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 […]
PulmCrit Wee- Could the best mode of noninvasive support for COVID-19 be… CPAP ??
COVID-19 patients seem to behave in a somewhat unique fashion, compared to other patients with ARDS. This isn’t based on high-level data, but it seems to be a theme emerging from a variety of centers (including my experience with one patient). Some salient points are: Low driving pressures are seen among ventilated patients. Thus, it […]
PulmCrit – Splitting ventilators to provide titrated support to a large group of patients
COVID-19 might out-strip the number of mechanical ventilators available to us. This has led to interest in using a single ventilator to support multiple patients. This post will review the theory and evidence regarding this (with the admission that I don’t have experience with this). basic principles Bedrock principle: Patient-Ventilator Independence Normally, we adjust the […]
PulmCrit – Preview of Lopinavir/Ritonavir efficacy in COVID-19?
background Lopinavir/Ritonavir (tradename KALETRA) is a combination of protease inhibitors typically used in HIV, including post-exposure prophylaxis (lopinavir is the actual antiviral agent, with ritonavir functioning to inhibit metabolism of lopinavir, thereby boosting levels of lopinavir). In vitro, Lopinavir/Ritonavir has activity against SARS-CoV-1 and functions synergistically with ribavirin (the addition of ribavirin increases Lopinavir’s potency […]
IBCC: COVID-19
Friends, As COVID-19 has exploded, so has the amount of information about COVID-19. There are currently over 700 publications regarding coronavirus listed in PubMed within the past few months. More are being released daily. Many haven’t been catalogued on PubMed yet. This chapter will attempt to synthesize the latest and most important information on COVID-19. […]
PulmCrit- Nonsedation in ventilated patients: Two dueling RCTs
A new study in NEJM compared nonsedation with light sedation in ventilated ICU patients. This is a follow-up study, aimed at clarifying the results of a prior trial at the same center. To best understand the current study, we need to start with the first trial… Strom et al. 2010: A protocol of no sedation […]
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