Letter from Singapore

Singapore, the ‘Lion City’ is an island city-state, home to a rich multi-cultural population. This multi-ethnic mix offers unique opportunities to inform clinical care and research across the wider Asian sub-continent. The Singapore Thoracic Society (STS; https://www.thoracic.sg), inaugurated in 1974, hosted the 3rd Asian Pacific Society of Respirology (APSR) congress in 1993. Fast forward three decades, and we are honoured to again host the meeting this year (2023). Clinical care and research in Respiratory and Critical Care Medicine has thrived in Singapore in the intervening period. Clinically relevant phenotypes of respiratory disease have been described including a high-blood eosinophil ‘life-threatening’ form of severe asthma, post-tuberculosis variants of Chronic Obstructive Pulmonary Disease (COPD) and profiling of non-tuberculous mycobacteria.1-3 Longitudinal cohorts to understand the natural history of developing allergy, allergic rhinitis and asthma have been established and include Growing Up in Singapore Towards Healthy Outcomes (GUSTO), a prospective population-based cohort of >1200 healthy, pregnant mothers (recruited antenatally) with >900 mother-offspring pairs on active follow up.4 Other key cohorts include the Singapore Preconception Study of Long-Term Maternal and Child Outcomes (S-PRESTO), the Singapore-Malaysia Cross Sectional Genetic Epidemiology Study (SMCGES) and the Health for Life in Singapore (HELIOS) study that have contributed to developing spirometry reference equations for South Asians and, demonstrated the additive climatic influence (beyond familial tendency) on risks of developing allergy, asthma and allergic rhinitis in our tropical climate.5, 6 With the ongoing transformational shift in national population health delivery through Healthier SG, the focus on preventative and proactive care needs to leverage on these established cohorts especially once chronic respiratory conditions such as asthma and COPD come onboard next year (2024).7 A local lung cancer study demonstrated that many females and non-smokers diagnosed with lung cancer did not fit US National Lung Screening Trial criteria, a finding observed across other Asia Pacific countries.8 The Lung Cancer Consortium Singapore (LCCS) SOLSTICE screening study is currently ongoing to assess the early detection of lung cancer (https://lccs.com.sg). In 2018, the Academic Respiratory Initiative for Pulmonary Health (TARIPH) was established with the vision of ‘bringing research to patients through partnerships’. TARIPH aligns strategic academic expertise across Singapore to benefit Singaporeans with lung disease through research and has served as a ‘nucleus’ for academic respiratory efforts bringing together interdisciplinary groups to address the healthy and diseased lung by aligning basic, translational and clinical studies.9, 10 TARIPH has established a formal partnership with the STS and >40 other local and international partners and maintains an active membership of >500 individuals from all respiratory disciplines.10 TARIPH partners have established a new paradigm to understand pulmonary infection, discovered a novel Asian pathobiont and host the Singapore Severe Asthma Registry (SSAR), part of the International Severe Asthma Registry (ISAR), a global collaborative initiative that collates longitudinal, real-life data on severe asthma. SSAR (and ISAR) offer a rich data source for scientific research in Singaporeans with severe asthma while providing an international platform for benchmarking care and research collaborations.11-13 In addition, and as part of a private-public partnership to improve asthma and COPD care across Singapore, a real-world database for these diseases was developed through data linkage between a tertiary hospital (Singapore General Hospital) and nine separate (primary care) polyclinics. The database provides dynamic, real-world data for operational insight, use in evidence-based research and to inform national policy.14 The delivery of critical care in Singapore is world-class and supplemented by national, regional, and internationally impactful research. Stringent standards with continuous quality improvement initiatives ensure the safety and excellence of Intensive Care Unit (ICU) care, including during the COVID-19 pandemic.15, 16 The National ICU Repository (NICUR) captures continuous data on the epidemiology, management, and outcomes of critical illness across all public hospitals and the Society of Intensive Care Medicine, Singapore (SICM), founded in 1995, serves as the professional organization dedicated to advancing intensive care practices. Since 2011, SICM has established a partnership with the Australian and New Zealand Intensive Care Society (ANZICS) to launch the Asia Pacific Intensive Care Symposium (APICS) (https://sg-apics.com/), now an annual conference. The first accredited training programme for critical care nurses was formalized in 2005 while the sub-speciality training committee in Intensive Care Medicine (ICM) was inaugurated in 2007 with formal recognition of ICM as a sub-specialty in 2012.17 The critical care community places significant emphasis on research to improve outcomes with focus on sepsis management, organ support, infection control, and the use of technology to enhance capacity and care delivery. In 2008, SICM established the National Investigators for Clinical Epidemiology and Research (SICM-NICER), a multicentre initiative to further research, for example in the use of critical care ultrasound and high-flow nasal cannula. SICM collaborates with the Asian Critical Care Clinical Trials Group to address key topics including bed capacity, staff burnout, end-of-life care and sepsis, providing essential data from an Asian perspective.17, 18 Recognizing that disease does not respect borders, ICUs across Singapore are participating in large international trials including Randomized Embedded Multifactorial Adaptive Platform for Community-acquired Pneumonia (REMAP CAP). Singapore has also established a pipeline of innovation for respiratory and critical care including the development of ‘Spirobooth’, an enclosed paediatric facility to perform spirometry in children, allowing for easier cleaning and reduced exposure to respiratory viruses. Collaborations between clinicians, engineers and basic scientists have led to the growth of new technologies including the implementation of artificial intelligence (AI) to detect ventilator dyssychrony, smart remote monitoring of vital signs, the use of virtual patient models to test novel ventilatory strategies and the redesign of dialysis machines to provide respiratory support. Reflecting on the past three decades between our first hosting of the APSR congress in 1993 and our upcoming meeting in 2023, the combined development of clinical care, research, networks, and collaborations have created a prodigious ecosystem for respiratory and critical care, with a robust capability to take ideas from the bench to the bedside, not only in Singapore, but regionally and with international relevance and impact. Sanjay H. Chotirmall has served on advisory boards for CSL Behring, Pneumagen Ltd. and Boehringer-Ingelheim, on DSMBs for Inovio Pharmaceuticals and Imam Abdulrahman Bin Faisal University and has received personal fees from Astra-Zeneca and Chiesi Farmaceutici, all unrelated to this work. Fook Tim Chew has been lead consultant and received consultancy fees from Sime Darby Technology Centre; First Resources Ltd; Genting Plantation, Olam International, and Syngenta Crop Protection, all unrelated to this work. Kay Choong See has received personal fees from Astrazeneca, Boehringer-Ingelheim, Boston Scientific, Fresenius, GE Healthcare, GSK, Medtronic, Novartis, and Pfizer, all unrelated to this work. Matthew E. Cove has received consulting fees from Baxter, B. Braun, Medtronic and Jaffron all unrelated to this work. Mariko Siyue Koh reports grant support from Astra-Zeneca, and honoraria for lectures and advisory board meetings paid to her hospital (Singapore General Hospital) from GlaxoSmithKline, Astra-Zeneca, Novartis, Sanofi and Boehringer Ingelheim, all unrelated to this work. Albert Y. H. Lim reports honoraria for advisory board meetings paid to his hospital (Tan Tock Seng Hospital) from GlaxoSmithKline, Astra-Zeneca and Boehringer Ingelheim, all unrelated to this work. John A. Abisheganaden, Anne E. N. Goh, Chee Hong Loh and Jason Phua have no disclosures to report.