ESICM Webinar Mentioned
Read this to See the Thoughts of Actual Smart People
Subtypes of COVID
Mild
Silent Hypoxemia (can cause iatrogenic injury when patients are intubated in this phase)
Indolent- Fine then Not (Intubated or Not-Inflammatory Markers)
Hyperacute
Cytokine Storm
Hemophagocytic Lymphohistiocytosis (HLH) Overlap / DIC
PathoPhys
Loss of hypoxic vasoconstriction
Micro-thrombotic disease
Avoidance of Intubation
Tachypnea, hypoxemia, do not seem to be indication
Mental status, Increased Dyspnea, PaCO2 rising
Progression of Therapies
NC
Venti
NRB+NC
Hi Flo with Surg Mask
CPAP—must monitor for excessive WOB
Non-Intubated Proning
ask them to move
Run them Dry
but not too dry–must replace external and insensible losses or else badness ensues
How to not kill patients with Intubation
How to Ventilate
High FiO2 Strategy—Normal Compliance Patients
8 ml/kg, high fiO2
keep checking Driving Press and Plat
Avoid the PEEP Tables
Driving Pressure <=15
Proning
Prost/NO
Low Compliance Patients
6 ml/kg
Conventional Low Vt PEEP Table
Driving Pressure > 15
APRV
works for either subtype
if experienced, should be dominant mode of ventilation
Other Meds
- Heparin
- Steroids
Here is the Video Version
Audio Version Here:
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Professor
Chief, Division of Emergency Critical Care
Director, Resuscitation and Acute Critical Care Unit
Stony Brook Medicine
Stony Brook, NY, USA
No conflicts of interest (coi).
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Thanks for info! Always appreciate everything you post! Any thoughts on surfactant? Throwing crap against the wall phase for me. No coi
Great seeing you at the microphone but is there a link to the Zoom presentation so we can see the slides you showed?
As discussed, most current recommendations preclude the use of HFNC and NIPPV/CPAP/BiPAP for SARS-CoV-2 patients. As I am sure you are all aware, experience in Italy, Spain, and now hot spots in the US shows that there are just not enough ventilators for all of these patients. Italy has had some good results with helmet CPAP, but those seem to be in short supply here in the States. Because of justified concern for contamination, patients that do not have COVID-19, but are instead exacerbations of COPD/asthma/CHF, are being intubated rather than receive the normal escalating oxygenation/ventilation support which is the… Read more »
Interested to hear your mention of HAPE high altitude pulmonary edema and later mention of inhaled pulmonary vasodilators. I have history of SIPE (swim induced pulm edema) and aware of a few trials using PO sildafenil prior to swimming with some success. Just wondering if you think rapidly declining patient might have a flash pulmonary edema like SIPE or if it takes place over more time through inflammatory leakage. Or if the rapidly declining patients might be having clotting.
[…] EMCrit: Webinar I Gave to Pulm/Crit Care Fellows on Avoiding Intubation and Initial Ventilation of COVID19 P… […]
A friend forwarded me this interesting representation and reasoning behind the theory of a microvascular thrombotic etiology to explain the later decline in these patients w silent hypoxemia/good lung compliance. It’s food for thought as we continue to sift through data and anecdotal accounts. Wondered thoughts.
http://farid.jalali.one/covid19emailpdf.pdf?fbclid=IwAR1ylWu4f-5RLjdyPE7iWOTq5gM-EZG-XedMhl7rE7pNDxPTVYiirQof0Ew
Interested in the theories of endothelial dysfunction, microvasculature thrombosis and also now possibly the COVID disruption of heme binding…to try to explain the not-so-ARDS-like picture of hypoxemia. Fascinating evolution of theories – I hope we can all figure this out quickly to help our patients!
[…] EMCrit Wee – Webinar I Gave to Pulm/Crit Care Fellows on Avoiding Intubation and Initial Ventilati… (Dan S.) […]
[…] EMCrit Wee – Webinar I Gave to Pulm/Crit Care Fellows on Avoiding Intubation and Initial Venti… (Dan S.) […]
Hi Scott,
Thanks for your continuous great resources.
What do you think about using surfactants? And since it appears somewhat similar to ACE inhibitor’s angioedema the potential benefits of FFP and TXA.
Thanks,
Ted
Would a CF percussion vest benefit these patients?
[…] EMCrit Wee – Webinar I Gave to Pulm/Crit Care Fellows on Avoiding Intubation and Initial Ventilati… (Dan S.) […]
Can you provide the reference for HFNC + surgical mask, please?
Hello, any thoughts on this ? If you tweet your comments on this “Article” – I will know. I see multiple issues with it – but curious to hear your take.
Here is the link
https://medium.com/@mycahyaeggleston/covid-19-had-us-all-fooled-but-now-we-might-have-finally-found-its-secret-666bdc7b0e06
epoprostenol may be interesting.
A couple questions from a 30 yr ER doc working in the sticks where we haven’t seen this yet. We have limited resources so want to maximize our preparation.
1- We have no HFNC. would nasal mask CPAP with supplemental O2 accomplish same thing?
2- Is there any thought that this disease and it’s effect on hemoglobin actually shifts the HgB Sautration curve allowing better oxygenation of tissues at lower O2 sats?
i’m an EM physician that also has 2 EMS agencies to write protocols for. We were looking at the apneic cpap eqt that you have to include, cpap mask, viral filter, bvm and peep valve connected to oxygen. this should be able to give continuous free flowing oxygen. however, We looked at our bvms (Laerdal brand) and it specifically says that oxygen will not pass thru unless squeezed. I’m waiting for the rep to call me back on the Ambu Spur II, but not holding my breath. A lot of other agencies are just making protocols on what you recommended… Read more »
The idea of using a BVM as an oxygen reservoir with PEEP valve attached, connected to a CPAP mask is a cool idea for a high FiO2 and CPAP without special equipment. But an issue I’ve found is that 15 L/min flow (typical oxygen regulator) isn’t enough to meet minute ventilation demands when someone is distressed, additionally, the thick plastic of the BVM isn’t ideal for spontaneous ventilation and actually feels like you’re drowning to breathe against it (I’ve tried it!). Something that seems to work better is the use of an anesthesia oxygen reservoir bag (that most anesthesia stock… Read more »
I am also interested in the paper on HFNC + surgical mask My main question is how you are balancing the risk of aerosol generation with oxygen delivery, specifically with ventimask, NRB, CPAP/BiPAP, Surgical mask for all? A different connection or setup on the machines themselves? Inquiring minds want to know, as they say. We haven’t seen any cases yet (small town Appalachia) but all are concerned with aerosols and provider infection. We have to run 2000 hours of overtime a year just to make the RT’s baseline schedule work, so we can’t afford to have anyone out. Nursing isn’t… Read more »
Wondering the thoughts on this talk: https://www.youtube.com/watch?feature=youtu.be&v=3zAMlOZ2F6k&app=desktop
Their outcomes seem great doing simple ARDSnet crit care, going against this whole other hypoxemic theory. Thoughts?
Pre-print / not peer reviewed… another angle on the profound hypoxaemia – explains some of L-phenotype…
Pre-print HERE
I must say the recollection of the fortunate ventilated survivors of covid are disturbing. The sensations of drowning, being “buried alive” (ie paralyzed but not enough sedation) and ptsd are concerning. How can we best sedate but allow spontaneous ventilation? #myworstfear
This is very usefull information and hope this webinar will be great.
[…] EMCrit Wee – Avoid Intubation […]
Great webinar! I just had a question about using high frequency oscillatory ventilation in these patients. I was wondering if anyone has tried this/had any success with it. I am a novice at vent management so forgive me if this has already been discussed or is a bad idea due to higher mPaw need for this maneuver.
Lee
Hi I am wondering whether to feed patients on HFNC or CPAP while they are at risk of sudden deterioration and ending up in a situation of emergency or semielective intubation with full stomach. Do benefit oral intake or ng feeding overweights the risk of aspiration?
maybe it would be better to start peripheral parenteral nutrition at some point?
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