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Introduction: To improve the nutritional care and resource allocation of critically ill patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), we described their characteristics, treatment modalities and clinical outcomes, and compared their nutrition interventions against the American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations. Methods: This was a retrospective observational study conducted in 5 tertiary hospitals in Singapore. Characteristics, treatment modalities, clinical outcomes and nutrition interventions of critically ill patients with SARS-CoV-2 who received enteral and parenteral nutrition were collected between January and May 2020. Results: Among the 83 critically ill patients with SARS-CoV-2, 22 (28%) were obese, 45 (54%) had hypertension, and 21 (25%) had diabetes. Neuromuscular blockade, prone therapy and dialysis were applied in 70% (58), 47% (39) and 35% (29) of the patients, respectively. Refeeding hypophosphataemia and hospital mortality occurred respectively in 6% (5) and 18% (15) of the critically ill patients with SARS-CoV-2. Late enteral nutrition and cardiovascular comorbidities were associated with higher hospital mortality (adjusted relative risk 9.00, 95% confidence interval [CI] 2.25–35.99; 6.30, 95% CI 1.15–34.40, respectively). Prone therapy was not associated with a higher incidence of high gastric residual volume (≥250mL). The minimum caloric (15kcal/kg) and protein (1.2g/kg) recommendations of ASPEN were achieved in 54% (39) and 0% of the patients, respectively. Conclusion: The high obesity prevalence and frequent usage of neuromuscular blockade, prone therapy, and dialysis had considerable implications for the nutritional care of critically ill patients with SARS-CoV-2. They also did not receive adequate calories and protein. More audits should be conducted to refine nutritional interventions and guidelines for this ever-evolving disease. Keywords: COVID-19, critical illness, energy intake, enteral nutrition, nutrition support, protein intake

Introduction: There is paucity of data on the occurrence of cardiovascular events (CVEs) in critically ill patients with sepsis. We aimed to describe the incidence, risk factors and impact on mortality of CVEs in these patients. Methods: This was a retrospective cohort study of critically ill patients admitted to the medical intensive care unit (ICU) between July 2015 and October 2016. The primary outcome was intra-hospital CVEs, while the secondary outcomes were in-hospital mortality, ICU and hospital length of stay. Results: Patients with sepsis (n=662) had significantly more CVEs compared to those without (52.9% versus 23.0%, P

Item does not contain fulltext BACKGROUND: Rezafungin is a next-generation, once-a-week echinocandin in development for the treatment of candidaemia and invasive candidiasis and for the prevention of invasive fungal disease caused by Candida, Aspergillus, and Pneumocystis spp after blood and marrow transplantation. We aimed to compare the efficacy and safety of intravenous rezafungin versus intravenous caspofungin in patients with candidaemia and invasive candidiasis. METHODS: ReSTORE was a multicentre, double-blind, double-dummy, randomised phase 3 trial done at 66 tertiary care centres in 15 countries. Adults (≥18 years) with systemic signs and mycological confirmation of candidaemia or invasive candidiasis were eligible for inclusion and randomly assigned (1:1) to receive intravenous rezafungin once a week (400 mg in week 1, followed by 200 mg weekly, for a total of two to four doses) or intravenous caspofungin (70 mg loading dose on day 1, followed by 50 mg daily) for no more than 4 weeks. The primary endpoints were global cure (consisting of clinical cure, radiological cure, and mycological eradication) at day 14 for the European Medical Agency (EMA) and 30-day all-cause mortality for the US Food and Drug Administration (FDA), both with a target non-inferiority margin of 20%, assessed in the modified intention-to-treat population (all patients who received one or more doses of study drug and had documented Candida infection based on a culture from blood or another normally sterile site obtained within 96 h before randomisation). Safety was evaluated by the incidence and type of adverse events and deaths in the safety population, defined as all patients who received any amount of study drug. The trial is registered with ClinicalTrials.gov, NCT03667690, and is complete. FINDINGS: Between Oct 12, 2018, and Aug 29, 2021, 222 patients were screened for inclusion, and 199 patients (118 [59%] men; 81 [41%] women; mean age 61 years [SD 15·2]) were randomly assigned (100 [50%] patients to the rezafungin group and 99 [50%] patients to the caspofungin group). 55 (59%) of 93 patients in the rezafungin group and 57 (61%) of 94 patients in the caspofungin group had a global cure at day 14 (weighted treatment difference -1·1% [95% CI -14·9 to 12·7]; EMA primary endpoint). 22 (24%) of 93 patients in the rezafungin group and 20 (21%) of 94 patients in the caspofungin group died or had an unknown survival status at day 30 (treatment difference 2·4% [95% CI -9·7 to 14·4]; FDA primary endpoint). In the safety analysis, 89 (91%) of 98 patients in the rezafungin group and 83 (85%) of 98 patients in the caspofungin group had at least one treatment-emergent adverse event. The most common treatment-emergent adverse events that occurred in at least 5% of patients in either group were pyrexia, hypokalaemia, pneumonia, septic shock, and anaemia. 55 (56%) patients in the rezafungin group and 52 (53%) patients in the caspofungin group had serious adverse events. INTERPRETATION: Our data show that rezafungin was non-inferior to caspofungin for the primary endpoints of day-14 global cure (EMA) and 30-day all-cause mortality (FDA). Efficacy in the initial days of treatment warrants evaluation. There were no concerning trends in treatment-emergent or serious adverse events. These phase 3 results show the efficacy and safety of rezafungin and support its ongoing development. FUNDING: Cidara Therapeutics and Mundipharma.

Introduction: Acute respiratory distress syndrome (ARDS) in COVID-19 is associated with a high mortality rate, though outcomes of the different lung compliance phenotypes are unclear. We aimed to measure lung compliance and examine other factors associated with mortality in COVID-19 patients with ARDS. Methods: Adult patients with COVID-19 ARDS who required invasive mechanical ventilation at 8 hospitals in Singapore were prospectively enrolled. Factors associated with both mortality and differences between high (

Introduction: Despite adhering to criteria for extubation, up to 20% of intensive care patients require re-intubation, even with use of post-extubation high-flow nasal cannula (HFNC). This study aims to identify independent predictors and outcomes of extubation failure in patients who failed postextubation HFNC. Methods: We conducted a multicentre observational study involving 9 adult intensive care units (ICUs) across 5 public hospitals in Singapore. We included patients extubated to HFNC following spontaneous breathing trials. We compared patients who were successfully weaned off HFNC with those who failed HFNC (defined as re-intubation ≤7 days following extubation). Generalised additive logistic regression analysis was used to identify independent risk factors for failed HFNC. Results: Among 244 patients (mean age: 63.92±15.51 years, 65.2% male, median APACHE II score 23.55±7.35), 41 (16.8%) failed HFNC; hypoxia, hypercapnia and excessive secretions were primary reasons. Stroke was an independent predictor of HFNC failure (odds ratio 2.48, 95% confidence interval 1.83–3.37). Failed HFNC, as compared to successful HFNC, was associated with increased median ICU length of stay (14 versus 7 days, P

BACKGROUND: We aimed to assess the efficacy and safety of two neutralising monoclonal antibody therapies (sotrovimab [Vir Biotechnology and GlaxoSmithKline] and BRII-196 plus BRII-198 [Brii Biosciences]) for adults admitted to hospital for COVID-19 (hereafter referred to as hospitalised) with COVID-19.METHODS: In this multinational, double-blind, randomised, placebo-controlled, clinical trial (Therapeutics for Inpatients with COVID-19 [TICO]), adults (aged ≥18 years) hospitalised with COVID-19 at 43 hospitals in the USA, Denmark, Switzerland, and Poland were recruited. Patients were eligible if they had laboratory-confirmed SARS-CoV-2 infection and COVID-19 symptoms for up to 12 days. Using a web-based application, participants were randomly assigned (2:1:2:1), stratified by trial site pharmacy, to sotrovimab 500 mg, matching placebo for sotrovimab, BRII-196 1000 mg plus BRII-198 1000 mg, or matching placebo for BRII-196 plus BRII-198, in addition to standard of care. Each study product was administered as a single dose given intravenously over 60 min. The concurrent placebo groups were pooled for analyses. The primary outcome was time to sustained clinical recovery, defined as discharge from the hospital to home and remaining at home for 14 consecutive days, up to day 90 after randomisation. Interim futility analyses were based on two seven-category ordinal outcome scales on day 5 that measured pulmonary status and extrapulmonary complications of COVID-19. The safety outcome was a composite of death, serious adverse events, incident organ failure, and serious coinfection up to day 90 after randomisation. Efficacy and safety outcomes were assessed in the modified intention-to-treat population, defined as all patients randomly assigned to treatment who started the study infusion. This study is registered with ClinicalTrials.gov, NCT04501978.FINDINGS: Between Dec 16, 2020, and March 1, 2021, 546 patients were enrolled and randomly assigned to sotrovimab (n=184), BRII-196 plus BRII-198 (n=183), or placebo (n=179), of whom 536 received part or all of their assigned study drug (sotrovimab n=182, BRII-196 plus BRII-198 n=176, or placebo n=178; median age of 60 years [IQR 50-72], 228 [43%] patients were female and 308 [57%] were male). At this point, enrolment was halted on the basis of the interim futility analysis. At day 5, neither the sotrovimab group nor the BRII-196 plus BRII-198 group had significantly higher odds of more favourable outcomes than the placebo group on either the pulmonary scale (adjusted odds ratio sotrovimab 1·07 [95% CI 0·74-1·56]; BRII-196 plus BRII-198 0·98 [95% CI 0·67-1·43]) or the pulmonary-plus complications scale (sotrovimab 1·08 [0·74-1·58]; BRII-196 plus BRII-198 1·00 [0·68-1·46]). By day 90, sustained clinical recovery was seen in 151 (85%) patients in the placebo group compared with 160 (88%) in the sotrovimab group (adjusted rate ratio 1·12 [95% CI 0·91-1·37]) and 155 (88%) in the BRII-196 plus BRII-198 group (1·08 [0·88-1·32]). The composite safety outcome up to day 90 was met by 48 (27%) patients in the placebo group, 42 (23%) in the sotrovimab group, and 45 (26%) in the BRII-196 plus BRII-198 group. 13 (7%) patients in the placebo group, 14 (8%) in the sotrovimab group, and 15 (9%) in the BRII-196 plus BRII-198 group died up to day 90.INTERPRETATION: Neither sotrovimab nor BRII-196 plus BRII-198 showed efficacy for improving clinical outcomes among adults hospitalised with COVID-19.FUNDING: US National Institutes of Health and Operation Warp Speed.

As of 27 October 2020, there have been 57,980 confirmed cases of COVID-19 in Singapore, with 28 fatalities. To summarise the Singapore experience in managing and containing COVID-19 based on available published data and from relevant sources, a review of literature using research databases such as PubMed and OVID Medline, along with non-peer-reviewed articles and other sources, was conducted with the search terms ‘COVID-19’ and ‘Singapore’. Research conducted in Singapore has provided insight into the clinical manifestations and period of infectivity of COVID-19, demonstrated evidence of pre-symptomatic transmission, linked infection clusters using serological tools, and highlighted aspects of hospital-based environmental contamination. It has also provided guidance for diagnostic testing and has described immune and virologic correlates with disease severity. Evidence of effectiveness of containment measures such as early border control, rigorous contact training, and calibrated social distancing measures have also been demonstrated. Singapore’s multipronged strategy has been largely successful at containing COVID-19 and minimising fatalities, but the risk of re-emergence is high. Keywords: Epidemiology, management, prevention, transmission

Background An elevated blood eosinophil count when asthma is stable predicts exacerbations and therapeutic response to corticosteroids or biologics targeting eosinophils. Few studies have examined the prognostic value of blood eosinophils measured at exacerbation. Aim To elucidate the relationship between a spot blood eosinophil count-measured at the onset of a life-threatening asthma exacerbation-with indices of exacerbation severity and risk of subsequent exacerbations. Methods Real-world, retrospective review of all life-threatening asthma cases admitted at 4 public hospitals in Singapore between 2011-2015. We assessed the trends and correlations between blood eosinophil count on admission with arterial blood gas values, duration of mechanical ventilation, and risk of death, hypoxic ischemic encephalopathy or respiratory arrest. Risk of future exacerbations among survivors was modelled using Cox regression and survival curves. Results There were 376 index life-threatening exacerbations with median blood eosinophil count (5-95th percentiles) of 0.270 × 109 /L (0-1.410 × 109 /L). Arterial pH decreased and PCO2 increased with increasing eosinophil count. Duration of mechanical ventilation and risk of death, hypoxic ischaemic encephalopathy or respiratory arrest did not vary with eosinophils. Among 329 survivors who were followed-up over a median of 52 months, blood eosinophils ≥1.200 × 109 /L was associated with an increased hazard of emergency visits and/or admissions for asthma (hazard ratio 1.8, 95% confidence interval 1.1-2.9, P = .02). Conclusion In this study of life-threatening asthma, we found that a spot blood eosinophil count correlates with severity of respiratory failure and predicts risk of subsequent exacerbations.

Surveillance of nosocomial infections, like catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), possible ventilator-associated pneumonia (PVAP) and secondary bloodstream infections were observed to study the impact of COVID-19 outbreak in ICUs from Tan Tock Seng Hospital and National Centre for Infectious Diseases, Singapore between February and June 2020. Higher nosocomial infection rates were observed in COVID-19 patients, although it was not statistically significant. Moreover, COVID-19 patients seem to be more predisposed to CAUTI despite a higher proportion of non-COVID-19 patients having urinary catheters. Thus, continued vigilance to ensure adherence to IPC measures is needed.

Background Delaying intubation in patients who fail high-flow nasal cannula (HFNC) may result in increased mortality. The ROX index has been validated to predict HFNC failure among pneumonia patients with acute hypoxemic respiratory failure (AHRF), but little information is available for non-pneumonia causes. In this study, we validate the ROX index among AHRF patients due to both pneumonia or non-pneumonia causes, focusing on early prediction. Methods This was a retrospective observational study in eight Singapore intensive care units from 1 January 2015 to 30 September 2017. All patients >18 years who were treated with HFNC for AHRF were eligible and recruited. Clinical parameters and arterial blood gas values at HFNC initiation and one hour were recorded. HFNC failure was defined as requiring intubation post-HFNC initiation. Results HFNC was used in 483 patients with 185 (38.3%) failing HFNC. Among pneumonia patients, the ROX index was most discriminatory in pneumonia patients one hour after HFNC initiation [AUC 0.71 (95% CI 0.64–0.79)], with a threshold value of Conclusion The ROX index demonstrated moderate discriminatory power among patients with either pneumonia or non-pneumonia-related AHRF at HFNC initiation and one hour later.

We aim to describe a case series of critically and non-critically ill COVID-19 patients in Singapore. This was a multicentered prospective study with clinical and laboratory details. Details for fifty uncomplicated COVID-19 patients and ten who required mechanical ventilation were collected. We compared clinical features between the groups, assessed predictors of intubation, and described ventilatory management in ICU patients. Ventilated patients were significantly older, reported more dyspnea, had elevated C-reactive protein and lactate dehydrogenase. A multivariable logistic regression model identified respiratory rate (aOR 2.83, 95% CI 1.24–6.47) and neutrophil count (aOR 2.39, 95% CI 1.34–4.26) on admission as independent predictors of intubation with area under receiver operating characteristic curve of 0.928 (95% CI 0.828–0.979). Median APACHE II score was 19 (IQR 17–22) and PaO2/FiO2 ratio before intubation was 104 (IQR 89–129). Median peak FiO2 was 0.75 (IQR 0.6–1.0), positive end-expiratory pressure 12 (IQR 10–14) and plateau pressure 22 (IQR 18–26) in the first 24 h of ventilation. Median duration of ventilation was 6.5 days (IQR 5.5–13). There were no fatalities. Most COVID-19 patients in Singapore who required mechanical ventilation because of ARDS were extubated with no mortality.

Background Use of high-flow nasal cannula (HFNC) has become a regular intervention in the intensive care units especially in patients coming in with hypoxaemic respiratory failure. Clinical practices may differ from published literature. Objectives The objective of this study was to determine the clinical practices of physicians and respiratory therapists (RTs) on the use of HFNC. Methods A retrospective observational study looking at medical records on HFNC usage from January 2015 to September 2017 was performed and was followed by a series of questions related to HFNC practices. The survey involved physicians and RTs in intensive care units from multiple centres in Singapore from January to April 2018. Indications and thresholds for HFNC usage with titration and weaning practices were compared with the retrospective observational study data. Results One hundred twenty-three recipients (69.9%) responded to the survey and reported postextubation (87.8%), pneumonia in nonimmunocompromised (65.9%), and pneumonia in immunocompromised (61.8%) patients as the top three indications for HFNC. Of all, 39.8% of respondents wanted to use HFNC for palliative intent. Similar practices were observed in the retrospective study with the large cohort of 63% patients (483 of the total 768 patients) where HFNC was used for acute hypoxaemic respiratory failure and 274 (35.7%) patients to facilitate extubation. The survey suggested that respondents would initiate HFNC at a lower fraction of inspired oxygen (FiO2), higher partial pressure of oxygen to FiO2 ratio, and higher oxygen saturation to FiO2 ratio for nonpneumonia patients than patients with pneumonia. RTs were less likely to start HFNC for patients suffering from pneumonia and interstitial lung disease than physicians. RTs also preferred adjustment of FiO2 to improve oxygen saturations and noninvasive ventilation for rescue. Conclusions Among the different intensive care units surveyed, the indications and thresholds for the initiation of HFNC differed in the clinical practices of physicians and RTs.

Background:COVID-19 (Coronavirus Disease 2019) is a global cause of morbidity and mortality currently. We aim to describe the acute functional outcomes of critically ill coronavirus disease 2019 (COVID-19) patients after transferring out of the intensive care unit (ICU).Methods:51 consecutive critically ill COVID-19 patients at a national designated center for COVID-19 were included in this exploratory, retrospective observational cohort study from January 1 to May 31, 2020. Demographic and clinical data were collected and analyzed. Functional outcomes were measured primarily with the Functional Ambulation Category (FAC), and divided into 2 categories: dependent ambulators (FAC 0–3) and independent ambulators (FAC 4–5). Multivariate analysis was performed to determine associations.Results:Many patients were dependent ambulators (47.1%) upon transferring out of ICU, although 92.2% regained independent ambulation at discharge. On multivariate analysis, we found that a Charlson Comorbidity Index of 1 or more (odds ratio 14.02, 95% CI 1.15–171.28,P= 0.039) and a longer length of ICU stay (odds ratio 1.50, 95% CI 1.04–2.16,P= 0.029) were associated with dependent ambulation upon discharge from ICU.Conclusions:Critically ill COVID-19 survivors have a high level of impairment following discharge from ICU. Such patients should be screened for impairment and managed appropriately by rehabilitation professionals, so as to achieve good functional outcomes on discharge.

This study aimed to explore changes in psychological responses (perceived stress, traumatic stress, stigma, coping) over time in residents, as well as their predictors. The level of perceived stress, traumatic stress, stigma, and coping responses were assessed using the Perceived Stress Scale, Impact of Event-Revised, Healthcare Workers Stigma Scale, and Brief Coping Orientation to Problems Experienced (COPE) Inventory, respectively. We collected responses from 274 residents at baseline and 221 residents at 3 months follow-up (timepoint 2) from the National Healthcare Group (NHG) residency programs in Singapore. All residents reported lower perceived stress and lower perceived stigma compared to baseline. Use of avoidance coping was associated with all three psychological responses (perceived stress, traumatic stress, and stigma) across the two timepoints. Compared to baseline, specific factors associated with perceived stress and traumatic stress at timepoint 2 were living alone, less problem solving, and seeking social support. Residency programs should encourage active coping strategies (e.g., seeking social support, positive thinking, problem solving) among residents, and proactively identify residents who may be at higher risk of psychological sequelae due to circumstances that contribute to isolation.

BACKGROUND Proper inhaler device usage is paramount for control of underlying obstructive airway disease. Hence, education to healthcare professionals who will eventually educate patients need to be done effectively. OBJECTIVE We developed an application for mobile devices for education on medical inhaler devices and studied if there were any difference between the application and the manufacturer’s instructions on inhaler technique. METHODS Participants, who were nursing students, were randomized to learn the inhaler devices via the manufacturer’s instruction guide or a mobile device app designed specifically for education on inhaler devices. RESULTS There were 45 participants in each group. 78% of them were females with a median age of 21 (IQR 3). 67% used an Apple mobile device and the remainder used an Android device. Both interventions showed improvement in total scores for demonstrating the correct usage of all inhaler devices. The mobile device showed better total improvement points for the Turbuhaler device (262 vs 287 points; P=0.02). Participants learning from the manufacturer’s guide had a significantly higher total improvement points in the Breezhaler (370 vs 327 points; P CONCLUSIONS Using a mobile inhaler app is just as effective to teach inhaler device techniques to healthcare professionals and is likely a more convenient, versatile and important adjunct to learning. CLINICALTRIAL

Highlights • Platypnea-orthodeoxia syndrome (POS) is observed in COVID-19 acute respiratory distress syndrome (ARDS) survivors. • POS is associated with older age, lower body mass index and varying degrees of dyspnea. • Arterial to end-tidal carbon dioxide and alveolar to arterial oxygen partial pressure differences were persistently elevated. • POS is likely a gravitational exacerbation of intrapulmonary shunt in ARDS due to COVID-19 specific changes. • POS may cause alarm and requires adjustment in the rehabilitation approach during the recovery period., Platypnea-orthodeoxia syndrome (POS) is a rare clinical syndrome characterized by orthostatic oxygen desaturation and positional dyspnea from supine to an upright position. We observed POS in 5 of 20 cases of severe 2019 novel coronavirus (COVID-19) pneumonia, which demonstrated persistently elevated shunt fraction even after liberation from mechanical ventilation. POS was first observed during physiotherapy sessions; median oxygen desaturation was 8 % (range: 8–12 %). Affected individuals were older (median 64 vs 53 years old, p = 0.05) and had lower body mass index (median 24.7 vs 27.6 kg/m2, p = 0.03) compared to those without POS. While POS caused alarm and reduced tolerance to therapy, this phenomenon resolved over a median of 17 days with improvement of parenchymal disease. The mechanisms of POS are likely due to gravitational redistribution of pulmonary blood flow resulting in increased basal physiological shunting and upper zone dead space ventilation due to the predominantly basal distribution of consolidative change and reported vasculoplegia and microthrombi in severe COVID-19 disease.

Since the outbreak of the 2019 novel coronavirus (COVID-19), the role of physiotherapy for patients with COVID-19 infection has been highlighted by various international guidelines. Despite that, clinical information regarding the rehabilitation of patients with COVID-19 infection remains limited. In this case series, we provide a novel insight into the physiotherapy management in patients infected with COVID-19 in Singapore. The main findings are: (1) Respiratory physiotherapy interventions were not indicated in the majority of the patients with COVID-19 in this case series; (2) During rehabilitation, exertional or position-related desaturation is a common feature observed in critically ill patients with COVID-19 infection locally. This clinical phenomenon of exertional or positional-related desaturation has significantly slowed down the progression of rehabilitation in our patients. As such, it can potentially result in a significant burden on healthcare resources to provide rehabilitation to these patients. Based on these findings, we have highlighted several recommendations for the provision of rehabilitation in patients who are critically ill with COVID-19.

Research Objectives To describe the functional outcomes of patients with critically ill coronavirus disease 2019 (COVID-19) after transfer out of intensive care unit (ICU). Design Retrospective observational cohort study. Setting National designated center for patients with COVID-19. Participants 51 consecutive critically ill COVID-19 patients admitted to the ICU. Interventions Patients were referred for physical therapy after transferring out from ICU if they had functional impairments. Main Outcome Measures Functional outcomes were measured primarily with the Functional Ambulation Category (FAC), and divided into 2 categories: dependent ambulators (FAC 0-3) and independent ambulators (FAC 4-5). Secondary outcomes measured included ADL dependence of patients and the need for supplemental oxygen. Results All patients were premorbidly independent in walking and in basic ADLs, and did not require supplementary oxygen. Upon transfer out of ICU, there were 24 patients (47.1%) who were dependent walkers (defined as FAC of 0-3) with 22 patients (43.1%) who were dependent in 1 or more basic ADLs. However, upon discharge, a majority achieved independence in ambulation and basic ADLs (92.2% and 90.2% respectively). All 41 patients (80.4%) who required continuous supplementary oxygen upon transferring out of ICU did not require supplementary oxygen on discharge. On multivariate analysis, we found that a Charlson Comorbidity Index of 1 or more (odds ratio 14.02, 95% CI 1.15-171.28, P=0.039) and a longer length of ICU stay (odds ratio 1.50, 95% CI 1.04-2.16, P=0.029) were associated with dependent ambulation upon discharge from ICU. Conclusions Critically ill COVID-19 survivors have a high level of impairment following discharge from ICU. Such patients should be screened for impairment and managed appropriately by rehabilitation professionals, so as to achieve good functional outcomes on discharge. Author(s) Disclosures None to disclose.

Aspergillus terreus is an uncommon cause of pulmonary infection and is usually seen in association with immunosuppression. In 2012 we reported an immunocompetent patient with right eye Aspergillus ...

Background Intensive care unit (ICU) stays are 2.5 times more costly than other hospital stays, and 93.3% of ICU use is for respiratory disease with ventilator support. The aim of this study was to assess the role of bronchoscopy on discontinuation of mechanical ventilation, and prompt discharge from ICU in our institution. Methods Retrospective review of medical records of patients referred for bronchoscopic intervention for acute respiratory failure from malignant or benign central airway diseases requiring ICU admission. Results Twelve critically ill patients were studied. Median (range) age was 63 years (range, 35 to 85 y). Nine (75%) had endotracheal tube, and 3 (25%) had tracheostomy tube. Nine (75%) of 12 patients admitted to ICU could be transferred to general ward after median (range) interval of 2 days (range, 1 to 7 d) after the day of intervention. Median (range) prebronchoscopy and postbronchoscopy PaO2/FiO2 ratio was 102.8 (range, 99.2 to 328) and 180 (range, 129 to 380), respectively, with significant improvement postintervention (P=0.002). Radiologically, all 8 patients with lung atelectasis on presentation experienced complete reexpansion of the lung on the day after bronchoscopic intervention. Conclusion The majority of patients in our cohort (75%) of benign and malignant etiology could be promptly (within 2 d postbronchoscopy) transferred out from ICU to general ward after successful discontinuation of mechanical ventilation and extubation after bronchoscopic intervention. We advocate early recognition and bronchoscopic intervention in suitable patients.

Background: Blood eosinophil count (BEC) predicts frequent exacerbations and therapeutic response to anti-eosinophil biologics in patients with stable asthma. However, the role of BEC in stratifying risk in severe life-threatening asthma (SLTA) is unknown. We evaluated BEC, obtained when a patient presents with SLTA, as a predictive biomarker for short-term and long-term adverse outcomes such as severity of respiratory failure, death, and recurrent exacerbations after recovery from SLTA. Methods: Retrospective review of SLTA cases presenting to 4 public hospitals in Singapore between 2011-2015. SLTA was defined as asthma exacerbation requiring mechanical ventilation, or admission to intensive care unit or high-dependency unit. Results: There were a total of 384 SLTA events. After excluding recurrent SLTA readmissions, a total of 340 unique patients and first SLTA events within the study period were analysed. Mean age was 57±18 years, 194 (57.1%) were female. Median BEC at presentation of SLTA was 275/µL. BEC was negatively correlated with arterial blood pH (rho=-0.186, p=0.001) and positively correlated with arterial blood PaCO2 (rho=0.154, p=0.005). BEC was associated with increased rate of emergency visits or admissions for asthma in the previous year (rate ratio 1.76, 95% CI 1.132-2.736, p=0.012). Over a median follow up of 1.6 years (IQR 0.3-4.0 years), BEC at index SLTA was associated with increased hazard of death from or future emergency visit/admission for asthma (hazard ratio 1.3, 95% CI 1.01-1.7, p=0.041). Conclusion: BEC at index SLTA predicts more severe respiratory acidosis, higher risk of death and future exacerbations.

Introduction: Asthma mortality in Singapore is high despite moderate asthma prevalence and having a modern, well-resourced healthcare system. Aim: To perform a national audit of severe life-threatening asthma (SLTA) in Singapore and identify gaps in care. Methods: Review of SLTA cases in 4 public hospitals in Singapore between 2011-2015. SLTA was defined as exacerbation requiring mechanical ventilation or intensive care unit/high dependency admission. “Adverse outcomes” (AO) was defined as death, hypoxic ischemic encephalopathy or respiratory arrest. Results: 340 patients accounted for 384 SLTA events, age 55±18y, 56% female and 28.4% had history of SLTA. AO occurred in 59 (15.4%). There was a high proportion of current smokers (22.9%) compared to national smoking rate of 13.3%. Prior to the index SLTA, 17.1% had no regular asthma follow-up, and 32.1% were not on inhaled corticosteroid (ICS) i.e. Step 1 of GINA. The proportion of patients on Step 1 GINA was most prevalent in those not on regular follow-up (79.3%) and those followed-up with private GPs (56.6%) or private pulmonologists (40.0%), and least in patients on follow-up with polyclinic (16.7%) or restructured hospitals (4.6%) (p Conclusion: We identified underuse of ICS and spirometry, lack of regular-follow-up, and high defaulter and smoking rates as gaps in care and potential future areas of intervention among SLTA cases in Singapore.

Measurement of disability and breathlessness in asthma is important to guide treatment. Using an incentive spirometer, Triflo II (Tyco Healthcare, Mansfield, MA, USA), we developed a three-minute respiratory exercise test (3-MRET) to score the maximal breathing capacity (MBC) and perception of dyspnea (POD) index by means of repetitive inspiratory efforts achieved within 3 minutes. POD index was calculated based on the ratio of breathlessness on visual analogue scale over MBC score. In 175 normal healthy subjects and 158 asthmatic patients of mild (n = 26), moderate (n = 78), and severe (n = 54), severity, the mean (95% CI) MBC scores in mild, moderate, and severe asthma patients were 168 (145-192), 153 (136-169), and 125 (109-142) respectively, and 202 (191-214) in normal subjects (p < 0.001). The mean POD index in mild, moderate, and severe asthma patients was 16 (9-23), 25 (14-37), and 57 (14-100), respectively, and 6 (4-7) in normal subjects (p < 0.001). Intraclass correlation coefficients for MBC score and POD index in 17 asthmatic and 20 normal subjects were high. In 14 asthmatic patients randomized to receiving nebulized beta2-agonist or saline in a cross-over, double-blind study, % forced expiratory volume in one second (FEV1) change correlated with % change in MBC score [r(s) = 0.49, p < 0.01] and POD index [r(s)-0.46, p = 0.012]. In 21 asthmatic and 26 normal subjects, the MBC score and POD index correlated with the walking distance and walking POD index of the six-minute walking test (6MWT). We conclude that 3MRET is discriminative between asthmatic patients of varying severity and normal subjects, is reproducible, is responsive to bronchodilator effect, and is comparable with 6MWT. Taken together, it has the potential to score disability and POD in asthma simply and effectively.