Respiratory critical care

1. Airway secretions
2. Effort of breathing: calculation of WOB, PTP
3. Haemodynamic assessment: central venous pressure, invasive arterial pressure, pulmonary wedge pressure, vascular resistance, pressure delta calculation
4. Systemic signs

1. Differential diagnosis of acute hypercapnic respiratory failure
2. Differential diagnosis of acute hypoxic respiratory failure

1. Different approaches to flexible bronchoscopy in spontaneously breathing patients and those on high-flow nasal therapy, non-invasive ventilation (NIV) and invasive mechanical ventilation (IMV)
2. Bronchoscopy
   1. Goals of bronchoscopy (therapeutic/diagnostic)
   2. Effects and side effects (risks and benefits) of bronchoscopy in secretion management (e.g. risk of atelectasis)
   3. Indications for NIV during bronchoscopy
   4. Monitoring requirements for the procedure
   5. Appropriate setting for bronchoscopy according to the patient’s condition
   6. Patient consent
   7. Selection and application of appropriate topical and systemic medications for the procedure
   8. Selection and mounting of appropriate interface that allows bronchoscopy during NIV
   9. Selection and applying the appropriate ventilator settings to achieve optimal ventilator support and minimise the side effects of bronchoscopy
   10. Set up of the monitoring equipment for bronchoscopy
   11. Performance of bronchoscopy
3. Diagnostic bronchoscopy including airway examination and bronchoalveolar lavage
   1. Indications, contraindications and risks of bronchoscopy and lavage
   2. Principles of patient preparation for bronchoscopy and evaluation prior to bronchoscopy
   3. Principles of sedation management during bronchoscopy
   4. Airway anatomy
   5. Bronchoscopy technique including biopsy and lavage equipment
   6. Different routes to perform bronchoscopy (artificial airway, oral cavity, nasal cavity and during NIV)
   7. Methods to treat endobronchial bleeding during bronchoscopy including the limitations of these measures
   8. Management of sedation during bronchoscopy
   9. Bronchoscopy (pass the upper airway and locate all accessible segmental ostia)
   10. Mucosal biopsy
   11. Bronchoalveolar lavage
   12. Therapeutic bronchoscopy (through an artificial airway) to remove secretions
   13. Indications, contraindications and risks of therapeutic bronchoscopy via an artificial airway
   14. Ventilator management when bronchoscopy is performed during ventilation
   15. Techniques to supply oxygen when bronchoscopy is performed during spontaneous breathing through an artificial airway
   16. Therapeutic bronchoscopy through an artificial airway
4. Foreign body airway aspiration
   1. Pathophysiology and complications of gross and silent aspiration
   2. Indications for flexible or rigid bronchoscopy
   3. Performance of flexible bronchoscopy and recognition of indications for rigid bronchoscopy

1. Diagnostic and therapeutic thoracentesis
   1. Indications, contraindications and risks of thoracentesis
   2. Anatomic sites for thoracentesis
   3. Different thoracentesis systems (closed versus open, cannula, Seldinger technique, etc.)
   4. Performance of thoracentesis
   5. Recognition of appropriate procedure-related complications
   6. Appropriate management of complications with support from different specialties
   7. Chest trauma (e.g. flail chest, pulmonary contusion and rib fractures)
   8. Pathophysiology of the clinical signs of haemothorax/pneumothorax, cardiac contusion and aortic injuries
   9. Indications for chest tube drainage/needle thoracentesis in cases with chest trauma
   10. Principles of pain evaluation and its impact on cough
   11. Indications for mechanical ventilation
   12. Diagnostic work-up in cases with suspected chest trauma
   13. Interpretation of imaging in cases with chest trauma
   14. Insertion of a chest tube in cases with tension pneumothorax or haemothorax
   15. Treatment of pain to avoid sputum retention
   16. Recognition of empyema
   17. Principles of empyema treatment (antibiotics, thoracic drainage and thoracic surgery)
   18. Thoracentesis in cases with empyema
   19. Interpretation of laboratory results of thoracentesis in cases with empyema
   20. Initiation of appropriate antibiotic therapy in cases with empyema
2. Performing thoracentesis in cases with pleural effusion
3. Thoracentesis in cases with suspected haemothorax

1. Radiological correlates of chest organs and bony chest structures
2. Describing radiological findings of a chest radiograph
3. Recognition of abnormal results and formulation of a diagnosis
4. Changes in chest X-rays during mechanical ventilation, recruitment manoeuvres and positive pressure ventilation
5. Position of central venous lines, a endotracheal tube and a nasogastric tube
6. Risks associated with chest radiography (irradiation)

1. Lung ultrasound for differential diagnosis of acute respiratory failure
2. Lung ultrasound for monitoring treatment effects
3. Ultrasound for diaphragm assessment
4. Ultrasound for haemodynamic assessment
5. Echoguided central venous catheter
6. Extended Focused Assesment with Sonography in Trauma (E-FAST EXAM)

1. Identify causes of acute respiratory failure (ARF)
2. Effects of ventilator settings (recruitments) on atelectasis
3. Risks associated with CT in (ventilated) patient (irradiation, transport)
4. Role of thoracic MRI

1. Culture, PCR results and ELISA
2. Choose and obtain the appropriate respiratory sample

1. Inhalation therapies and humidification
2. Principles and the physiologic and anatomic basis of airway conditioning
3. Principles of inhaled drug therapy in invasively and non-invasively mechanically ventilated patients
4. Indications, limitations and side effects

1. Basic principles of physiotherapy
2. Physiological rationale and technical issues of non-invasive tools for secretion management and cough assist in spontaneously breathing and non-invasively supported patients
3. Non-disconnectable patients on invasive ventilation. Physiotherapy procedures using the mechanical respirator and online devices.
4. Use of devices to train inspiratory muscles
5. Positive expiratory pressure therapy: rationale and devices
6. The specific case of the patient on Extracorporeal Membrane Oxygenation (ECMO)

End-of-life relief of dyspnoea by:

1. Drug administration
2. NIV
3. High-flow nasal oxygen (HFNO)
4. Discuss end-of-life decisions with patients and their relatives
5. Legal implications
6. Constitutional principles and laws that currently arbitrate decision-making

1. Oxygen transport and utilisation
   1. Mechanisms involved in oxygen transport and tissue oxygenation
   2. Clinical conditions that compromise oxygen transport and utilisation
   3. Diagnostic and therapeutic strategies aimed at improving oxygen transport and utilisation
   4. Physiology oxygen delivery (i.e. cardiac output × arterial oxygen content)
   5. Early recognition and treatment of generalised or local hypoxia/hypoxaemia
   6. Differentiation between oxygen saturation (SaO2) and pO2 in blood gas analysis (BGA)
   7. Proactive attitude in early recognition and management
2. Practical skills: modes and principles of oxygen supplementation
   1. Oxygen uptake and delivery
   2. Indications and contraindications for oxygen therapy
   3. Gas pressure and liquid oxygen systems as well as oxygen blenders
   4. Different probe systems used to administer oxygen during spontaneous breathing, including their impact on FiO2
   5. Oxygen humidification
   6. Appropriate selection of an oxygen system, flow rate and FiO2
   7. Appropriate selection of tests to monitor oxygen supplementation
   8. Selection of appropriate patients for HFNO, excluding patients who require (non)invasive ventilation or low-flow oxygen
   9. Current evidence for the use of high flow combined with NIV
   10. Indications for HFNO in postextubation management, postoperative prophylactic or therapeutic treatment, in acute hypoxemic failure of lesional origin and in acute hypercapnic failure.
   11. Indications for home HFNO

1. Indications for NIV
2. Contraindications for NIV
3. Side effects and complications of NIV
4. Continuous positive airway pressure
5. Failure of NIV
6. Humidification during NIV
7. Circuits
8. Synchronies/dyssynchronies during NIV
9. Ventilator modes and parameters
10. Technical maintenance
11. Withdrawal of NIV
12. Interfaces for NIV
13. Limitations in acute respiratory distress syndrome (ARDS)

1. Principles of IVM in the general intensive care unit (ICU) population
2. Principles of IMV in ICU patients with specific pulmonary conditions (e.g. ARDS)
3. Modes of ventilation and their indications and principles of intelligent modes of ventilation.
4. Effects of positive airway pressure on gas exchange, respiratory mechanics and haemodynamics
5. Ventilation modes (e.g. assist versus assisted modes, and auto-modes)
6. Neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV) and biological ventilation
7. Interpretation of flow and pressure curves
8. Types of humidification systems and their indications
9. Indications for nebulisation of bronchodilators and mucolytic drugs
10. Nebulisation systems and their advantages and disadvantages
11. Adjustment of ventilator settings to:
    1. Optimise gas exchange according to BGA
    2. Prevent haemodynamic compromise
    3. Minimise the risks of ventilator-induced lung injury (VILI)
    4. In assisted modes minimise the risks of patient-induced lung injury (P-SILI)
12. Titrate positive end expiratory pressure (PEEP) according to different methods
13. Initiate and set the right level of PEEP
14. Calculate driving pressure and p-plat
15. Diagnosis and recognition of barotrauma
16. Diagnosis and recognition of volotrauma
17. Diagnosis and recognition of atelectotrauma
18. Pendelluft Phenomena
19. When should intubation not be delayed?
20. Lung protective ventilation
21. Ultra-protective ventilation and circulatory support
22. Management of barotrauma (pneumothorax)
23. Effectively communicate with patients about the risks and benefits of invasive ventilation versus NIV
24. General principles of monitoring
25. Pressure and volumes (applied)
26. Hazards of mechanical ventilation
27. Patient-ventilator interaction
28. Rescue
29. IMV in specific patient groups
30. Weaning
31. Long-term complications
32. Extracorporeal carbon dioxide removal (ECCO2-R) and venovenous (VV) ECMO in refractory ARF – when to refer and contraindications

1. Chest tube insertion, maintenance of the tube and drainage systems and insertion of a decompression needle for tension pneumothorax
2. Indications, contraindications and risks of chest tube insertion and needle decompression
3. Anatomic sites for tube placement or needle insertion
4. Different thoracentesis systems (open preparation versus trocar tubes)
5. Drainage and suction systems
6. Perform chest tube insertion and needle decompression
7. Manage complications as appropriate with support from different specialties

1. Evaluation, differential diagnosis, immediate management steps, first-line treatment and specific conditions
2. Diagnosis and first-line treatment of:
   1. Massive pulmonary bleeding
   2. Massive pulmonary embolism
   3. Acute pulmonary oedema
   4. Acute respiratory distress syndrome
   5. Tension pneumothorax
   6. Tracheal stenosis

1. Pathophysiology of asthma
2. Status asthmaticus
3. Principles of recognition of status asthmaticus
4. Indications for oxygen therapy, NIV and intubation
5. Pharmacology and side effects of anti-asthmatic drugs
6. Principles of delivery of and response to aerosol therapy
7. Possible complications of status asthmaticus (e.g. pneumothorax and pneumomediastinum) and their management
8. Indications for non-pharmacological treatment (e.g. oxygen therapy and mechanical ventilation)
9. Provision of outpatient and inpatient care as well as emergency and ICU treatment
10. Translation of national and international management recommendations for status asthmaticus to individualised management
11. Recognition and management of patients at risk of life-threatening asthma requiring intubation
12. Mechanical ventilation of status asthmaticus patients
13. Knowledge of emergency therapeutic strategies

1. Hospital-acquired and opportunistic infections in critically ill patients
2. Most frequent infections acquired in the ICU, their predisposing factors including immunosuppression, their diagnostic criteria, the most frequent etiologic pathogens and recommended empiric treatment for each infection
3. Detection and diagnosis of these patients
4. Implementation of appropriate diagnostic methods
5. Appropriate selection of empiric treatment
6. Most frequent support measures in critically ill and immunosuppressed patients, including haemotherapy, antimicrobial treatment and life support measures such as mechanical ventilation, vasoactive drugs, renal replacement therapy and immunostimulation
7. Establishment of indications for each support measure and selection of the most appropriate measure in each clinical condition

1. Detection and diagnosis of these patients
2. Implementation of appropriate diagnostic methods
3. Selection of empiric treatment

1. Identify immunotherapy and diffuse metastasis as causes of respiratory failure
2. Discuss the appropriateness of mechanical ventilation for patients with lung cancer during the diagnostic process

1. Physiology and pathophysiology of sleep apnoea syndromes relevant to ARF
2. Diagnosis and screening of obstructive sleep apnoea, upper airway obstruction and hypoventilation
3. Interpretation of blood gases and other tests for sleep-disordered breathing
4. Recognition of obesity as a cause of weaning failure in obese patients

1. ARF
   1. Physiology and pathophysiology of ARF
   2. Respiratory pump function and dysfunction
   3. BGA
   4. Difference between hypoxia and hypoxaemia
   5. Imaging (e.g. chest X-ray)
   6. National and international guidelines for treatment of ARF
   7. Evaluation, performance, interpretation and reporting of BGA, O2 saturation, transcutaneous CO2 measurement, chest X-ray (imaging) and lung/chest wall mechanics
2. Hypoxemic respiratory failure including ARDS
   1. Causes of hypoxemic ARF
   2. Definition and classification of ARDS
   3. Ventilator and tube-associated complications
   4. Intubation-associated pneumonia (IAP)
   5. Protective mechanical ventilation and VILI
   6. Identification and management of hypoxemic ARF
   7. Indications for NIV in patients with hypoxemic ARF
   8. Risk assessment and management of NIV failure and indications for intubation
   9. Intubation and IMV
3. Acute and chronic hypercapnic respiratory failure
   1. Causes of respiratory failure
   2. Principles of interpretation of BGA
   3. National and international guidelines for treatment of acute and chronic hypercapnic respiratory failure
   4. Indications for additional O2 treatment
   5. Indications for long-term (home) mechanical ventilation
   6. Management of patients with prolonged weaning
   7. Non-IVM
   8. Care for patients that are highly dependent on mechanical ventilation, e.g. those with a tracheostomy
4. Pleural diseases in patients with severe respiratory failure
   1. Pathophysiology of restrictive thoracic/pleural diseases that cause severe respiratory failure
   2. Various types of chest tubes and insertion techniques
   3. Recognition of pleural diseases as a cause of severe respiratory failure
   4. Performance of ultrasound examination of the pleural space
   5. Interpretation of pleural pathology on chest X-rays
   6. Chest tube insertion: technical issues must be considered to drain located effusions in some cases with organising parapneumonic pleural effusions
   7. Interpretation of laboratory findings in patients with pleural effusion

1. Identify acute ILD as a cause of ARF
2. Differential diagnosis and optimal testing

1. Conditions/diseases associated with an increased risk of thromboembolic disease
2. Adverse effects associated with anticoagulation therapy
3. Interpretation of coagulation laboratory tests
4. Drug indications and their appropriate dosages

1. Pathophysiology of pulmonary hypertension
2. Pharmacological treatment of pulmonary hypertension according to the underlying disease
3. Diagnosis of pulmonary hypertension and cor pulmonale
4. Insertion of pulmonary artery catheter and interpretation of wave-forms.
5. Use of vasoactive and inotrotropic agents in these cases
6. Inhaled nitric oxide in spontaneous ventilation, invasive ventilation, non-invasive ventilation and HFNO
7. Translating national and international management guidelines to an individual patient
8. Appropriate decisions for referral and transfer to specialised referral centres
9. Prognosis of patients with pulmonary hypertension in acute care settings

1. Differential diagnoses, diagnostic steps and therapeutic options for pulmonary haemorrhage and haemoptysis
2. Triage by severity
3. Localisation of haemorrhage by bronchoscopy
4. Performance of bronchoscopic interventions
5. Initiation of ventilatory assistance
6. Recognition of the technical limitations of bronchoscopic interventions and immediate referral of patients to the appropriate specialty

1. Symptoms of AV malformation
2. Diseases associated with AV malformation
3. Diagnostic strategies when AV malformation is suspected
4. Therapeutic interventions

Identify chest wall abnormalities as a cause of restrictive lung disease, respiratory failure and weaning failure

1. Neuromuscular conditions associated with respiratory muscle weakness
2. Symptoms and signs of nocturnal hypoventilation and the probability of respiratory failure
3. Role of NIV versus invasive ventilation and cough augmentation (cough assist) techniques
4. Assessment of respiratory muscle strength (e.g. vital capacity)
5. Assessment of non-invasive respiratory muscle strength (e.g. mouth pressures and sniff inspiratory pressure)
6. Measurement of cough peak flow
7. Use of NIV
8. Clinical assessment of bulbar function
9. Causes, assessment and prognosis of coma
10. Principles of the assessment of coma severity (i.e. Glasgow coma scale)
11. Clinical assessment of coma
12. Differential diagnosis of coma
13. Indications for airway protection and mechanical ventilation
14. Guillain-Barré syndrome
    1. Causes, subtypes, pathophysiology and natural history
    2. Diagnostic methods and treatments (plasmapheresis and immunoglobulin)
    3. Amyotrophic lateral sclerosis (ALS)
    4. Different presentations of the motor neuron disease ALS: types (bulbar/non-bulbar), diagnosis (electromyography and nerve conduction studies) and natural history
    5. Role of riluzole and symptom palliation
    6. Respiratory muscle strength and bulbar function assessment
    7. Careful handling of symptom palliation and discussion of advance directives
15. Myasthenia gravis
    1. Pathophysiology of acquired myasthenia and congenital variants, diagnostic methods and therapies including anticholinesterases
    2. Assessment of respiratory muscle strength
    3. Myopathies and muscular dystrophies (Duchenne, etc.)
    4. Understanding the classification of common myopathies (e.g. nemaline, Pompe disease and myotubular), muscular dystrophies (Duchenne and limb girdle) and neuropathies
    5. Natural history of disorders such as cardiomyopathy in some conditions and the likelihood of respiratory failure
    6. Assessment of respiratory muscle strength
    7. Performance of sleep studies and NIV
    8. Effective communication with patients and their families
    9. Establish effective interactions with the multidisciplinary team of health professionals
16. Postoperative phrenic nerve dysfunction
    1. Types of phrenic nerve dysfunction (nerve transection and paresis)
    2. Predisposing surgical procedures
    3. Natural history and clinical features
    4. Assessment of respiratory muscle strength
    5. Referral for phrenic nerve conduction studies
17. Principles of sedation
    1. Diagnostic and therapeutic procedures for sedation and analgesia
    2. Pharmacological basis of sedative agents
    3. Indications for sedation and analgesia
    4. Scores and scales for assessment of sedation in conscious and unconscious patients
    5. Sedation and pain management including treatment of delirium and anxiety in critically ill patients using both pharmacologic and non-pharmacologic methods
    6. Use of sedative drugs and reversal drugs

1. Identify diaphragm weakness as a cause of acute respiratory failure and weaning failure
2. Differential diagnosis of diaphragm weakness
3. Therapeutic options for diaphragm weakness
4. Pathophysiology of critical illness associated respiratory muscle weakness
5. Prevention of critical illness associated respiratory muscle weakness

1. Pathophysiology of pleural effusions (exudates versus transudate)
2. Differential diagnosis of pleural effusion
3. Laboratory diagnostic tests for pleural effusion
4. Principles of therapy for pleural effusion (diuretics and thoracic drainage)
5. Various drainage devices for use as chest tubes
6. Translating national and international guidelines for diagnosis and treatment of pleural effusion to individualised management
7. Performing ultrasound of the pleural space to establish the diagnosis of pleural effusion
8. Performing thoracentesis in patients with pleural effusion
9. Inserting a drainage tube

1. Pathophysiology of pneumothorax
2. Diagnosis and treatment of pneumothorax
3. Recognition of pneumothorax using imaging techniques
4. Treatment of pneumothorax according to national and international guidelines

1. Differentiate between cardiac and pulmonary disease as a cause of ARF
2. Describe the differential diagnosis of cardiac causes of ARF
3. Basic principles of invasive cardiovascular monitoring (e.g. pulmonary artery catheter)
4. Cardiovascular effect of positive pressure ventilation
5. Respiratory support in post cardiac risk surgery and in post extubation failure
6. Characteristics of the complex weaning of these patients (epicardial pacemaker, opening of the pleuras, slooling of the breast artery etc.)

Sleep-disordered breathing:

1. Physiology and pathophysiology of sleep relevant to ARF
2. Diagnosis and screening of obstructive sleep apnoea, upper airway obstruction and hypoventilation
3. Interpretation of blood gases and other tests for sleep-disordered breathing
4. Recognition of obesity as a cause of weaning failure in obese patients

Management of obese patients:

1. Pathophysiologic effects of morbid obesity on the respiratory system (upper airways, respiratory mechanics and central respiratory drive)
2. Principles of drug dosing in morbidly obese patients
3. Recognition of obesity as a reason for respiratory impairment
4. Interpretation of BGA and polysomnography results
5. Initiation of non-invasive respiratory treatment
6. Initiation of therapy in obese patients
7. Associated respiratory problems

1. Identify acute ILD as a cause of ARF
2. Differential diagnosis and optimal testing
3. Choose the optimal treatment
4. Prognostication of the identified ILD

1. Identify smoke inhalation and burns as causes of respiratory failure
2. Biological accidents
3. Assessment of the degree of severity of pulmonary involvement
4. Optimal treatment of inhalation injury, including systemic effects

1. Identify acute ILD as a cause of ARF
2. Differential diagnosis and optimal testing
3. Choose the optimal treatment
4. Prognostication of the identified ILD

1. Tuberculosis and Non-Tuberculous Mycobacteria
2. Fungal Diseases

1. Integration of physiological and biological data in the ICU
2. Automated interpretation of big data in the ICU
3. Data capture and preparation
4. Language models (Python, R, C++, JAVA)
5. Structured and unstructured data
6. Bayesian, Neural and Random Forest Networks
7. Time series and hidden Markov models
8. Clustering, Machine Learning and Artificial Intelligence