Epidemiological Characteristics, Ventilator Management, and Clinical Outcome in Patients Receiving Invasive Ventilation in Intensive Care Units from 10 Asian Middle-Income Countries (PRoVENT-iMiC): An International, Multicenter, Prospective Study

Effect of automated versus conventional ventilation on mechanical power of ventilation-A randomized crossover clinical trial

INTRODUCTION

Mechanical power of ventilation, a summary parameter reflecting the energy transferred from the ventilator to the respiratory system, has associations with outcomes. INTELLiVENT-Adaptive Support Ventilation is an automated ventilation mode that changes ventilator settings according to algorithms that target a low work-and force of breathing. The study aims to compare mechanical power between automated ventilation by means of INTELLiVENT-Adaptive Support Ventilation and conventional ventilation in critically ill patients.

MATERIALS AND METHODS

International, multicenter, randomized crossover clinical trial in patients that were expected to need invasive ventilation > 24 hours. Patients were randomly assigned to start with a 3-hour period of automated ventilation or conventional ventilation after which the alternate ventilation mode was selected. The primary outcome was mechanical power in passive and active patients; secondary outcomes included key ventilator settings and ventilatory parameters that affect mechanical power.

RESULTS

A total of 96 patients were randomized. Median mechanical power was not different between automated and conventional ventilation (15.8 [11.5-21.0] versus 16.1 [10.9-22.6] J/min; mean difference -0.44 (95%-CI -1.17 to 0.29) J/min; P = 0.24). Subgroup analyses showed that mechanical power was lower with automated ventilation in passive patients, 16.9 [12.5-22.1] versus 19.0 [14.1-25.0] J/min; mean difference -1.76 (95%-CI -2.47 to -10.34J/min; P < 0.01), and not in active patients (14.6 [11.0-20.3] vs 14.1 [10.1-21.3] J/min; mean difference 0.81 (95%-CI -2.13 to 0.49) J/min; P = 0.23).

CONCLUSIONS

In this cohort of unselected critically ill invasively ventilated patients, automated ventilation by means of INTELLiVENT-Adaptive Support Ventilation did not reduce mechanical power. A reduction in mechanical power was only seen in passive patients.

STUDY REGISTRATION

Clinicaltrials.gov (study identifier NCT04827927), April 1, 2021.

URL OF TRIAL REGISTRY RECORD

https://clinicaltrials.gov/study/NCT04827927?term=intellipower&rank=1.

Mortality and its associated factors among mechanically ventilated adult patients in the intensive care units of referral hospitals in Northwest Amhara, Ethiopia, 2023

Background

Worldwide, nearly half of the patients admitted to intensive care units require ventilatory support. Despite advances in intensive care unit patient management and mechanical ventilator utilization, the odds of mortality among mechanically ventilated patients are higher in resource-limited settings. Little is known about the mortality of patients on mechanical ventilation outside the capital of Ethiopia. This study aimed to assess mortality and its associated factors among mechanically ventilated adult patients in intensive care units.

Method

An institutional-based cross-sectional study was conducted on mechanically ventilated patients in intensive care units from 1 February 2020 to 1 March 2023. A simple random sampling technique was used to select 434 patients' charts. A data extraction tool designed on the Kobo toolbox, a smartphone data collection platform, was used to collect the data. The data were exported into Microsoft Excel 2019 and then into Stata 17 for data management and analysis. Descriptive statistics were used to summarize the characteristics of the study participants. A bivariable logistic regression was conducted, and variables with p ≤ 0.20 were recruited for multivariable analysis. Statistical significance was declared at p < 0.05, and the strength of associations was summarized using an adjusted odds ratio with 95% confidence intervals.

Result

A total of 404 charts of mechanically ventilated patients were included, with a completeness rate of 93.1%. The overall proportion of mortality was 62.87%, with a 95% CI of (58.16-67.58). In the multivariable logistic regression, age 41-70 years (AOR: 4.28, 95% CI: 1.89-9.62), sepsis (AOR: 2.43, 95% CI: 1.08-5.46), reintubation (AOR: 2.76, 95% CI: 1.06-7.21), and sedation use (AOR: 0.41, 95% CI: 0.18-0.98) were found to be significant factors associated with the mortality of mechanically ventilated patients in the intensive care unit.

Conclusion

The magnitude of mortality among mechanically ventilated patients was high. Factors associated with increased odds of death were advanced age, sepsis, and reintubation. However, sedation use was a factor associated with decreased mortality. Healthcare professionals in intensive care units should pay special attention to patients with sepsis, those requiring reintubation, those undergoing sedation, and those who are of advanced age.

Factors associated with mortality in acute respiratory failure patients without acute respiratory distress syndrome

Background

Excess tidal volume and driving pressure were associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). Still, the appropriate mechanical ventilation strategy for patients who do not have ARDS needs to be understood. This study aimed to identify risk factors for mortality in acute respiratory failure patients without ARDS.

Methods

We included all mechanically ventilated patients who did not meet the criteria for ARDS and were admitted to the medical intensive care unit (ICU) from October 2017 to September 2018. Patients who had tracheostomy before admission, were intubated for more than 24 hours before transfer to ICU, or underwent extracorporeal membrane oxygenation within 24 hours of ICU admission were excluded. Clinical and physiologic data were recorded and compared between survived and non-survived patients.

Results

Of 289 patients with acute respiratory failure, 134 patients without ARDS were included; 69 (51%) died within 28 days. Demographics, principal diagnosis, and lung injury score on the first day of admission were not significantly different between survived and non-survived patients. In multivariate analysis, higher peak inspiratory pressure (PIP) during the first 3 days of admission [odds ratio (OR) 1.11, 95% confidence interval (CI): 1.01-1.22, P=0.04], higher sequential organ failure assessment score (OR 1.15, 95% CI: 1.04-1.28, P=0.008) and underlying cerebrovascular diseases (OR 7.09, 95% CI: 1.78-28.28, P=0.006) were independently associated with mortality in these patients, whereas dynamic lung compliance (Cdyn) and respiratory rate were not associated with mortality in the multivariate model.

Conclusions

Mortality was high in mechanically ventilated patients without ARDS. Higher PIP is a potentially modifiable risk factor for mortality in these patients, independent of the baseline Cdyn. Underlying cerebrovascular diseases and increased disease severity are also independent factors associated with 28-day mortality.

Different ventilation intensities among various categories of patients ventilated for reasons other than ARDS--A pooled analysis of 4 observational studies

PURPOSE

We investigated driving pressure (ΔP) and mechanical power (MP) and associations with clinical outcomes in critically ill patients ventilated for reasons other than ARDS.

MATERIALS AND METHODS

Individual patient data analysis of a pooled database that included patients from four observational studies of ventilation. ΔP and MP were compared among invasively ventilated non-ARDS patients with sepsis, with pneumonia, and not having sepsis or pneumonia. The primary endpoint was ΔP; secondary endpoints included MP, ICU mortality and length of stay, and duration of ventilation.

RESULTS

This analysis included 372 (11%) sepsis patients, 944 (28%) pneumonia patients, and 2040 (61%) patients ventilated for any other reason. On day 1, median ΔP was higher in sepsis (14 [11-18] cmH2O) and pneumonia patients (14 [11-18]cmH2O), as compared to patients not having sepsis or pneumonia (13 [10-16] cmH2O) (P < 0.001). Median MP was also higher in sepsis and pneumonia patients. ΔP, as opposed to MP, was associated with ICU mortality in sepsis and pneumonia patients.

CONCLUSIONS

The intensity of ventilation differed between patients with sepsis or pneumonia and patients receiving ventilation for any other reason; ΔP was associated with higher mortality in sepsis and pneumonia patients.

REGISTRATION

This post hoc analysis was not registered; the individual studies that were merged into the used database were registered at clinicaltrials.gov: NCT01268410 (ERICC), NCT02010073 (LUNG SAFE), NCT01868321 (PRoVENT), and NCT03188770 (PRoVENT-iMiC).

Adherence to lung protective mechanical ventilation in patients admitted to a surgical intensive care unit and the associated increased mortality

Background

The adherence rate to the lung protective ventilation (LPV) strategy, which is generally accepted as a standard practice in mechanically ventilated patients, reported in the literature is approximately 40%. This study aimed to determine the adherence rate to the LPV strategy, factors associated with this adherence, and related clinical outcomes in mechanically ventilated patients admitted to the surgical intensive care unit (SICU).

Methods

This prospective observational study was conducted in the SICU of a tertiary university-based hospital between April 2018 and February 2019. Three hundred and six adult patients admitted to the SICU who required mechanical ventilation support for more than 12 h were included. Ventilator parameters at the initiation of mechanical ventilation support in the SICU were recorded. The LPV strategy was defined as ventilation with a tidal volume of equal or less than 8 ml/kg of predicted body weight plus positive end-expiratory pressure of at least 5 cm H2O. Demographic and clinical data were recorded and analyzed.

Results

There were 306 patients included in this study. The adherence rate to the LPV strategy was 36.9%. Height was the only factor associated with adherence to the LPV strategy (odds ratio for each cm, 1.10; 95% confidence interval (CI), 1.06-1.15). Cox regression analysis showed that the LPV strategy was associated with increased 90-day mortality (hazard ratio, 1.73; 95% CI, 1.02-2.94).

Conclusion

The adherence rate to the LPV strategy among patients admitted to the SICU was modest. Further studies are warranted to explore whether the application of the LPV strategy is simply a marker of disease severity or a causative factor for increased mortality.

EPidemiology, clinical characteristics and Outcomes of 4546 adult admissions to high-dependency and intensive care units in Kenya (EPOK): a multicentre registry-based observational study

Objective

to describe clinical, management and outcome features of critically ill patients admitted to intensive care units (ICUs) and high dependency units (HDUs) in Kenya.

Design

prospective registry-based observational study.

Setting

three HDUs and eight ICUs in Kenya.

Patients

consecutive adult patients admitted between January 2021 and June 2022.

Interventions

none.

Measurements and main results

data was entered in a cloud based platform using a common data model. Study endpoints included case mix variables, management features and patient centred outcomes. Patients with Coronavirus disease 2019 (COVID-19) were reported separately. Of the 3892/4546 patients without COVID-19, 2445 patients (62.8%) were from HDUs and 1447 (37.2%) from ICUs. Patients had a median age of 53 years (interquartile range [IQR] 38-68), with HDU patients being older but with a lower severity (APACHE II 6 [3-9] in HDUs vs 12 [7-17] in ICUs; p<0.001). One out of four patients were postoperative with 604 (63.4%) receiving emergency surgery. Readmission rate was 4.8%. Hypertension and diabetes were prevalent comorbidities, with a 4.0% HIV/AIDS rate. Invasive mechanical ventilation (IMV) was applied in 3.4% in HDUs vs. 47.6% in ICUs (P<0.001), with a duration of 7 days (IQR 3-21). There was a similar use of renal replacement therapy (4.0% vs. 4.7%; P<0.001). Vasopressor use was infrequent while half of patients received antibiotics. Average length of stay was 2 days (IQR 1-5). Crude HDU mortality rate was 6.5% in HDUs versus 30.5% in the ICUs (P<0.001). Of the 654 COVID-19 admissions, most were admitted in ICUs (72.3%) with a 33.2% mortality.

Conclusions

We provide the first multicenter observational cohort study from an African ICU national registry. Distinct management features and outcomes characterise HDU from ICU patients.

Study registration

Clinicaltrials.gov (reference number NCT05456217, date of registration 07 Nov 2022).

Ten rules for optimizing ventilatory settings and targets in post-cardiac arrest patients

Cardiac arrest (CA) is a major cause of morbidity and mortality frequently associated with neurological and systemic involvement. Supportive therapeutic strategies such as mechanical ventilation, hemodynamic settings, and temperature management have been implemented in the last decade in post-CA patients, aiming at protecting both the brain and the lungs and preventing systemic complications. A lung-protective ventilator strategy is currently the standard of care among critically ill patients since it demonstrated beneficial effects on mortality, ventilator-free days, and other clinical outcomes. The role of protective and personalized mechanical ventilation setting in patients without acute respiratory distress syndrome and after CA is becoming more evident. The individual effect of different parameters of lung-protective ventilation, including mechanical power as well as the optimal oxygen and carbon dioxide targets, on clinical outcomes is a matter of debate in post-CA patients. The management of hemodynamics and temperature in post-CA patients represents critical steps for obtaining clinical improvement. The aim of this review is to summarize and discuss current evidence on how to optimize mechanical ventilation in post-CA patients. We will provide ten tips and key insights to apply a lung-protective ventilator strategy in post-CA patients, considering the interplay between the lungs and other systems and organs, including the brain.

Predictors of ICU Mortality among Mechanically Ventilated Patients: An Inception Cohort Study from a Tertiary Care Center in Addis Ababa, Ethiopia

BACKGROUND

Mechanical ventilation is a life-saving intervention for patients with critical illnesses, yet it is associated with higher mortality in resource-constrained settings. This study intended to determine factors associated with the mortality of mechanically ventilated adult intensive care unit (ICU) patients.

METHODS

A one-year retrospective inception cohort study was conducted using manual chart review in ICU patients (age >13) admitted to Tikur Anbessa Specialized Hospital (Addis Ababa, Ethiopia) from September 2019 to September 2020; mechanically ventilated patients were followed to hospital discharge. Demographic, clinical, and outcome data were collected; logistic regression was used to determine mortality predictors in the ICU.

RESULT

A total of 160 patients were included; 85/160 (53.1%) were females and the mean (SD) age was 38.9 (16.2) years. The commonest indication for ICU admission was a respiratory problem (n = 97/160, 60.7%). ICU and hospital mortality were 60.7% (n = 97/160) and 63.1% (n = 101/160), respectively. Coma (Glasgow Coma Score <8 or 7 with an endotracheal tube (7T)) (adjusted odds ratio [AOR] 6.3, 95% confidence interval 1.19-33.00), cardiovascular diagnosis (AOR 5.05 [1.80-14.15]), and a very low serum albumin level (<2 g/dl) (AOR 4.9 [1.73-13.93]) were independent predictors of mortality (P < 0.05). The most commonly observed complication was ICU acquired infection (n = 48, 30%).

CONCLUSIONS

ICU mortality in ventilated patients is high. Coma, a very low serum albumin level (<2 g/dl), and cardiovascular diagnosis were independent predictors of mortality. A multifaceted approach focused on developing and implementing context appropriate guidelines and improving skilled healthcare worker availability may prove effective in reducing mortality.

Performance evaluation of a multinational data platform for critical care in Asia

Background: The value of medical registries strongly depends on the quality of the data collected. This must be objectively measured before large clinical databases can be promoted for observational research, quality improvement, and clinical trials. We aimed to evaluate the quality of a multinational intensive care unit (ICU) network of registries of critically ill patients established in seven Asian low- and middle-income countries (LMICs). Methods: The Critical Care Asia federated registry platform enables ICUs to collect clinical, outcome and process data for aggregate and unit-level analysis. The evaluation used the standardised criteria of the Directory of Clinical Databases (DoCDat) and a framework for data quality assurance in medical registries. Six reviewers assessed structure, coverage, reliability and validity of the ICU registry data. Case mix and process measures on patient episodes from June to December 2020 were analysed. Results: Data on 20,507 consecutive patient episodes from 97 ICUs in Afghanistan, Bangladesh, India, Malaysia, Nepal, Pakistan and Vietnam were included. The quality level achieved according to the ten prespecified DoCDat criteria was high (average score 3.4 out of 4) as was the structural and organizational performance -- comparable to ICU registries in high-income countries. Identified strengths were types of variables included, reliability of coding, data completeness and validation. Potential improvements included extension of national coverage, optimization of recruitment completeness validation in all centers and the use of interobserver reliability checks. Conclusions: The Critical Care Asia platform evaluates well using standardised frameworks for data quality and equally to registries in resource-rich settings.

Performance evaluation of a multinational data platform for critical care in Asia

Background: The value of medical registries strongly depends on the quality of the data collected. This must be objectively measured before large clinical databases can be promoted for observational research, quality improvement, and clinical trials. We aimed to evaluate the quality of a multinational intensive care unit (ICU) network of registries of critically ill patients established in seven Asian low- and middle-income countries (LMICs). Methods: The Critical Care Asia federated registry platform enables ICUs to collect clinical, outcome and process data for aggregate and unit-level analysis. The evaluation used the standardised criteria of the Directory of Clinical Databases (DoCDat) and a framework for data quality assurance in medical registries. Six reviewers assessed structure, coverage, reliability and validity of the ICU registry data. Case mix and process measures on patient episodes from June to December 2020 were analysed. Results: Data on 20,507 consecutive patient episodes from 97 ICUs in Afghanistan, Bangladesh, India, Malaysia, Nepal, Pakistan and Vietnam were included. The quality level achieved according to the ten prespecified DoCDat criteria was high (average score 3.4 out of 4) as was the structural and organizational performance -- comparable to ICU registries in high-income countries. Identified strengths were types of variables included, reliability of coding, data completeness and validation. Potential improvements included extension of national coverage, optimization of recruitment completeness validation in all centers and the use of interobserver reliability checks. Conclusions: The Critical Care Asia platform evaluates well using standardised frameworks for data quality and equally to registries in resource-rich settings.

The Prognostic Capacity of the Radiographic Assessment for Lung Edema Score in Patients With COVID-19 Acute Respiratory Distress Syndrome-An International Multicenter Observational Study

Background: The radiographic assessment for lung edema (RALE) score has an association with mortality in patients with acute respiratory distress syndrome (ARDS). It is uncertain whether the RALE scores at the start of invasive ventilation or changes thereof in the next days have prognostic capacities in patients with COVID-19 ARDS.

Aims and Objectives: To determine the prognostic capacity of the RALE score for mortality and duration of invasive ventilation in patients with COVID-19 ARDS.

Methods: An international multicenter observational study included consecutive patients from 6 ICUs. Trained observers scored the first available chest X-ray (CXR) obtained within 48 h after the start of invasive ventilation (“baseline CXR”) and each CXRs thereafter up to day 14 (“follow-up CXR”). The primary endpoint was mortality at day 90. The secondary endpoint was the number of days free from the ventilator and alive at day 28 (VFD-28).

Results: A total of 350 CXRs were scored in 139 patients with COVID-19 ARDS. The RALE score of the baseline CXR was high and was not different between survivors and non-survivors (33 [24–38] vs. 30 [25–38], P = 0.602). The RALE score of the baseline CXR had no association with mortality (hazard ratio [HR], 1.24 [95% CI 0.88–1.76]; P = 0.222; area under the receiver operating characteristic curve (AUROC) 0.50 [0.40–0.60]). A change in the RALE score over the first 14 days of invasive ventilation, however, had an independent association with mortality (HR, 1.03 [95% CI 1.01–1.05]; P < 0.001). When the event of death was considered, there was no significant association between the RALE score of the baseline CXR and the probability of being liberated from the ventilator (HR 1.02 [95% CI 0.99–1.04]; P = 0.08).

Conclusion: In this cohort of patients with COVID-19 ARDS, with high RALE scores of the baseline CXR, the RALE score of the baseline CXR had no prognostic capacity, but an increase in the RALE score in the next days had an association with higher mortality.

Geo-economic variations in epidemiology, ventilation management and outcome of patients receiving intraoperative ventilation during general anesthesia- posthoc analysis of an observational study in 29 countries

BACKGROUND

The aim of this analysis is to determine geo-economic variations in epidemiology, ventilator settings and outcome in patients receiving general anesthesia for surgery.

METHODS

Posthoc analysis of a worldwide study in 29 countries. Lower and upper middle-income countries (LMIC and UMIC), and high-income countries (HIC) were compared. The coprimary endpoint was the risk for and incidence of postoperative pulmonary complications (PPC); secondary endpoints were intraoperative ventilator settings, intraoperative complications, hospital stay and mortality.

RESULTS

Of 9864 patients, 4% originated from LMIC, 11% from UMIC and 85% from HIC. The ARISCAT score was 17.5 [15.0-26.0] in LMIC, 16.0 [3.0-27.0] in UMIC and 15.0 [3.0-26.0] in HIC (P = .003). The incidence of PPC was 9.0% in LMIC, 3.2% in UMIC and 2.5% in HIC (P < .001). Median tidal volume in ml kg^- 1 predicted bodyweight (PBW) was 8.6 [7.7-9.7] in LMIC, 8.4 [7.6-9.5] in UMIC and 8.1 [7.2-9.1] in HIC (P < .001). Median positive end-expiratory pressure in cmH₂O was 3.3 [2.0-5.0]) in LMIC, 4.0 [3.0-5.0] in UMIC and 5.0 [3.0-5.0] in HIC (P < .001). Median driving pressure in cmH₂O was 14.0 [11.5-18.0] in LMIC, 13.5 [11.0-16.0] in UMIC and 12.0 [10.0-15.0] in HIC (P < .001). Median fraction of inspired oxygen in % was 75 [50-80] in LMIC, 50 [50-63] in UMIC and 53 [45-70] in HIC (P < .001). Intraoperative complications occurred in 25.9% in LMIC, in 18.7% in UMIC and in 37.1% in HIC (P < .001). Hospital mortality was 0.0% in LMIC, 1.3% in UMIC and 0.6% in HIC (P = .009).

CONCLUSION

The risk for and incidence of PPC is higher in LMIC than in UMIC and HIC. Ventilation management could be improved in LMIC and UMIC.

TRIAL REGISTRATION

Clinicaltrials.gov , identifier: NCT01601223.

Survival of mechanically ventilated ward patients and association with organisational factors: a multicentre prospective study

OBJECTIVES

Determine 90-day mortality of mechanically ventilated ward patients outside the intensive care unit (ICU) and its association with organisational factors.

DESIGN

Multicentre prospective observational study of mechanically ventilated ward patients. Modified Poisson regression was used to assess association between nurse to patient ratio (NPR) and 90-day mortality, adjusted for designated medical team, Society of Critical Care Medicine (SCCM) triage priority and centre effect. NPR was divided into low (1:9.6 to 1:10), medium (1:6 to 1:8) and high (1:2.6). Sensitivity analysis was conducted for pneumonia with or without acute respiratory distress syndrome (ARDS) to assess magnitude of association.

SETTING

7 acute public hospitals in Hong Kong.

PARTICIPANTS

All 485 mechanically ventilated patients in wards from participating hospitals between 18 January 2016 and 17 April 2016 were recruited. Three hundred patients were included after excluding patients with limitation of therapy within 24 hours of intubation.

MAIN OUTCOMES

90-day mortality, Mortality Prediction Model III Standardised mortality ratio (MPMIII₀ SMR).

RESULTS

201 patients died within 90 days after intubation (67.0%, 95% CI 61.5% to 72.1%), with MPMIII₀ SMR 1.88, 95% CI 1.63 to 2.17. Compared with high NPR, medium and low NPRs were associated with higher risk of 90-day mortality (adjusted relative risk (RR_adj) 1.84, 95% CI 1.70 to 1.99 and 1.64, 95% CI 1.47 to 1.83, respectively). For 114 patients with pneumonia with or without ARDS, low to medium NPR, too sick to benefit from ICU (SCCM priority 4b), no ICU consultation and designated medical team were associated with risk of 90-day mortality (RR_adj 1.49, 95% CI 1.40 to 1.58; RR_adj 1.60, 95% CI 1.49 to 1.72; RR_adj 1.34, 95% CI 1.27 to 1.40; RR_adj 0.85, 95% CI 0.78 to 0.93, respectively).

CONCLUSION

The 90-day mortality rates of mechanically ventilated ward patients were high. NPR was an independent predictor of survival for mechanically ventilated ward patients.

The story of critical care in Asia: a narrative review

Background

Asia has more critically ill people than any other part of our planet. The aim of this article is to review the development of critical care as a specialty, critical care societies and education and research, the epidemiology of critical illness as well as epidemics and pandemics, accessibility and cost and quality of critical care, culture and end-of-life care, and future directions for critical care in Asia.

Main body

Although the first Asian intensive care units (ICUs) surfaced in the 1960s and the 1970s and specialisation started in the 1990s, multiple challenges still exist, including the lack of intensivists, critical care nurses, and respiratory therapists in many countries. This is aggravated by the brain drain of skilled ICU staff to high-income countries. Critical care societies have been integral to the development of the discipline and have increasingly contributed to critical care education, although critical care research is only just starting to take off through collaboration across groups. Sepsis, increasingly aggravated by multidrug resistance, contributes to a significant burden of critical illness, while epidemics and pandemics continue to haunt the continent intermittently. In particular, the coronavirus disease 2019 (COVID-19) has highlighted the central role of critical care in pandemic response. Accessibility to critical care is affected by lack of ICU beds and high costs, and quality of critical care is affected by limited capability for investigations and treatment in low- and middle-income countries. Meanwhile, there are clear cultural differences across countries, with considerable variations in end-of-life care. Demand for critical care will rise across the continent due to ageing populations and rising comorbidity burdens. Even as countries respond by increasing critical care capacity, the critical care community must continue to focus on training for ICU healthcare workers, processes anchored on evidence-based medicine, technology guided by feasibility and impact, research applicable to Asian and local settings, and rallying of governments for support for the specialty.

Conclusions

Critical care in Asia has progressed through the years, but multiple challenges remain. These challenges should be addressed through a collaborative approach across disciplines, ICUs, hospitals, societies, governments, and countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-021-00574-4.

Pragmatic Recommendations for the Use of Diagnostic Testing and Prognostic Models in Hospitalized Patients with Severe COVID-19 in Low- and Middle-Income Countries

Management of patients with severe or critical COVID-19 is mainly modeled after care of patients with severe pneumonia or acute respiratory distress syndrome from other causes. These models are based on evidence that primarily originates from investigations in high-income countries, but it may be impractical to apply these recommendations to resource-restricted settings in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for microbiology and laboratory testing, imaging, and the use of diagnostic and prognostic models in patients with severe COVID-19 in LMICs. For diagnostic testing, where reverse transcription-PCR (RT-PCR) testing is available and affordable, we recommend using RT-PCR of the upper or lower respiratory specimens and suggest using lower respiratory samples for patients suspected of having COVID-19 but have negative RT-PCR results for upper respiratory tract samples. We recommend that a positive RT-PCR from any anatomical source be considered confirmatory for SARS-CoV-2 infection, but, because false-negative testing can occur, recommend that a negative RT-PCR does not definitively rule out active infection if the patient has high suspicion for COVID-19. We suggest against using serologic assays for the detection of active or past SARS-CoV-2 infection, until there is better evidence for its usefulness. Where available, we recommend the use of point-of-care antigen-detecting rapid diagnostic testing for SARS-CoV-2 infection as an alternative to RT-PCR, only if strict quality control measures are guaranteed. For laboratory testing, we recommend a baseline white blood cell differential platelet count and hemoglobin, creatinine, and liver function tests and suggest a baseline C-reactive protein, lactate dehydrogenase, troponin, prothrombin time (or other coagulation test), and D-dimer, where such testing capabilities are available. For imaging, where availability of standard thoracic imaging is limited, we suggest using lung ultrasound to identify patients with possible COVID-19, but recommend against its use to exclude COVID-19. We suggest using lung ultrasound in combination with clinical parameters to monitor progress of the disease and responses to therapy in COVID-19 patients. We currently suggest against using diagnostic and prognostic models as these models require extensive laboratory testing and imaging, which often are limited in LMICs.