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CICM 2021 ASM: Respiratory
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CICM 2021

Virtual ASM Scientific Program

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Associate Professor Federico Pappalardo
Department of Anesthesia and Intensive Care at ISMETT (Mediterranean Institute for transplantation and Advanced Therapies) Palermo: Italy.
Facilitator: Dr Priya Nair

Session Objectives :
•            Learn the hemodynamics of Impella in relation to ECMO, IABP and inotropes
•            MCS in Cardiogenic shock – what is the role of Impella?
•            MCS in acute decompensated heart failure – what is the role of Impella?
•            ECpella – rationale behind the combined use of Impella & ECMO and management
•            Selecting the right patient for Impella

Presenter:  Professor Dianne Vella-Brodrick

Welcome to our final day of the 2021 ASM.
Dr Angelly Martinez will host the day and will lead us through another inspiring and educational packed program. 
SESSION CHAIR: Dr Allan Beswick

The forgotten ventricle no longer, the right heart is easily interrogated by the intensivist using bedside echocardiography.  In this talk, the how and why of the right sided evaluation using ultrasound will be discussed and heavily supported by plenty of examples that take us through basic and advanced techniques for the intensivist.  

This talk covers mechanisms of right ventricular failure in relation to pulmonary hypertension and both medical and mechanical options for support.

Don't miss the opportunity to enter the daily draw and win an amazing piece of indigenous art.  Visit our exhibitors and sponsors now. 

                                                                 Unconventional therapies for submassive PE save lives: Dr Jayshree Lavana
                                                         Unconventional therapies for submassive PE should not be offered outside research trials: Dr Priya Nair

Collegial Intensive Care: A practical approach for centres where access to Cardiothoracics, Interventional Radiology, dedicated Cardiology or Respiratory On Call, CTPA and even echo may be a challenge. 

Presenters: Louise Leslie – BD Clinical Nurse Educator and Tina van Weelderen - BD National Sales and Clinical Manager

A number of options are available to attendees during our break times: 
Room 1 (Main stream) will broadcast a short 20 minutes Tai Chi exercise session followed by a presentation from our premium sponsors  Device Technologies. 

Over in Room 1 (concurrent stream): Professor Rinaldo Bellomo will present: Small volume resuscitation: rationale and SWIPE trial results

Don't miss this opportunity to visit the exhibition zone to receive your daily codeword.  Today's prize is the last of our beautiful indigenous painting from Australia . 

A number of networking rooms are also available to catch up with friends. 

Join us for a 20 minute relaxing Qigong session

Presenter: Professor Anil Hormis (Rotheram NHS Trust, UK)

Professor Anil Hormis (Rotheram NHS Trust, UK) discusses the clinical indications for inhaled sedation and the selection of patients best suited for this form of sedation. He also describes lessons learned in his unit since the adoption of the Sedana AnaConda system for inhalational sedation.

Sponsored by our Premium Sponsor:

Presenter: Associate Professor David Gattas

Presenter: Professor Rinaldo Bellomo

Fluids are one of the most common treatments administered in acute hospitalized patients. Even small differences in fluid management outcomes data can have significant effects on the healthcare system.
In this webinar Prof Rinaldo Bellomo (Professor of Intensive Care, University of Melbourne & Department of Intensive Care Austin Hospital and Royal Melbourne Hospital) presents on the ‘SWIPE’ randomised clinical trial he co-authored, sharing the rationale and data on why small volume fluid resuscitation with albumin 20% is an option for your ICU patients.
Session Sponsor: Device Technologies

Ventilator-induced lung injury is a widely appreciated clinical problem in mechanically ventilated patients with acute hypoxemic respiratory failure. Lung-protective ventilation has traditionally focused on limiting tidal volume based on the findings of seminal clinical trials and clinical practice guideline recommendations. The driving pressure hypothesis suggests that lung-protective ventilation should focus on the pressure distending the lung as a consequence of tidal volume rather than the tidal volume per se. This issue has been examined in multiple observational studies and more recently in a re-analysis of clinical trials. This presentation will summarize the evidence in support of the driving pressure hypothesis and discuss clinical implications for setting the ventilator during both passive and assisted mechanical ventilation. I will argue that a focus on driving pressure over tidal volume may improve outcomes in patients with both low elastance (permitting higher tidal volumes reduces sedation requirements and facilitates spontaneous breathing) and high elastance (targeting driving pressure will limit injurious lung stress and strain). Methods for assessing driving pressure during both passive and assisted ventilation will be briefly described.

The lungs are a complex organ. In sickness, they behave as a multi compartment model. Positive pressure ventilation and a myriad of ICU interventions are applied without the ability to safely and repeatedly assess the effect of these techniques on regional ventilation within the lung. 
A great deal has been learned through CT of the lungs in mechanically ventilated patients and how ventilation is not distributed equally. However, practicalities dictate that these hazardous and expensive procedures cannot be performed repeatedly after every intervention, particularly in the most unstable patients with ARDS, in whom the information on regional ventilation is perhaps the most useful. 
The advent of electrical impedance tomography (EIT) has brought the ability to assess in a real time fashion, radiation-free monitoring of lung ventilation and perhaps of perfusion, at the bedside of critically-ill mechanically ventilated patients.  The technique’s dependence on measurement of the delta impedance allows it to assess anything within the chest whose impedance changes. Primarily this change in impedance correlates to change in lung volume. but more work is improving its ability to assess regional changes in blood flow too – and in doing so, providing a low fidelity ventilation-perfusion assessment tool at the bed side. 
Further work is being conducted to assess the ability of EIT to track the movement of noxious biofluid within the lung through nebulisation of electrically conductive solutions. The combination of an improved ability to assess in a more holistic fashion the movement of gas, blood and biofluid within the lung in a dynamic fashion may lead to improved ability to monitor and treat patients with ARDS. 

This presentation will briefly review previously published research on molecular phenotypes of ARDS, including the hyper-inflammatory and hypo-inflammatory phenotypes identified using latent class analysis, as background.  The majority of the presentation will focus on recently published or unpublished new data on ARDS molecular phenotypes, including data related to generalizability, feasibility of identification, potential mechanisms, and relevance to COVID-19 ARDS.  The presentation will conclude with some thoughts on future directions in research on this topic and how molecular phenotypes might be targeted in clinical trials.

Papazian and colleagues reported lower mortality (NNT ~10) with a 48-hour infusion of high dose cisatracurium (ED95) versus heavy sedation in patients with moderate to severe ARDS (PMID: 20843245). The ROSE trial examined the same dose/duration of cisatracurium versus a lower sedation approach for a similar ARDS population (PMID: 31112383). Both ROSE arms received the same mechanical ventilation strategies including a higher PEEP strategy. ROSE enrolled 1006 patients early after onset of moderate-to-severe ARDS (median: 7.6 hours). During the first 48 hours, 97.4%) patients in the intervention group received cisatracurium (median duration: 47.8 hours; median dose: 1807 mg), whereas 17.0%) of patients in the control group received neuromuscular blockade (median dose: 38 mg, usually bolus dosing). The primary endpoint of 90-day all-cause in-hospital mortality was 42.5% and 42.8% in the intervention and control groups (difference: -0.3 percentage points, 95% CI: -6.4% to 5.9%, p=0.93). The intervention group was less physically active and developed more cardiovascular adverse events while in hospital. There were no consistent between-group differences in long term outcomes assessed at three, six, and twelve months. The reasons for the discordant results between these two studies are unclear and may lie in differences in the control arms, as will be discussed in this presentation. Based on the ROSE trial results, for patients with moderate-to-severe ARDS managed with a higher PEEP and a lower sedation strategy, routine use of an early and continuous cisatracurium infusion is not recommended.

Should we still worry about modes of ventilation and do we really (really?!) still need more research? Airway Pressure Release Ventilation (APRV) is a mode of ventilation that has been around for years. Endorsed by proponents as a useful tool to improve oxygenation. Derived by detractors as a modality lacking evidence of benefit and associated with safety concerns. Like many questions in modern ICU practice, the answers may be nuanced and uncertain. Nevertheless, new studies inform the understanding of the potential role of APRV. Recent evidence can help assist in considering where to place this therapy amongst the options in addressing hypoxia in mechanically ventilated patients. 

Presenter: Professor Yin Paradies

It is thought that medical practice cannot be clinically safe without being culturally safe. But what exactly is cultural safety and why is it so important? How can we work towards culturally safe practice and environments for our patients, their families, and our colleagues? Professor Yin Paradies, an expert in Indigenous knowledges and anti-racism theory, policy and practice will explore these questions and stimulate thinking around actions for change. 

In March 2020, the United Kingdom was hit by the first wave COVID-19 outbreak. COVID-19-associated ARDS led to unprecedent numbers of referrals to ECMO services. Royal Brompton Hospital, one of the five NHS-commissioned ECMO centres, following NHS-modified inclusion/exclusion criteria during COVID-19 pandemic, retrieved and managed 52 respiratory ECMO patients with a 6-month survival of 84.6%. This presentation will review a single-centre experience in referrals, clinical progression and outcome of respiratory ECMO for COVID-19 patients.

ECMO is a well-established therapy for patients with potentially reversible severe respiratory failure that is not responding to conventional management. Due to the high risk nature of ECMO support, and the specialised knowledge and experience required to efficiently and effectively manage patients receiving support, as well as the ancillary services usually required in the care of patients, ECMO is usually provided by regional or national centres. Other regional or national centres therefore refer patients for consideration of retrieval and ECMO therapy. This presentation will discuss the current potential indications for support with ECMO in patients with a range of pathologies causing respiratory failure, and will highlight conditions with a high risk of requiring ECMO support. Contraindications and cautions prior to providing ECMO support will also be outlined. Pragmatic considerations and potential dilemmas will be briefly discussed, along with regional variation, with reference to cases and literature. Early communication, discussion, and ongoing clinical review will be emphasised.

Paediatric acute respiratory distress syndrome accounts for 1-10% of paediatric intensive care admissions. PARDS carries a mortality risk between 10 and 15% for mild or moderate and up to 33% for severe presentations. ECMO, either as veno-venous or veno-arterial support has been a long established treatment modality for PARDS. Several randomised controlled trials showed a mortality benefit of ECMO for PARDS in neonates, with one trial showing a halved relative risk of death with the use of ECMO. However, recent trials in adult patients with ARDS (most recently the EOLIA trial) did not demonstrate a survival benefit with the use of ECMO. Albeit retrospective, but with the largest cohort of children, the recently published RESTORE trial (2449 children) did not show a benefit of ECMO treatment in PARDS. In few of these trials ventilation at time of ECMO support has been vigorously standardised. A recent survey in 59 PICUs in 12 countries demonstrated that lung protective ventilation is often not followed. During ECMO support several ventilation strategies have been investigated such as limiting the peak inspiratory pressures, using ultralow tidal volume ventilation, high PEEP or mechanical-power-asserted-on-the-lungs targeted ventilation. Unfortunately, none of these strategies have shown conclusively to be of survival benefit during ECMO support. There is a need for prospective randomised trials to identify the benefit of ECMO for PARDS and to define which ventilation strategies during the time of ECMO support will benefit patients most. 

Venovenous extracorporeal membrane oxygenation (ECMO) has been shown to improve mortality in critically ill patients with the most severe forms of acute respiratory failure. However whether ECMO provides benefit in less severe forms of respiratory failure remains uncertain. On the one hand, the use of ECMO in less severe disease may facilitate protective lung ventilation without the need for sedation, intubation and neuromuscular blockade, which themselves have been associated with prolonged mechanical ventilation and complications. On the other hand, ECMO is costly, and may be associated with other important complications, particularly bleeding. The REDEEM pilot is an Australian-initiated, registry-based, 2 centre, randomised controlled pilot study designed to determine if a strategy of ECMO in moderate to severe respiratory failure (with desedation, early extubation, and mobilisation), in comparison to standard care (including mechanical ventilation with rescue ECMO if required), is safe and feasible. The results of this study will inform a larger international trial designed to investigate key patient centred outcomes, such as patient related quality of life and health care costs, and has the potential to change the way we manage moderate to severe respiratory failure in the ICU.

1Adult Intensive Care Services, the Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Queensland, Australia. 2 Queensland University of Technology, Brisbane ; University of Queensland, Brisbane and Bond University, Gold Coast, Queensland, Australia
Extracorporeal carbon dioxide removal (ECCO2R) devices are specialised extracorporeal respiratory support devices that predominantly focus on CO2 removal using smaller vascular access catheters and lower blood flows. ECCO2R can also be achieved with standard extracorporeal membrane oxygenation (ECMO) circuitry that provides an added advantage of utilising much higher blood flows for extracorporeal oxygenation support if needed. Although, hypercapnia is permissible to an extent and it may enable better lung healing by reducing inflammation, it becomes problematic in patients with raised intracranial pressure or in those with right heart failure. 

Reducing partial pressure of arterial (PaCO2) with ECCO2R, not only mitigates ventilator induced lung injury (VILI) by allowing more protective lung protection, it also reduces the work of breathing and may prevent fatigue in those breathing spontaneously. It may also reduce pulmonary vascular resistance and improve right ventricular performance. Thus ECCO2R may have a potential role in both acute respiratory distress syndrome (ARDS) and in those with more chronic forms of hypercapnic respiratory failure such as chronic obstructive pulmonary disease (COPD).  

A strategy of lung protective ventilation that limits tidal volume and inspiratory pressures, mitigates VILI, and has been shown to improve outcomes in patients with ARDS. ECCO2R may facilitate ultra-protective ventilation , with even lower tidal volumes and driving pressures. However, heterogeneity amongst ECCO2R studies, a lack of supporting evidence from randomised controlled trials, and variable safety reporting in studies have been barriers for  widespread adoption of ECCO2R in this setting. Apart from identification of the ARDS sub-population that is likely to benefit, prospective evaluation of optimal device operating characteristics and anticoagulation strategies in high quality studies is required.

In patients who present with exacerbations of  COPD, ventilation support can be provided both non-invasively or invasively, of which the former has shown a better prognosis. Although non-invasive ventilation (NIV) has been shown to reduce mortality when compared with invasive mechanical ventilation (IMV), 25-50% of this population initially supported with NIV, eventually requires IMV over time. These patients often wean slowly from IMV, and, consequently have a prolonged hospital stay. In patients on NIV, ECCO2R has been shown to prevent the need for IMV significantly in some studies. The use of ECCO2R in patients requiring IMV may allow earlier extubation, rehabilitation and may be an useful bridge to lung transplantation in selected patients. Once again, the uptake of ECCO2R in patients with exacerbations of COPD is limited due to lack of robust evidence.

There are ongoing clinical trails that are evaluating the efficacy of ECCO2R in both ARDS and COPD populations. 

ASM Closing Credits