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Respiratory critical care HERMES: a European core syllabus in respiratory critical care medicine

A. Artigas, T. Vassilakopoulos, L. Brochard, D. Dellweg, A. Farr, M. Ferrer, J. Geiseler, A. Larsson, S. Nava, P. Navalesi, J-L Noël, S. Orfanos, P. Palange, B. Schoenhofer, A. Simonds, P. Pelosi
Breathe 2012 8: 216-229; DOI: 10.1183/20734735.000112
A. Artigas
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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T. Vassilakopoulos
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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L. Brochard
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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D. Dellweg
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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A. Farr
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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M. Ferrer
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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J. Geiseler
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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A. Larsson
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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S. Nava
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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P. Navalesi
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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J-L Noël
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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  • For correspondence: Julie-Lyn.Noel@ersnet.org
S. Orfanos
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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P. Palange
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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B. Schoenhofer
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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A. Simonds
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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P. Pelosi
Educational Activities, ERS Headquarters 4, Avenue Ste-Luce, CH 1003 Lausanne, Switzerland
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  • Article
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Figures

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  • Figure 1
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    Figure 1

    Four key phases of the HERMES model.

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    Figure 2
  • Figure 3
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    Figure 3
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    Figure 4

    Timeline of the Delphi process.

Tables

  • Figures
  • Table 1
    CATEGORYTotal nDelphi 1Delphi 2Delphi 3
    Task Force Members14100%93%N/A
    National Respondents5152%47%18%
    Respiratory Intensive Care Assembly48627%22%17%
    EU country representation262621
  • Table 2 Syllabus modules
    Module
    1Respiratory physiology and pathophysiology
    2Respiratory failure
    3Respiratory medical and surgical conditions
    4Ventilation and airway management
    5Other respiratory therapies
    6Cardiovascular disorders
    7Renal disorders
    8Central nervous system disorders
    9Metabolic and endocrine effects in critical illness
    10Infectious diseases
    11Acute haematological and oncological disorders
    12Acute gastrointestinal and abdominal disorders
    13Environmental hazards
    14Immunology and transplantation
    15Monitoring, quality control and biostatistics
    16Practical skills
    17Management
    18Communications and ethics
    19Research and evidence-based medicine
  • Table 3
    European representation
    AlbaniaGreeceRomania
    AustriaHungaryRussian Federation
    BelgiumIcelandSerbia
    BulgariaIrelandSlovakia
    CroatiaItalySlovenia
    CyprusLithuaniaSpain
    Czech RepublicNetherlandsSweden
    DenmarkNorwaySwitzerland
    FrancePolandTurkey
    GermanyPortugalUK
  • Syllabus #ItemLevel 1Level 2Level 3
    Module 1: Respiratory physiology and pathophysiology
    1Pulmonary mechanics and gas exchange•
    2Ventilatory muscle physiology, pathophysiology, and therapy, including polyneuropathy of the critically ill and prolonged effect of neuromuscular blockers•
    3Pulmonary haemorrhage and haemoptysis•
    4Oxygen transport and utilisation•
    Module 2: Respiratory failure
    1Acute respiratory failure•
     1.1Hypoxaemic respiratory failure including acute respiratory distress syndrome•
     1.2Acute and chronic hypercapnic respiratory failure•
    Module 3: Respiratory medical and surgical conditions
    1Status asthmaticus•
    2Aspiration•
    3Chest trauma (e.g. flail chest, pulmonary contusion, rib fractures)•
    4Bronchopulmonary infections including bronchiolitis•
    5Upper airway obstruction•
    6Bronchopleural fistulas•
    7Pleural diseases in severe respiratory failure•
     7.1Empyema•
     7.2Pleural effusion•
     7.3Pneumothorax•
     7.4Haemothorax•
    8Pulmonary embolism — thrombus, air, fat, amniotic•
    9Pulmonary hypertension and cor pulmonale (including pharmacological treatment)•
    10Management of obese patient•
    11Sleep disordered breathing•
    12Near drowning (optional item)•
    Module 4: Ventilation and airway management
    1Oxygen therapy•
    2Hyperbaric oxygenation (optional item)•
    3Invasive mechanical ventilation•
     3.1PEEP and CPAP•
     3.2Indications for and hazards of mechanical ventilation•
     3.3Barotrauma and volutrauma, atelectrauma, biotrauma•
     3.4Extracorporeal membrane oxygenation (optional item)•
     3.5Extracorporeal CO2 removal (optional item)•
     3.6Lung-protective mechanical ventilation•
     3.7High-frequency oscillatory ventilation (optional item)•
    4Criteria for extubation and weaning techniques•
    5Airway maintenance•
     5.1Emergency airway management•
     5.2Endotracheal intubation•
     5.3Tracheostomy•
    6Noninvasive ventilation•
     6.1Choice of interfaces•
     6.2Ventilatory modes incl. CPAP•
     6.3Choice of ventilators•
     6.4Oxygen supply during NIV•
     6.5Indications and contra-indications for NIV•
     6.6Indication for withdrawing NIV•
     6.7Criteria of failure•
    Module 5: Other respiratory therapies
    1Positional therapy (i.e. prone position, rotational therapy)•
    2Inhalation therapies and humidification•
    3Nitric oxide (optional item)•
    Module 6: Cardiovascular disorders
    1Shock syndromes and hypoperfusion including management principles (obstructive shock, sepsis and sepsis shock, other distributive shock, multi-organ dysfunction syndrome, hypovolaemic shock, cardiogenic shock)•
    2Myocardial infarction and its complications•
    3Cardiac rhythm and conduction disturbances•
    4Pulmonary oedema — cardiogenic, noncardiogenic•
    5Vasoactive and inotropic therapy•
    6Haemodynamic effects caused by ventilatory assist devices•
    7Thrombolytic and anticoagulant therapy•
    8Recognition, evaluation, and management of hypertensive emergencies and urgencies••
    Module 7: Renal disorders
    1Regulation of fluid balance and electrolytes•
    2Renal failure: pre-renal, renal and post-renal•
    3Acid–base disorders and their management•
    4Evaluation of oliguria•
    5Drug dosing in renal failure•
    Module 8: Central nervous system disorders
    1Coma: causes, assessment and prognosis•
    2Neuromuscular disease causing respiratory failure•
     2.1Guillain-Barré syndrome•
     2.2Amyotrophic lateral sclerosis•
     2.3Myasthenia gravis•
     2.4Myopathies (Duchenne's, etc.)•
     2.5Post-operative phrenic nerve dysfunction•
    3Principles of sedation•
    4Principles of pain management•
    5Neuromuscular blockade: use, monitoring, and complications•
    6Delirium and agitation•
    Module 9: Metabolic and endocrine effects in critical illness
    1Evaluation of nutritional state•
     1.1Enteral and parenteral•
    2Glucose management•
    Module 10: Infectious diseases
    1Antibiotics•
     1.1Antibacterial agents•
     1.2Antifungal agents•
     1.3Antituberculosis agents•
     1.4Antiviral agents•
    2Infection control for special care units•
     2.1Development of antibiotic resistance•
     2.2Universal precautions•
     2.3Isolation and reverse isolation•
     2.4Infectious risks to healthcare workers•
    3Definition, diagnosis and treatment of sepsis syndrome•
    4Systemic inflammatory response syndrome•
    5Hospital-acquired and opportunistic infections in the critically ill•
    6ICU support of the immunosuppressed patient•
    7Evaluation of fever in the ICU patient•
    Module 11: Acute haematological and oncological disorders
    1Disseminated intravascular coagulation•
    2Anticoagulation; fibrinolytic therapy•
    3Principles of blood component therapy including complications•
    4Prophylaxis against thromboembolic disease•
    5ICU-acquired anaemia•
    Module 12: Acute gastrointestinal and abdominal disorders
    1Prevention, treatment and principles of gastrointestinal bleeding•
    Module 13: Environmental hazards
    1Drugs and narcotics leading to respiratory failure•
    2CO poisoning•
    3Biological and chemical terrorism (optional item)•
    Module 14: Immunology and transplantation
    1Principles of transplantation (organ donation, procurement, preservation, transportation, allocation, implantation, maintenance of organ donors, national organisation of transplantation activities)•
    2Immunosuppression•
    3Lung transplantation: indications, pre-operative and post-operative care•
    Module 15: Monitoring, quality control and biostatistics
    1Prognostic indexes, severity, and therapeutic intervention scores•
    2Principles of ECG monitoring, measurement of skin temperature and resistance, transcutaneous measurements•
    3Noninvasive haemodynamic monitoring•
    4Respiratory monitoring•
    5Telemetric systems (optional item)•
    Module 16: Practical skills
    1Interpretation of sputum, bronchopulmonary secretions, and pleural fluid•
    2Arterial puncture for blood gas determination and arterial catheter placement•
    3Principles, indications and limitations of pulse oximetry•
    4Physical principles, indications and limitations of end tidal and transcutaneous CO2 monitoring•
    5Pulmonary function testing to assess respiratory mechanics and gas exchange, including spirometry, flow–volume studies, lung volumes, diffusing capacity•
    6Arterial blood gas analysis•
    7Airway management including endotracheal intubation•
    8Management of the difficult airway•
    9Modes and principles of mechanical ventilation — invasive and noninvasive•
    10Modes and principles of oxygen supplementation•
    11Tracheostomy tube management and decannulation•
    12Emergent cardioversion and defibrillation•
    13Evaluation of sedation•
    14Diagnostic and therapeutic thoracentesis•
    15Chest tube insertion and maintenance of the tube and drainage systems, insertion of decompression needle for tension pneumothorax•
    16Central venous catheter placement (subclavian, femoral, jugular) with/without ultrasound guidance•
    17Set-up and operation of haemodynamic and respiratory monitoring systems•
    18Interpretation of haemodynamic and oxygen delivery and extraction data•
    19Diagnostic bronchoscopy including airway examination and bronchoalveolar lavage•
    20Therapeutic bronchoscopy (through an artificial airway) for secretion removal•
    21Insertion of nasal gastric and feeding tubes•
    22Imaging techniques commonly employed in the evaluation of patients with critical illness and/or pulmonary disorders•
    23Basic interpretation of chest radiograph•
    24Advanced cardiac life support•
    25Inhalation and humidification and secretion clearance devices•
    26Application of extracorporeal CO2 removal (optional item)•
    27Percutaneous tracheostomy (optional item)•
    Module 17: Management
    1Understanding and evaluation of health cost and economics•
    2Resource allocation•
    3Triage (direction of patient flow to and off critical care units)•
    4Knowledge of prevailing legal norms regarding the legally incompetent patient, euthanasia, brain death determination and organ donation•
    Module 18: Communications and ethics
    1Appropriate verbal and written communication•
    2Handling emotional effects of severe illness•
    3Handling of unfavourable messages and complaints•
    4Understanding medical ethics in due consideration of socioeconomic, cultural and religious differences•
    5Respect of patient autonomy•
    6Assessment of utility and futility of diagnostic and therapeutic procedures•
    7Informed consent•
    8End-of-life decision making and care•
    9Quality of end of life•
    Module 19: Research and evidence-based medicine
    1Application of guidelines•
    2Scientific literature appraisal•
    3Use of information technology•
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Respiratory critical care HERMES: a European core syllabus in respiratory critical care medicine
A. Artigas, T. Vassilakopoulos, L. Brochard, D. Dellweg, A. Farr, M. Ferrer, J. Geiseler, A. Larsson, S. Nava, P. Navalesi, J-L Noël, S. Orfanos, P. Palange, B. Schoenhofer, A. Simonds, P. Pelosi
Breathe Mar 2012, 8 (3) 216-229; DOI: 10.1183/20734735.000112

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Respiratory critical care HERMES: a European core syllabus in respiratory critical care medicine
A. Artigas, T. Vassilakopoulos, L. Brochard, D. Dellweg, A. Farr, M. Ferrer, J. Geiseler, A. Larsson, S. Nava, P. Navalesi, J-L Noël, S. Orfanos, P. Palange, B. Schoenhofer, A. Simonds, P. Pelosi
Breathe Mar 2012, 8 (3) 216-229; DOI: 10.1183/20734735.000112
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