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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.
Welcome to our final day of the 2021 ASM.
Dr Angelly Martinez will host the day, she will lead us through another inspiring and educational packed program. 
Welcome to Day 3 of the CICM 2021 ASM
A number of presentations will be running during the break.  Stay and watch or take time to visit the exhibition zone to support our valued sponsors and exhibitors or pop into one of the networking rooms. 
Join us for a quick 20 minute yoga session, no mat required.
Session Sponsor: Device Technologies
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  The majority of the presentation will focus on recently published or unpublished new data on ARDS molecular phenotypes, including data related to generalizability, feasibility of identification, potential mechanisms, and relevance to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. 
This is your last opportunity to meet with our much valued sponsors and exhibitors, click into the exhibition zone.