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Purpose Guidelines recommend teaching of lung ultrasound for critical care, though little information exists on how much training is required for independent practice, especially for non-physician trainees. We thus aimed to elucidate a threshold number of cases above which competency for independent practice may be attained for respiratory therapists (RTs). Methods We conducted a prospective audit of lung ultrasound training between July 2014 and April 2015 in our 20-bed medical intensive care unit. Following theoretical instruction and self-learning, trainees acquired images from 12 lung zones under direct supervision and classified images into six patterns. Assistance during image acquisition and correct interpretation of ultrasound images were recorded. Results Eleven ultrasound-naïve RTs scanned an average of 15 patients each (170 patients in total). Among supervisor-adjudicated lung ultrasound findings, 35.5 % were abnormal. Blinded verification of the adjudicated findings was done for the first 92 patients (1104 images), with an agreement of 95.4 %. As RTs scanned more patients, there was a significant decrease in the proportion of images requiring supervisor assistance (Cuzick's P < 0.001), and a significant increase in the proportion of correctly identified images (Cuzick's P = 0.008). After trainees performed at least ten scans, less than 2 % of images required assistance with acquisition and less than 5 % were wrongly interpreted. Conclusions Our training method allowed RTs to independently perform lung ultrasound after at least ten directly supervised scans. Given that RTs are likely to have less ultrasound knowledge and less clinical know-how compared to physicians, we believe that the same threshold number of scans may be also safely applied to the latter., Author(s): K. C. See [sup.1] [sup.2], V. Ong [sup.1] [sup.2], S. H. Wong [sup.3], R. Leanda [sup.3], J. Santos [sup.3], J. Taculod [sup.3], J. Phua [sup.1] [sup.2], C. M. Teoh [...]

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 (FiO 2 ), higher partial pressure of oxygen to FiO 2 ratio, and higher oxygen saturation to FiO 2 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 FiO 2 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., Competing Interests: Conflict of interest Dr Matthew Cove received consultancy fees from Baxter and Medtronic which are paid directly to the institution. The other authors have no financial or personal interests to declare., (Copyright © 2021 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

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 <6.06 at one hour predicting HFNC failure (sensitivity 51%, specificity 80%, positive predictive value 61%, negative predictive value 73%). The discriminatory power remained moderate among pneumonia patients upon HFNC initiation [AUC 0.65 (95% CI 0.57-0.72)], non-pneumonia patients at HFNC initiation [AUC 0.62 (95% CI 0.55-0.69)] and one hour later [AUC 0.63 (95% CI 0.56-0.70)]., 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., Competing Interests: The authors have read the journal’s policy and have the following competing interests: KCS received honoraria and travel support from Medtronic and GE Healthcare. MC received travel support and honorarium from Baxter and Medtronic. JP and KR have received travel support from Medtronic. The rest of the authors have no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare.

Purpose: Severe patient-ventilator asynchrony (PVA) might be associated with prolonged mechanical ventilation and mortality. It is unknown if systematic screening and application of conventional methods for PVA management can modify these outcomes. We therefore constructed a twice-daily bedside PVA screening and management protocol and investigated its effect on patient outcomes., Materials and Methods: A retrospective cohort study of patients who were intubated in the emergency department and directly admitted to the medical intensive care unit (ICU). In phase 1 (6 months; August 2016 to January 2017), patients received usual care comprising lung protective ventilation and moderate analgesia/sedation. In phase 2 (6 months; February 2017 to July 2017), patients were additionally managed with a PVA protocol on ICU admission and twice daily (7 am, 7 pm)., Results: A total of 280 patients (160 in phase 1, 120 in phase 2) were studied (age = 64.5 ± 21.4 years, 107 women [38.2%], Acute Physiology and Chronic Health Evaluation II score = 27.1 ± 8.5, 271 [96.8%] on volume assist-control ventilation initially). Phase 2 patients had lower hospital mortality than phase 1 patients (20.0% versus 34.4%, respectively, P = 0.011), even after adjustment for age and Acute Physiology and Chronic Health Evaluation II scores (odds ratio = 0.46, 95% confidence interval = 0.25-0.84)., Conclusions: Application of a bedside PVA protocol for mechanically ventilated patients on ICU admission and twice daily was associated with decreased hospital mortality. There was however no association with sedation-free days or mechanical ventilation-free days through day 28 or length of hospital stay., Competing Interests: Conflict of Interest K.C.S. and M.C. have received honoraria and travel support from Medtronic. None of the other authors have any conflicts of interest to declare., (Copyright © 2021 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

It remains uncertain how best to set positive end-expiratory pressure (PEEP) for mechanically ventilated patients with the acute respiratory distress syndrome (ARDS). Among patients on low tidal volume ventilation (LTVV), we investigated if further adherence to the low PEEP/FIO2 (inspired oxygen fraction) table would be associated with better survival compared to nonadherence. Patients with ARDS, admitted directly from the Emergency Department to our 20-bed Medical Intensive Care Unit (ICU) from August 2016 to July 2017, were retrospectively studied. To determine adherence to the low PEEP/FIO2 table, PEEP and FIO2 12 h after ICU admission were used, to reflect ventilator adjustments by ICU clinicians after initial stabilization. Logistic regression was used to analyze hospital mortality as an outcome with adherence to the low PEEP/FIO2 as the key independent variable, adjusted for age, APACHE II score, initial P/F ratio and initial systolic blood pressure. 138 patients with ARDS were analysed. Overall adherence to the low PEEP/FIO2 table was 75.4%. Among patients on LTVV, nonadherence to the low PEEP/FIO2 table was associated with increased mortality compared to adherence (adjusted odds ratio 4.10, 95% confidence interval 1.68-9.99, P = 0.002). Patient characteristics at baseline were not associated with adherence to the low PEEP/FIO2 table., (© 2021. The Author(s).)

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 post-extubation 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 <0.001), ICU mortality (14.6% versus 2.0%, P <0.001) and hospital mortality (29.3% versus 12.3%, P =0.006)., Conclusion: Post-extubation HFNC failure, especially in patients with stroke as a comorbidity, remains a clinical challenge and predicts poorer clinical outcomes. Our observational study highlights the need for future prospective trials to better identify patients at high risk of post-extubation HFNC failure.

Background: Lung ultrasound may be a reasonable alternative to chest radiography for the identification of acute respiratory distress syndrome (ARDS), but the diagnostic performance of lung ultrasound for ARDS is uncertain. We therefore analyzed the clinical outcomes of ARDS diagnosed according to the Berlin Definition, using either chest radiography (Berlin-CXR) or lung ultrasound (Berlin-LUS) as an alternative imaging method., Methods: This was a retrospective observational study in a 20-bed medical intensive care unit (ICU). Patients who required noninvasive ventilation or invasive ventilation for hypoxemic respiratory failure on ICU admission from August 2014 to March 2017 were included. Both chest radiography and lung ultrasound were performed routinely upon ICU admission. Comparisons were made using either the Berlin-CXR or Berlin-LUS definitions to diagnose ARDS with respect to the patient characteristics and clinical outcomes for each definition. ICU and hospital mortality were the main outcome measures for both definitions., Results: The first admissions of 456 distinct patients were analyzed. Compared with the 216 patients who met the Berlin-CXR definition (ICU mortality 19.4%, hospital mortality 36.1%), 229 patients who met the Berlin-LUS definition (ICU mortality 22.7%, hospital mortality 34.5%) and 79 patients who met the Berlin-LUS but not the Berlin-CXR definition (ICU mortality 21.5%, hospital mortality 29.1%) had similar outcomes. In contrast, the 295 patients who met either definition had higher mortality than the 161 patients who did not meet either definition (ICU mortality 20.0% versus 12.4%, P = 0.041; hospital mortality 34.2% versus 24.2%, P = 0.027). Compared with Berlin-CXR, Berlin-LUS had a positive predictive value of 0.66 (95% confidence interval 0.59-0.72) and a negative predictive value of 0.71 (0.65-0.77). Among the 216 Berlin-CXR ARDS patients, 150 patients (69.4%) also fulfilled Berlin-LUS definition., Conclusions: For the identification of ARDS using the Berlin definition, both chest radiography and lung ultrasound were equally related to mortality. The Berlin definition using lung ultrasound helped identify patients at higher risk of death, even if these patients did not fulfill the conventional Berlin definition using chest radiography. However, the moderate overlap of patients when chest imaging modalities differed suggests that chest radiography and lung ultrasound should be complementary rather than used interchangeably.

Introduction: In the past 20 years, our understanding of acute respiratory distress syndrome (ARDS) management has improved, but the worldwide incidence and current outcomes are unclear. The reported incidence is highly variable, and no studies specifically characterise ARDS epidemiology in Asia. This observation study aims to determine the incidence, mortality and management practices of ARDS in a high income South East Asian country., Methods: We conducted a prospective, population based observational study in 6 public hospitals. During a one month period, we identified all ARDS patients admitted to public hospital intensive care units (ICU) in Singapore, according to the Berlin definition. Demographic information, clinical management data and ICU outcome data was collected., Results: A total of 904 adult patients were admitted to ICU during the study period and 15 patients met ARDS criteria. The unadjusted incidence of ARDS was 4.5 cases per 100,000 population, accounting for 1.25% of all ICU patients. Most patients were male (75%), Chinese (62%), had pneumonia (73%), and were admitted to a Medical ICU (56%). Management strategies varied across all ICUs. In-hospital mortality was 40% and median length of ICU stay was 7 days., Conclusion: The incidence of ARDS in a developed S.E Asia country is comparable to reported rates in European studies.