Asia Ventilation Forum

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.

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

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.

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.

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/.

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.

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 [email protected] 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

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.

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.

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.