Review questionWhat is known about the evidence that web-based/online/computerised tools for self management of asthma can improve indices of asthma control, lung function, health care utilisation, patient quality of life, and patient satisfaction, and what helps or hinders the use of such interventions by patients, carers and health professionals. Objectives• To undertake a systematic review of all published reviews (quanti tative and qualitative) of web-based/online/computerised self-management asthma interventions.• To establish if the use of web-based/online/computerised self care interventions have been found to have a positive effect on asthma symptom scores, lung function, medication use, health care utilisation, or asthma quality of life scores.• To identify the presence of techniques in these interventions known to promote behavioural change e.g. educational information, self monitoring, attitudinal arguments, and the use of prompts.• To examine what factors, if any, have been identified as promoting or inhibiting the uptake and utilisation of online tools by patients, carers and practitioners? Searches• Databases to be searched: MEDL I NE, EMBASE, CINAH L, PsycINFO, ERIC, Cochrane Library (including CDSR, DARE, Central, and HTA databases), DoPHER and TROPHI (both produced by the EPPI Centre), Social Science Citation Index and Science Citation Index. These databases will be searched using a combination of subject headings where available (such as MeSH) and words in the t i tle and abstracts.The search strategy combines 3 facets of search terms:1. Online technology 2. Asthma 3. Self management/behavior change/patient experience Searches employing more general terms, such as respiratory t ract diseases, will be explored as they may identify records where in the full document i t becomes clear that patients with asthma are included.

IMPORTANCEIn patients who require mechanical ventilation for acute hypoxemic respiratory failure, further reduction in tidal volumes, compared with conventional low tidal volume ventilation, may improve outcomes. OBJECTIVE To determine whether lower tidal volume mechanical ventilation using extracorporeal carbon dioxide removal improves outcomes in patients with acute hypoxemic respiratory failure. DESIGN, SETTING, AND PARTICIPANTS This multicenter, randomized, allocation-concealed, open-label, pragmatic clinical trial enrolled 412 adult patients receiving mechanical ventilation for acute hypoxemic respiratory failure, of a planned sample size of 1120, between May 2016 and December 2019 from 51 intensive care units in the UK. Follow-up ended on March 11, 2020. INTERVENTIONS Participants were randomized to receive lower tidal volume ventilation facilitated by extracorporeal carbon dioxide removal for at least 48 hours (n = 202) or standard care with conventional low tidal volume ventilation (n = 210). MAIN OUTCOMES AND MEASURESThe primary outcome was all-cause mortality 90 days after randomization. Prespecified secondary outcomes included ventilator-free days at day 28 and adverse event rates. RESULTS Among 412 patients who were randomized (mean age, 59 years; 143 [35%] women), 405 (98%) completed the trial. The trial was stopped early because of futility and feasibility following recommendations from the data monitoring and ethics committee. The 90-day mortality rate was 41.5% in the lower tidal volume ventilation with extracorporeal carbon dioxide removal group vs 39.5% in the standard care group (risk ratio, 1.05 [95% CI, 0.83-1.33]; difference, 2.0% [95% CI, −7.6% to 11.5%]; P = .68). There were significantly fewer mean ventilator-free days in the extracorporeal carbon dioxide removal group compared with the standard care group (7.1 [95% CI, 5.9-8.3] vs 9.2 [95% CI, 7.9-10.4] days; mean difference, −2.1 [95% CI, −3.8 to −0.3]; P = .02). Serious adverse events were reported for 62 patients (31%) in the extracorporeal carbon dioxide removal group and 18 (9%) in the standard care group, including intracranial hemorrhage in 9 patients (4.5%) vs 0 (0%) and bleeding at other sites in 6 (3.0%) vs 1 (0.5%) in the extracorporeal carbon dioxide removal group vs the control group. Overall, 21 patients experienced 22 serious adverse events related to the study device.CONCLUSIONS AND RELEVANCE Among patients with acute hypoxemic respiratory failure, the use of extracorporeal carbon dioxide removal to facilitate lower tidal volume mechanical ventilation, compared with conventional low tidal volume mechanical ventilation, did not significantly reduce 90-day mortality. However, due to early termination, the study may have been underpowered to detect a clinically important difference.

Acute kidney injury (AKI) affects up to 60% of intensive care unit (ICU) patients and is associated with mortality rates of between 15 and 60%. Up to two-thirds of patients with AKI go on to require renal replacement therapy (RRT). 1 Without the ability to replace native renal function, mortality from the complications of fluid overload, refractory hyperkalaemia, and metabolic derangement would be far higher. From the 1960s, hollow-fibre dialysers became available as a form of RRT and were able to be mass produced, with Scribner starting the first outpatient dialysis centres in the USA. Haemofiltration, as a form of RRT, began in the 1970s and is now an indispensable tool used as part of modern critical care management. Despite improvements in technologies, there has been only slow improvement in mortality since the 1980s. The reasons postulated for this include the lack of diagnostic tools available to detect early AKI, delayed initiation of RRT, inadequate delivery of RRT, and the inability to replace kidney function fully with current RRT modalities. Little information exists on trends in the epidemiology of AKI; however, there are several reasons to suspect that its incidence is on the rise: the increasing age and comorbidities of the hospitalized population; an increase in the prevalence of risk factors for AKI such as chronic kidney disease and diabetes; and more widespread use of i.v. contrast for cardiovascular and other radiological procedures. Mechanisms of RRT Worldwide, RRT can be provided as peritoneal dialysis, intermittent haemodialysis (IHD), and continuous renal replacement therapy (CRRT), which includes continuous veno-venous haemofiltration (CVVH), continuous veno-venous haemodialysis (CVVHD) and continuous veno-venous haemodiafiltration (CVVHDF). The majority of UK critical care units use either CVVHF or CVVHDF. 2 Some units use hybrid therapies that combine IHD and CRRT; this technique is commonly known as slow low-efficiency daily dialysis. Slow continuous ultrafiltration (SCUF) is an alternative mode of RRT used to control fluid balance particularly in patients with diuretic-unresponsive cardiorenal syndrome. The aims of RRT are solute and water removal, correction of electrolyte abnormalities, and normalization of acid-base disturbances. This is achieved via diffusion or convection which is, respectively, referred to as haemodialysis or haemofiltration. The system comprises an extracorporeal circuit filled by blood arising from a wide-bore double-lumen central venous catheter Key points • Despite improvements in renal replacement therapy (RRT) technology, the mortality associated with acute kidney injury remains high.

Introduction Tracheostomy is a common surgical procedure used to create a secure airway in patients, now performed by a variety of specialties, with a notable rise in critical care environments. It is unclear whether this rise is seen in units with large head and neck surgery departments, and how practice in such units compares with the rest of the UK. Methods A three-year retrospective audit was carried out between anaesthetic, surgical and critical care departments. All tracheostomy procedures were recorded anonymously. Results A total of 523 tracheostomies were performed, 66% of which were in men. The mean patient age was 60 years. The majority (83%) were elective, performed for various indications, while the remaining 17% were emergency tracheostomies performed for pending airway obstruction. A fifth of the tracheostomies were percutaneous procedures. Most emergency tracheostomies (78%) were performed by otolaryngology. Three cricothyroidotomies were performed within critical care and theatres. Complications related to tracheostomy occurred in 47 cases (9%), most commonly lower respiratory tract infection. The mean time to decannulation was 12.8 days. Conclusions This paper discusses the findings of a comprehensive, multispecialty audit of tracheostomy experience in a large health board, with over 150 tracheostomies performed annually. Elective cases form the majority although there is a significant case series of emergency tracheostomies performed for a range of pathologies. Around a quarter of those requiring tracheostomy ultimately died, mostly as a result of advanced cancer.

Decisions regarding admission to intensive care are made considering both the physiological state of the patient and the burden of comorbidity. Despite many retrospective cohort studies looking at isolated comorbidities, there has been little work to study multiple comorbidities and their effect upon intensive care outcome. In this retrospective cohort analysis, detailed comorbidity and demographic data were gathered on 1,029 patients from the West of Scotland and matched to both unit and hospital mortality at 30 days. Logistic regression was performed to investigate the factors associated with death within 30 days at both hospital and unit level. Variables with a p-value <0.25 at the univariable level were considered in a multivariable model. Variable selection for the multivariable modelling was carried out using backward selection and then replicated using forward selection to check for model stability. A modelling tool was constructed for both unit and hospital mortality at 30 days. This modelling has shown significant odds ratios for hospital death for alcoholic liver disease (OR 4.83), age (1.03), rheumatological diseases (1.93) and functional exercise tolerance prior to admission (3.08). Results from this work may inform a national prospective study to validate the modelling tool on a wider population.