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The management of coronavirus disease-2019 (COVID-19) is witnessing a change as we learn more about the pathophysiology and the severity of the disease. Several randomized controlled trials (RCTs) and meta-analysis have been published over the last few months. Several interventions and therapies which showed promise in the initial days of the pandemic have subsequently failed to show benefit in well-designed trials. Understanding of the methods of oxygen delivery and ventilation have also evolved over the past few months. The Indian Society of Critical Care Medicine (ISCCM) has reviewed the evidence that has emerged since the publication of its position statement in May and has put together an addendum of updated evidence. How to cite this article: Mehta Y, Chaudhry D, Abraham OC, Chacko J, Divatia J, Jagiasi B, et al. Critical Care for COVID-19 Affected Patients: Position Statement of the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2020;24(Suppl 5):S225–S230.

Background: Muscle wasting is common among critically ill patients with sepsis and has a significant effect on clinical outcome. However, appropriate tool for measurement of muscle loss is debatable. Ultrasonography (USG) has been used for objective assessment of quadriceps muscle thickness among these patients; however, there is limited data on its reliability. Aims and Objective: This study was aimed to assess the reliability of quadriceps muscle thickness as measured by critical care physicians. Methodology: This cross-sectional study included twenty patients with sepsis. Quadriceps muscle thickness was measured on right mid-thigh at a predefined point by two critical care fellows using bedside USG. Intra- and inter-observer reliability of the measurements was assessed by intra-class correlation coefficient (ICC). Results: Hundred and twenty quadriceps muscle thickness measurements, three by each of the two critical care fellows, were done in twenty patients with sepsis. First, second, and third measurements (mean ± standard deviation) taken by the first observer (RK) were 35.030 ± 3.546 mm, 35.055 ± 3.307 mm, and 35.245 ± 3.027 mm, respectively. The three values recorded by the second observer (AD) were 35.585 ± 3.746 mm, 35.1 ± 3.006 mm, and 34.89 ± 2.556 mm, respectively. ICC for observer 1 and 2 was 0.925 (95% confidence interval [CI]: 0.851–0.967) and 0.835 (95% CI: 0.689–0.925), respectively. The mean difference of measurement between two observers was 0.082 mm (95% CI: −1.194–1.031). The mean ICC (95% CI) for inter-observer reliability was 0.992 (0.979–0.997); P Conclusions: This study shows that ultrasound is a reliable tool for the measurement of quadriceps muscle thickness by critical care physicians with excellent inter- and intra-class reliability.

How to cite this article: Kulkarni AP, Sengar M, Chinnaswamy G, Hegde A, Rodrigues C, Soman R, Khilnani GC, Ramasubban S, Desai M, Pandit R, Khasne R, Shetty A, Gilada T, Bhosale S, Kothekar A, Dixit S, Zirpe K, Mehta Y, Pulinilkunnathil JG, Bhagat V, Khan MS, Narkhede AM, Baliga N, Ammapalli S, Bamne S, Turkar S, Bhat KV, Choudhary J, Kumar R, Divatia JV. Indian Journal of Critical Care Medicine 2019;23(Suppl 1): S64-S96.

Purpose of the Study: Data regarding the use of noninvasive ventilation (NIV) for treatment of acute respiratory failure (ARF) among patients with noncystic fibrosis (CF) bronchiectasis are limited. We intend to describe our experience with NIV use in this setting. Methodology: This was a retrospective study which included 99 patients with bronchiectasis and ARF who required either NIV or invasive mechanical ventilation (IMV). Results: NIV was started as the primary modality of ventilatory support in 81 (66.3%) patients. Fifty-three (65.4%) patients were managed successfully with NIV. Twenty-eight (34.56%) patients failed NIV and required endotracheal intubation. Reasons for NIV failure were worsening or nonimprovement of ventilatory or oxygenation parameters ( n = 15), hypotension ( n = 6), worsening of sensorium ( n = 3), and intolerance ( n = 4). None of the patients failed NIV due to excessive respiratory secretions. The rate of correction of arterial blood gases was comparable between NIV and IMV groups. The total duration of stay (median [interquartile range] days) in hospital was comparable between patients treated with NIV and IMV (8 [7–10] vs. 11 [5–11]; P = 0.99), respectively. The mortality rate between NIV and IMV groups were statistically comparable (8.64% vs. 16.6%; P = 0.08). High APACHE score at admission was associated with NIV failure (odd's ratio [95% confidence interval]: 1.21 (1.07–1.38)]. Conclusions: NIV is feasible for management of ARF with non-CF bronchiectasis. High APACHE may predict NIV failure among these patients.

Background: The diagnosis of ventilator associated pneumonia (VAP) remains a challenge because the clinical signs and symptoms lack both sensitivity and specificity and the selection of microbiologic diagnostic procedure is still a matter of debate. Aims and Objective: To study the role of various bronchoscopic and non-bronchoscopic diagnostic techniques for diagnosis of VAP. Settings and Design: This prospective comparative study was conducted in a medical ICU of a tertiary care center. Materials and Methods: Twenty-five patients, clinically diagnosed with VAP, were evaluated by bronchoscopic and non-bronchoscopic procedures for diagnosis. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of various bronchoscopic and non-bronchoscopic techniques were calculated, taking clinical pulmonary infection score (CPIS) of ≥6 as reference standard. Results: Our study has shown that for the diagnosis of VAP, bronchoscopic brush had a sensitivity, specificity, PPV and NPV of 94.9% [confidence interval (CI): 70.6-99.7], 57.1% (CI: 13.4-86.1), 85% (CI: 61.1-96) and 80% (CI: 21.9-98.7), respectively. Bronchoscopic bronchoalveolar lavage (BAL) had a sensitivity, specificity, PPV and NPV of 77.8% (CI: 51.9-92.6), 71.8% (CI: 24.1-94), 87.3% (CI: 60.4-97.8) and 55.5% (CI: 17.4-82.6), respectively. Sensitivity, specificity, PPV and NPV for non-bronchoscopic BAL (NBAL) were 83.3% (CI: 57.7-95.6), 71.43% (CI: 24.1-94), 88.2% (CI: 62.3-97.4) and 62.5% (CI: 20.2-88.2), respectively. Endotracheal aspirate (ETA) yield was only 52% and showed poor concordance with BAL (k-0.351; P-0.064) and NBAL (k-0.272; P-0.161). There was a good microbiologic concordance among different bronchoscopic and non-bronchoscopic distal airway sampling techniques. Conclusion: NBAL is an inexpensive, easy, and useful technique for microbiologic diagnosis of VAP. Our findings, if verified, might simplify the approach for the diagnosis of VAP.