Asia Ventilation Forum

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.

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.

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

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.

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/. 

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.

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.