Background Little information is available about the geo-economic variations in demographics, management, and outcomes of patients with acute respiratory distress syndrome (ARDS). We aimed to characterise the effect of these geo-economic variations in patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE). Methods LUNG SAFE was done during 4 consecutive weeks in winter, 2014, in a convenience sample of 459 intensivecare units in 50 countries across six continents. Inclusion criteria were admission to a participating intensive-care unit (including transfers) within the enrolment window and receipt of invasive or non-invasive ventilation. One of the trial's secondary aims was to characterise variations in the demographics, management, and outcome of patients with ARDS. We used the 2016 World Bank countries classification to define three major geo-economic groupings, namely European high-income countries (Europe-High), high-income countries in the rest of the world (rWORLD-High), and middle-income countries (Middle). We compared patient outcomes across these three groupings. LUNG SAFE is registered with ClinicalTrials.gov, number NCT02010073. Findings Of the 2813 patients enrolled in LUNG SAFE who fulfilled ARDS criteria on day 1 or 2, 1521 (54%) were recruited from Europe-High, 746 (27%) from rWORLD-High, and 546 (19%) from Middle countries. We noted significant geographical variations in demographics, risk factors for ARDS, and comorbid diseases. The proportion of patients with severe ARDS or with ratios of the partial pressure of arterial oxygen (PaO 2) to the fractional concentration of oxygen in inspired air (F I O 2) less than 150 was significantly lower in rWORLD-High countries than in the two other regions. Use of prone positioning and neuromuscular blockade was significantly more common in Europe-High countries than in the other two regions. Adjusted duration of invasive mechanical ventilation and length of stay in the intensive-care unit were significantly shorter in patients in rWORLD-High countries than in Europe-High or Middle countries. High gross national income per person was associated with increased survival in ARDS; hospital survival was significantly lower in Middle countries than in Europe-High or rWORLD-High countries. Interpretation Important geo-economic differences exist in the severity, clinician recognition, and management of ARDS, and in patients' outcomes. Income per person and outcomes in ARDS are independently associated.

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Training individuals with speech and hearing impairment in basic life support: A pilot studyTo the Editor, Current data suggests that ischaemic heart disease (IHD), is the leading cause of death globally [1]. If untreated, IHD can lead to cardiac arrest which is an economic burden for the health care system. The incidence of out-of-hospital cardiac arrest (OHCA) is 110.8 per 100 000 people [2]. Cardiopulmonary resuscitation (CPR) is a lifesaving intervention for victims suffering from cardiac arrest [3].The key determinants of survival in OHCA victims are the timely performance of bystander CPR and early defibrillation for those in ventricular fibrillation or pulseless ventricular tachycardia [4]. Although, it is proven that immediate bystander CPR along with early defibrillation can double the survival rate for OHCA [5], it has been seen that only 45.7% receive bystander CPR, and only 10.6% survive [2]. This highlights the need to increase the response for bystander CPR and to improve the survival rates for OHCA. In certain situations, disabled individuals may be bystanders. A physically challenged individual can also be proficient in knowledge and skills of CPR [6]. However, no studies have attempted to train a speech and hearing impaired individual (SHI) in the skill of CPR, i.e., basic life support (BLS). The aim of this study was, therefore, to assess the barriers, feasibility and explore possible modifications for training and teaching SHIs on adult BLS.This study was conducted during the month of April 2015, received institutional ethics clearance (IEC 70/2015) and was registered in Clinical Trials Registry India (CTRI/2015/03/005647). A written informed consent was taken from all the SHI participants. All the participants were trained using the 2010 American Heart Association (AHA) guidelines [3]. A special education school teacher (SEST) proficient in total communication (TC) was identified as a communicator between the AHA certified instructor (AHA-CI) and the participants. An AHA-CI taught the SEST skills for adult BLS (layperson) which was assessed later by a post-session skill demonstration. The participants were trained in adult BLS, very next day by the same AHA-CI along with SEST. At the end of the session, participants were evaluated using a checklist as recommended by the AHA for the BLS training program.Six SHI individuals (mean age 23 ± 8.14 years) trained and experienced in TC, with disability ranging between 80 and 90% participated in the study. Two participants were using hearing aids for auditory awareness. None of them had prior exposure or knowledge in CPR, first aid or BLS. Barriers during the training program were identified and are summarized in Table 1. The major challenges were activating emergency services (EMS) and following voice prompts of the Automated external defibrillator (AED).The study identified limitations in applications of the recommended chain of survival for individuals with SHI. The challenge in activating EMS and following voice prompts of the AED are

Background Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. MethodsIn this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middleincome countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42•4% vs 44•2%; absolute difference -1•69 [-9•58 to 6•11] p=0•67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H 2 O; p=0•0011). ICU mortality was higher in MICs than in HICs (30•5% vs 19•9%; p=0•0004; adjusted effect 16•41% [95% CI 9•52-23•52]; p<0•0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0•80 [95% CI 0•75-0•86]; p<0•0001).Interpretation Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status.

Background Cardiopulmonary resuscitation (CPR) is a lifesaving skill performed during the cardiac arrest. Various factors of rescuer affect CPR quality, and rescuers physical fitness is one among the important factors needs to be explored for improved CPR quality. This study aimed to assess the physical activity (PA) levels of the health care providers (HCPs) who were trained in basic life support (BLS) and its relationship on chest compression duration, hemodynamic parameters, and fatigue levels of the rescuers. Materials and methods A single-center, cross-sectional study was conducted on 48 HCPs who were trained in BLS within one year. Eligible participants were contacted by email, and the responders’ level of PA was determined using the global physical activity questionnaire (GPAQ). The participants were recruited for chest compression-only cardiac arrest scenarios. Each subject performed continuous chest compression on the manikin until they perceived maximum fatigue. Heart rate (HR), blood pressure (BP), oxygen saturation (SpO 2 ), and fatigue level were assessed at baseline, immediately after and following two minutes of cessation of chest compressions. The total duration of chest compression was also documented. Results Most participants (24, 50%) reported high levels of PA while 22 (45.83%) and 2 (4.17%) reported moderate and low intensity of PA, respectively. The mean age of the 35 participants was 26.08 ± 4.60 years. The mean duration of chest compressions was 193.25 seconds with higher times reported for those with high PA when compared to those with moderate PA ( p = 0.017). Similar findings were also observed for fatigue. Conclusion Rescuers who reported high PA had lower levels of fatigue and could perform longer duration of chest compressions. How to cite this article Nayak VR, Babu A, Unnikrishnan R, Babu AS, Krishna HM. Influence of Physical Activity of the Rescuer on Chest Compression Duration and its Effects on Hemodynamics and Fatigue Levels of the Rescuer: a Simulation-based Study. Indian J Crit Care Med 2020;24(6):409–413.

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