidney-replacement therapy for acute kidney injury. N Engl J Med 2022;386:964-75.

  2. Gaudry S, Hajage D, Benichou N, et al. Delayed versus early initiation of renal replacement therapy for severe acute kidney injury: a systematic review and individual patient data meta-analysis of randomised clinical trials. Lancet 2020;395:1506-15.

  3. Gaudry S, Hajage D, Schortgen F, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med 2016;375:122-33.

  4. Barbar SD, Clere-Jehl R, Bourredjem A, et al. Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. N Engl J Med 2018;379:1431-42.

  5. Starrt-Aki Investigators, Canadian Critical Care Trials Group, Australian New Zealand Intensive Care Society Clinical Trials Group, et al. Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med 2020;383:240-51.

  6. Gaudry S, Hajage D, Martin-Lefevre L, et al. Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): a multicentre, open-label, randomised, controlled trial. Lancet 2021;397:1293-300.

  7. Vinsonneau C, Camus C, Combes A, et al. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet 2006;368:379-85.

  8. Rabindranath K, Adams J, Macleod AM, Muirhead N. Intermittent versus continuous renal replacement therapy for acute renal failure in adults. Cochrane Database Syst Rev 2007:CD003773.

  9. Mehta RL, McDonald B, Gabbai FB, et al. A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure. Kidney Int 2001;60:1154-63.

  10. Schortgen F, Soubrier N, Delclaux C, et al. Hemodynamic tolerance of intermittent hemodialysis in critically ill patients: usefulness of practice guidelines. Am J Respir Crit Care Med 2000;162:197-202.

  11. VA NIH Acute Renal Failure Trial Network, Palevsky PM, Zhang JH, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 2008;359:7-20.

  12. Renal Replacement Therapy Study Investigators, Bellomo R, Cass A, et al. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med 2009;361:1627-38

  13. Gaudry S, Grolleau F, Barbar S, et al. Continuous renal replacement therapy versus intermittent hemodialysis as first modality for renal replacement therapy in severe acute kidney injury: a secondary analysis of AKIKI and IDEAL-ICU studies. Crit Care 2022;26:93

  14. Poyan Mehr A, Tran MT, Ralto KM, et al. De novo NAD(+) biosynthetic impairment in acute kidney injury in humans. Nat Med 2018;24:1351-9

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In this AVF Podcast: Behind-The-Scenes ICU Stories episode, Professor Kathy Rowan shares her journey starting and growing one of the world’s most successful critical care research networks, the Intensive Care National Audit & Research Centre (ICNARC), and provides candid advice for anyone who may want to follow in her footsteps. Professor Rowan is the Director and founder of ICNARC, Honorary Professor at the London School of Hygiene & Tropical Medicine, and Adjunct Professor (Research) at Monash University, Australia.

Issues discussed in this interview:

  • What ICNARC does
  • What inspires one to set up a critical care research network
  • What hurdles to expect
  • How audit, quality improvement, and research go together
  • Ingredients needed for a good registry and research network
  • How to scale a critical care research network
  • The emphasis on humanity, equity, and effectiveness
  • How to use data to study COVID-19
  • Three final tips for anyone starting out

Work cited:

  1. Rowan KM, Kerr JH, Major E, McPherson K, Short A, Vessey MP. Intensive Care Society's APACHE II study in Britain and Ireland--I: Variations in case mix of adult admissions to general intensive care units and impact on outcome. BMJ 1993;307:972-7.
  2. Harvey SE, Parrott F, Harrison DA, et al. Trial of the route of early nutritional support in critically ill adults. N Engl J Med 2014;371:1673-84.
  3. Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015;372:1301-11.
  4. Lamontagne F, Richards-Belle A, Thomas K, et al. Effect of reduced exposure to vasopressors on 90-day mortality in older critically ill patients with vasodilatory hypotension: a randomized clinical trial. JAMA 2020;323:938-49.
  5. Ferrando P, Gould DW, Walmsley E, et al. Family satisfaction with critical care in the UK: a multicentre cohort study. BMJ Open 2019;9:e028956.

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In this AVF Podcast: ICU Tips & Tricks episode, Professor Manu Malbrain discusses the implications of increased intra-abdominal pressure on mechanical ventilation. Professor Malbrain is Professor of critical care research at the First Department of Anaesthesiology and Intensive Therapy at the Medical University of Lublin in Poland. He is the current President and co-founder of the International Fluid Academy, and the inaugural President, co-founder, and Treasurer of the Abdominal Compartment Society.

Issues discussed in this interview:

  • General effects of intra-abdominal hypertension
  • Physiologic effects of increased intra-abdominal pressure on intra-thoracic pressure
  • Guidance for adjusting ventilation in the presence of increased intra-abdominal pressure
  • General concerns and common pitfalls in the measurement of intra-abdominal pressure

Work cited:

1.       Pelosi P, Quintel M, Malbrain ML. Effect of intra-abdominal pressure on respiratory mechanics. Acta Clinica Belg. 2007;62-Suppl 1:78-88.

2.       Regli A, Pelosi P, Malbrain MLNG. Ventilation in patients with intra-abdominal hypertension: what every critical care physician needs to know. Ann Intensive Care. 2019;9:52.

3.       Martini A, Tonelli R, Rossi G, et al. Ventilatory support and mechanical properties of the fibrotic lung acting as a “squishy ball.” Ann Intensive Care, 2020;10:13.

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In this AVF Podcast: ICU Tips & Tricks episode, Dr Jorge Salluh discusses how one can drive quality improvement in the intensive care unit (ICU), both at the local level and in international registries. Dr Salluh is a Brazilian critical care physician working in Rio de Janeiro and a researcher at the not-for-profit D'or Institute for Research and Education. He has been working with outcomes and quality improvement projects for the last 17 years. He is a founder of the Brazilian Research in Intensive Care Network (BRICnet), the Brazilian ICUs registry, and the Linking of Global Intensive Care (LOGIC) consortium.

Issues discussed in this interview:

  • What quality improvement is
  • Skillsets needed for quality improvement
  • How to choose data for collection
  • How to choose quality indicators
  • How to establish targets
  • Frameworks for quality improvement such as the PDCA cycle
  • Role of ICU registries
  • Linking of Global Intensive Care (LOGIC) consortium

Work cited:

  1. da Silva Ramos FJ, de Freitas FGR, de Souza Pacheco E, Salluh JIF, Machado F. Top five priorities for a new ICU director during the first year. ICU Management & Practice 2021;21:113-116.

  2. Rhodes A, Moreno RP, Azoulay E, et al. Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the Task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM). Intensive Care Med. 2012;38:598-605.

  3. Zampieri FG, Salluh JIF, Azevedo LCP, et al. ICU staffing feature phenotypes and their relationship with patients' outcomes: an unsupervised machine learning analysis. Intensive Care Med 2019;45:1599-1607.

  4. Dongelmans DA, Pilcher D, Beane A, et al. Linking of global intensive care (LOGIC): An international benchmarking in critical care initiative. J Crit Care 2020;60:305-310.

  5. LOGIC: Linking of Global Intensive Care. https://www.icubenchmarking.com/logic-linking-of-global-intensive-care/.

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In this AVF Podcast: ICU Tips & Tricks episode, Professor Guerin discusses unanswered questions about prone positioning and shares specifics on how he uses it to manage patients with acute respiratory distress syndrome (ARDS). Professor Guerin is Professor of critical care medicine in the University of Lyon in France. He was the lead author of the landmark PROSEVA trial on prone positioning, and a leading figure in critical care and ARDS.

Issues discussed in this interview:

  • How prone positioning improves oxygenation and reduces lung injury
  • When to start prone positioning: PaO2/FIO2 of 100 or 150 or higher
  • What the real contraindications to prone positioning are
  • Whether to turn patients back to supine if oxygenation does not improve with prone position
  • Whether to use sedation and neuromuscular blockade
  • Ventilator settings during prone positioning
  • Duration of prone positioning: at least 12 hours or 16 hours or longer
  • When to stop prone positioning for patients who do not improve after several weeks
  • Awake prone positioning
  • Whether COVID-19 including type L patients should be dealt with differently
  • Top unanswered questions for research

Work cited:

  1. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159-2168.

  2. Munshi L, Del Sorbo L, Adhikari NKJ, et al. Prone position for acute respiratory distress syndrome. A systematic review and meta‐ analysis. Ann Am Thorac Soc 2017;14:S280-S288.

  3. Fan E, Del Sorbo L, Goligher EC, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2017;195:1253-1263.

  4. Papazian L, Aubron C, Brochard L, et al. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care 2019;9:69.

  5. Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. New Engl J Med 2000;342:1301-8.

  6. Albert RK, Keniston A, Baboi L, Ayzac L, Guérin C. Prone position-induced improvement in gas exchange does not predict improved survival in the acute respiratory distress syndrome. Am J Respi Crit Care Med 2014;189:494-496.

  7. National Heart, Lung, and Blood Institute PETAL Clinical Trials Network, Moss M, Huang DT, et al. Early neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med 2019;380:1997-2008.

  8. Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med 2010;363:1107-1116.

  9. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Ehrmann S, Li J, Ibarra-Estrada M, et al. Lancet Respir Med. 2021;9:1387-1395.

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In this AVF Podcast: Behind-The-Scenes ICU Stories episode, Mr Jaffer Shah and Ms Sara Nabil discuss the humanitarian crisis that has engulfed Afghanistan since the Taliban takeover in August 2021. Mr Shah graduated from Hofstra University in New York where he studied neuroscience. He has authored over 50 publications in peer-reviewed medical journals and works with the Department of Health in New York to monitor the current COVID-19 pandemic and public health measures. He is a clinical researcher, statistics instructor, and medical journalist with an interest in global health, and together with his colleagues published an article on the respiratory health and critical care concerns in Afghanistan in the journal Lancet Respiratory Medicine on 23 December 2021. Ms Sara Nabil is an artist and women’s rights activist who is currently doing her Masters in Visual Arts in Germany.

Issues discussed in this interview:

  • The Taliban takeover and the cessation of foreign funding
  • Multiple overlapping disasters related to COVID-19 and starvation and beyond
  • Collapse of the healthcare and critical care system
  • Loss of women’s rights
  • Ground-up support through TelemedAF (www.telemedaf.com) and its telemedicine service
  • How the international community can help (please email info@telemedaf.com if you wish to help, e.g. by providing teleconsultations, training and education for healthcare workers, provision of medical supplies, designing of websites and apps and databases, donations, etc)

Work cited:

  1. Shah J, Essar MY, Qaderi S, et al. Respiratory health and critical care concerns in Afghanistan. Lancet Respir Med 2021 Dec 23. Online ahead of print. https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(21)00583-X/fulltext
  2. Afghanistan’s health-care system is crumbling. The Economist 2021 Dec 19. https://www.economist.com/asia/2021/12/19/afghanistans-health-care-system-is-crumbling
  3. UNHCR, the UN Refugee Agency. UNHCR highlights urgent needs of forcibly displaced in Afghanistan as winter bites. Briefing Notes 2021 Dec 3. https://www.unhcr.org/news/briefing/2021/12/61a9d0e34/unhcr-highlights-urgent-needs-forcibly-displaced-afghanistan-winter-bites.html
  4. United Nations Entity for Gender Equality and the Empowerment of Women (UN Women). Women’s rights in Afghanistan: Where are we now? Gender Alerts 2021 Dec. https://www.unwomen.org/en/digital-library/publications/2021/1

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In this AVF Podcast: ICU Tips & Tricks episode, Professor Levy discusses selected points in the recent 2021 Surviving Sepsis Campaign (SSC) guidelines that we thought were potentially more controversial in clinical practice. Professor Levy is a founding member of the SSC and Co-Chair of its Steering Committee, Past President of the Society of Critical Care Medicine (SCCM), Professor of Medicine and Division Chief of Pulmonary and Critical Care Medicine at Alpert Medical School of Brown University, and Medical Director of the Medical Intensive Care Unit (MICU) at Rhode Island Hospital.

Issues discussed in this interview:

  • Appropriate use and timing of antifungals
  • Fluid resuscitation: volumes and fluid types
  • Bicarbonate use
  • Kidney replacement therapy
  • Norepinephrine dosing and vasopressin use
  • Top unanswered questions for the next SSC Campaign guidelines
  • Importance of evidence-based medicine

Work cited:

  1. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med 2021;49:e1063-e143.
  2. Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015;372:1301-11.
  3. ProCess Investigators, Yealy DM, Kellum JA, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014;370:1683-93.
  4. ARISE Investigators, ANZICS Clinical Trials Group, Peake SL, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014;371:1496-506.
  5. Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med 2018;378:829-39.
  6. Levy MM. An evidence-based evaluation of the use of sodium bicarbonate during cardiopulmonary resuscitation. Crit Care Clin 1998;14:457-83.
  7. von Planta M, Weil MH, Gazmuri RJ, Bisera J, Rackow EC. Myocardial acidosis associated with CO2 production during cardiac arrest and resuscitation. Circulation 1989;80:684-92.
  8. Jaber S, Paugam C, Futier E, et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. Lancet 2018;392:31-40.
  9. Gordon AC, Mason AJ, Thirunavukkarasu N, et al. Effect of early vasopressin vs norepinephrine on kidney failure in patients with septic shock: the VANISH randomized clinical trial. JAMA 2016;316:509-18.
  10. Russell JA, Walley KR, Singer J, et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med 2008;358:877-87.

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In this AVF Podcast: ICU Tips & Tricks episode, Professor Amato shares his thoughts on driving pressure and how he uses it to manage patients on mechanical ventilation. Professor Amato is from the Faculty of Medicine at the University of Sāo Paulo, Brazil. He is a pulmonologist and intensivist at the Pulmonary Division of the Hospital das Clínicas.

Issues discussed in this interview:

  • The concept of driving pressure
  • Association of driving pressure with mortality: cause or effect?
  • How to measure driving pressure
  • How to adjust driving pressure
  • Transpulmonary driving pressure
  • Driving pressure, respiratory rate, and mechanical power

Work cited:

  1. Dreyfuss D, Soler P, Basset G, Saumon G. High inflation pressure pulmonary edema. Respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure. Am Rev Respir Dis 1988;137:1159-64.
  2. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 2015;372:747-55.
  3. Bertoni M, Telias I, Urner M, et al. A novel non-invasive method to detect excessively high respiratory effort and dynamic transpulmonary driving pressure during mechanical ventilation. Crit Care 2019;23:346.
  4. Gattinoni L, Tonetti T, Cressoni M, et al. Ventilator-related causes of lung injury: the mechanical power. Intensive Care Med 2016;42:1567-75.
  5. Costa ELV, Slutsky AS, Brochard LJ, et al. Ventilatory variables and mechanical power in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2021;204:303-11.

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In this AVF Podcast: Behind-The-Scenes ICU Stories episode, an anaesthesiologist and intensivist from Myanmar provides a disturbing account of the humanitarian crisis that has gripped her country since its military coup in February 2021, while also sharing her inspiring story – and those of her fellow healthcare workers – of courage and defiance, and of duty and patriotism. To ensure the safety of the doctor, her family, and her colleagues, her identity has not been revealed, and her voice has been distorted post-recording.

Issues discussed in this interview:

  • The military coup in Myanmar and the subsequent civil disobedience movement
  • How healthcare workers struggled to treat civilian protestors gunned down by the military
  • The military’s crackdown on healthcare workers
  • How healthcare workers have continued to provide aid
  • Limited healthcare resources amidst the COVID-19 pandemic
  • Humanitarian crisis in areas such as the Chin state
  • A call for help from the international community

Work cited:

  1. Krisha G, Howard S. Myanmar doctors are under fire from the military and covid-19. BMJ 2021;375:n2409. doi: https://www.bmj.com/content/375/bmj.n2409.
  2. Assistance Association for Political Prisoners (Burma). https://aappb.org/.
  3. Violence Against or Obstruction of Health Care in Myanmar, Feb-Sep 2021. Published 26 Oct 2021.http://insecurityinsight.org/wp-content/uploads/2021/10/Violence-Against-Health-Care-in-Myanmar-February-September-2021-October-update.pdf.
  4. U.S. concerned over Myanmar army operations in Chin state, town ablaze. Reuters. Published 1 Nov 2021. https://www.reuters.com/world/asia-pacific/us-says-it-is-concerned-by-alleged-human-rights-abuse-by-myanmar-security-forces-2021-10-31/
  5. University of Oxford. Our World in Data. Myanmar: Coronavirus Pandemic Country Profile. https://ourworldindata.org/coronavirus/country/myanmar.

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In this AVF Podcast: Behind-The-Scenes ICU Stories episode, Professor Wes Ely (@WesElyMD) talks about his recently published book on healing, recovery, and transforming medicine in the intensive care unit (ICU): Every Deep-Drawn Breath (#EveryDeepDrawnBreath, #EDDB). Professor Ely is a pulmonary and critical care physician-scientist and serves as the Grant W. Liddle Endowed Chair in medicine at Vanderbilt University Medical Center. He is the associate director of ageing research for the Tennessee Valley Veterans Affairs Geriatric Research Education Clinical Center (GRECC). He is also the founder and codirector of the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center.

Issues discussed in this interview:

  1. The impact of delirium and post-intensive care syndrome on ICU patients and their families
  2. The science behind the prevention, detection, and management of delirium in the ICU
  3. The ABCDEF bundle and the COVID-19 pandemic
  4. Real life stories of persons with delirium and post-intensive care syndrome
  5. Bringing humanity back to medicine, one person at a time

Work cited:

  1. Ely W. Every deep drawn breath. New York, US: Scribner, 2021.
  2. Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (https://www.icudelirium.org/).
  3. Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 1996;335:1864-9.
  4. Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Crit Care Med 2012;40:502-9.
  5. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001;286:2703-10.
  6. Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 2003;289:2983-91.
  7. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004;291:1753-62.
  8. Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007;298:2644-53.
  9. Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA 2009;301:489-99.
  10. Hughes CG, Mailloux PT, Devlin JW, et al. Dexmedetomidine or propofol for sedation in mechanically ventilated adults with sepsis. N Engl J Med 2021;384:1424-36.
  11. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008;371:126-34.
  12. Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med 2013;369:1306-16.
  13. Pun BT, Balas MC, Barnes-Daly MA, et al. Caring for critically ill patients with the ABCDEF bundle: results of the ICU Liberation Collaborative in over 15,000 adults. Crit Care Med 2019;47:3-14.
  14. Girard TD, Exline MC, Carson SS, et al. Haloperidol and ziprasidone for treatment of delirium in critical illness. N Engl J Med 2018;379:2506-16.
  15. Liu K, Nakamura K, Katsukawa H, et al. Implementation of the ABCDEF bundle for critically ill ICU patients during the COVID-19 pandemic: a multi-national 1-day point prevalence study. Front Med (Lausanne) 2021;8:735860.

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In this AVF Podcast: ICU Tips & Tricks episode, Dr Domenico Luca Grieco shares his thoughts on noninvasive respiratory support for patients with acute hypoxaemic respiratory failure. Dr Grieco is an intensive care unit (ICU) physician at the Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli, in Rome, Italy. He is the lead author of the landmark HENIVOT trial which compared helmet noninvasive ventilation (NIV) versus high-flow nasal oxygen (HFNO) in patients with the coronavirus disease 2019 (COVID-19), and which was published in the Journal of the American Medical Association (JAMA) in March 2021.

Issues discussed in this interview:

  • Physiology underlying support by the helmet NIV, HFNO, and facemask NIV
  • A nuanced interpretation of the findings of the HENIVOT trial
  • Choosing between the helmet NIV, HFNO, and facemask NIV for acute hypoxaemic respiratory failure
  • The importance of close monitoring during noninvasive respiratory support
  • Criteria for failure of noninvasive respiratory support and intubation
  • Lung-protective ventilation post-intubation

Work cited:

  1. Grieco DL, Menga LS, Cesarano M, et al. Effect of helmet noninvasive ventilation vs high-flow nasal oxygen on days free of respiratory support in patients with COVID-19 and moderate to severe hypoxemic respiratory failure: the HENIVOT randomized clinical trial. JAMA 2021;325:1731-43.
  2. Grieco DL, Menga LS, Raggi V, et al. Physiological comparison of high-flow nasal cannula and helmet noninvasive ventilation in acute hypoxemic respiratory failure. Am J Respir Crit Care Med 2020;201:303-12.
  3. Yoshida T, Fujino Y, Amato MB, Kavanagh BP. Fifty years of research in ARDS. Spontaneous breathing during mechanical ventilation. Risks, mechanisms, and management. Am J Respir Crit Care Med 2017;195:985-92.
  4. Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015;372:2185-96.
  5. Ehrmann S, Li J, Ibarra-Estrada M, et al. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Lancet Respir Med 2021.
  6. Roca O, Caralt B, Messika J, et al. An index combining respiratory rate and oxygenation to predict outcome of nasal high-flow therapy. Am J Respir Crit Care Med 2019;199:1368-76.
  7. Duan J, Han X, Bai L, Zhou L, Huang S. Assessment of heart rate, acidosis, consciousness, oxygenation, and respiratory rate to predict noninvasive ventilation failure in hypoxemic patients. Intensive Care Med 2017;43:192-9.

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In this AVF Podcast: Behind-The-Scenes ICU Stories episode, Professor Charles Gomersall shares his thoughts on the world-renowned Basic Assessment and Support in Intensive Care (BASIC) Course which he developed, the teaching of intensive care, and retirement from intensive care. Professor Gomersall was an intensivist at the Department of Anaesthesia and Intensive Care of the Chinese University of Hong Kong and the Prince of Wales Hospital. He now spends his time happily working as a professional chocolatier.

Issues discussed in this interview:

  • The inspiration behind the BASIC Course and how it was scaled across the world
  • How one should teach intensive care, with or without COVID-19
  • How one knows if teaching has been effective
  • Specific advice for budding educators
  • Life advice for intensivists the world over who will one day retire

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Patient autonomy at the end of life in Asian ICUs: Professor Younsuck Koh

In this AVF Podcast: Behind-The-Scenes ICU Stories episode, Professor Younsuck Koh shares his thoughts on patient autonomy at the end of life in Asian intensive care units (ICUs). Professor Koh is an intensivist and respiratory physician at Asan Medical Center in Seoul, South Korea. He was previously President of the Korean Society of Critical Care Medicine (KSCCM), Chair of the Asian Critical Care Clinical Trials (ACCCT) Group, and Chair of the Asia Ventilation Forum (AVF).

Issues discussed in this interview:

  • Challenges of upholding patient autonomy at the end of life in Asian ICUs
  • How clinicians, the public, and governments can work together to improve communication regarding end-of-life issues
  • Specific strategies by clinicians to improve how we care for patients at the end of life or where clinical futility is present

Work cited:

  1. Phua J, Joynt GM, Nishimura M, et al. Withholding and withdrawal of life-sustaining treatments in intensive care units in Asia. JAMA Intern Med 2015;175:363-71.

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In this AVF Podcast: ICU Tips & Tricks episode, Professor Laurent Brochard shares his thoughts on the setting of positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome (ARDS). Professor Brochard is Keenan Chair in Critical Care and Respiratory Medicine at St. Michael’s Hospital and the University of Toronto, Head of the Interdepartmental Division of Critical Care Medicine at the University of Toronto, Deputy Editor of the American Journal Of Respiratory and Critical Care Medicine, former Editor-In-Chief of Intensive Care Medicine, Head of the PLUG Working Group on pleural pressure for the European Society of Intensive Care Medicine, former Head and Member of the REVA (European Research Network on Mechanical Ventilation), and Member of the Canadian Critical Care Trials Group.

Issues discussed in this interview:

  • Why we set a PEEP for ARDS and problems if the PEEP is too low or too high
  • Ranges of PEEP when we say higher versus lower levels of PEEP
  • Issues with the PEEP:FIO2 tables
  • Issues with older ways of using compliance to define optimal PEEP
  • Individualising PEEP using the recruitment-to-inflation ratio
  • Other methods of individualising PEEP, including oesophageal pressure measurements and computed tomography (CT) scans
  • Titrating PEEP after initial settings
  • What to do if plateau pressure exceeds 30 cmH2O on optimal PEEP

Work cited:

  1. Fan E, Del Sorbo L, Goligher EC, et al. An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: Mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2017;195:1253-63.
  2. Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial Investigators, Cavalcanti AB, Suzumura EA, et al. Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA 2017;318:1335-45.
  3. Dantzker DR, Lynch JP, Weg JG. Depression of cardiac output is a mechanism of shunt reduction in the therapy of acute respiratory failure. Chest 1980;77:636-42.
  4. Mekontso Dessap A, Boissier F, Leon R, et al. Prevalence and prognosis of shunting across patent foramen ovale during acute respiratory distress syndrome. Crit Care Med 2010;38:1786-92.
  5. Chen L, Del Sorbo L, Grieco DL, et al. Potential for lung recruitment estimated by the recruitment-to-inflation ratio in acute respiratory distress syndrome. A clinical trial. Am J Respir Crit Care Med 2020;201:178-87.

Useful website to guide assessment of recruitment-to-inflation ratio: https://rtmaven.com/.

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In this AVF Podcast: ICU Tips & Tricks episode, Professor Sheila Nainan Myatra shares her thoughts on airway management, and how the COVID-19 pandemic has changed the way we approach intubation. Professor Myatra is Professor of Intensive Care at Tata Memorial Hospital, Mumbai, India, President of the All India Difficult Airway Association (AIDAA), Chair of the Intensive & Critical Care Medicine (ICCM) Committee of the World Federation of Societies of Anaesthesiologists (WFSA), President Elect of the Indian Society of Critical Care Medicine (ISCCM) 2022, and one of the 14 international experts working on the American Society of Anesthesiologists (ASA) difficult airway guidelines and the PUMA (Project for the Universal Management of the Airway) guidelines.

Issues discussed in this interview:

  • The challenges of preparing for airway emergencies during the pandemic
  • Necessary adjustments to airway procedures from pre-oxygenation to induction and airway intervention
  • Changing understanding of healthcare worker risks and the role of different add-on protections
  • Airway procedural outcomes

Work cited:

  1. Russotto V, Myatra SN, Laffey JG, et al. Intubation practices and adverse peri-intubation events in critically ill patients from 29 countries. JAMA 2021;325:1164-72.
  2. Brown J, Gregson FKA, Shrimpton A, et al. A quantitative evaluation of aerosol generation during tracheal intubation and extubation. Anaesthesia 2021;76:174-81.
  3. Sorbello M, Rosenblatt W, Hofmeyr R, Greif R, Urdaneta F. Aerosol boxes and barrier enclosures for airway management in COVID-19 patients: a scoping review and narrative synthesis. Br J Anaesth 2020;125:880-94.
  4. Begley JL, Lavery KE, Nickson CP, Brewster DJ. The aerosol box for intubation in coronavirus disease 2019 patients: an in-situ simulation crossover study. Anaesthesia 2020;75:1014-21.
  5. Wong DJN, El-Boghdadly K, Owen R, et al. Emergency airway management in patients with COVID-19: a prospective international multicenter cohort study. Anesthesiology 2021;135:292-303.

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In this AVF Podcast: Behind-The-Scenes ICU Stories episode, Professor Jigi Divatia reflects on how ICU healthcare workers fought India’s second COVID-19 wave for their patients – and for their team mates. Professor Divatia is Head of the Department of Anaesthesia, Critical Care & Pain at Tata Memorial Hospital in Mumbai, India. He is Past-President of the Indian Society of Critical Care Medicine, Past Editor-In-Chief of the Indian Journal of Anaesthesia, and a current Board Member of the Asia Ventilation Forum.

Issues discussed in this interview:

  • Reported versus actual number of COVID-19 deaths in India
  • How COVID-19 affected ICUs in different states differently
  • Estimates for ICU capacity in India
  • Triage when resources are limited
  • Evidence-based and non-evidence based medical treatment
  • Impact of the second wave on ICU healthcare workers’ physical and mental health
  • How the ICUs are doing now
  • Lessons learnt and words of advice for all

Work cited:

  1. Center for Global Development. Three new estimates of India’s all cause excess mortality during the COVID-19 pandemic. 2021. https://www.cgdev.org/sites/default/files/three-new-estimates-indias-all-cause-excess-mortality-during-covid-19-pandemic.pdf.
  2. Phua J, Faruq MO, Kulkarni AP, et al. Critical care bed capacity in Asian countries and regions. Crit Care Med 2020;48:654-62.