Call for ICU patients in S’pore to participate in trial to find best pneumonia treatment

Professor Paul Tambyah (left) and Dr Matthew Cove are both involved in the global trial. ST PHOTO: MARK CHEONG

SINGAPORE - After a few days of high fever, Mr Tony Goh was rushed to the intensive care unit (ICU) six days after testing positive for Covid-19 on Oct 13, 2021.

His oxygen levels had plummeted from 90 per cent to a mere 54 per cent, seriously endangering the life of the 73-year-old.

This marked the start of 89 harrowing days in the National University Hospital’s (NUH) ICU for the owner of an audio production studio; he was sedated, intubated and hooked up to a ventilator as viral pneumonia wrecked his lungs.

Patients like him who have been hospitalised in the ICU, aged 21 and above, are currently being recruited in Singapore for a global trial to quickly discover the best combination of therapies for community acquired pneumonia.

Community acquired pneumonia – one of the leading causes of death in Singapore – is an inflammation of the lungs caused by a bacterial or viral respiratory infection, which takes place outside the hospital.

While Mr Goh can cycle, eat and drink normally again, his wife Elaine Guoh told The Straits Times that having to deal with different consultants on a weekly basis during her husband’s stay in the ICU had been a struggle even though they were supportive.

They often had their own varying interpretation of the situation at hand, she said.

The 57-year-old marketing consultant added: “One time, a consultant hinted that we might want to consider taking Tony off the ventilator. In the following week, another one suggested a tracheotomy. And after we made a decision to go ahead (with the procedure), another one said it would make little difference.”

The Randomised Embedded Multifactorial Adaptive Platform for Community Acquired Pneumonia (Remap-Cap) – as the global trial is called – simultaneously assesses the effectiveness of multiple treatments for critically ill people across 25 countries, including Singapore, to help intensive care units manage the expected surge in patients with breathing problems in future pandemics.

It was launched in Europe in 2020.

Since the global trial commenced in Singapore at NUH in August 2022 with funding from the National University of Singapore (NUS), three patients have joined the study.

With funding from the National Medical Research Council, the study will expand to Singapore General Hospital, Tan Tock Seng Hospital and Ng Teng Fong General Hospital this year.

Speaking to ST, senior investigator of the Remap-Cap International Trial Steering Committee Paul Tambyah said: “There are no good treatments for viral pneumonia right now, especially for ICU patients.

“The big lesson of Covid-19 is that once you start getting an epidemic... or a spate of patients with worsening of chronic lung disease with a known virus, that puts a strain on ICU resources.”

Findings from the global trial have helped direct treatment since 2020 amid the Covid-19 pandemic by testing various therapies, said NUH intensive care physician Matthew Cove, who is also senior investigator of the Remap-Cap International Trial Steering Committee.

For example, it has revealed that blood thinners did not have a significant benefit when treating Covid-19 infections in the ICU, despite talk about the link between the virus and blood clots, said NUS Professor Tambyah, who is also an infectious disease expert.

Mr Tony Goh contracted pneumonia after testing positive for Covid-19 in 2021 and was hospitalised in the ICU. ST PHOTO: RYAN CHIONG

Participants in the study will be given antivirals, steroids or various combinations of both therapies, which are commonly used to treat pneumonia.

Said Prof Tambyah: “Unlike antibiotics, there is no uniform consensus on treatment of community acquired pneumonia using steroids due to the lack of funding for large randomised trials.”

Unlike standard randomised trials, the Remap-Cap study can recruit patients in perpetuity using statistical analysis to assign patients to therapies with more favourable outcomes, said Dr Cove.

He said: “Adaptive platform studies are novel for intensive care but not within the broader world of clinical trials, where they have been used to test treatments in cancer for years.

“What prompted the design of such an ongoing study was the H1N1 pandemic – when the wave of patients in intensive care had decreased by the time researchers had finally set up their studies.”

To be part of the study, patients must be admitted to the ICU within 48 hours of hospital admission.

The challenge in recruiting patients, however, is that treatment must start as soon as possible, which means that caregivers sometimes may decline to participate because they are overwhelmed with decisions when their relatives are admitted into intensive care, Dr Cove added.

Singapore is also exploring partnerships with Indonesia, Malaysia and Thailand to support participation in the trial with Singapore as the regional management centre, said Prof Tambyah.

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