Technical Innovation in Critical Care in a World of Constraints: Lessons from the COVID-19 Pandemic.

The COVID-19 crisis was characterized by a massive need for respiratory support, which has unfortunately not been met globally. This situation mimicked those which gave rise to critical care in the past. Since the polio epidemic in the 50's, the technological evolution of respiratory support has enabled health professionals to save the lives of critically-ill patients worldwide every year. However, much of the current innovation work has turned around developing sophisticated, complex, and high-cost standards and approaches whose resilience is still questionable upon facing constrained environments or contexts, as seen in resuscitation work outside intensive care units, during pandemics, or in low-income countries. Ventilatory support is an essential life-saving tool for patients with respiratory distress. It requires an oxygen source combined to a ventilatory assistance device, an adequate monitoring system, and properly trained caregivers to operate it. Each of these elements can be subject to critical constraints, which we can no longer ignore. The innovation process should incorporate them as a prima materia, whilst focusing on the core need of the field using the concept of frugal innovation. Having a universal access to oxygen and respiratory support, irrespective of the context and constraints, necessitates: i) developing cost-effective, energy-efficient, and maintenance-free oxygen generation devices; ii) improving the design of non-invasive respiratory devices (for example, with oxygen saving properties); iii) conceiving fully frugal ventilators and universal monitoring systems; iv) broadening ventilation expertise by developing end-user training programs in ventilator assistance. The frugal innovation approach may give rise to a more resilient and inclusive critical care system. This paradigm shift is essential for the current and future challenges.

A review of the role of non-invasive ventilation in critical care responses to COVID-19 in low- and middle-income countries: lessons learnt from Baghdad.

In 2021, the burden of the coronavirus disease 2019 (COVID-19) pandemic became especially severe in low- and middle-income countries (LMICs). With high numbers of patients requiring advanced respiratory support and invasive mechanical ventilation (IMV), many ICUs were overwhelmed. This problem is particularly pronounced in LMICs, where the availability of intensive care beds may be limited. Non-invasive ventilation (NIV) has been increasingly used in COVID-19, as both a bridge to intubation as well as a definitive treatment. Use of NIV may be a feasible management strategy in settings where performing IMV is not possible on a large scale due to resource constraints. During 2020-2021, Médecins Sans Frontière helped manage a COVID-19 ICU in Baghdad, Iraq. The predominant mode of treatment was NIV. Due to a shortage of intensive care ventilators, NIV was delivered in the majority of cases by home continuous positive airway pressure machines. In total, 709 patients were admitted to the ICU during the study period with an overall mortality of 61.1%. In addition to the ventilation strategy, patients must be treated holistically, with a comprehensive package of critical care. We aim to highlight the role of NIV in this setting and summarise our experiences to assist future critical care projects during the pandemic.