There has been considerable speculation in the literature regarding the physiology of intubated patients with COVID, but little actual data. A fresh study describing the physiology of intubated patients at Massachusetts General Hospital and Beth Israel offers to finally answer some questions. This is a retrospective case series involving 66 patients intubated during March 11-30. […]
PulmCrit- First placebo-controlled RCT on remdesivir for COVID-19
Remdesivir is being promoted as an anti-viral agent for the treatment of COVID-19. The first randomized, blinded, placebo-controlled trial of remdesivir was just released (Wang et al.). But before we dig into this trial, a little background… Background: Animal studies on Remdesivir Remdesivir is an anti-viral agent with strong efficacy against COVID-19 both in vitro […]
PulmCrit- American research infrastructure is killing us: The misbegotten battle between the ivory tower academics and the rogue cowboys
the battle between the ivory tower academics vs. the rogue cowboys An internecine war is brewing about the treatment of COVID-19. You can hardly open up a journal or look at social media without getting caught in the cross-fire. The cause of the schism is pretty simple. There are no proven treatments for COVID-19. Based […]
PulmCrit Wee: Lung pathology of COVID-19: is AFOP in play?
We’re beginning to start to see some information about lung pathology due to COVID-19. But before jumping into that, a little background… background: lung pathology, DAD, and AFOP Lung pathology & treatment: the bigger picture In an ideal world, different insults to the lung would cause specific histologic patterns. These patterns would be related to […]
PulmCrit Wee – Some take-home messages about the COVID experience in New York
Currently, three publications are available describing coronavirus outcomes among hospitalized patients in New York: Goyal et al: 393 patients at Cornell. Cummings et al: described 257 patients who were critically ill (among a total of 1,150 patients at Columbia and a community affiliate). Richardson et al: 5700 patients at Northwell Health System (including North Shore […]
PulmCrit- Timed & titrated use of steroid in COVID-19?
Guideline recommendations on steroid use in COVID are contradictory. For example, the Surviving Sepsis Campaign recommends steroid for intubated patients with COVID and ARDS,1 whereas the IDSA guidelines recommend that steroid should be restricted to randomized controlled trials. Reviewing these documents shows that they often lean on data from influenza and MERS, which may not […]
PulmCrit – Defining ARDS & recruitability, with implications for COVID treatment
In the past few weeks, there has been considerable debate regarding whether or not early COVID respiratory failure is ARDS. This is a linguistic mess, but it has real implications for treatment. So, it’s worth trying to sort it out… definition(s) of ARDS When clinicians use the term “ARDS” they are referring to a variety […]
PulmCrit – Hydroxychloroquine fails first meaningful RCT
Hydroxychloroquine has been a highly controversial potential treatment for COVID-19. To date, available evidence has consisted of in vitro data as well as some heavily flawed studies from France. A new pre-print from China offers the most meaningful investigation of hydroxychloroquine to date. design Tang et al. is a multi-center, open-label RCT involving administration of […]
PulmCrit – Understanding happy hypoxemia physiology: how COVID taught me to treat pneumococcus
Happy hypoxemia is severe hypoxemia (poorly responsive to supplemental oxygen) without dyspnea. This isn’t anything especially new – we have occasionally seen this since time immemorial. However, COVID is causing us to re-think how to manage this physiology. understanding the paradox of happy hypoxemia The key to understanding this is thinking about oxygenation and CO2 […]
PulmCrit – Eleven reasons the NEJM paper on remdesivir reveals nothing
Grein et al. just published a case series of patients with COVID-19 treated with remdesivir via a compassionate use program. I’ve been expecting this paper with cold dread for some time now. There are several reasons that this publication is a media show, rather than a serious scientific endeavor. #1. Lack of a control group […]
PulmCrit Wee: D-dimer cutoffs to predict thrombosis in COVID-19
It’s increasingly clear that critically ill patients with COVID-19 can develop a pro-thrombotic form of DIC which places them at a dramatically increased risk of thrombosis. Thrombotic events may include pulmonary micro-vascular thrombosis (reported in some autopsies) or macro-vascular thrombosis (e.g., deep vein thrombosis). To date, an evidentiary vacuum has left it highly controversial as […]
IBCC chapter: Guide to APRV for COVID-19
COVID appears to cause a form of pseudoARDS (rather than true ARDS). This responds especially well to APRV, often avoiding many forms of iatrogenesis (e.g., proning, paralysis, myopathy, deep sedation, and delirium). Embracing APRV requires a zentensivist perspective on tidal volumes and minute ventilation (they will vary a bit! you won’t have total control of […]
PulmCrit Theoretical Post – The COVID Severity Index (CSI 1.0)
Prognostication is tough. The challenge is often not that we have too little data, but rather that we have too much data. There are now about two dozen risk factors for poor outcomes with COVID-19. How are we supposed to integrate all these bits of information at the bedside? Which pieces of information are redundant […]
PulmCrit wee – Why the SCCM/AARC/ASA/APSF/AACN/CHEST joint statement on split ventilators is wrong.
The story began in early March. With COVID-19 bearing down upon us, it became clear that we could run out of ventilators. This sparked interest in the concept of splitting ventilators between several patients. Some articles and videos were circulated on twitter describing how this could be done. These mostly described splitting a ventilator set […]
PulmCrit- Is Lopinavir/Ritonavir down and out?
A lot has happened since the last post on Lopinavir/Ritonavir (it was only March 4, but it seems like a year ago). Here is a quick reminder of where we left off: Lopinavir/ritonavir (tradename KALETRA) is a combination of protease inhibitors used in HIV, which might also be effective in COVID-19. Prior studies on SARS […]
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